Effects of dry needling on function, hypertonia and quality of life in chronic stroke: a randomized clinical trial.

BACKGROUND: Persons with stroke commonly have impairments associated with a reduction in functionality. Motor impairments are the most prevalent, causing an impact on activities of daily life. OBJECTIVE: The aim of this study was to evaluate the effect of a session of dry needling (DN) applied to the upper extremity muscles on the sensorimotor function, hypertonia, and quality of life of persons with chronic stroke. METHODS: A randomized, sham-controlled clinical trial was performed. Participants were randomly assigned into an intervention group that received a single session DN in the biceps brachii, brachialis, flexor digitorum superficialis and profundus, extensor digitorum, adductor pollicis and triceps brachii muscles, or into a control group that received the same treatment but with a sham DN intervention. Treatment outcomes included the Fugl-Meyer Assessment Scale for the upper extremity, the Modified Modified Ashworth Scale, and the EuroQol-5D questionnaire. Measurements were carried out before, immediately after, and 14 days after intervention. RESULTS: Twenty-three persons participated in the study. Significant differences between groups were observed after the intervention in the total wrist-hand motor score (p = 0.023) and sensorimotor score (p = 0.022), for hypertonia in the elbow extensors both after treatment (p = 0.002) and at follow-up (p = 0.018), and in quality of life at follow-up (p = 0.030). CONCLUSIONS: A single session of DN improved total wrist-hand motor function and total sensorimotor function in persons with chronic stroke immediately after treatment, as well as quality of life 2 weeks after treatment. TRIAL REGISTRATION NUMBER: NCT03546517 (ClinicalTrials.gov).

Effects of dry needling on gait and muscle tone in Parkinson's disease: a randomized clinical trial.

BACKGROUND: Alterations in gait and muscular rigidity are common and disabling in persons with Parkinson's disease (PD). OBJECTIVE: The aim of this study was to determine whether a single dry needling (DN) session can promote changes in gait and muscle tone in the lower extremities as well as in the evolution of the disease in persons with PD. METHODS: A randomized double-blind clinical trial was designed. Participants were randomly assigned to an intervention group (IG) that received a session of DN over the semitendinosus, medial gastrocnemius, soleus and rectus femoris muscles, or to a control group (CG) that received a session of sham DN in the same muscles. The effects of DN were assessed using the timed up and go test (TUG), 10 meter walk test (10MWT), 6 minute walk test (6MWT) and myotonometry before, immediately after, and 7 days after the intervention. RESULTS: Thirty-three participants were analyzed aged 69.9 ± 7.2 years (mean ± SD; 39% female). There were no significant differences between the IG and CG for any outcomes. Significant differences were observed when comparing the Pre and Follow-up values in the IG for functional mobility of gait in the TUG (p = 0.049), gait speed in the 10MWT (p = 0.041) and muscle tone in the lower extremities by myotonometry (frequency (p = 0.027) and stiffness (p = 0.013)). By comparison, there were no significant within-group differences in the CG. CONCLUSION: A single session of DN had no measurable benefit compared to a single session of sham DN. Within-group changes in the IG suggested improvements in functional mobility of gait and gait speed, as well as changes in the muscle tone in the lower extremities of PD patients, which could be worthy of further exploration by future research.

The effect of dry needling of myofascial trigger points on muscle stiffness and motoneuron excitability in healthy subjects.

BACKGROUND: Myofascial trigger points (MTrPs) are hypersensitive nodules in a taut band (TB) of skeletal muscle. Dry needling (DN) is an invasive technique recommended for the treatment of MTrPs. However, to our knowledge, no studies have investigated the influence of the DN technique on modification of muscle stiffness and neurophysiological properties of MTrPs. OBJECTIVE: The objective was to examine the effect of DN on muscle stiffness and motoneuron excitability of a latent medial MTrP (nodule and TB) of the soleus muscle in non-injured subjects. METHODS: A double-blinded randomised controlled trial of 46 subjects with latent medial MTrPs of the soleus was conducted, in which all received one session of DN. The intervention group (n = 23) were subjected to DN into the MTrP (the nodule), while the control group (n = 23) were subjected to DN into the TB. Assessment was carried out at baseline (pre-test), after the intervention (post-test) and 1 week after the intervention (follow-up). Biomechanical variables (muscle resistive force at 10°/s and 180°/s, muscle extensibility and strength), as measured with an isokinetic dynamometer, and neurophysiological variables (H-reflex), were recorded. RESULTS: There were no statistically significant differences in biomechanical or neurophysiological assessments between groups. Considering the intra-group analysis, subjects in the intervention group exhibited increased maximal isometric voluntary force to ankle plantarflexion (MIVFp) at both post-intervention and follow-up assessment (p < 0.0125; 0.2 < d < 0.5), while no changes were found in the control group. CONCLUSION: One session of DN targeting latent MTrPs did not change muscle stiffness, muscle extensibility or motoneuron excitability. Further research on subjects with muscle tone disorders should be considered to better address the impact of DN on muscle tone. TRIAL REGISTRATION NUMBER: NCT02575586 (ClinicalTrials.gov).

Effects of Dry Needling on Biomechanical Properties of the Myofascial Trigger Points Measured by Myotonometry: A Randomized Controlled Trial.

OBJECTIVE: The purpose of the present study was to examine the effect of dry needling (DN) on the biomechanical properties of a latent medial myofascial trigger point (MTrP) of the soleus muscle compared with an adjacent point within the taut band (TB) measured by myotonometry. METHODS: Fifty asymptomatic volunteers were randomly assigned to an intervention group (n = 26) or control group (n = 24). One session of DN was performed in every group as follows: 10 needle insertions into the MTrP area (intervention group) or TB area (control group). Myotonometric measurements (frequency, decrement, and stiffness) were performed at baseline (pre-intervention) and after the intervention (post-intervention) in both locations (MTrP and TB areas). RESULTS: The results showed that stiffness outcome significantly decreased with a large effect size after DN in the MTrP when measured in the MTrP location (P = .002; d = 0.928) but not when measured in the TB location. In contrast, no significant changes were observed in any location when the TB was needled (P > .05). CONCLUSIONS: The findings suggest that only DN into the MTrP area was effective in decreasing stiffness outcome, therefore a specific puncture was needed to modify myofascial muscle stiffness.

Effectiveness of dry needling for upper extremity spasticity, quality of life and function in subacute phase stroke patients.

BACKGROUND: Stroke is the fourth leading cause of death in Europe, represents one of the most common causes of disability in adult patients, and involves considerable short- and long-term social and healthcare costs. The effectiveness of deep dry needling (DDN) on affected arm functionality was assessed throughout 8 weeks of treatment in patients with stroke in the subacute phase. METHODS: Eighty patients were included in this two-group non-randomised study after a propensity score analysis was carried out. Both groups received standard physiotherapy treatment on the affected arm. The needling group also received six sessions of DDN during the 8-week period. Patients were evaluated before and after each session using the Fugl-Meyer upper extremity (FM UE) scale, the modified modified Ashworth scale (MMAS), the resistance to passive movement scale (REPAS) and a 10-point numeric pain rating scale (NPRS 10). The Brunnstrom recovery stage was recorded at the beginning and at the end of the study, and the EuroQoL quality of life survey was completed at the beginning of the study, after the first month of treatment and at the end of the study. RESULTS: Patients treated with DDN showed a reduction in spasticity measured using the REPAS (p < 0.001) and the MMAS (p < 0.05). There was also an improvement in the Brunnstrom recovery stages (p < 0.05). CONCLUSION: The addition of a specific DDN treatment to a standard physiotherapy treatment appeared to lead to a higher reduction in spasticity in the affected arm; however, it did not provide additional changes in functionality, pain and quality of life. Further studies with a randomised controlled trial design are required to confirm our findings.

Effects of Deep Dry Needling on Tremor Severity and Functionality in Stroke: A Case Report.

This study aimed to determine the effect of one session of dry needling on the severity of tremor, motor function and skills, and quality of life of a 39-year-old woman with post-stroke tremor. Myofascial trigger points (MTrP) of the following muscles were treated: extensor digitorum, flexor digitorum superficialis and profundus, brachioradialis, short head of biceps brachii, long head of triceps brachii, mid deltoid, infraspinatus, teres minor, upper trapezius, and supraspinatus. Outcomes were assessed via (i) clinical scales (activity of daily living (ADL-T24), a visual analog scale (VAS), and the Archimedes spiral), (ii) a functional test (9-Hole Peg test), and (iii) biomechanical and neurophysiological measurements (inertial sensors, electromyography (EMG), and dynamometry). The subject showed a decrease in the severity of tremor during postural (72.7%) and functional (54%) tasks after treatment. EMG activity decreased after the session and returned to basal levels 4 days after. There was an improvement post-intervention (27.84 s) and 4 days after (32.43 s) in functionality and manual dexterity of the affected limb, measured with the 9-Hole Peg test, as well as in the patient's hand and lateral pinch strength after the treatment (26.9% and 5%, respectively), that was maintained 4 days later (15.4% and 16.7%, respectively).

Does Frequency Modulation of Transcutaneous Electrical Nerve Stimulation Affect Habituation and Mechanical Hypoalgesia? A Randomized, Double-Blind, Sham-Controlled Crossover Trial.

BACKGROUND: Devices for applying transcutaneous electrical nerve stimulation (TENS) use numerous frequency modulation patterns for decreasing habituation to currents. However, there is no evidence supporting the use of an optimal pattern instead of the others, or even modulated frequencies instead of a fixed frequency. OBJECTIVE: The objectives of this study were to determine the effects of 3 TENS patterns (fixed frequency, random modulation, and 6-second-6-second [6s-6s] modulation) on habituation, to examine the subjective perception of habituation and comfort, and to determine their effects on the mechanical pain threshold (MPT). DESIGN: This study was a randomized, double-blind, sham-controlled crossover trial. SETTING: The study took place in a university research laboratory under attenuated noise conditions at a regulated temperature of 22°C to 26°C. PARTICIPANTS: Thirty-nine volunteers who were healthy participated in this trial. INTERVENTION: The participants received 4 different TENS interventions (fixed frequency, random modulation, 6s-6s modulation, and sham) in random order, with a 24-hour washout period, on the radial nerve. MEASUREMENTS: The main outcome-habituation-was quantified by the increase in current density and the number of times the intensity had to be increased during the session. Secondary outcome variables were subjective perception of habituation and comfort and MPT. RESULTS: Random modulation reduced the number of times the intensity had to be increased because of habituation compared with no modulation (1.6 times; 95% confidence interval [CI] = 0.7-2.6) and 6s-6s modulation (0.8 times; 95% CI = 0.01-1.6). No differences were observed between interventions in terms of an increase in current density, self-perceived habituation, or self-perceived comfort. MPT increased during the intervention in the random-modulation group (4.4 N; 95% CI = 1.8-7.0) and the no-modulation group (5.9 N; 95% CI = 1.9-10.0); there were no significant changes in the other 2 groups. LIMITATIONS: The success of masking or blinding procedures of the participants was not assessed. CONCLUSIONS: Randomly modulated frequencies caused less habituation than nonmodulated frequencies or 6s-6s modulation. Further research on more prolonged (hours-long) interventions in participants with pain is required.

Soleus H-reflex modulation following transcutaneous high- and low-frequency spinal stimulation in healthy volunteers.

The main aim of this work was to investigate the difference in the excitability of the soleus H-reflex in healthy volunteers following spinal transcutaneous electrical nerve stimulation (TENS) and high-frequency alternating current (HFAC) at a frequency of 10 kHz applied at the lower thoracic spinal level (T10-T12). A double-blind, randomized, crossover, controlled clinical trial was designed. Participants received three randomized interventions (TENS, 10 kHz, and sham stimulation) during 40 min. The amplitude and latency of the soleus H-reflex were registered prior to, during, and 10 min following stimulation. Twenty-four participants completed the study. A significant inhibition of H-reflex amplitude was observed following transcutaneous spinal TENS (12.7%; 95% CI 1.5-22.2%) when compared with sham stimulation (5.5%; 95% CI 3.6-14.5%; p = 0.03). An increase in H-reflex latency was also observed following transcutaneous spinal stimulation at 10 kHz (2%; 95% CI 1.4-2.5%) as compared with sham stimulation (0.7%; 95% CI 0.07-1.3%; p < 0.01). No differences were found between TENS and 10 kHz for H-reflex modulation. Transcutaneous spinal TENS and HFAC at a frequency of 10 kHz had a modulatory effect on the soleus H-reflex when compared to sham stimulation; however, no differences were found between these two interventions.

[Analgesic effects of transcutaneous electrical nerve stimulation (TENS) in patients with fibromyalgia: A systematic review]. / Efectos analgésicos de la estimulación eléctrica nerviosa transcutánea en pacientes con fibromialgia: una revisión sistemática.

OBJECTIVE: To determine whether transcutaneous electrical nerve stimulation (TENS) has an analgesic effect greater than placebo or other treatments in patients with fibromyalgia. Furthermore, it was intended to analyze the optimal application parameters to achieve a greater reduction of pain. DESIGN: A systematic review. DATA SOURCE: Randomized clinical trials on the effect of TENS on fibromyalgia in the databases Pubmed, Cochrane and PEDro until November 2016. SELECTION OF STUDIES: 8 studies out of a total of 62 were selected. Controlled clinical trials in which TENS was applied in patients with fibromyalgia were included. DATA EXTRACTION: Pain was analyzed as the main variable, although other variables such as fatigue, quality of life and impact, range of motion and depression were also included. RESULTS: 6 out of 8 studies obtained a significant decrease of pain. In 2 studies, TENS was applied as complementary treatment to therapeutic exercise with results evidencing a decrease in pain. The rest of the variables studied presented a great variability and conclusive results could not be established. CONCLUSIONS: Treatment with TENS is effective for reducing pain in people with fibromyalgia. In addition, the inclusion of TENS in therapeutic exercise programs seems to have a greater effect than practicing therapeutic exercise in isolation. However, no efficacy has been demonstrated in other variables different to pain. Further studies are needed to investigate the optimization of the parameters of the TENS and a greater consensus among the variables used.

Afferent stimulation inhibits abnormal cutaneous reflex activity in patients with spinal cord injury spasticity syndrome.

BACKGROUND: Tibialis Anterior (TA) cutaneous reflex (CR) activity evoked following cutaneous stimulation of the plantar (Pl) surface (Pl-TA CR) has demonstrated hyperreflexia and damage of inhibitory mechanisms in subjects with spinal cord injury (SCI) and spasticity. OBJECTIVES: To modulate Pl-TA CR and Soleus H-reflex activity with transcutaneous electrical nerve stimulation (TENS) and vibratory stimulation of the plantar pad during rest and controlled isometric plantarflexion. METHODS: Non-injured subjects (n = 11) and individuals with incomplete SCI with (n = 14) and without spasticity (n = 14) were recruited. The effect of TENS and vibratory stimuli on Pl-TA CR and soleus H-reflex activity were assessed during rest and controlled ramp-and-hold plantarflexion. RESULTS: Vibration failed to inhibit H-reflex activity during rest or plantarflexoin following SCI compared to healthy subjects. In contrast, vibration-induced inhibition of Pl-TA CR was specifically detected in SCI spastic subjects during both rest and the hold phase of plantarflexion. TENS inhibited Pl-TA CR activity in the SCI spasticity group only during hold plantarflexion. CONCLUSIONS: Plantar vibratory stimuli inhibited the pl-TA CR, but not the H reflex, during rest and controlled movement in SCI spastic subjects. Assessment of Pl-TA CR modulation should contribute to the development of modality-specific sensory stimuli programmes for the neurorehabilitation of SCI spasticity.

Intensity matters: Therapist-dependent dose of spinal transcutaneous electrical nerve stimulation.

The intensity used during transcutaneous electrical nerve stimulation (TENS) in both, clinical practice and research studies, is often based on subjective commands such as "strong but comfortable sensation". There is no consensus regarding the effectiveness dose of TENS. The objective was to determine the difference in the effect of spinal TENS on soleus H-reflex modulation when applied by two therapists instructed to apply the stimulation at a "strong but comfortable" intensity. Twenty healthy volunteers divided into two groups: Therapist 1 (n = 10) and Therapist 2 (n = 10). Both therapist applied spinal TENS and sham stimulation at the T10-12 spinal level for 40min in random order to each subject, at an intensity designed to produce a "strong but comfortable" sensation. To avoid habituation, the intensity was adjusted every 2min. Soleus H-reflex was recorded before, during, and 10min after TENS by an observer blinded to the stimulus applied. Despite the instruction to apply TENS at a "strong comfortable" level, a significant difference in current density was identified: Therapist 1 (0.67mA/cm2, SD 0.54) applied more than Therapist 2 (0.53mA/cm2, SD 0.57; p<0.001) at the onset of the intervention. Maximal peak-to-peak H-reflex amplitude was inhibited significantly more 10min following TENS applied by Therapist 1 (-0.15mV, SD 0.16) compared with Therapist 2 (0.04mV, SD 0.16; p = 0.03). Furthermore, current density significantly correlated with the inhibitory effect on peak-to-peak Soleus H-reflex amplitude 10 min after stimulation (Rho = -0.38; p = 0.04). TENS intensity dosage by the therapist based on the subjective perception of the participants alone is unreliable and requires objective standardization. In addition, higher current density TENS produced greater inhibition of the Soleus H-reflex.

Maintenance of cutaneomuscular neuronal excitability after leg-cycling predicts lower limb muscle strength after incomplete spinal cord injury.

OBJECTIVE: Controlled leg-cycling modulates H-reflex activity after spinal cord injury (SCI). Preserved cutaneomuscular reflex activity is also essential for recovery of residual motor function after SCI. Here the effect of a single leg-cycling session was assessed on cutaneomuscular-conditioned H-reflex excitability in relation to residual lower limb muscle function after incomplete SCI (iSCI). METHODS: Modulation of Soleus H-reflex activity was evaluated following ipsilateral plantar electrical stimulation applied at 25-100ms inter-stimulus intervals (ISI's), before and after leg-cycling in ten healthy individuals and nine subjects with iSCI. RESULTS: Leg-cycling in healthy subjects increased cutaneomuscular-conditioned H-reflex excitability between 25 and 75ms ISI (p<0.001), compared to a small loss of excitability at 75ms ISI after iSCI (p<0.05). In addition, change in cutaneomuscular-conditioned H-reflex excitability at 50ms and 75ms ISI in subjects with iSCI after leg-cycling predicted lower ankle joint hypertonia and higher Triceps Surae muscle strength, respectively. CONCLUSION: Leg-cycling modulates cutaneomuscular-conditioned spinal neuronal excitability in healthy subjects and individuals with iSCI, and is related to residual lower limb muscle function. SIGNIFICANCE: Cutaneomuscular-conditioned H reflex modulation could be used as a surrogate biomarker of both central neuroplasticity and lower limb muscle function, and could benchmark lower-limb rehabilitation programs in subjects with iSCI.

Potenciación del reaprendizaje motor y la recuperación funcional en pacientes con ictus: estrategias no invasivas de modulación del sistema nervioso central / Enhancement of motor relearning and functional recovery in stroke patients: non-invasive strategies for modulating the central nervous system

Introducción. La mayoría de los pacientes que han sufrido un ictus no recuperan el estado funcional basal de la extremidad superior afecta y sufren una grave limitación que permanece en la fase crónica de la enfermedad y que repercute de manera devastadora en su calidad de vida. Por ello, las estrategias de neurorrehabilitación tratan de evitar o minimizar las posibles disfunciones sensitivomotoras asociadas al ictus mediante la promoción de cambios plásticos en el sistema nervioso central. Desarrollo. La reorganización cerebral que tiene lugar tras el ictus puede promover la recuperación motora y funcional de los sujetos con ictus. No obstante, tras la lesión, también se pueden iniciar cambios neuroplásticos maladaptativos responsables del desarrollo de trastornos sensitivomotores, como el síndrome de espasticidad. Las estrategias no invasivas de estimulación cerebral, como la estimulación con corriente directa y la estimulación magnética transcraneal, son unas técnicas ampliamente utilizadas que, aplicadas sobre la corteza motora primaria, pueden modificar la excitabilidad de los circuitos neuronales y las funciones cognitivas, tanto en las personas sanas como en los pacientes con afectación neuroló- gica. Asimismo, los sistemas de interfaces cerebro-máquina también son capaces de generar esa reorganización por medio de la asociación contingente y simultánea entre la activación cerebral y la estimulación periférica. Conclusiones. Se evidencian los efectos positivos de las estrategias de neurorrehabilitación citadas previamente en la potenciación de la reorganización cortical después del ictus, así como en la paliación de los efectos adversos asociados al desarrollo de la espasticidad (AU)

Introduction. Most of the stroke survivors do not recover the basal state of the affected upper limb, suffering from a severe disability which remains during the chronic phase of the illness. This has an extremely negative impact in the quality of life of these patients. Hence, neurorehabilitation strategies aim at the minimization of the sensorimotor dysfunctions associated to stroke, by promoting neuroplasticity in the central nervous system. Development. Brain reorganization can facilitate motor and functional recovery in stroke subjects. Nonetheless, after the insult, maladaptive neuroplastic changes can also happen, which may lead to the appearance of certain sensorimotor disorders such as spasticity. Noninvasive brain stimulation strategies, like transcranial direct current stimulation or transcranial magnetic stimulation, are widely used techniques that, when applied over the primary motor cortex, can modify neural networks excitability, as well as cognitive functions, both in healthy subjects and individuals with neurological disorders. Similarly, brain-machine-interface systems also have the potential to induce a brain reorganization by the contingent and simultaneous association between the brain activation and the peripheral stimulation. Conclusion. This review describes the positive effects of the previously mentioned neurorehabilitation strategies for the enhancement of cortical reorganization after stroke, and how they can be used to alleviate the symptoms of the spasticity síndrome (AU)