Dry Needling Versus Trigger Point Injection for Neck Pain Symptoms Associated with Myofascial Trigger Points: A Systematic Review and Meta-Analysis.

OBJECTIVE: To examine the effects of dry needling against trigger point (TrP) injections (wet needling) applied to TrPs associated with neck pain. METHODS: Electronic databases were searched for randomized clinical trials in which dry needling was compared with TrP injections (wet needling) applied to neck muscles and in which outcomes on pain or pain-related disability were collected. Secondary outcomes consisted of pressure pain thresholds, cervical mobility, and psychological factors. The Cochrane Risk of Bias tool, the Physiotherapy Evidence Database score, and the Grading of Recommendations Assessment, Development, and Evaluation approach were used. RESULTS: Six trials were included. TrP injection reduced pain intensity (mean difference [MD ] -2.13, 95% confidence interval [CI] -3.22 to -1.03) with a large effect size (standardized mean difference [SMD] -1.46, 95% CI -2.27 to -0.65) as compared with dry needling. No differences between TrP injection and dry needling were found for pain-related disability (MD 0.9, 95% CI -3.09 to 4.89), pressure pain thresholds (MD 25.78 kPa, 95% CI -6.43 to 57.99 kPa), cervical lateral-flexion (MD 2.02°, 95% CI -0.19° to 4.24°), or depression (SMD -0.22, 95% CI -0.85 to 0.41). The risk of bias was low, but the heterogenicity and imprecision of results downgraded the evidence level. CONCLUSION: Low evidence suggests a superior effect of TrP injection (wet needling) for decreasing pain of cervical muscle TrPs in the short term as compared with dry needling. No significant effects on other outcomes (very low-quality evidence) were observed. LEVEL OF EVIDENCE: Therapy, level 1a.

The importance of the local twitch response during needling interventions in spinal pain associated with myofascial trigger points: a systematic review and meta-analysis.

OBJECTIVE: To compare the clinical effects of needling interventions eliciting local twitch responses (LTRs) versus needling without eliciting LTRs when applied to muscle trigger points (TrPs) associated with spinal pain of musculoskeletal origin. DATABASES AND DATA TREATMENT: Electronic databases were searched for randomized or non-randomized clinical trials where one group received needling intervention where LTRs were elicited and was compared with another group receiving the same intervention without elicitation of LTRs in spinal pain disorders associated with TrPs. Outcomes included pain intensity, pain-related disability, and pressure pain thresholds. The risk of bias (RoB) was assessed using the Cochrane risk of bias tool or ROBINS-I tool, methodological quality was assessed with the PEDro score, and quality of evidence was evaluated using the GRADE approach. RESULTS: Six trials were included. The application of a needling intervention eliciting LTRs was associated with a significant reduction in pain intensity immediately after treatment (mean difference (MD): -2.03 points, 95% confidence interval (CI): -3.77 to -0.29; standardized MD (SMD): -1.35, 95% CI: -2.32 to -0.38, p = 0.02) when compared to the same needling intervention without elicitation of LTRs. No effect at short-term follow-up (MD: -0.20 points, 95% CI: -1.46 to 1.06, p = 0.75) was observed. No significant differences based on elicitation or non-elicitation of LTRs were found in related disability (SMD: -0.05, 95% CI: -0.41 to 0.30, p = 0.77) or pressure pain thresholds (MD: 23.39 kPa, 95% CI: -13.68 to 60.47, p = 0.22). DISCUSSION: Low-level evidence suggests an immediate effect of obtaining LTRs during needling interventions on pain intensity, with no significant effects on related disability or pressure pain sensitivity in spinal pain disorders associated with muscle TrPs. REGISTRATION NUMBER: OSF Registry-https://doi.org/10.17605/OSF.IO/5ZX9N.

Is Dry Needling Effective When Combined with Other Therapies for Myofascial Trigger Points Associated with Neck Pain Symptoms? A Systematic Review and Meta-Analysis.

Objective: To evaluate the effects of combining dry needling with other physical therapy interventions versus the application of the other interventions or dry needling alone applied over trigger points (TrPs) associated to neck pain. Databases and Data Treatment. Electronic databases were searched for randomized controlled trials where at least one group received dry needling combined with other interventions for TrPs associated with neck pain. Outcomes included pain intensity, pain-related disability, pressure pain thresholds, and cervical range of motion. The risk of bias (RoB) was assessed using the Cochrane risk of bias tool, methodological quality was assessed with PEDro score, and the quality of evidence was assessed by using the GRADE approach. Between-groups mean differences (MD) and standardized mean difference (SMD) were calculated. Results: Eight trials were included. Dry needling combined with other interventions reduced pain intensity at short-term (SMD -1.46, 95% CI -2.25 to -0.67) and midterm (SMD -0.38, 95% CI -0.74 to -0.03) but not immediately after or at long-term compared with the other interventions alone. A small effect on pain-related disability was observed at short-term (SMD -0.45, 95% CI -0.87 to -0.03) but not at midterm or long-term. The inclusion of dry needling was also effective for improving pressure pain thresholds only at short-term (MD 112.02 kPa, 95% CI 27.99 to 196.06). No significant effects on cervical range of motion or pain catastrophism were observed. Conclusion: Low-to-moderate evidence suggests a positive effect to the combination of dry needling with other interventions for improving pain intensity, pain-related disability, pressure pain thresholds, and cervical range of motion in people with neck pain associated with TrPs at short-term. No midterm or long-term effects were observed.

Effects of manual acupuncture and electroacupuncture for lateral epicondylalgia of musculoskeletal origin: a systematic review and meta-analysis.

OBJECTIVE: The aim of this study was to evaluate the effect of acupuncture/electroacupuncture, alone or combined with other interventions, on pain intensity, pain-related disability, and strength in lateral epicondylalgia (LE) of musculoskeletal origin. DATABASES AND DATA TREATMENT: Electronic databases were searched for randomized clinical trials, where at least one group received acupuncture or electroacupuncture for LE of musculoskeletal origin. To be eligible, trials had to include humans and collect outcomes on pain intensity or pain-related disability in LE. Data were extracted by two reviewers. The risk of bias (RoB) of the trials was assessed using the Cochrane RoB tool, methodological quality was assessed with the Physiotherapy Evidence Database (PEDro) score, and the level of evidence was summarized using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE). Standardized mean differences (SMDs) using random effects were calculated. RESULTS: A total of 14 trials (10 acupuncture) were included. The meta-analysis found a moderate effect size of acupuncture (SMD = -0.66, 95% confidence interval (CI) = -1.22 to -0.10), but not electroacupuncture (SMD = -0.08, 95% CI = -0.99 to 0.83), in the reduction of elbow pain as compared to a comparative group. Acupuncture exhibited a significant moderate effect size (SMD = -0.51, 95% CI = -0.91 to -0.11) in the improvement of related-disability. Acupuncture (SMD = 0.36, 95% CI = 0.16 to 0.57), but not electroacupuncture (SMD = 0.34, 95% CI = -0.29 to 0.98), exhibited a significant but small effect size on strength. Most significant effects were in the short term. The RoB was low but the heterogeneity of trial results led to a downgrading of the GRADE evidence level. CONCLUSION: Low-level evidence suggests positive effects of acupuncture, but not electroacupuncture, for pain, related-disability, and strength, in LE of musculoskeletal origin, in the short term.

Effects of Trigger Point Dry Needling for Nontraumatic Shoulder Pain of Musculoskeletal Origin: A Systematic Review and Meta-Analysis.

OBJECTIVE: The purpose of this study was to evaluate the effects of trigger point (TrP) dry needling alone or as an adjunct to other interventions on pain intensity and related disability in nontraumatic shoulder pain. METHODS: Ten databases were searched from inception to January 2020 for randomized clinical trials in which at least 1 group received TrP dry needling for shoulder pain of musculoskeletal origin with outcomes collected on pain intensity and related disability. Data extraction including participant and therapist details, interventions, blinding strategy, blinding assessment outcomes, and results were extracted by 2 reviewers. The risk of bias (Cochrane Risk of Bias, Cochrane Guidelines), methodological quality (Physiotherapy Evidence Database score), and evidence level (Grading of Recommendations Assessment, Development, and Evaluation approach) were assessed. The search identified 551 publications with 6 trials eligible for inclusion. RESULTS: There was moderate-quality evidence that TrP dry needling reduces shoulder pain intensity with a small effect (mean difference = -0.49 points, 95% CI = -0.84 to -0.13; standardized mean difference = -0.25, 95% CI = -0.42 to -0.09) and low-quality evidence that TrP dry needling improves related disability with a large effect (mean difference = -9.99 points, 95% CI -15.97 to -4.01; standardized mean difference = -1.14, 95% CI -1.81 to -0.47) compared with a comparison group. The effects on pain were only found at short term. The Cochrane Risk of Bias was generally low, but the heterogenicity of the results downgraded the evidence level. CONCLUSION: Moderate- to low-quality evidence suggests positive effects of TrP dry needling for pain intensity (small effect) and pain-related disability (large effect) in nontraumatic shoulder pain of musculoskeletal origin, mostly at short term. Future clinical trials investigating long-term effects are needed. IMPACT: Dry needling is commonly used for the management of musculoskeletal pain. This is the first meta-analysis to examine the effects of dry needling on nontraumatic shoulder pain.

Effectiveness of Ultrasound-Guided Percutaneous Electrolysis for Musculoskeletal Pain: A Systematic Review and Meta-Analysis.

OBJECTIVE: To evaluate the effects of ultrasound-guided percutaneous electrolysis alone or as an adjunct to other interventions on pain and pain-related disability for musculoskeletal pain conditions. DATABASES AND DATA TREATMENT: Search of MEDLINE database, Allied and Complementary Medicine Database, EMBASE database, Cumulative Index to Nursing & Allied Health Literature database, EBSCO database, PubMed database, Physiotherapy Evidence Database, Cochrane Library database, Scopus database, and Web of Science database. Randomized controlled trials in which at least one group received ultrasound-guided percutaneous electrolysis for treatment of musculoskeletal pain. To be eligible, studies had to include humans and collect outcomes on pain intensity and pain-related disability for musculoskeletal pain syndromes. Data were extracted by two reviewers. The risk of bias was assessed by the Cochrane Guidelines and the quality of evidence was reported using the Grading of Recommendations Assessment, Development and Evaluation approach. Standardized mean differences (SMDs) and random effects were calculated. RESULTS: Ten studies were included. The meta-analysis found that ultrasound-guided percutaneous electrolysis reduced the mean pain intensity by -2.06 (95% confidence interval [CI], -2.69 to -1.42) and the pain intensity as assessed with a visual analog scale or a numeric pain rating scale with a large size effect (SMD = -1.15; 95% CI, -1.48 to -0.81) and also improved pain-related disability with a large size effect (SMD = 0.95; 95% CI, 0.73-1.18) as compared with comparison groups. No differences in effect sizes were found among the short-term, midterm, and long-term follow-ups. The risk of bias was generally low, but the heterogeneity of the overall result downgraded the evidence level. Trials included heterogeneous musculoskeletal pain conditions and short-term, midterm, and long-term follow-ups. CONCLUSION: Moderate evidence suggests positive effects of ultrasound-guided percutaneous electrolysis for pain and pain-related disability in musculoskeletal pain conditions relative to a comparison group in the short term, midterm, and long term.

Effects of Trigger Point Dry Needling for the Management of Knee Pain Syndromes: A Systematic Review and Meta-Analysis.

BACKGROUND: To evaluate the effect of trigger point dry needling alone or as an adjunct with other interventions on pain and related disability in people with knee pain. METHODS: Several electronic databases were searched for randomized controlled trials where at least one group received dry needling for knee pain. Studies had to include human subjects and collect outcomes on pain and pain-related disability in musculoskeletal knee pain. Data were extracted by two reviewers. The risk of bias was assessed by the Cochrane Guidelines, methodological quality was assessed with the Physiotherapy Evidence Database (PEDro) score, and the quality of evidence by using the GRADE approach. Standardized mean differences (SMD) were calculated. RESULTS: Ten studies (six patellofemoral pain, two knee osteoarthritis, two post-surgery knee pain) were included. The meta-analysis found moderate effect sizes of dry needling for reducing pain (SMD -0.53, 95% CI -0.87 to -0.19) and improving related disability (SMD -0.58, 95% CI -1.08 to -0.09) as compared to a comparison group at short-term. The main effect was observed for patellofemoral pain (SMD -0.64, 95% CI -1.17 to -0.11). No significant effects were observed at mid- or long-term follow-ups. The risk of bias was generally low, but the heterogenicity and the imprecision of the results downgraded the level of evidence. CONCLUSION: Low to moderate evidence suggests a positive effect of trigger point dry needling on pain and related disability in patellofemoral pain, but not knee osteoarthritis or post-surgery knee pain, at short-term. More high-quality trials investigating long-term effects are clearly needed.

Effects of trigger point dry needling on lateral epicondylalgia of musculoskeletal origin: a systematic review and meta-analysis.

OBJECTIVE: This meta-analysis evaluated the effect of dry needling alone or combined with other treatment interventions on pain, related-disability, pressure pain sensitivity, and strength in people with lateral epicondylalgia of musculoskeletal origin. DATA SOURCES: MEDLINE, CINAHL, PubMed, PEDro, Cochrane Library, SCOPUS and Web of Science databases from their inception to 5 April 2020. REVIEW METHODS: Randomized controlled trials collecting outcomes on pain, related-disability, pressure pain thresholds, or strength where one group received dry needling for lateral epicondylalgia of musculoskeletal origin. The risk of bias was assessed by the Cochrane Guidelines, methodological quality was assessed with the PEDro score, and the quality of evidence by using the GRADE approach. RESULTS: Seven studies including 320 patients with lateral epicondylalgia were included. The meta-analysis found that dry needling reduced pain intensity (SMD ‒1.13, 95%CI ‒1.64 to ‒0.62) and related-disability (SMD ‒2.17, 95%CI ‒3.34 to ‒1.01) with large effect sizes compared to a comparative group. Dry needling also increased pressure pain thresholds with a large effect size (SMD 0.98, 95%CI 0.30 to 1.67) and grip strength with a small size effect (SMD 0.48, 95%CI 0.16 to 0.81) when compared to a comparative group. The most significant effect was at short-term. The risk of bias was generally low, but the heterogenicity of the results downgraded the evidence level. CONCLUSION: Low to moderate evidence suggests a positive effect of dry needling for pain, pain-related disability, pressure pain sensitivity and strength at short-term in patients with lateral epicondylalgia of musculoskeletal origin. LEVEL OF EVIDENCE: Therapy, level 1a. REGISTRATION NUMBER: OSF Registry - https://doi.org/10.17605/OSF.IO/ZY3E8.

Effectiveness of percutaneous electrical nerve stimulation for musculoskeletal pain: A systematic review and meta-analysis.

BACKGROUND AND OBJECTIVE: To evaluate the effects of percutaneous electrical stimulation (PENS) alone or as an adjunct with other interventions on pain and related disability in musculoskeletal pain conditions. DATABASES AND DATA TREATMENT: Search of MEDLINE, EMBASE, AMED, CINAHL, EBSCO, PubMed, PEDro, Cochrane Library, SCOPUS and Web of Science databases. Randomized controlled trials where at least one group received any form of PENS for musculoskeletal condition. Studies had to include humans and collect outcomes on pain and related disability in musculoskeletal pain. Risk of bias was assessed by the Cochrane Guidelines, the quality of evidence by using the GRADE approach. Standardized mean differences (SMD) were calculated. RESULTS: Sixteen studies were included and included heterogeneous musculoskeletal conditions with short- or midterm follow-ups. PENS alone had a large effect (SMD -1.22, 95% CI -1.66 to -0.79) on pain and a small effect (SMD -0.33, 95% CI -0.61 to -0.06) on related disability at short-term as compared with sham. A moderate effect of PENS alone (SMD -0.71, 95% CI -1.23 to -0.19) on pain when compared with other interventions was observed. The inclusion of PENS with other interventions had a moderate effect for decreasing pain at short- (SMD -0.70, 95% CI -1.02 to -0.37) and midterm (SMD -0.68, 95% CI -1.10 to -0.27). No effect at midterm (SMD -0.21, 95% CI -0.52 to 0.10) on related disability was seen. The risk of bias was generally low; but the heterogenicity of the results downgraded the level of evidence. CONCLUSION: There is low level of evidence suggesting the effects of PENS alone or in combination for pain, but not related disability, in musculoskeletal pain. LEVEL OF EVIDENCE: Therapy, level 1a. Registration number: CRD42019131331. SIGNIFICANCE: This meta-analysis investigating the effectiveness of PENS for the management of pain and related disability in musculoskeletal pain conditions found that PENS could decrease level of pain intensity but not relateddisability in musculoskeletal pain disorders.

Effects of joint mobilisation on clinical manifestations of sympathetic nervous system activity: a systematic review and meta-analysis.

BACKGROUND: A potential mechanism of action of manual therapy is the activation of a sympathetic-excitatory response. OBJECTIVE: To evaluate the effects of joint mobilisation on changes in clinical manifestations of sympathetic nervous system activity. DATA SOURCES: MEDLINE, EMBASE, AMED, CINAHL, EBSCO, PubMed, PEDro, Cochrane Collaboration Trials Register, Cochrane Database of Systematic Reviews and SCOPUS databases. STUDY SELECTION: Randomised controlled trials that compared a mobilisation technique applied to the spine or the extremities with a control or placebo. DATA EXTRACTION AND DATA SYNTHESIS: Human studies collecting data on skin conductance or skin temperature were used. Data were extracted by two reviewers. Risk of bias was assessed using the Cochrane guidelines, and quality of evidence was assessed using the GRADE approach. Standardised mean differences (SMD) and random effects were calculated. RESULTS: Eighteen studies were included in the review and 17 were included in the meta-analysis. The meta-analysis found a significant increase in skin conductance [SMD 1.21, 95% confidence interval (CI) 0.88 to 1.53, n=269] and a decrease in temperature (SMD 0.92, 95% CI -1.47 to -0.37, n=128) after mobilisation compared with the control group. An increase in skin conductance (SMD 0.73, 95% CI 0.51 to 0.96, n=293) and a decrease in temperature (SMD -0.50, 95% CI -0.82 to -0.18, n=134) were seen after mobilisation compared with placebo. The risk of bias was generally low, but the heterogenicity of the results downgraded the level of evidence. LIMITATIONS: Most trials (14/18) were conducted on asymptomatic healthy subjects. CONCLUSION: There is moderate evidence suggesting a sympatho-excitatory effect of joint mobilisation. Systematic Review Registration Number PROSPERO CRD42018089991.