revitalize 2018...4/10/18 1 dry needling paul thomas, pt, dpt, ocs, faaompt 2018 conference &...
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DryNeedlingPaulThomas,PT,DPT,OCS,
FAAOMPT
2018CONFERENCE&EXPO
MaterialpresentedatIPTA2018REVITALIZEConference
“Myofascialpainisarguablythemostcommoncauseofpaintoafflicthumankind”
-Gerwin,2011
Title
MaterialpresentedatIPTA2018REVITALIZEConference
• JanetTravelrediscoveredtriggerpointsintheearly1940’sanddevelopedtheideaoftriggerpointinjecZons
• By1944theideathattheneedlemaybepartlyresponsibleforthetherapeuZceffectshadalreadybeenmenZoned
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• Atfirstmanagementofmyofascialpainwithinvasivetechniqueswasreservedforphysicians
• MostMD’spreferredinjecZonsoverdryneedling
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Theneedleeffect
• In1979,KarlLewitpublishedontheneedleeffect§ Achievedsuccessfuloutcomesin86%ofpaZentstreated§ Successdefinedasimmediateanesthesia
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Acupuncturists
• Inthe1980’ssomeacupuncturistsawareofTravellandSimons’workanddevelopedaninterestinthetriggerpointconcepts§ Seem2007
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PhysicalTherapists
• PT’sthathadstudiedwithDr.JanetTravelldevelopedaninterestindryneedling
• 1984MarylandBoardofPhysicalTherapyExaminerswasthefirstintheUStoapproveddryneedlingaswithinthescopeofPTpracZce
MaterialpresentedatIPTA2016REVITALIZEConference
MyofascialTriggerpoint
• TrP’scanbepresentasaprimaryproblemandindependentcauseofpain
• Ortheycanbeaco-morbiditysecondarytoamedicalissue§ OAorotherjointproblems(e.g.,knee,hip,etc)§ Systemicdiseases§ NutriZonaldisorders(e.g.,vitamindeficiencies)§ VisceraldysfuncZons(e.g.,endometriosis,intersZtalcysZZs,IBS,prostaZZs)
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MTrP
• TriggerpointscanpersistbeyondtheduraZonoftheiniZaZngcondiZon
• MusclehavevarietyofnocioceptorsthatcanbeacZvatedbymechanicalorchemical
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TrPDefined
• Atriggerpointisahyperirritablespotinatautbandofaskeletalmusclethatispainfuloncompression,stretch,overload,orcontracZonoftheZssuewhichusuallyrespondswithareferredpainthatisperceiveddistantfromthespot§ Simonsetal.1999
MaterialpresentedatIPTA2016REVITALIZEConference
AcZveorLatent
• LocalandreferredpainfromacZvetriggerpointsreproducessymptomsreportedbypaZents
• BothacZveandlatenttriggerpointscauseallodyniaattheTrPandhyperalgesiaawayfromtheTrP
• LatenttriggerpointsthelocalandreferredpainarenotrecognizedasbeingusualpainthatpaZentexperiences
MaterialpresentedatIPTA2016REVITALIZEConference
Latenttriggerpoints
• AlthoughlatenttriggerpointsarenotproducingacZvepain,theyprovidenociocepZveinputtothedorsalhorn(Geetal.2008,2009,Ge&Arendt-Nielson2011)
• LatentTrPcanbecomeacZvetriggerpointswithcentralsensiZzaZonandincreasedefficacyinthedorsalhorn
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AcZveTrP’s
• AcZvetriggerpointsinducelargerreferredpainareasandhigherpainintensiZes(Hongetal2000)
• OverlyingcutaneousandsubcutaneousZssuesmoresensiZvetopressureandelectricalsZmulaZonthanlatentTrP’s.(Vecchietetal.1990)
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• BothacZveandlatenttriggerpointscanprovokemuscledysfuncZons§ Muscleweakness§ InhibiZon§ Increasedmotorirritability§ Spasm§ Muscleimbalance§ Alteredmotorrecruitment
• ChangesoccurintheeffectedmuscleorfuncZonallyrelatedmuscles
MaterialpresentedatIPTA2016REVITALIZEConference
MotoracZvaZonlatentTrP
• Lucasetal2010demonstratedimpairedmotoracZvaZonpamernsinlatenttriggerpoints
• CorrecZonoftheTrPnormalizedthemotoracZvaZon
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Referredpain
• Mensedescribedreferredpaincomingfromdeepstructures(muscles,joint,tendons,viscera)asdeep,diffuse,anddifficulttolocalize
• Referredpaincanbeexperiencedanywhereinthebody
• Sizeofthereferredareaisvariableandrelatedtothepaininducedchangesinthecentralsomatosensorymaps
MaterialpresentedatIPTA2016REVITALIZEConference
Referredpain
• Characterizedby:§ DuraZonofreferredpaincanlastafewsecondstohours,weeks,or
indefinitely.§ Deep,diffuse,burning,Zghtening,orpressingpain(completely
differentfromneuropathicorcutaneouspain)§ SimilarreferralofpainfrommuscleZssuesasreferralfromjoints§ Referredpaincanspreadsuperior/inferiororventral/dorsal§ IntensityofpainandsizeofreferredareaareposiZvelycorrelatedto
thedegreeofirritabilityofthecentralnervoussystem(sensiZzaZon)§ FrequentlyfollowsdistribuZonofscleratomes,notdermatomes§ Maybeaccompaniedbynumbness,coldness,sZffness,weakness,
faZgue,ormotordysfuncZon
§ Arendt-Nielsen&Ge2009,Fernandez-de-las-Penasetal2011
MaterialpresentedatIPTA2016REVITALIZEConference
BasisofReferredPain
• Convergent-projecZontheory(1961)§ AfferentsfromdifferentZssuesincludingskin,viscera,muscles,andjointsconvergeontocommonspinalneuronswhichleadstomisinterpretaZonofthesourceofthenociocepZveacZvityfromthespinalcord
§ Doesn’texplainthedelayinonsetofsymptoms
• Covergence-facilitaZontheory§ SomatosensorychangesinthereferredareaduetosensaZzaZonmechanismsinthedorsalhornandbrainstemneurons
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BasisofReferredPain
• Thalamic-convergencetheory(1949)§ SummaZonofinputfrominjuredareaandfromreferredareawithin
neuronsinthebrain,butnotinthespinalcord§ EvidenceofpainreducZonwithanestheZzingthereferredarea
suggesZngaperipheralprocesscontributes§ Centralprocessarebelievedtobedominant
• Central-Hyper-excitabilitytheory§ FollowingnoxioussZmulus,dorsalhornneuronsthatwerepreviously
responsivetoonlyoneareawithinamusclebegantorespondtonociocepZonfromareasthatdidnotpreviouslytriggeraresponse
§ LatentconvergentafferentsonthedorsalhornneuronareopenedbynoxioussZmulifrommuscleZssues
MaterialpresentedatIPTA2016REVITALIZEConference
NatureofTrPs
• Tautbandscanbepalpatedwithflatorpincergrip• TautbandsignifiescontracZonwithinacertainnumber
ofmusclefibersindependentofelectromyogenicacZvityanddoesnotinvolvetheenZremuscle
• Localtwitchresponseusuallyoccurswithmanualstrummingorneedling
• Canbeobservedvisually,recordedonEMG,orvisualizedwithdiagnosZcUS
• NumberofLTR’smayberelatedtotheirritabilityofthemusclewithmayberelatedtothedegreeofsensiZzaZonofnocioceptors(Biochemicalchanges)
MaterialpresentedatIPTA2016REVITALIZEConference
LTR’s
• EliciZngtheLTRhasbeenadvocatedforneedling(Hong1994,Shah2005)
• Shah2005observedimmediatedropinconcentraZonsofbiochemicalsintheextracellularfluidoflocalTrP’s
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TrPDevelopment
• MayresultfromrepiZZvemuscleoveruse,acuteorsustainedoverload,psychologicalstress,orotherprimaryTrP
• FollowingintenseconcentriccontracZonoreccentriccontracZons
• Muscletrauma,repeZZvelowintensitymuscleoverloadmaycreatedamageinthesacroplasmicreZculumorcellmembrane,shortageofATP,andimpairedcalciumconcentraZon,shorteningofacZn/myosin
MaterialpresentedatIPTA2016REVITALIZEConference
MTrPDevelopment
• MTrPmaydevelopintheabsenceofmedicalproblemsorasaco-morbiditywithothercondiZons
• MTrPcanbeassociatedwithsystemicdiseases,arthriZccondiZons;metabolic,parasiZc,ornutriZonaldisorders;secondarytoinjuries
• PainfromMTrPcancauseseparateandindependentcauseofacuteandespeciallychronicpainthatmaycompoundthesymptomsoftheothercondiZonandmaypersistaqertheoriginaliniZalizingcondiZonhasresolved
MaterialpresentedatIPTA2016REVITALIZEConference
Integratedmodel
• ProposesthatabnormaldepolorizaZonofpost-juncZonalmembraneofmotorendplatescauseslocalhypoxiaacZvaZngreflexarcsthensustainedbysensaZzaZonmechanisms
• Musclespindlesalsoinvolved.H-reflexesassociatedhavegreateramplitudesandlowerthresholds
• Believedtoberelatedtogreaterexcitabilityofmusclespindleafferents(Geetal2009)
• IncreasedchemicalmediatorsmaycontributetoincreasedspindlesensiZvity(Shahetal2005)
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ProposedmechanismsforTDN
• MechanicallyitmaydisruptcontracZonknots,stretchcontracturedsacromeres,reduceoverlapofacZn/myosin
• MaydestroymotorendplatesandcausedistalaxondenervaZonandchangesintheendplatecholinesteraseandacetylcholinereceptorsimilartonormalmuscleregeneraZonprocess
• ReducedendplatenoisefollowingLTRfromTDN
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AcetylcholineresponsetoTDN
• DecreasedSpontaneousElectricalAcZvityandAcetylocholineatMyofascialTriggerSpotsaqerDryNeedlingTreatment§ Ratstudy,dividedinto2groupsreceivingTDNtotriggerpointornon-triggerpoints
§ Dryneedlingtreatmentlast2weeks,onceperweek§ SEAs,Ach,AChR,AChElevelsmeasuredaqeroneweekresyofdryneedling
§ ResultsAmplitudeandfrequenciesofendplatenoiseandendplatespikessignificantlydecreasedaqerTDNingroupreceivingtreatmenttoMTrP
§ AchandAChRlevelssignificantlydecreasedandAChEsignificantlyincreasedintreamentgroup
MaterialpresentedatIPTA2016REVITALIZEConference
Mechanisms
• LTRreducesconcentraZonsofbiochemicalsintheimmediateareaofTrP’sincludingCGRP,substanceP,serotonin,interleukins,epinepherine
• DropinsubstancePandCGRPlikelycorrespondwiththedecreasedpainfollowingTDN
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Mechanisms
• Effectonthecentralnervoussystem§ hasbeensuggestedthatneedlinghaseffectsonlimbicsystemanddescendinginhibitorysystem
• StudiesonTDNoffibromyalgiapaZentsdemonstratesthatneedlingafewpointsonpaZentsreducespainnotonlyinthetreatedareasbutreducesoverallsensiZvityandwidespreadpain.
MaterialpresentedatIPTA2016REVITALIZEConference
Mechanisms
• ReducessegmentalnociocepZveinput
• ExperimentallyinducedmusclepainimpairsnoxiousinhibitorycontrolmechanismsandTDNseemstoeffectcentralsensiZzaZonbyalteringthenociocepZveprocessing
MaterialpresentedatIPTA2016REVITALIZEConference
ConnecZveZssueresponse
• Langevinetal.mulZplestudies• Whenneedlesrotatedcollagenbundleadheretotheneedleand
winditselfaroundtheshaqinimmediatevicinity• StretchismaintainedaqertherotaZngtheneedleifleqinplace• Sustainedstretchcausesvisco-elasZcrelaxaZon,Zssuetension
dropsandsemlesatequilibriumduetomolecularreorganizaZonwithinthecollagenmatrix
• ConnecZveZssuefibroblastsrespondbychangingshape,formaZonofnewcytoplasmicextensions.
• Remodelingofcell’scytoskeleton• ChangecausesfurtherreducZoninZssuetensionthenthat
achievedbyviscoelasZcrelaxaZon• Fibroblastsresponduptoseveralcmawayfromtheneedle• Needlesrequiredtostayinforlongperiod(10’)
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SuperficialTDNMechanisms
• AmributedtothesZmulaZonofA𝛿fiberswhichmayoutlastthesZmulusforupto72hours(Baldry2005)
• TypeIhighthresholdfibersacZvatedbynociocepZvemechanicalsZmulaZon
• SZmulaZonofA𝛿fibersmayacZvateenkephalinergic,seratonergic,andnoradrenergicinhibitorysystems
• MayacZvatemechanoreceptorscoupledtoslowconducZngunmyelinatedCfiberafferents
MaterialpresentedatIPTA2016REVITALIZEConference
SuperficialDryNeedling
• PeterBaldrybeganemployingthetechniqueinthe1980’s§ .3mmneedle,30mmlength§ Insertfor30secondsabovetheMTrPtobeinacZvated§ Iffailstorespondthenwillleaveforupto2-3minutes§ IfveryweakresponderthenmayintermimentlytwirltheneedletosZmulate
MaterialpresentedatIPTA2016REVITALIZEConference
Gunn-IMS
• GunnIntramuscularSZmulaZon• Developedinthe1970’sbyChanGunn,MD• Cannon’s“SupersensiZvityofDenervatedStructures,aLawofDenervaZon”
• Believedinradiculo-neuropathic-myofascialpain(RNMP)
• Leadtolookingforsegmentalmyotomalinvolvement
• PredictstriggerpointsinmyotomaldistribuZonincludingtheposteriorramus
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Gunn
• Increasedmuscletone• Neurogenicedema–matchsZcktest,peaud’orange• Vasomotordisturbanceswithhypothermia–coolertopalpaZon
• Exaggeratedpilomotorandsudomotorreflexes–goosebumps,increasedsweat
• Dermatomalhairloss
MaterialpresentedatIPTA2016REVITALIZEConference
CannonandRosenbluth’sLaw
• Whenaunitisdestroyedinaseriesofefferentneurons,anincreasedirritabilitytochemicalagentsdevelopsintheisolatedstructureorstructures,theeffectbeingmaximalinthepartdirectlydenervated
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BiomedicalAcupuncture
• WMAisatherapeuZcmodalityinvolvingtheinserZonoffineneedles;itisanadaptaZonofChineseacupunctureusingcurrentknowledgeofanatomy,physiologyandpathology,andtheprinciplesofevidencebasedmedicine
• Characterizedbydryneedlingoftriggerpointsandsegmentalacupuncture(needlingofanareainnnervatedbythesamespinalsegment
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Biomedicalacupuncture
• Localeffects• Segmentalanalgesia
§ SZmulatestheA𝛿fibersinskinandmuscle§ TheseacZvatesmallintermediatecellsinthedorsalhorn§ IntermediatecellsreleaseneuromodulatorenkephalinwhichblocksthetransmissionofpaininthesubstanZagletainosacells,partofthenociocepZvepathway(fromtheunmyelinatedC-fibers
• Extrasegmentalanalgesia
MaterialpresentedatIPTA2016REVITALIZEConference
BiomedicalAcupuncture
• ExtrasegmentalAnalgesia§ OpioidpepZdes(neuromodulators):
• β-endorphin(midbrain,PAG)• Enkaphalin(dorsalhornofspinalcord)• Dynorphin(brainandspinalcord)• Orphanin–akaendomorphinornocicepZn(widespread)
§ HaveeffectontargetcellforsustainedperiodofZme• Descendinginhibitorypaincontrol
§ PAGacZvatedbyβ-endorphin,releasedfromfibersdescendingfromthehypothalamusspecificallythearcuatenucleuswheresomeafferentpathwaysoftheA𝛿terminate
MaterialpresentedatIPTA2016REVITALIZEConference
Extrasegmentaleffects
• Descendingpaincontrolreleasesserotonin,sZmulaZngtheintermediatecelltoreleasemet-enkephalinwhichinhibitsthesubstanZagelaZnosacells(addiZonaltothesegmentalinhibiZonalreadyacZvated)
• Alsocausesreleaseornoradrenalinediffuselythroughoutthedorsalhornwhichhasadirectinhibitoryeffectonpost-synapZcmembraneoftransmissioncellsfurthercontrollingnociocepZon
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E-sZm
• 2Hz–releasesβ-endorphin,enkephalin,andorphanin
• 80-100Hz–releasesdynorphin• 15Hz–limitedreleaseofenkephalinandβ-endorphin
MaterialpresentedatIPTA2016REVITALIZEConference
AdverseEventsreportedin7629treatmentswithTDN
Event CasesReported Numberper100treatments
Number(%)ofPT’srepor<ngnone
Extremevaluesbyindividualprac<onersper100treatments
Bleeding 576 7.55 4(10.25) 32.23,30
Bruising 355 4.65 3(7.69) 26.09,21.84
Painduringtreatment
230 3.01 9(23.08) 20.75,20.69
Painaqertreatment
167 2.19 14(35.9) 20.69,18.4
AggravaZon 67 0.88 22(56.41) 10.99,5.75
Drowsiness 20 0.26 32(82.05) 4.44,3.26
Feelingfaint 17 0.22 28(71.79) 4.17,2.5
Headache 11 0.14 31(79.49) 1.15,1.1
Nausea 10 0.13 31(79.49) 1.15,1.1
FaZgue 3 0.04 37(94.87) 1.77,0.27
EmoZonal 3 0.04 37(94.87) 1.59,0.27
Shaky 1 0.01 38(97.44) 3.03
Itching 1 0.01 38(97.44) 0.47
Claustophobia 1 0.01 38(97.44) 0.16
Numbness 1 0.01 38(97.44) 0.47
MaterialpresentedatIPTA2016REVITALIZEConference
AdverseEvents
VeryCommon Common Uncommon Rare VeryRare
>10%/>1-10 >1-10%/1-10/100
>0.1%-1%1-10/1000
>0.01%-0.1%1-10/10,000
<0.01%<1/10,000
BleedingHematomaNeedlesitepain
InflammaZonSwellingStrongpainduringNerveirritaZonNerveinjuryHeadacheFaZgueVerZgoNausea
LocalinfecZonRednessItchingSweaZngBloodpressurechangesUnconsciousnessTachycardiaBreathingdifficulZesVomiZng
PneumothoraxBrokenneedleForgomenneedleSystemicinfecZonAffectedspeechDisorientaZon
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Guidelines
• Handhygiene§ washhandswithsoap/waterorusehandsaniZzersifnotvisiblysoiled
• Gloves§ UseisinlinewithOSHAguidelines,likelycontactwithblood
• Skinprep§ NotusuallyrequiredforTDNperWorldHealthOrganizaZonforintradermal,subcutaneous,orintramuscularinjecZons
§ Ifskinisvisiblysoiledshouldbecleanedwithsoap/waterfirst§ Mayuse70%alcoholleqonskinforatleast2minutesespeciallyifpaZentisimmunocompromisedyetsuitableforTDN
MaterialpresentedatIPTA2016REVITALIZEConference
AbsoluteContra-indicaZons
• PaZenthasneedlephobia• PaZentisunwilling–fear,belief• Unabletogiveconsent• AcutemedicalcondiZon• OveranareaorlimbwithlymphodemaasitmayincreaseriskofcelluliZs/infecZon
• Inappropriateforanyotherreason
MaterialpresentedatIPTA2016REVITALIZEConference
RelaZvecontra-indicaZons
• Abnormalbleeding• Compromisedimmunesystem• Vasculardisease• Diabetes• Pregnancy• Children• FrailpaZents• PaZentwithepilepsy• Psychologicalstatus• PaZentallergies• PaZentmedicaZon• UnsuitablepaZentforanyotherreason
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AnatomicalconsideraZons
• Lungsandpleura• Bloodvessels• Nerves• Organs• Joints• ProstheZcimplants/fixaZondevises• Implanteddevices
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MuscleCramps
• Geetal2008demonstratedlatenttriggerpointscouldbeatleastparZallyinvolvedinmusclecrampsbyinducingcrampswithglutamateinjecZonsin92.86%ofsubjectstested
• NocrampswereobservedwheninjecZonoccurredinnon-TrP’s
• IncreasednociocepZvesensiZvityattheTrPisbelievedtobeonemechanismforthedevelopmentofmusclecramps
MaterialpresentedatIPTA2016REVITALIZEConference
EffectsofTDNonPower/ForceProducZon
• 40malesseparatedin4groups§ RectusfemorisTDN§ MedialgastrocTDN§ RectusfemorisandmedialgastrocTDN§ Control(noneedles)
• Peformedjumpsquatsatincrementalloadsandmeasuredforjumpheight,poweroutput,opZmalforce,andopZmalvelocity
• Results:§ Immediateincreaseinjumpheightforgroup2(gastroconly)andat48
hourspostintervenZon§ From48hoursonwardatrendwasobservedforjumpheight,power,and
velocity§ AuthorsconclusionthatTDNcausesiniZaldecreasedperformancewith
levelsimprovingabovebaselineaqer48hours
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LTR
• TheassociaZonbetweendryneedling-inducedtwitchresponseandchangeinpainandmusclefuncZoninpaZentswithlowbackpain:aquasi-experimentalstudy.
• 66paZentwithmechanicalLBP• TDNtoL3andL5bilaterally• NumericpainraZng,modifiedOswestry,pressurealgometry,ultrasound
imagingbeforeandaqertreatment• Results:parZcipantswithLTRexhibitedgreaterimprovementinmulZfidus
funcZon12.6%changevs5.7%)• Howeverdifferencewasnotpresentatoneweek• Nobetweengroupdifferencesindisability,painintensity,ornociocepZve
sensiZvity.• ConclusionsthatLTRmaynotbenecessaryforsuccessfultreatment• ResultsmayhavelastedlongeriffollowedbystrengtheningoracZvaZon
exercises
MaterialpresentedatIPTA2016REVITALIZEConference
CosteffecZveness
• CosteffecZvenessoftheinclusionofTDNintoanExerciseProgramforSubacromialPainSyndrome:EvidencefromaRCT§ 50paZentsrandomizedintoexerciseorexerciseplusTDN§ BothgroupsaskedtoperformRCexercises2x/dayfor5weeks§ AllparZcipantssawPTforsupervisedexercisesonceperweekfor5weeks§ PaZentsintheneedlinggroupalsoreceivedTDNon2ndand4thsessions§ SocietalcostsandhealthrelatedQOLovera1yearfollowupwereusedto
generatecostperquality-adjustedlife-year(QALY)raZosforeachintervenZon
§ Exercisegroupmademoredoctorvisitsandreceivedgreaternumberofothertreatments
§ Majorcontributertothesocietalcostswasabsenteeism(lostproducZvity)
MaterialpresentedatIPTA2016REVITALIZEConference
TrA/MulZfidus
• ImmediateChangesinResZngandContractedThicknessofTransversusAbdominisAqerDryNeedlingofLumbarMulZfidusinHealthyParZcipants:ARandomizedControlledCrossoverTrial§ 47healthyindividualswithoutLBPinprevious6monthsassignedTDNtomulZfidusorsham-TDN(usedtubeonly).
§ ParZcipantsreceivedbothintervenZonsatleast7daysapart.§ InstructedhowtocontractTrAandmeasuredwithultrasoundatrestandcontractedbeforeandimmediatelyaqereachintervenZonbyevaluatorblindedtotheintervenZonreceived
§ ResultsdemonstratedTDNtothemulZfidus(L4)wasaccompaniedbydecreasedresZngthicknessandincreasedcontracZonthicknessoftheTrA
MaterialpresentedatIPTA2016REVITALIZEConference
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MulZfiduschangeswithTDN
• 66volunteerswithmechanicalLBP• Ultrasoundmeasurementsandpainalgometry(PPT)ofthe
mulZfidustakenatbaseline,immediatelyaqerTDN,and1week.
• PercentagechangeinmusclethicknessfromresttocontracZonwascalculatedtodeterminemusclefuncZon.
• ParZcipantdeterminedtoberespondersornon-respondersbasedonimprovementmeasuredwithmodifiedOswestryatoneweek.
• RespondersexhibitedlargerimprovementsinmulyiduscontracZonandnociocepZvesensiZvityat1week,butnotimmediatelyaqerintervenZonthannon-responders
MaterialpresentedatIPTA2016REVITALIZEConference
TDNforLBP
• Evidencefordryneedlinginthemanagementofmyofascialtriggerpointsassociatedwithlowbackpain:asystemaZcreviewandmeta-analysis§ 11RCTinvolving802paZentsincludedinmeta-analysiswithresultssuggesZngthatcomparedtoothertreatements,dryneedlingofMTrPswasmoreeffecZveinallevaiZngintesityofLBPandfuncZonaldisability
§ However,significanteffectsofdryneedlingplusotherintervenZonscouldbesuperiortodryneedlingalonepostintervenZon
§ ConclusionthatTDNofMTrPcanberecommendedespeciallyifassociatedwithotherintervenZonstorelieveintensityofLBP
MaterialpresentedatIPTA2016REVITALIZEConference
Heelpain
• EffecZvenessoftriggerpointdryneedlingforplantarheelpain:ameta-analysisofsevenrandomizedcontrolledtrials
• Extensiveliteraturereviewfoundonly7RCT’smeeZnginclusioncriteria.
• PooledresultsshowedMTrPneedlingsignificantlyreducedVASscorecomparedwithcontrol
• TDNhadsimilaradverseeventincidenceascontrols• ConclusionTDNeffecZveforreducingheelpainduetoplantarfasciZs
MaterialpresentedatIPTA2016REVITALIZEConference
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CervicalPain
• Beneficialeffectsofdryneedlingfortreatmentofchronicmyofascialpainpersistfor6weeksaqertreatmentcompleZon§ 45paZentswith>3monthscervicalpainandMTrP’scompleted3sessionTDNand
evaluated6weeksaqerwards§ VAS,BriefPainInventory(BPI),andMTrPstatus§ RespondersdefinedasthosewhereMTrPchangedfromacZvetolatentornon-palpable
nodule§ SecondaryoutcomesPPT,ProfileofMoodStates,OswestryDisabilityIndex(ODI),MOS
36ItemShortFormHealthSurvey,andcervicalROM§ Results:Painmeasuresremainedsignificantlyimproved6weeksposttreatment,asdid
theSF-36physicalfuncZoningscoreandODI.SidebendingandPPTforsubjectswithunilateralMTrPhadsustainedimprovement.
§ Respondersandnon-responders,changesinVASandBPIwerestaZsZcallysignificant,butchangeinPPTwasnot
§ HigherbaselineVASwasassociatedwithhigherlikelihoodofnotrespondingtoTDN§ GreaterdropofVASfrombaselinewasassociatedwithhigherlikelihoodofsustained
improvement
MaterialpresentedatIPTA2016REVITALIZEConference
KneePain
• EffecZvenessofinclusionofdryneedlinginamulZmodaltherapyprogramforpatellofemoralpain:arandomizedparallel-grouptrial§ 60paZentsrandomizedintomanualtherapyandexerciseormanualtherapy,exercise,plusdry
needling§ Bothgroupreceivedthesamemanualtherapyandstrengtheningprogramfor3sessions(1x/wkfor
3wks)§ TDNgroupalsoreceivedTDNtovastusmedialisandlateralis§ PaZentsassessedatbaseline,15dayposttreatmentand3months§ Nosignificantdifferencesbetweengroupsforanyoutcomemeasure(KneeInjuryandOsteoparthriZs
Outcomescale,InternaZonalKneeDocumentaZonCommimeeSubjecZveKneeEvaluaZonForm,painraZng
§ Bothgroupsimprovedoutcomescores§ Conclusion:AddiZonofTDNdidnotresultinanyaddiZonalimprovedoutcomesforpainordisability
MaterialpresentedatIPTA2016REVITALIZEConference
TDNvsOMT
• ComparisonofdryneedlingversusorthopedicmanualtherapyinpaZentswithmyofascialchronicneckpain:asingle-blind,randomizedpilotstudy§ 36paZentsplacedintooneof3groups:manualtherapy,TDNandstretching,orsoqZssuetechniques
§ Allgroupsreceived2sessionwith48hoursbetween§ AssessedforNDI,paincatastrophizingscale,VAS,cervicalROM,PPTformechanicalhyperalgesia
§ Results:all3groupsreporteddecreasedpainintensity§ TDNandOMTgroupshadreduceddisability§ TDNandOMTgrouphadincreasedcervicalROM§ ReducedmechanicalhyperalgesiaandpaincatastrophizinginOMTgrouponly
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TDNforshoulderpain
• Exercisesanddryneedlingforsubacromialpainsyndrome:arandomizedparallel-grouptrial§ 50subjectswithsubacromialpainrandomizedtoexercisegroupor
exerciseplusTDN§ ParZcipantsaskedtoperformexercises2x/dayfor5weeks§ Supervisedexerciseonceperweekfor5weeks§ TDNgroupalsoreceivedneedlingtoMTrPsessions2and4§ Assessedatbaseline,1week,3wk,6wk,and12monthsaqer
treatment§ Results:largerimprovementsfortheexerciseplusTDNgroupin
shoulderdisabilityatallf/uperiods§ Bothgroupshadsimilarimprovementsinshoulderpainoutcomesat
allpoints§ Conclusion:TDNeffecZveforimprovingdisabilityinsubacromialpain
syndrome
MaterialpresentedatIPTA2016REVITALIZEConference
Flexibility
• ClinicaleffectsofdryneedlingamongasymptomaZcindividualswithhamstringZghtness:arandomizedcontrolledtrial§ 27subjectswithhamstringextensibilitydeficitsrandomizedintoside
oftreatment(non-dominant/dominant)andgroup(bluntneedling/dryneedling)
§ FirstsessionmeasuredHSextensibilityandperformanceon4unilateralhoptests,HEPinstrucZoninHSstretching,andneedlingdistaltoischealtuberosityandmidbelliesofmedial/lateralHS
§ 2ndsession3-5daysaqerre-measuredandneedling§ 3rdsession4-6weeksforoutcomesonly§ Results:HSextensibilityimprovedinbothgroups,triplehopshowed
improvementforTDN§ Conclusion:Dryneedlingdoesnotresultinincreasedextensibility
beyondthatofstretchingaloneinasymptomaZcgroups
MaterialpresentedatIPTA2016REVITALIZEConference
TDNforsportsimprovement
• Comparisonofdryneedlingvs.shamontheperformanceofverZcaljump§ 35parZcipantsdividedintoshamorTDNgroup§ TDNgroupreceivedneedlingto4sitsin(B)gastrocnemiusmuscles,2eachformedial/lateralhead
§ TwoleggedverZcaljumpheightwasrecordedpre-andpost-forbothgroups
§ Results:TDNgroupincreaseverZcalsignificantly(1.2”)overshamgroup
§ Conclusion:singlesessionofTDNcancauseimmediateeffectonincreasingverZcaljumpheight
MaterialpresentedatIPTA2016REVITALIZEConference
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TDNforTMD
• Short-termeffectsofdryneedlingforacZvemyofascialtriggerpointsinthemassetermuscleinpaZentswithtemporomandibulardisorders§ 12femaleseachamendedtwosessionsandreceiveddryneedlingorsham,randomizedontwoseparatedays
§ PPTovermasseterandmandibularcondyle,pain-freeacZvejawopeningwereassessedpre-and5minutespostintervenZonbyblindedexaminer
§ Results:subjectsshowedgreaterimprovementinallmeasureswithTDNcomparedtosham
MaterialpresentedatIPTA2016REVITALIZEConference
TDNvssteroidforplantarfasciZs
• ComparisonofdryneedlingandsteroidinjecZoninthetreatementofplantarfasciZs:asingle-blindrandomizedclinicaltrial§ 66paZentswithrandomizedtoreceiveddryneedlingor1mlDepo-Medrol
§ F/ufor12monthsandmonitoredforVASatbaseline,3wk,6wk,3month,6months,1year
§ Results:steroidinjecZongroupsignificantlyreducedVASscoresunZl3weeksposttreatmentcomparedtoTDN
§ PaZentsintheTDNgroupreportedlowerVASatendofstudycomparedtosteroidintervenZon
§ Conclusion:steroidcandecreaseheelpainrapidlybutdryneedlingcanprovidemoresaZsfactoryresultsforpaZentswithplantarfasciZslongterm
MaterialpresentedatIPTA2016REVITALIZEConference
Deepvssuperficialdryneedling
• ComparisonofacuteeffectsofsuperficialanddeepdryneedlingintotriggerpointsofthesuboccipitalanduppertrapeziusmusclesinpaZentswithcervicogenicheadache§ 30parZcipantswithdiagnosisofcervicogenicHAdividedrandomlyintodeepandsuperficialgroups
§ HeadacheIndex,triggerpointtenderness,cervicalROM,funcZonalraZngindexassessedatbaseline,immediate,and1weekaqertreatment
§ Results:bothgroupsshowedreduucZoninheadacheindexandtriggerpointtenderness.
§ DeepdryneedlinggroupshowedgreaterimprovementincervicalROMandfuncZonalraZngindex
MaterialpresentedatIPTA2016REVITALIZEConference
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LateralepicondyliZs
• DryneedlinginlateralepicondyliZs:aprospecZvecontrolledstudy§ PaZentsselectediftheyhadpainatlateralepicondylefor>3months,painduringresistedsupinaZon,andresisted3rdfingerextension
§ PaZentevaluatedwiththePaZent-ratedTennisElbowEvaluaZon(PRTEE)atbaseline,3weeks,and6months
§ 110paZentsrandomizedtoreceivedryneedlingoribuprofen100mg2x/dayandforearmbrace
§ TDNtoMTrParoundthelateralepicondyle2x/wkfor5sessions§ Results:bothgroupsimprovedat3weeks,butdryneedlingsignificantlymoreeffecZveat6months
MaterialpresentedatIPTA2016REVITALIZEConference
Wryneck
• ImmediateeffectsofparaspinaldryneedlinginpaZentswithacutefacetjointlockinducedwryneck§ 21paZentswithacutefacet
lockedwryneckweretreatedwithsinglesessionofdryneedlingfor12-15minutes.
§ VASandcervicalROMimmediate,24hours,and1week
§ Results:reducedVASandcervicalROMincreasedimmediatelypostintervenZonandwasmaintainedatthe1weekfollowup.
Measure
Baseline
Immediate
24hour 1week
VAS 73.47 18.80 5.85 2.12
Flex/ext 30.38° 95.33°
115.04°
122°
SB 13.76°
91.90°
117.42°
125°
Rot 15.42°
88.28°
107.66°
115°
MaterialpresentedatIPTA2016REVITALIZEConference
DiscogenicLBP
• TheeffectofdryneedlingontheradiaZngpaininsubjectswithdiscogeniclowbackpain:arandomizedcontroltrial§ 58paZentswithdiscogenicradicularLBPrandomizedtocontrolgroupand
experimentalgroup§ VAS,OswestryDisabilityIndexatbaseline,endoftreatment,2months
postintervenZon§ ReceivedthermalmodaliZes,US,TENS,exercise(McKenzieand
stabilizaZon).§ Experimentalgroupreceived5sessionsTDNparaspinals,mulZfidus,QL,
glutemax/med/min,piriformis,psoas,HS,gastrocneedledaccordingtopresenceofMTrP’s.
§ SignificantimprovementinVASandOswestryforbothgroupsfollowingintervenZonatduringf/uperiod
§ PainanddisabilityimprovementgreaterintheexperimentalgrouppostintervenZonVAS25.17,ODI22.17vsVAS42.41,ODI30.27)andmaintainedduringf/u
§ ConclusionthatdryneedlingmayenhanceeffectofstandardintervenZon
MaterialpresentedatIPTA2016REVITALIZEConference
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