The Effect of Combining Spinal Manipulation and Dry Needling in Individuals With Nonspecific Low Back Pain.

Low back pain (LBP) is one of the most common and costly musculoskeletal conditions impacting health care in the United States. The development of multimodal strategies of treatment is imperative in order to curb the growing incidence and prevalence of LBP. Spinal manipulative therapy (SMT), dry needling (DN), and exercise are common nonpharmacological treatments for LBP. This study is a 3-armed parallel-group design randomized clinical trial. We enrolled and randomized 96 participants with LBP into a multimodal strategy of treatment consisting of a combination of DN and SMT, DN only, and SMT only, followed by an at-home exercise program. All participants received 4 treatment sessions in the first 2 weeks followed by a 2-week home exercise program. Outcomes included clinical (Oswestry Disability Index, numeric pain intensity rating) and mechanistic (lumbar multifidus, erector spinae, and gluteus medius muscle activation) measures at baseline, 2, and 4 weeks. Participants in the DN and SMT groups showed larger effects and statistically significant improvement in pain and disability scores, and muscle percent thickness change at 2 weeks and 4 weeks of treatment when compared to the other groups. This study was registered prior to participant enrollment. PERSPECTIVE: This article presents the process of developing an optimized multimodal treatment plan utilizing SMT, DN, and exercise to address the burden of LBP for impacted individuals and the health care system. This method could potentially help clinicians who treat LBP to lower initial pain and increase exercise compliance. (clinicaltrials.gov NCT05802901).

Dry Needling Versus Manual Therapy for Patients With Mechanical Neck Pain: A Randomized Controlled Trial.

OBJECTIVE: To compare the short- and intermediate-term effects of dry needling to manual therapy on pain, disability, function, and patient-perceived improvement in patients with mechanical neck pain. DESIGN: A single (therapist) blinded randomized controlled trial. METHODS: Seventy-eight patients (mean ± SD age, 50.74 ± 13.81) were randomly assigned to one of the 2 groups: (1) dry needling and therapeutic exercises (DN + Exercises) and (2) manual therapy and therapeutic exercises (MT + Exercises). Both groups received 7 treatment sessions over a maximum of 6 weeks. Outcome measures, collected at baseline, 2 weeks, discharge (7th treatment session), and 3 months after discharge, were as follows: Neck Disability Index (NDI), numeric pain-rating scale (NPRS), Patient-Specific Functional Scale (PSFS), global rating of change (GROC), Fear-Avoidance Belief Questionnaire (FABQ), and Deep Neck Flexor Endurance Test (DNFET). Data were analyzed with mixed-model analysis of covariance (ANCOVA), using pretest scores as covariates, and a Mann-Whitney U test for GROC scores. RESULTS: The ANCOVA revealed significant group-by-time interaction for all variables. Significant between-group differences, favoring MT + Exercises, were observed at all 3 time points on the NDI (2 weeks: F1,446 = 172.68, P≤.001, [Formula: see text] = .27; discharge: F1,446 = 254.15, P≤.001, [Formula: see text] = .36; and 3 months: F1,446 = 339.40, P≤.001, [Formula: see text] = .43). Results for the MT + Exercises group exceeded recommended minimal clinically important difference for all variables, at all follow-up points. CONCLUSION: MT + Exercises was more effective, both in the short term and intermediate term, than DN + Exercises in reducing pain, disability, and improving function in patients with mechanical neck pain. J Orthop Sports Phys Ther 2024;54(4):1-12. Epub 29 January 2024. doi:10.2519/jospt.2024.12091.

Improvements after dry needling for craniofacial pain in a patient with chronic rhinosinusitis: a case report.

BACKGROUND: Typically treated medically, chronic rhinosinusitis (CRS) is a prevalent condition characterized by multiple craniofacial symptoms, some of which may respond favorably to dry needling intervention. OBJECTIVE: To describe the outcomes of a patient presenting with craniofacial pain and symptoms consistent with a diagnosis of CRS who was treated with dry needling. Case Description: A 41-year-old male, self-referred to physical therapy with a diagnosis of CRS, with a 20-year history of signs and symptoms associated with CRS, including craniofacial pain and headaches. The patient had been treated with multiple medication regimens over this time, including antihistamines, anti-inflammatories, decongestants, leukotriene inhibitors, and antibiotics; all of which provided only short-term relief. On initial examination, the patient was tender to palpation in multiple muscles of the head, neck, and face. Intervention consisted of dry needling to these muscular tender points once or twice weekly over 2 months. OUTCOMES: After 2 months of dry needling, the patient demonstrated clinically meaningful improvements in pain and quality of life, which included a decrease in both medication usage and the frequency of sinus infections. CONCLUSION: Although CRS is generally managed medically, we observed areas of muscular tenderness in this case, which were effectively managed with dry needling. Rehabilitative providers may consider screening CRS patients for muscular impairments that may be modifiable with dry needling. Further research should be performed to determine whether dry needling has a role in the management of CRS.

Immediate Effects of Adding Dry Needling to Thoracic Manipulation and Exercise in Cervical Range of Motion for Adults With Neck Pain: A Randomized Clinical Trial.

OBJECTIVE: The purpose of this study was to determine the immediate effects of adding dry needling (DN) to thoracic spine manipulation and neck-specific exercise in individuals with neck pain. METHODS: Forty-two participants with neck pain were randomized to either the true (n = 21) or sham (n = 21) DN groups, receiving treatment on the initial visit and 2 to 3 days later. Outcomes were assessed on day 1, both at baseline and immediately after the initial treatment, at the second treatment 2 to 3 days later, and at the final visit 5 to 7 days after visit 2. Primary outcomes were Neck Disability Index (NDI) (0-50) and current pain via numeric pain rating scale (0-10). Secondary outcomes were cervical range of motion, pain pressure threshold, and global rating of change. RESULTS: Repeated measures analysis of covariance with baseline value as covariate revealed no significant difference in NDI scores at either follow-up time point with adjusted mean differences (95% confidence interval) of -0.11 (-2.70 to 2.48) and 0.31 (-1.96 to 2.57). There were no between-group differences in pain at any time point via Independent-Samples Median Test (P value range of .54-1.0). Secondary outcome measures were similarly not statistically different between groups except for immediate improvements in rotation to the side opposite of pain, which favored DN, with an adjusted mean difference (95% confidence interval) of 7.85 (3.54-12.15) degrees. CONCLUSION: The addition of DN to thoracic spinal manipulation and neck-specific exercise did not affect improvements in NDI score or numeric pain rating scale but showed an increase in cervical range of motion.

The posterior/medial dry needling approach of the tibialis posterior muscle is an accurate and safe procedure: a cadaveric study.

BACKGROUND: Evidence suggests that tibialis posterior muscle plays an important role in equinovarus foot deformity in patients who had suffered a stroke and it is one of the most frequently injected lower-extremity muscles for the management of spasticity. Our aim was to assess if a needle accurately and safely penetrates the tibialis posterior muscle during the application of dry needling.  METHODS : We conducted a cadaveric descriptive study. Needling insertion of the tibialis posterior was conducted in 11 cryopreserved cadavers with a 70 mm needle. The needle was inserted using two common approaches, at midpoint (posterior/medial approach) and at upper third (anterior approach) of the leg towards the tibialis posterior. The needle was advanced into the tibialis posterior based upon clinician judgement. Cross-sectional anatomical dissections were photographed and analyzed by photometry. Safety was assessed by calculating the distances from the tip and the path of the needle to proximate neurovascular structures. RESULTS: Accurate needle penetration of the tibialis posterior muscle was observed in all cadavers with both approaches. In general, distances from the needle to the neurovascular bundles were larger with the posterior/medial approach than with the anterior approach, reaching statistically significance for needle tip to nerve (mean difference: 0.6 cm, 95%CI 0.35 to 0.85 cm) and vascular bundle (mean difference: 0.55 cm, 95%CI 0.3 to 0.8 cm) distances (P < 0.001) and needle path to vascular bundle distance (difference: 0.25 cm, 95%CI 0.1 to 0.4 cm, P = 0.045). Age and gender did not influence the main results. CONCLUSIONS: This cadaveric study suggests that needling of the tibialis posterior muscle can be accurately and safely conducted. Safety seems to be larger with the posterior/medial approach when compared with the anterior approach.

Effect of dry needling on lumbar muscle stiffness in patients with low back pain: A double blind, randomized controlled trial using shear wave elastography.

BACKGROUND: Dry needling treatment focuses on restoring normal muscle function in patients with musculoskeletal pain; however, little research has investigated this assertion. Shear wave elastography (SWE) allows quantification of individual muscle function by estimating both resting and contracted muscle stiffness. OBJECTIVE: To compare the effects of dry needling to sham dry needling on lumbar muscle stiffness in individuals with low back pain (LBP) using SWE. METHODS: Sixty participants with LBP were randomly allocated to receive one session of dry needling or sham dry needling treatment to the lumbar multifidus and erector spinae muscles on the most painful side and spinal level. Stiffness (shear modulus) of the lumbar multifidus and erector spinae muscles was assessed using SWE at rest and during submaximal contraction before treatment, immediately after treatment, and 1 week later. Treatment effects were estimated using linear mixed models. RESULTS: After 1 week, resting erector spinae muscle stiffness was lower in individuals who received dry needling than those that received sham dry needling. All other between-groups differences in muscle stiffness were similar, but non-significant. CONCLUSION: Dry needling appears to reduce resting erector spinae muscle following treatment of patients with LBP. Therefore, providers should consider the use of dry needling when patients exhibit aberrant stiffness of the lumbar muscles.

Ultrasonographic Validation for Needle Placement in the Tibialis Posterior Muscle.

BACKGROUND: The tibialis posterior (TP) muscle plays an important role in normal foot function. Safe, efficacious therapeutic approaches addressing this muscle are necessary; however, the location of the muscle in the deep posterior compartment can create challenges. PURPOSE: The purpose of this study was to assess the accuracy of needle placement in the TP muscle and determine the needle placement in relation to the neurovascular structures located within the deep compartment. DESIGN: Cross Sectional Study. METHODS: Needle placement and ultrasound imaging were performed on 20 healthy individuals. A 50 mm or 60 mm needle was inserted between 30 - 50% of the tibial length measured from the medial tibiofemoral joint. The needle was inserted in a medial to lateral direction into the right extremity with the patient in right side lying. Placement of the needle into the TP muscle was verified with ultrasound imaging, and the shortest distance from the needle to the posterior tibial artery and tibial nerve was measured. The depth from the skin to the superficial border of the TP muscle was also measured. RESULTS: Ultrasonography confirmed the needle filament was inserted into the TP muscle in all 20 individuals and did not penetrate the neurovascular bundle in any individual. The mean distance from the needle to the tibial nerve and posterior tibial artery was 10.0 + 4.7 mm and 10.2 + 4.7 mm respectively. The superficial border of the TP muscle from the skin was at a mean depth of 25.8 + 4.9 mm. CONCLUSION: This ultrasound imaging needle placement study supports placement of a solid filament needle into the TP muscle with avoidance of the neurovascular structures of the deep posterior compartment when placed from a medial to lateral direction at 30-50% of the tibial length. LEVEL OF EVIDENCE: 2b.

Reliability and discriminative validity of real-time ultrasound elastography in the assessment of tissue stiffness after calf muscle injury.

OBJECTIVE: To investigate the reliability and discriminative validity of real-time ultrasound elastography (RTE) measures of soft-tissue elasticity after calf muscle tear. DESIGN: Cross-sectional, intra/inter-examiner reliability and comparative validity study. SETTING: Department of Physical Therapy. PARTICIPANTS: Twenty-one recreational athletes were included and examined 6 weeks after sustaining a grade I-II calf musculature tear. MAIN OUTCOME MEASURES: Soft-tissue elasticity was measured by two experienced assessors using RTE assessments in both the longitudinal and transverse planes of the athletes' injured and uninjured calf muscles. Elasticity was estimated by using the strain ratio (SR), which was calculated by dividing the strain (displacement) value taken at the medial gastrocnemius-soleus myotendinous junction (reference) by the strain value taken at the centre of the injury (index) as visualized on B-mode sonogram. Intra- and inter-observer reliability was estimated calculating intra-class correlation coefficients (ICCs) and standard error of measurement (SEM). Differences in elasticity between injured and healthy legs were assessed using t-tests or Wilcoxon tests for repeated measures. RESULTS: All RTE assessments in both planes showed ICC values ranging from 0.77 to 0.95 and SEM values ranging from 0.72 to 0.99. Additionally, RTE enabled both assessors to determine differences in elastic properties between injured and control legs (p < 0.001). CONCLUSION: RTE measures of calf muscles demonstrated good reliability and were able to differentiate injured from non-injured muscle tissue. RTE may provide a fast and objective measure in sports medicine to improve the detection of risk factors for muscle injury related to alterations of the mechanical behaviour of soft tissues during healing process.

Immediate decrease of muscle biomechanical stiffness following dry needling in asymptomatic participants.

BACKGROUND: Biomechanical muscle stiffness has been linked to musculoskeletal disorders. Assessing changes in muscle stiffness following DN may help elucidate a physiologic mechanism of DN. This study characterizes the effects of dry needling (DN) to the infraspinatus, erector spinae, and gastrocnemius muscles on biomechanical muscle stiffness. METHOD: 60 healthy participants were randomized into infraspinatus, erector spinae, or gastrocnemius groups. One session of DN was applied to the muscle in standardized location. Stiffness was assessed using a MyotonPRO at baseline, immediately post DN, and 24 h later. The presence of a localized twitch response (LTR) during DN was used to subgroup participants. RESULTS: A statistically significant decrease in stiffness was observed in the gastrocnemius, the LTR gastrocnemius, and the LTR erector spinae group immediately following DN treatment. However, stiffness increased after 24 h. No significant change was found in the infraspinatus group. CONCLUSIONS: DN may cause an immediate, yet transitory change in local muscle stiffness. It is unknown whether these effects are present in a symptomatic population or related to improvements in clinical outcomes. Future studies are necessary to determine if a decrease in biomechanical stiffness is related to improvement in symptomatic individuals.

Accuracy and safety of dry needling placement in the popliteus muscle: A cadaveric study.

BACKGROUND: The popliteus muscle attaches posteriorly to the joint capsule of the knee. Although it is an important rotational stabiliser and has been implicated in various knee pathologies, research on its treatment with dry needling is scarce. OBJECTIVE: To determine if a needle accurately and safely penetrates the popliteus muscle during the clinical application of dry needling. METHODS: A cadaveric descriptive study was conducted. Needling insertion of the popliteus muscle was conducted in 11 cryopreserved cadavers with a 50-mm needle. The needle was inserted at upper third of the posterior part of the tibia closest to the knee towards the popliteus. The needle was advanced into the muscle based upon clinician judgement. Cross-sectional anatomical dissections were photographed and analysed by photometry. Safety of the intervention was assessed by calculating the distance from the tip of the needle to the proximate neurovascular structures. RESULTS: Accurate needle penetration of the popliteus muscle was observed in 10 out of 11 (91%) of the cadavers (mean needle penetration: 25.7 ± 6.7mm, 95% CI 21.3-30.3 mm). The distances from the tip of the needle were 17±6mm (95% CI 13-21 mm) to the tibial nerve and 15 ± 0.7mm (95% CI 10-20 mm) to the popliteus vascular bundle. CONCLUSION: The results from this cadaveric study support the notion that needling of the popliteus can be accurately and safely conducted by an experienced clinician. Future studies investigating the clinical effectiveness of these interventions are needed.

The effects of dry needling to the thoracolumbar junction multifidi on measures of regional and remote flexibility and pain sensitivity: A randomized controlled trial.

BACKGROUND: Dry needling (DN) has been consistently shown to decrease pain sensitivity and increase flexibility local to the site of treatment, however it is unclear whether these effects are limited to the region of treatment or can be observed remote to the area of treatment. OBJECTIVE: To determine the immediate, short-term effects of DN to the thoracolumbar junction on regional and remote flexibility, and to observe if changes in pain sensitivity can occur remote to site of treatment. DESIGN: Double-blind randomized clinical trial. METHODS: Fifty-four subjects with low back pain and decreased length in at least one hamstring were randomized to receive either DN or sham DN to the T12 and L1 multifidi. Participants underwent regional (fingertip-to-floor) and remote flexibility (passive knee extension, passive straight leg raise) and pressure pain threshold (PPT) testing of the upper and lower extremity before, immediately after and 1 day after treatment. ANCOVAs were used to analyze flexibility data, with the covariate of pre-treatment values. Paired t-tests were used for difference in remote pain sensitivity. RESULTS: Statistically larger improvements in regional flexibility, but not remote flexibility, were observed immediately post-treatment in those who received DN than in those receiving sham DN (p = .0495; adjusted difference 1.2, 95% CI 0.002-2.3). Differences between upper and lower extremity PPT were not significant. CONCLUSION: DN can potentially have immediate changes in regional flexibility, but effects are not sustained at 24-h follow-up. DN may not affect remote flexibility or segmental pain sensitivity.

Cadaveric and in vivo validation of needle placement in the medial pterygoid muscle.

BACKGROUND: Evidence suggests that medial pterygoid muscle plays an important role in temporomandibular pain. Therapeutic approaches targeting this muscle are needed. OBJECTIVE: To determine if a solid needle accurately penetrates the medial pterygoid muscle during the application of dry needling. DESIGN: A cadaveric and human descriptive study. METHODS: Needling insertion of the medial pterygoid was conducted in 5 fresh cadaver and 5 subjects with temporomandibular pain. Needling insertion was performed using a 40 mm needle inserted at the inferior angle of the mandibular bone. The needle was advanced from an inferior to superior direction into the medial pterygoid to a maximum depth of 30 mm. In cadavers, medial pterygoid placement was assessed by observation after resecting the superficial overlying tissues. In patients, medial pterygoid placement was assessed by self-reported pain referral during insertion. RESULTS: Accurate needle penetration of the medial pterygoid was observed in all fresh cadavers and pain referral was reported by 4/5 patients during needling insertion. CONCLUSION: Results from both cadavers and patients support the assertion that needling of the medial pterygoid can be accurately conducted.

Cadaveric and ultrasonographic validation of needling placement in the obliquus capitis inferior muscle.

BACKGROUND: Evidence suggests that suboccipital musculature plays an important role in headache. Proper therapeutic approaches targeting this muscle are needed. OBJECTIVE: Our aim was to determine with fresh cadavers and ultrasound imaging if a solid needle is able to properly penetrate the obliquus capitis inferior muscle during the application of dry needling. DESIGN: A cadaveric and human descriptive study. METHODS: Needling insertion and ultrasound imaging of the obliquus capitis inferior muscle was conducted on 10 pain-free healthy subjects and 5 fresh cadavers. Needling insertion was performed using a 40 mm needle inserted midway between the spinous process of C2 and transverse process of C1. The needle was advanced from a posterior to anterior direction into the obliquus capitis inferior muscle with an inferior-lateral angle to reach the lamina of C2. For the cadaveric study, the obliquus capitis inferior placement was verified by resecting the superficial upper trapezius, splenius capitis, and semispinalis capitis muscles. For ultrasographic study, a linear transducer was aligned with the long axis of the obliquus capitis inferior muscle after needle insertion. RESULTS: Both the cadaveric and ultrasonic studies showed that the needle penetrated the obliquus capitis inferior muscle during its insertion and that the tip of the needle rested against C2 laminae, thereby reaching the targeted muscle. CONCLUSION: This anatomical and ultrasound imaging study supports the assertion that needling insertion of the obliquus capitis inferior muscle can be properly conducted by an experienced clinician.

DRY NEEDLING IN THE MANAGEMENT OF PATIENTS MEETING CLINICAL DIAGNOSTIC CRITERIA FOR SUBACROMIAL PAIN SYNDROME: A CASE SERIES.

BACKGROUND: Physical therapy interventions of exercise and manual therapy provide benefit in treatment of subacromial pain syndrome (SAPS). Dry needling is an emerging technique for treating musculoskeletal conditions; however, conflicting investigative evidence exists regarding the use of dry needling for SAPS. PURPOSE: The purpose of this case series was to describe the use of dry needling, in conjunction with exercise, as a management strategy for patients meeting clinical diagnostic criteria of SAPS and to observe the short- and intermediate-term effects of dry needling with therapeutic exercise in this population. A secondary purpose was to describe a framework of clinical reasoning to guide the pragmatic application of dry needling and exercise in clinical practice. STUDY DESIGN: Case series. METHODS: Twenty-five patients met criteria for SAPS and provided informed consent. Patients received examination-based dry needling for the first two visits with exercises added beginning at the third treatment session to help distinguish treatment effects. The primary outcome measure used in this study was the Quick Disabilities of the Arm, Shoulder, and Hand (Q-DASH) survey assessed at their third clinical visit, at four-weeks after starting intervention and again at a three-month follow up visit. RESULTS: On the Q-DASH survey 21 of 24 patients reported improvement at the third visit (range 4.5 to 38.6 points) and 19 of 22 reported improvement at the 3-month follow-up (range 0.1-54.5 points) relative to baseline. Sixteen of 24 patients at the third visit and 19 of 22 patients at the 3-month follow-up reported Global Rating of Changes scores of +3 or greater. CONCLUSION: This case series provides insight to the observed short- and intermediate-term effects of dry needling combined with exercise for SAPS. Additionally, it discusses the framework of clinical reasoning when applying this intervention. The results are encouraging for dry needling as an adjunct to exercise for treating patients with SAPS. LEVEL OF EVIDENCE: Therapy, level 4.

The relative risk to the femoral nerve as a function of patient positioning: potential implications for trigger point dry needling of the iliacus muscle.

Objectives: Prudent dry needling techniques are commonly practiced with the intent to avoid large neurovascular structures, thereby minimizing potential excessive bleeding and neural injury. Patient position is one factor thought to affect the size of the safe zone during dry needling of some muscles. This study aimed to compare the size of the needle safe zone of the iliacus muscle during two different patient positions using ultrasound imaging. Methods: The distance from the anterior inferior iliac spine (AIIS) to the posterior pole of the femoral nerve was measured in 25 healthy participants (11 male, 14 female, mean age = 40) in both supine and sidelying positions using a Chison Eco1 musculoskeletal ultrasound unit. The average distance was calculated for each position and a two-tailed, paired t-test (α < 0.05) was used to examine the difference between positions. Results: The mean distance from the AIIS to the posterior pole of the femoral nerve was statistically greater with participants in the sidelying position (mean[SD] = 35.7 [6.2] mm) than in the supine position (mean[SD] = 32.1 [7.3] mm, p < .001). Discussion: Although more study is needed, these results suggest that patient positioning is one of several potential variables that should be considered in the optimization of patient safety/relative risk when performing trigger point dry needling. Level of Evidence: Level 4 (Pre-Post Test).

Short-term Effects of Manual Therapy in Patients After Surgical Fixation of Ankle and/or Hindfoot Fracture: A Randomized Clinical Trial.

BACKGROUND: Patients with surgical fixation of ankle and/or hindfoot fractures often experience decreased range of motion and loss of function following surgery and postsurgical immobilization, yet there is minimal evidence to guide care for these patients. OBJECTIVES: To assess whether manual therapy may provide short-term improvements in range of motion, muscle stiffness, gait, and balance in patients who undergo operative fixation of an ankle and/or hindfoot fracture. METHODS: In this multisite, double-blind randomized clinical trial, 72 consecutive patients who underwent open reduction internal fixation of an ankle and/or hindfoot fracture and were receiving physical therapy treatment of exercise and gait training were randomized to receive either impairment-based manual therapy (manual therapy group) or a sham manual therapy treatment of light soft tissue mobilization and proximal tibiofibular joint mobilizations (control group). Participants in both groups received 3 treatment sessions over 7 to 10 days, and outcomes were assessed immediately post intervention. Outcomes included ankle joint range of motion, muscle stiffness, gait characteristics, and balance measures. Group-by-time effects were compared using linear mixed modeling. RESULTS: There were no significant differences between the manual therapy and control groups for range of motion, gait, or balance outcomes. There was a significant difference from baseline to the final follow-up in resting gastrocnemius muscle stiffness between the manual therapy and control groups (-47.9 N/m; 95% confidence interval: -86.1, -9.8; P = .01). There was no change in muscle stiffness for the manual therapy group between baseline and final follow-up, whereas muscle stiffness increased in the control group by 6.4%. CONCLUSION: A brief course of manual therapy consisting of 3 treatment sessions over 7 to 10 days did not lead to better short-term improvement than the application of sham manual therapy for most clinical outcomes in patients after ankle and/or hindfoot fracture who were already being treated with exercise and gait training. Our results, however, suggest that manual therapy might decrease aberrant resting muscle stiffness after ankle and/or hindfoot surgical fixation. LEVEL OF EVIDENCE: Therapy, level 2. J Orthop Sports Phys Ther 2019;49(5):310-319. Epub 13 Feb 2019. doi:10.2519/jospt.2019.8864.

The effect of manual therapy on gastrocnemius muscle stiffness in healthy individuals.

STUDY DESIGN: Randomized clinical trial. BACKGROUND: Muscle stiffness is a potential complication after injury and has been shown to be a risk factor for injury in healthy individuals. OBJECTIVES: The primary purpose of this study was to assess the short-term effects of manual therapy (MT) on muscle stiffness of the gastrocnemius in both a relaxed and contracted state. The secondary purpose was to assess the reliability of a novel clinical tool (MyotonPRO) to measure muscle stiffness in the gastrocnemius in both a passive and contracted state. METHODS: Eighty-four consecutive healthy individuals were randomized to receive Manual Therapy (MT group) directed at the right-side ankle and foot or no treatment (CONTROL group). Muscle stiffness of the gastrocnemius was assessed bilaterally in all participants at baseline and then immediately after intervention in a relaxed and contracted state. Group (MT vs. CONTROL) by side (ipsilateral vs. contralateral) by time (pre vs. post) effects were compared through a 3-way interaction utilizing mixed model ANOVA. Reliability of the MyotonPRO was assessed with two-way mixed model intraclass correlation coefficients. RESULTS: There was a significant 3-way interaction for muscle stiffness of the gastrocnemius in a relaxed state (p<0.01), but not contracted state (p=0.54). All conditions had increased resting muscle stiffness from pre to post measures except for the ipsilateral limb of the MT group. There was not a significant interaction for muscle stiffness in a contracted state. Reliability estimates (ICC) for muscle stiffness measures ranged between 0.898 and 0.986. CONCLUSION: The change in muscle stiffness of the gastrocnemius in a relaxed state depended upon whether individuals received MT. Muscle stiffness measures were highly reliable based on single measurements. LEVEL OF EVIDENCE: Therapy, level 2.

SHORT-TERM EFFECTS OF TRIGGER POINT DRY NEEDLING ON PAIN AND DISABILITY IN SUBJECTS WITH PATELLOFEMORAL PAIN SYNDROME.

BACKGROUND: Patellofemoral pain syndrome (PFPS) is a prevalent knee disorder. A novel yet increasingly popular treatment for PFPS is trigger point dry needling (DN). PURPOSE: The purpose of this study was to determine if DN is more effective at reducing pain and disability than a sham treatment in individuals with PFPS. STUDY DESIGN: Randomized trial. MATERIALS/METHODS: Sixty military health care beneficiaries (36 males) with a clinical diagnosis of PFPS were recruited and completed the study. Subjects underwent a standardized clinical examination and were randomized into a DN or sham treatment group. DN treatment consisted of insertion of an acupuncture-like needle into six sites in the quadriceps femoris muscles of the symptomatic lower extremity based on a palpation examination. The sham grouped received a simulated treatment with a sharp object and needle guide tube without puncturing the skin. Self-reports of pain, disability, and overall status were collected before treatment, immediately after treatment and at 72 hours. Data were analyzed with separate 2x2 repeated measures analysis of variance, with independent variables being Group (DN vs. sham) and Time (pre-treatment vs. immediately post-treatment, and pre-treatment vs. 72 hours). The hypothesis of interest in each case was the Group*Time interaction. The alpha-level was set a priori to .05 using 2-tailed tests. RESULTS: Both groups exhibited a clinically meaningful reduction in pain based on numeric pain rating scale scores immediately post-treatment and at 72 hours, but there was no statistically significant difference between groups (p = 0.219, 0.310). There was no significant difference between groups for any other outcome measures. CONCLUSION: These data suggest that DN treatment is not more effective than a sham DN treatment at reducing short-term pain and disability in individuals with PFPS when used as an isolated treatment approach. LEVEL OF EVIDENCE: 2.

Cost-effectiveness Evaluation of the Inclusion of Dry Needling into an Exercise Program for Subacromial Pain Syndrome: Evidence from a Randomized Clinical Trial.

Objective: To evaluate the cost-effectiveness of the inclusion of trigger point-dry needling (TrP-DN) into an exercise program for the management of subacromial pain syndrome. Methods: Fifty patients with unilateral subacromial pain syndrome were randomized with concealed allocation to exercise alone or exercise plus TrP-DN. Both groups were asked to perform an exercise program targeting the rotator cuff musculature twice daily for five weeks. Patients allocated to the exercise plus TrP-DN group also received dry needling during the second and fourth sessions. Societal costs and health-related quality of life (estimated by EuroQol-5D-5L) over a one-year follow-up were used to generate incremental cost per quality-adjusted life-year (QALY) ratios for each intervention. Results: Intention-to-treat analysis was possible for 48 (96%) of the participants. Those in the exercise group made more visits to medical doctors and received a greater number of other treatments (P < 0.001). The major contributor to societal costs (77%) was the absenteeism paid labor in favor of the exercise plus TrP-DN group (P = 0.03). The combination of exercise plus TrP-DN was less costly (mean difference cost/patient = €517.34, P = 0.003) than exercise alone. Incremental QALYs showed greater benefit for exercise plus TrP-DN (difference = 2.87, 95% confidence interval = 2.85-2.89). Therefore, the inclusion of TrP-DN into an exercise program was more likely to be cost-effective than an exercise program alone, with 99.5% of the iterations falling in the dominant area. Conclusions: The inclusion of TrP-DN into an exercise program was more cost-effective for individuals with subacromial pain syndrome than exercise alone. From a cost-benefit perspective, the inclusion of TrP-DN into multimodal management of patients with subacromial pain syndrome should be considered.

Effects of Low-Load Exercise on Postneedling-Induced Pain After Dry Needling of Active Trigger Point in Individuals With Subacromial Pain Syndrome.

BACKGROUND: The application of dry needling usually is associated with postneedling-induced pain. A postneedling intervention to reduce this adverse event is needed. OBJECTIVE: To determine the effectiveness of low-load exercise on reducing postneedling-induced pain after dry needling of active trigger points (TrPs) in the infraspinatus muscle in subacromial pain syndrome. DESIGN: A 72-hour follow-up, single-blind randomized controlled trial. SETTING: Urban hospitals. PARTICIPANTS: Individuals with subacromial pain syndrome (n = 90, 52% female, mean age: 35 ± 13 years) with active TrPs in the infraspinatus muscle. INTERVENTIONS: All individuals received dry needling into the infraspinatus active TrP. Then, they were divided randomly into an experimental group, which received a single bout of low-load exercise of shoulder muscles; a placebo group, which received inactive ultrasound for 10 minutes; and a control group, which did not receive any intervention. OUTCOME MEASURES: Numerical Pain Rating Scale (0-10 point) was administered postneedling, immediately postintervention (2 minutes), and 24, 48, and 72 hours after needling. Shoulder pain (Numerical Pain Rating Scale, 0-10) and disability (Disabilities of the Arm, Shoulder and Hand; Shoulder Pain and Disability Index) were assessed before and 72 hour after needling. RESULTS: The 5 × 3 analysis of covariance showed that the exercise group demonstrated a larger decrease in postneedling-induced pain immediately after (P = .001), 24 hours (P = .001), and 48 hours after (P = .006) than placebo or control groups. No differences were found at 72 hours (P = .03). Similar improvements in shoulder pain (P < .001) and related disability (Disabilities of the Arm, Shoulder and Hand: P < .001; Shoulder Pain and Disability Index: P < .001) were observed 72 hours after needling, irrespective of the treatment group. CONCLUSIONS: Low-load exercise was effective for reducing postneedling-induced pain on active TrPs in the infraspinatus muscle 24 and 48 hours after needling. The application of a postneedling intervention did not influence short-term pain and disability changes. LEVEL OF EVIDENCE: I.