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Efficacy of specific needling techniques in the treatment of myofascial pain syndrome Brunham, Candice; McNabney, Kelly; Wiebe, Jody; Norwood, Jeff 2008-08-21

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Efficacy of specific needling techniques in the treatment of myofascial pain syndrome Candice Brunham Kelly McNabney Jody Wiebe Jeff Norwood Research Supervisors: Dr. Darlene Reid Dr. Babak Shadgan Objectives • To evaluate the efficacy of available invasive dry needling techniques for treatment of persons diagnosed with myofascial pain syndrome (MPS) and/or myofascial trigger points (MTrPs) • Identify gaps in current research and provide guidance for future studies • Relate findings to best practice What is Myofascial Pain Syndrome? • Myofascial pain syndrome (MPS) is a condition characterized by the presence of myofascial trigger points (MTrP’s)1 • MTrP’s are hyper-irritable areas located on a taut band of skeletal muscle that illicit pain when stretched or compressed1 Myofascial Trigger Points • Exhibit sensory, motor and autonomic phenomenon1,2 – Sensory: local tenderness and referral of pain which can lead to peripheral and/or central sensitization – Motor: disturbed function in muscle of origin and related muscles, muscle weakness, stiffness, restricted ROM, poor coordination, & muscle imbalance – Autonomic: localized sweating, vasoconstriction/vasodilation, & pilomotor activation Common Treatment Methods • Step 1 = deactivate MTrP3,4 – Invasive Techniques: • Dry needling, acupuncture, wet needling – Non-invasive Techniques: • Ischemic compression, spray and stretch, laser, myofascial release • Step 2 = correcting or removing the precipitating/predisposing stimuli5 Dry Needling Techniques • Dry Needling (DN) – Simple insertion and removal of an acupuncture type needle following anatomical and biological principles3,4 • Acupuncture – Needling at acupoints along meridians and extrameridians to relieve the associated pain3,4 • Intramuscular Stimulation (IMS) – Manipulation of the inserted needle until a local twitch response is attained3,4 Who is affected by MPS and how?(American Pain Foundation, 2007) • Very common source of musculoskeletal complaints6 • Increasing in prevalence8 • The estimated cost of chronic pain in America is $100 billion per annum9 • Increased morbidity and decreased quality of life in those suffering Why is this Systematic Review (SR) needed? • Needling therapies are growing in popularity amongst clinicians, resulting in a need for scientific support10 • If strong evidence can support a positive effect of needling therapies, they may become accepted as standard form of treatment Existing Systematic Reviews • Evidence Based Practice: – Cummings and White (2001)11 • Wet needling therapy not therapeutically superior to dry needling in reduction of pain • Inconclusive evidence to support effect of needling therapies beyond placebo – Rickards (2006)12 • Non-invasive treatment of MPS • Unable to provide strong evidence for any treatment interventions – Furlan et al (2005)13 • Acupuncture or dry needling in treatment of non- specific low back pain • No firm conclusions as most studies were of low methodological quality Database Search • EMBASE • MEDLINE • PubMed • CINAHL • PEDro • Cochrane Library Database of Systematic Reviews • Hand Searching Embase Search Strategy • 1. myofascial pain or Myofascial Pain/ • 2. trigger or Trigger Point/ • 3. Acupuncture/ or needling • 4. • 5. needle • 6. dry • 7. intramuscular • 8. • 9. • 10. • 11. 1 or 2 • 12. 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 • 13. 11 and 12 • 14. from 13 keep 3 • 15. from 13 keep 10, 14, 21, 23, 35, 54... • 16. 14 or 15 Inclusion Criteria • Adults over 16 years • Diagnosis of MPS and/or myofascial pain with associated TrP’s • Clear definition of myofascial pain and/or MTrP • RCTs, CCTs, or quasi-experimental trials • Assessment of outcome measures blinded if feasible • Invasive dry needling technique • At least one standardized measure of pain, including pre-and post-test values Exclusion Criteria • Patients with diagnosed temporomandibular joint dysfunction and/or fibromyalgia • Patients diagnosed with myofascial pain as a direct result of a surgical procedure • Wet needling therapies that involve the injection of substance into subject without dry needling comparison group (ie. injection of analgesic/saline/Botox) • Patients with coexisting cognitive impairment (ie. acute stroke) • Studies with a PEDro score of < 4 Quality Assessment & Data Extraction • PEDro – 11 item quality assessment tool – Studies graded by two assessors independently – Assigned a grade of excellent, good, fair, poor • Data extraction tool – Tool selected due to comprehensiveness and ease of use – Includes written description of trial and quantitative results (change in mean and SD) – Data extracted by two assessors independently Results – Selected Studies • 45 articles selected for full-text review • 13 trials met the inclusion criteria14-26 – Needling interventions included: Dry Needling, Intramuscular Stimulation (IMS), Acupuncture (Traditional Chinese and Japanese, superficial and deep), and other variations – Subject characteristics: • Average age range = 32-79 yrs • 9 trials in neck/upper trapezius region, 2 trials in lumbar region, 1 trial in gluteal region, and 1 trial did not specify – PEDro quality assessment scores: • 8 high quality, 4 moderate quality, and 1 fair quality Data Synthesis – Effect Sizes • Effect Size: – Measure of the strength of relationship between two variables • Small effect size: d = 0.2-0.5 • Moderate effect size: d = 0.5-0.8 • Large effect size: d = 0.8+ • Calculated using REVMAN v.5.0 – 95% confidence interval – Standardized mean difference as effect measure – Hedges adjusted g • Calculated at two time periods: – Baseline to end of treatment – Baseline to follow-up Groupings for Data Synthesis • Needling Intervention vs Control • Needling Intervention vs Other Intervention • Needling Intervention + Adjunct Therapy vs Adjunct Therapy vs Control • Needling Intervention – no comparison group Needling Intervention vs Control Group • Studies comparing DN vs placebo control showed no significant difference at post treatment and follow up21, 20 – Ilbuldu et al (2004) & Huguenin et al (2005) • Three of four studies comparing acupuncture with placebo control had results favouring acupuncture at both end of treatment and follow up22-24,14 – Irnich et al (2001 & 2002), Itoh et al (2006), Birch & Jamison (1998) Forest Plots End of Treatment – Pain Scales Follow up – Pain Scales Needling Intervention vs Other Intervention • Comparison of two DN techniques: – Study by Fu (2007)17 showed no significant difference between treatment groups (no follow up measure) • Comparison of two acupuncture techniques: • Study by Birch & Jamison (1998)14 favoured relevant Japanese acupuncture over irrelevant acupuncture at both post treatment and follow up • Study by Ceccherelli et al (2002)15 compared superficial and deep acupuncture – No significant difference between groups post treatment but favoured deep acupuncture at follow up • Comparison of DN technique and acupuncture technique: – Study by Irnich et al (2002)22 favoured acupuncture over DN for reduction of motion related pain at end of treatment Needling Intervention vs Other Intervention • Comparison of DN and Wet Needling techniques: – Results of studies by Kamanli et al (2005)25 and Hong (1994)19 favoured lidocaine injection over DN at post treatment (for reduction of pain scores and increase in PPT) – Study by Hong (1994)19 retained significant treatment effect at follow up (for reduction of pain scores) – Ga et al (2007)18 favoured IMS over lidocaine injection for increase in PPT at follow up Needling Intervention vs Other Intervention • Comparison of acupuncture and conventional massage: – Study by Irnich et al (2001)23 showed significant difference in favour of acupuncture for reduction in motion related pain post treatment (no follow up) • Comparison of DN and laser therapy: – Study by Ilbuldu et al (2004)21 showed significant difference in favour of laser therapy post treatment, but was not retained at follow up (VAS at rest, VAS with activity, PPT) PPT Forest Plots – End of Treatment Pain Scales PPT Forest Plots – Follow up Pain Scales PPT Needling Intervention + Adjunct Therapy vs Adjunct Therapy vs Control • Comparison of superficial DN + stretching vs stretching vs control (Edwards & Knowles, 2003):16 – No significant difference between groups immediately post treatment – Superficial DN + stretch favoured at follow up for increase in PPT Needling Intervention without Control Group • Effects of traditional Chinese acupuncture over 3 week course of treatment (Kung et al, 2001):26 – Paired t-test analysis showed significant reduction in VAS pain scale at end of treatment Discussion – Needling Intervention vs Control • Studies that had a large effect size in favour of needling interventions shared a common trait of multiple needling treatments (at least 1x/week for 3 weeks) • Birch & Jamison (1998)14 identified a high correlation between previous acupuncture treatments and reduction in VAS scores • Many studies had design flaws which introduced confounding variables (ie attrition bias, additional non-controlled treatments, variable diagnoses) Discussion – Needling vs Needling Intervention • No trends seen due to heterogeneity of studies – Study by Irnich et al (2002)22 found acupuncture to be significantly more effective than DN – Ceccherelli et al (2002)15 found deep acupuncture to be more effective than superficial acupuncture – Birch & Jamison (1998)14 found relevant acupuncture to be more effective than irrelevant acupuncture • Future studies comparing needling techniques are needed to determine the most effective technique Discussion – Needling vs Other Intervention • Studies which favoured lidocaine injection over DN techniques involved only one treatment session • Study by Ga et al (2007)18 which favoured IMS over lidocaine injection had 3 treatments over 3 weeks • The form of dry needling may play a role in treatment efficacy • Study by Ilbuldu et al (2004)21 favoured laser over DN, but subjects received a greater number of laser treatments Limitations of this Review • Publication bias – Translation of foreign studies not feasible, timing of literature search • Quality assessment tool – High quality studies had serious design flaws • Heterogeneity of studies – Difficult to perform meaningful meta-analysis • Manipulation of data – Interpretation of some data by reviewers led to increased risk of translation error • Diagnostic criteria of MPS – Not all studies based on Travell & Simon’s criteria1 Implications for Research • Need for additional high quality studies • Standardization of research and treatment methods • Real-life treatment plans incorporated into study designs (ie. 2 treatments per week for 4 weeks) • Consistent timing of outcome measures (including end of treatment and long-term follow up measures) Implications for Practice • Best practice involves a structured interdisciplinary approach including physical and cognitive behavioral strategies • The national institute of health (USA) consensus statement on  acupuncture (1997) concluded that it may be useful as an adjunct treatment27 • This review indicates a need for future investigation of dry needling therapies as part of a comprehensive program Conclusions • No clear evidence that Dry Needling techniques are more efficacious than placebo, sham, or alternative treatment techniques • No clear recommendations can be made regarding the most effective needling technique or optimal length and frequency of treatment • Results suggest that multiple treatment sessions are more effective on pain outcomes than single treatment sessions • Level of evidence does not exceed moderate Thank you! ☺ Acknowledgements: Dr. Darlene Reid, Dr. Babak Shadgan, Charlotte Beck, Dr. Angela Busch, & Meredith Wilson References 1. Simons DG, Travell JG, Simons LS. Myofascial pain and dysfunction: the trigger point manual. Volume 1: Upper half of Body. 2nd ed. Baltimore (MD): Williams & Wilkins; 1999. 2. Lucas KR, Polus BI, Rich PS. Latent myofascial trigger points: their effect on muscle activity and movement efficiency. J Bodywork Mov Ther. 2004; 8:160-6. 3. Huguenin LK. Myofascial trigger points: The current evidence. Physical Therapy in Sport. 2004; 5:2-12. 4. Fernandez de las Penas C, Campo MS, Carnero JF, Page JCM. Manual therapies in myofascial trigger point pain: a systematic review. J Bodywork Mov Ther. 2005; 9: 27-34 5. Dommerholt J, Bron C, Franssen J. Myofascial Trigger Points: An evidence informed review. J Man Manip Ther. 2004; 2:203-21. 6. Chaiamnuay P, Darmawan J, Muirden KD, Assawatanabodee P. Epidemiology of rheumatic disease in rural Thailand: a Whoilar Copcord study. Community oriented program for the control of the rheumatic disease. J of Rheumatol 1998; 25:1382-1387. 7. Gerwin RD. A study of 96 subjects examined both for fibromyalgia and myofascial pain. J musculoskeletal Pain. 1995; 3: 121. 8. Fishbain DA, Goldberg M, Meagher BR, Steele R, Rosomoff H. Male and female chronic pain patients categorized by DSM-III psychiatric diagnostic criteria. Pain. 1986; 26:181-97. 9. American Pain Foundation: Pain Facts and Figures. [Online]. 2007 [cited 2007 Aug 2]; Available from: URL: 10. Canadian Physiotherapy Association-Physiotherapy, It’ll Move You. About CPA: Acupuncture Division [cited 2008 Jun 15]. Available at:|K=223722 11. Cummings TM, White AR. Needling therapies in the management of myofascial trigger point pain: a systematic review. Arch Phys Med Rehabil. 2001; 82: 986-992. 12. Rickards LD. The effectiveness of non-invasive treatments for active myofascial trigger point pain: a systematic review of the literature. Int J Osteopath Med. 2006; 9(4):120-136 13. Furlan AD, van Tulder MW, Cherkin DC, Tsukayama H, Lao L, Koes BW, Berman BM. Acupuncture and dry needling for low back pain. Cochrane Database Syst Rev. 2006. Issue 1. 14. Birch S, Jamison RN. Controlled trial of Japanese acupuncture for chronic myofascial neck pain: assessment of specific and nonspecific effects of treatment. Clin.J.Pain. 1998; 14(3):248-255. 15. Ceccherelli F, Rigoni MT, Gagliardi G, Ruzzante L. Comparison of superficial and deep acupuncture in the treatment of lumbar myofascial pain: a double-blind randomized controlled study. Clin J Pain. 2002;18(3):149-153. 16. Edwards J, Knowles N. Superficial dry needling and active stretching in the treatment of myofascial pain--a randomised controlled trial. Acupunct Med. 2003;21(3):80-86. 17. Fu Z, Wang J, Sun J, Chen X, Xu J. Fu's subcutaneous needling: possible clinical evidence of the subcutaneous connective tissue in acupuncture. J Altern Complement Med. 2007;13(1):47-51. 18. Ga H, Koh HJ, Choi JH, Kim CH. Intramuscular and nerve root stimulation vs lidocaine injection to trigger points in myofascial pain syndrome. J Rehabil Med. 2007; 39(5):374-378. 19. Hong C. Lidocaine injection versus dry needling to myofascial trigger point: the importance of the local twitch response. Am J Phys Med Rehabil. 1994;73(4):256-263. 20. Huguenin L, Brukner PD, McCrory P, Smith P, Wajswelner H, Bennell K. Effect of dry needling of gluteal muscles on straight leg raise: a randomised, placebo controlled, double blind trial. Br J Sports Med. 2005; 39(2):84-90. 21. Ilbuldu E, Cakmak A, Disci R, Aydin R. Comparison of laser, dry needling, and placebo laser treatments in myofascial pain syndrome. Photomed Laser Surg. 2004;22(4):306-311. 22. Irnich D, Behrens N, Gleditsch JM, Stor W, Schreiber MA, Schops P, et al. Immediate effects of dry needling and acupuncture at distant points in chronic neck pain: results of a randomized, double-blind, sham-controlled crossover trial. Pain. 2002;99(1-2):83-89. 23. Irnich D, Behrens N, Molzen H, Konig A, Gleditsch J, Krauss M, et al. Randomised trial of acupuncture compared with conventional massage and "sham" laser acupuncture for treatment of chronic neck pain. BMJ. 2001;322:1574-1578. 24. Itoh K, Katsumi Y, Hirota S, Kitakoji H. Effects of trigger point acupuncture on chronic low back pain in elderly patients -- a sham-controlled randomised trial. Acupuncture Med. 2006;24(1):5-12. 25. Kamanli A, Kaya A, Ardicoglu O, Ozgocmen S, Zengin FO, Bayik Y. Comparison of lidocaine injection, botulinum toxin injection, and dry needling to trigger points in myofascial pain syndrome. Rheumatol.Int. 2005;25(8):604-611. 26. Kung Y, Chen F, Chaung H, Chou C, Tsai Y, Hwang S. Evaluation of acupuncture effect to chronic myofascial pain syndrome in the cervical and upper back regions by the concept of meridians. Acupuncture Electro Res. 2001;26(3):195-202. 27. National Institute of Health (USA). 1997


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