Ultrasound-Guided Dry Needling As a Treatment For Postmastectomy Pain Syndrome - A Case Series of Twenty Patients.

CONTEXT: Existing interventions for postmastectomy pain syndrome (PMPS) address the neural component while overlooking a possible myofascial component. AIM: The aim of the study is to investigate the myofascial contribution to PMPS, by examining the effectiveness of myofascial trigger point release by ultrasound-guided dry needling (USGDN). PATIENTS AND METHODS: This retrospective review assessed the efficacy of USGDN in addressing myofascial pain in twenty consecutive patients with treatment-refractory PMPS. Patients in Group 1 (n = 16) received USGDN after neural interventions (NIs) such as neuraxial blocks, intrathecal pump implant, or pulsed radiofrequency, while those in Group 2 (n = 4) received USGDN alone. Outcome measures were changes in Numerical Rating Scale (NRS), PainDETECT (PD), Disabilities of Arm, Shoulder, and Hand (DASH), Patient Health Questionnaire-9 (PHQ-9) scores, and opioid use. RESULTS: In Group 1, the mean (standard deviation) NRS and PD scores (9.6 [0.9] and 28.3 [4.3], respectively, at baseline) reduced to 5.2 (1.1) and 16.1 (3.7) at 1-week post-NI. The post-NI DASH reduction was below the cutoff for clinical relevance (80.9 [10.5] at baseline vs. 71.1 [10.5] post-NI). The opioid dose remained unchanged. Following USGDN, NRS, PD, and DASH scores further reduced to 2.3 (0.8), 6.6 (1.2), and 34.6 (14.4), respectively. Patients receiving USGDN alone also showed reduction in NRS, PD, and DASH (7.8 [1.7], 20.0 [8.0], and 61.0 [14.4] at baseline vs. 1.3 [0.5], 6.0 [1.6], and 22.5 [10.4] post-USGDN, respectively). In all patients, opioid use and PHQ-9 scores reduced only post-USGDN. CONCLUSIONS: USGDN reduced pain, disability, and opioid use, whereas NI reduced only pain. This suggests a myofascial contribution to pain and disability in PMPS.

Ultrasound-Guided Intra-articular Injection of the Radio-ulnar and Radio-humeral Joints and Ultrasound-Guided Dry Needling of the Affected Limb Muscles to Relieve Fixed Pronation Deformity and Myofascial Issues around the Shoulder, in a Case of Complex Regional Pain Syndrome Type 1.

BACKGROUND: Complex regional pain syndrome (CRPS) occurs due to different pathophysiological mechanisms. Presently there is no description of definitive treatment that can resolve the especially recalcitrant motor issues of disability in CRPS type 1 (CRPS-1). CASE REPORT: We have herein described the successful management of motor disability with a multimodal approach in a patient with CRPS-1 that occurred as a result of a fracture sustained in the lower end of the radius. Sensory/sudomotor/vasomotor symptoms were relieved completely by medications and stellate ganglion block in 2 weeks. Ultrasound-guided dry needling secured near-complete improvement of shoulder and hand movements in 45 days. Ultrasound guided intra-articular (radio-ulnar and radio-humeral joint) injections with steroid reduced residual pain and improved forearm movements by 50% initially. The patient continued to receive regular sessions of dry needling, physiotherapy, and cognitive behavioral therapy. By the end of 1 year, the functions of the limb improved remarkably, as did the functional outcome scores. CONCLUSION: In this patient with CRPS-1, intra-articular injections with steroid reduced nociception in the affected local structures and sensitization in the nervous system; dry needling resolved the myofascial issues; sustained physiotherapy maintained the motor recovery; and behavioral therapy techniques addressed the cognitive and life stress issues. It was concluded that the presenting symptoms in this case were a consequence of interactions between humoral, nervous, and myofascial systems.

A New Perspective of Neuromyopathy to Explain Intractable Pancreatic Cancer Pains; Dry Needling as an Effective Adjunct to Neurolytic Blocks.

UNLABELLED: We present a new perspective of neuromyopathy in pancreatic cancer pain (PCP) referral to bodywall; proposal of new rationale to include ultrasound guided dry needling (USGDN) of body wall muscles as an effective adjunct to neurolytic coeliac plexus block (NCPB) or splanchnic nerve radiofrequency ablation (SRF) for comprehensive interventional management. METHODS: PCP response to SRF in 2 patients and NCPB in 3 patients was documented on numerical rating scale (NRS) on post procedure days 3 and 15. If the residual pain was >5 NRS on day 15, USGDN of abdominal and back muscles was started on a thrice weekly basis. The response to USGDN documented on day 30 after approximately 6 sessions of DN, showed a significant pain reduction (0-2 NRS) with 50% reduction of pre-treatment opioid consumption. This was sustained at 6 months or till their demise. Convergence of visceral and somatic nerves at the dorsal horn (viscerosomatic neurons) causes referral of visceral pain to the back and abdominal muscles. This leads to formation of myofascial trigger points (MTrPs) in the muscles which sets up a parallel network of sensitized peripheral and central motor nociceptive processing (neuromyopathy). USGDN specifically addressed the MTrPs that develop as an epiphenomenon of self-perpetuating neuromyopathy while SRF/NCPB, analgesics and neuromodulators could address only visceral nociceptive afferents (pain mediated through celiac plexus) which forms a meagre 10% of the total spinal cord afferent input. Thus, we conclude that combination of neuromyopathy and viscerosomatic convergence in PCP indicate a specific role for DN as an adjunct to SRF/NCPB in our patients.

Musculoskeletal Ultrasonography in CRPS: Assessment of Muscles Before and After Motor Function Recovery with Dry Needling as the Sole Treatment.

BACKGROUND: Motor impairment is an important criterion in the Clinical Diagnostic Criteria (CDC) of Complex Regional Pain Syndrome type-1 (CRPS-1) as defined by International Association for Study of Pain (IASP). OBJECTIVE: To describe the changes in musculoskeletal ultrasonography (MSKUSG) in CRPS-1 before and after treatment with ultrasound-guided dry needling (USGDN) in retrospective data from 44 patients. STUDY DESIGN: Patients irrespective of age, gender, or cause of CRPS were included in this retrospective data analysis; the Budapest criteria for the diagnosis of CRPS were stringently adhered to. SETTING: The analysis was done at Ashirvad Institute for Pain Management and Research with the database of CRPS patients who were treated between December 2005 and December 2014. METHODS: The CDC, range of motion at upper extremity joints, dynamometry, Disability of arm, shoulder and hand score (DASH) and ultrasonography were documented on days one, 15, and 45. MSKUSG demonstrated loss of myoarchitecture and reduced bulk. RESULTS: All 44 patients received USGDN as the sole intervention with medications and physiotherapy. MSKUSG at 15 and 45 days after starting USGDN showed a return of normalcy to the myoarchitecture and muscle bulk increase that coincided with the disappearance of CDC and a progressive and predictable improvement of the DASH scores in all the 44 patients. LIMITATION: The analysis focuses on only 2 parameters: the musculoskeletal changes of the forearm flexors and extensors on ultrasound guidance and the efficacy of the dry needling treatment. It is not a comparative study with another accepted form of treatment or intervention. We have not looked into the age and gender predilection of the condition owing to the small sample size of the study. Analysis of long term maintenance of relief and rehabilitation of the disability were limited to one year. CONCLUSION: Myofascial pathology of co-contraction appears to cause CDC of CRPS and probable ischemic loss of myoarchitecture. Relief of co-contraction with USGDN allowed resolution of tenosynovitis causing the CDC and return of normal myoarchitecture.

Complex Regional Pain Syndrome-Type 1 Presenting as deQuervain's Stenosing Tenosynovitis.

AIM: To report the presentation of complex regional pain syndrome-1 (CRPS-1) as deQuervain's stenosing tenosynovitis (DQST). CASE REPORT: A 24-year-old woman presented with 3-year history of clinical diagnostic criteria (CDC) of CRPS-1. Conservative and surgical treatment for this as DQST had failed to relieve her. We diagnosed the problem as CRPS-1with CDC as inflammatory manifestations of a mechanical tendinoses of all her 5 digital tendons caused by movement of the fingers and hand tethered by agonist (flexor)/ antagonist (extensor) muscles in co-contraction. Ultrasound guided dry needling (USGDN) relaxed the muscles, replacing the abnormal agonist/antagonist co-contraction with normal agonist/antagonist coordination. Resolution of tendinoses reversed the inflammation causing the CDC. Six months later she leads normal personal and professional life, with reduction of scores of painDetect (from 21 to 5), Patient Health Questionnaire (from 13 to 4), Disability of arm, shoulder and hand from 70.8 to 25 and reversal of muscle abnormality characteristic of CRPS-1 on Musculoskeletal Ultrasonography (MSKUSG). CONCLUSION: We believe the primary pathology of CRPS-1 to be co-contraction of agonist (flexor)/antagonist(extensor) muscles of digits resulting in tendinoses akin to DQST. CDC of CRPS are actually inflammatory manifestations of tendinoses amenable to reversal by USGDN which also addresses the disability, a hallmark of CRPS.

Successful management of chronic postsurgical pain following total knee replacement.

We report reversal of chronic postsurgical pain (CPSP) along with functional restoration after total knee replacement (TKR) in two patients, using a combination therapy that included ultrasonography-guided pulsed radiofrequency (PRF) of nerves supplying the knee to provide pain relief, along with dry needling (DN) to relax myofascial triggers/bands that caused painful stiffness and restricted movement of muscles acting across the knee. Both patients showed demonstrable pain relief, as evidenced by changes in pain as assessed on the Numeric Rating Scale (patient 1: 4-9/10 [pre-treatment] to 0-3/10 [6 months post-treatment]; patient 2: 5-9/10 to 0-4/10), Oxford Knee Score (patient 1: 17 to 40; patient 2: 12 to 39), Self-Administered Leeds Assessment of Neuropathic Symptoms and Signs score (patient 1: 16 to 0; patient 2: 18 to 0), and Patient Health Questionnaire-9 score (patient 1: 17 to 2; patient 2: 20 to 2). The selection of the PRF-and-DN combination for treating post-TKR CPSP was based on a new idea that CPSP is a neuromyopathic phenomenon involving both sensory and motor neuropathy. It has evolved from our experience of 8 years. Physiotherapy worked synergistically with DN, optimizing muscle performance and pain relief.