Convergent Validity between Electromyographic Muscle Activity, Ultrasound Muscle Thickness and Dynamometric Force Measurement for Assessing Muscle.

Muscle fatigue is defined as a reversible decline in performance after intensive use, which largely recovers after a resting period. Surface electromyography (EMG), ultrasound imaging (US) and dynamometry are used to assess muscle activity, muscle morphology and isometric force capacity. This study aimed to assess the convergent validity between these three methods for assessing muscle fatigue during a manual prehension maximal voluntary isometric contraction (MVIC). A diagnostic accuracy study was conducted, enrolling 50 healthy participants for the measurement of simultaneous changes in muscle thickness, muscle activity and isometric force using EMG, US and a hand dynamometer, respectively, during a 15 s MVIC. An adjustment line and its variance (R2) were calculated. Muscle activity and thickness were comparable between genders (p > 0.05). However, men exhibited lower force holding capacity (p < 0.05). No side-to-side or dominance differences were found for any variable. Significant correlations were found for the EMG slope with US (r = 0.359; p < 0.01) and dynamometry (r = 0.305; p < 0.01) slopes and between dynamometry and US slopes (r = 0.227; p < 0.05). The sample of this study was characterized by comparable muscle activity and muscle thickness change between genders. In addition, fatigue slopes were not associated with demography or anthropometry. Our findings showed fair convergent associations between these methods, providing synergistic muscle fatigue information.

Reliability of lumbar multifidus ultrasound assessment during the active straight leg raise test.

BACKGROUND: Previous evidence showed altered lumbar multifidus (LM) activation in populations with chronic nonspecific low back pain (LBP). We aimed to investigate the test-retest and inter-examiner reliability of ultrasound imaging (US) for assessing LM thickness at rest and activation during the active straight leg raise test (ASLR) and the association between thickness changes with clinical outcomes. METHODS: Fifty-two patients with LBP and two examiners (one experienced and one novice) participated in this study. A total of 18 B-mode images at L4-L5 or L5-S1 level (both sides, 3 at rest and 6 during ASLR) were collected. For assessing test-retest reliability, the experienced examiner repeated the procedure after 7 days. Intraclass correlation coefficients (ICC), standard error of measurements (SEM) and minimal detectable changes (MDC) were calculated. RESULTS: Inter-examiner agreement was good to excellent (ICC3,2 = 0.71-0.92) and test-retest reliability was excellent (ICC3,1 = 0.91-0.98). Mean average of multiple measurements improved the agreement. Greater LM thickness at rest (p < .05) and greater thickness change after 3 s (p < .01) and 10 s (homolateral side, p < .01; contralateral side, p < .05) were associated with less pain intensity. CONCLUSIONS: US is a reliable method to assess the LM thickness at rest and contracted during the ASLR in patients with LBP. The measurement at 3 s after maintaining ASLR, as well as the use of the mean of three measurements, has been shown to be the most reliable method for measuring LM muscle thickness during ASLR.

Localized and widespread pressure pain hypersensitivity in patients with episodic or chronic migraine: A systematic review and meta-analysis.

OBJECTIVE: This meta-analysis compared pressure pain sensitivity in trigeminal, cervical spine and remote pain-free areas between migraine patients and headache-free controls considering diagnosis (episodic versus chronic) and sex.Databases and data treatment: Electronic databases were searched for cross-sectional or prospective case-control studies comparing pressure pain thresholds between migraine and headache-free controls. Data were extracted by two reviewers. The risk of bias and methodological quality was assessed by Newcastle-Ottawa Quality Assessment Scale. Meta-analyses of trigeminal, extra-trigeminal (cervical spine) and remote pain-free areas were compared. Frequency of migraine and sex were taken into account. Mean differences (MD) and random effects were calculated. RESULTS: Eighteen studies were included. Patients with migraine showed lower pressure pain thresholds than headache-free controls: trigeminal (MD -71.33 kPa, 95%CI -92.14 to -50.53), cervical spine (MD -68.50 kPa, 95%CI -84.67 to -52.33), and remote pain-free (MD -62.49 kPa, 95%CI -99.52 to -25.45) areas. Differences were consistently significant for episodic migraine in all locations, but only significant in the trigeminal area for chronic migraine (MD -67.36 kOPa, 95%CI -101.31 to -33.42). Overall, women had lower pressure pain thresholds than men. The methodological quality of most studies (66.7%) was good. The results showed a high heterogeneity. CONCLUSION: This meta-analysis found low to high quality evidence showing lower pressure pain thresholds in trigeminal, extra-trigeminal, and remote pain-free areas in migraine sufferers when compared with headache-free controls. Hypersensitivity to pressure pain locally and widespread was consistently observed in episodic migraine, but locally in chronic migraine as compared to headache-free controls. Women with migraine were more sensitive than men.Registration number: https://doi.org/10.17605/OSF.IO/YJTAK.

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.

Evidence of localized and widespread pressure pain hypersensitivity in patients with tension-type headache: A systematic review and meta-analysis.

OBJECTIVE: This meta-analysis evaluates pressure pain sensitivity values in symptomatic and distant pain-free areas comparing individuals with tension-type headache to controls. DATABASES AND DATA TREATMENT: Electronic databases were searched for cross-sectional or prospective case-control studies comparing pressure pain thresholds in patients with tension-type headache to headache-free controls. Data were extracted by three reviewers. The methodological quality was assessed by the Newcastle-Ottawa Quality Assessment Scale. Meta-analyses of trigeminal, extra-trigeminal (neck) and distant pain-free areas in tension-type headache were compared to headache-free controls. Frequency of tension-type headache and gender were taken into account. RESULTS: Twenty studies were included. Patients with tension-type headache exhibited lower pressure pain thresholds than headache-free controls: Trigeminal (MD -49.11 kPa, 95% CI -66.05 to -32.17), cervical spine (MD -88.17 kPa, 95% CI -108.43 to -67.92) and distant pain-free areas (MD -98.43 kPa, 95% CI -136.78 to -60.09). Differences were significant for chronic, episodic, and mixed episodic and chronic tension-type headache within the trigeminal and neck (symptomatic areas), but only significant for chronic tension-type headache (MD -102.86, 95% CI -139.47 to -66.25 kPa) for distant pain-free areas. In general, women had lower pressure pain thresholds than men. The methodological quality ranged from fair (45%) to good (40%). The results showed a high heterogeneity and publication bias. CONCLUSION: This first meta-analysis addressing pressure pain thresholds differences in symptomatic and distant pain-free areas between patients with tension-type headache and controls found low to moderate evidence supporting the presence of pressure pain hypersensitivity in the trigeminal and neck areas in tension-type headache in comparison with headache-free controls. Sensitivity to pressure pain was widespread only in chronic, not episodic, tension-type headache (moderate evidence).Registration number: https://doi.org/10.17605/OSF.IO/R29HY.

Is Dry Needling Effective for the Management of Spasticity, Pain, and Motor Function in Post-Stroke Patients? A Systematic Review and Meta-Analysis.

OBJECTIVE: To evaluate the effects of muscle dry needling alone or combined with other interventions on post-stroke spasticity (muscle tone), related pain, motor function, and pressure sensitivity. DATABASES AND DATA TREATMENT: Electronic databases were searched for randomized controlled trials including post-stroke patients where at least one group received dry needling and outcomes were collected on spasticity and related pain. Secondary outcomes included motor function and pressure pain sensitivity. Data were extracted by two reviewers. The risk of bias was assessed with the Cochrane Risk of Bias tool, methodological quality was assessed with the Physiotherapy Evidence Database score, and the quality of evidence was assessed by the Grading of Recommendations Assessment, Development, and Evaluation approach. Between-groups mean differences (MDs) and standardized mean differences (SMDs) were calculated. RESULTS: Seven studies (three within the lower extremity, four in the upper extremity) were included. The meta-analysis found significantly large effect sizes of dry needling for reducing spasticity (SMD: -1.01, 95%confidence interval [CI] -1.68 to -0.34), post-stroke pain (SMD -1.01, 95%CI -1.73 to -0.30), and pressure pain sensitivity (SMD 1.21, 95% CI: 0.62 to 1.80) as compared with a comparative group at short-term follow-up. The effect on spasticity was found mainly in the lower extremity (MD -1.05, 95% CI: -1.32 to -0.78) at short-term follow-up. No effect on spasticity was seen at 4 weeks. No significant effect on motor function (SMD 0.16, 95% CI: -0.13 to 0.44) was observed. The risk of bias was generally low, but the imprecision of the results downgraded the level of evidence. CONCLUSION: Moderate evidence suggests a positive effect of dry needling on spasticity (muscle tone) in the lower extremity in post-stroke patients. The effects on related pain and motor function are inconclusive.

Is Dry Needling Effective for the Management of Plantar Heel Pain or Plantar Fasciitis? An Updated Systematic Review and Meta-Analysis.

OBJECTIVE: Dry needling is commonly used for the management of plantar fasciitis. This meta-analysis evaluated the effects of dry needling over trigger points associated with plantar heel pain on pain intensity and related disability or function. METHODS: Electronic databases were searched for randomized controlled trials in which at least one group received dry needling, not acupuncture, for trigger points associated with plantar heel pain and in which outcomes were collected on pain intensity and related disability. The risk of bias was assessed with the Cochrane Risk of Bias tool, methodological quality was assessed with the Physiotherapy Evidence Database (PEDro) score, and the level of evidence is reported according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Between-groups mean differences (MD) and standardized mean differences (SMD) were calculated. RESULTS: The search identified 297 publications, with six trials eligible for inclusion. The meta-analysis found low-quality evidence that trigger point dry needling reduces pain intensity in the short term (MD -1.70 points, 95% confidence interval [CI] -2.80 to -0.60; SMD -1.28, 95% CI -2.11 to -0.44) and moderate-quality evidence that it improves pain intensity (MD -1.77 points, 95% CI -2.44 to -1.11; SMD -1.45, 95% CI -2.19 to -0.70) and related disability (SMD -1.75, 95% CI -2.22 to -1.28) in the long term, as compared with a comparison group. The risk of bias of the trials was generally low, but the heterogeneity of the results downgraded the level of evidence. DISCUSSION: Moderate- to low-quality evidence suggests a positive effect of trigger point dry needling for improving pain intensity and pain-related disability in the short term and long term, respectively, in patients with plantar heel pain of musculoskeletal origin. The present results should be considered with caution because of the small number of trials.

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 Adding Motor Imagery to Early Physical Therapy in Patients with Knee Osteoarthritis who Had Received Total Knee Arthroplasty: A Randomized Clinical Trial.

OBJECTIVE: To investigate the effects of the inclusion of motor imagery (MI) principles into early physical therapy on pain, disability, pressure pain thresholds (PPTs), and range of motion in the early postsurgical phase after total knee arthroplasty (TKA). METHODS: A randomized clinical trial including patients with knee osteoarthritis who have received TKA was conducted. Participants were randomized to receive five treatment sessions of either physical therapy with or without MI principles in an early postsurgical phase after a TKA (five days after surgery). Pain intensity (visual analog scale [VAS], 0-100), pain-related disability (short-form Western Ontario McMaster Universities Osteoarthritis Index [WOMAC], 0-32), pressure pain thresholds (PPTs), and knee range of motion were assessed before and after five daily treatment sessions by an assessor blinded to the subject's condition. RESULTS: Twenty-four participants completed data collection and treatment. The adjusted analysis revealed significant group*time interactions for WOMAC (F = 17.29, P = 0.001, η2 = 0.48) and VAS (F = 14.56, P < 0.001, η2 = 0.45); patients receiving physiotherapy and MI principles experienced greater improvements in pain (Δ -28.0, 95% confidence interval [CI] = -43.0 to -13.0) and pain-related disability (Δ -6.0, 95% CI = -8.3 to -3.7) than those receiving physiotherapy alone. No significant group*time interactions for knee range of motion and PPTs were observed (all, P > 0.30). CONCLUSIONS: The application of MI to early physiotherapy was effective for improving pain and disability, but not range of motion or pressure pain sensitivity, in the early postsurgical phase after TKA in people with knee osteoarthritis.

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.

Effects of two exercise programmes on joint position sense, dynamic balance and countermovement jump in male amateur football players. A randomised controlled trial.

Introduction: The injury prevention and warm-up exercises programmes improve physical performance and injury ratio, but it is poorly investigated in amateur football. Objectives: To assess the effects of two warm-up multi-station programmes (IAI-Programme and FIFA11+) through JPS, LSDT and CMJ. Study design: Randomised controlled trial. Methods: 36 football players were randomised into 2 groups: IAI-Programme (n = 18) and FIFA11+ (n = 18) and performed the intervention protocol for 6 weeks. JPS, LSDT and CMJ were measured at baseline, after 6, 10 and 18 weeks (from baseline). The inter-group and intra-group differences were assessed by repeated-measures analysis of variance test (ANOVA). Results: Significant differences between groups were found after 18 weeks in the absolute angular error (-2.18[-4.33,-0.047], d = 0.69, p < 0.05) of the JPS and in the CMJ (p = 0.001, ŋ2p=,0.298) in favour of IAI-Programme when compared to FIFA11 +. No significant differences between groups were found in the LSDT. There were also intra-group differences observed in the LSDT in both groups. Conclusions: IAI-Programme can provide sensitive benefits with respect to the proprioceptive ability of knee flexion and CMJ than FIFA11 +. Both IAI-Programme and FIFA11+ present improvements in the dynamic postural control measured by the LSDT.

Prognostic Factors for Postoperative Chronic Pain after Knee or Hip Replacement in Patients with Knee or Hip Osteoarthritis: An Umbrella Review.

Knee and hip osteoarthritis are highly prevalent in the older population. Management of osteoarthritis-related pain includes conservative or surgical treatment. Although knee or hip joint replacement is associated with positive outcomes, up to 30% of patients report postoperative pain in the first two years. This study aimed to synthesize current evidence on prognostic factors for predicting postoperative pain after knee or hip replacement. An umbrella review of systematic reviews was conducted to summarize the magnitude and quality of the evidence for prognostic preoperative factors predictive of postoperative chronic pain (>6 months after surgery) in patients who had received knee or hip replacement. Searches were conducted in MEDLINE, CINAHL, PubMed, PEDro, SCOPUS, Cochrane Library, and Web of Science databases from inception up to 5 August 2022 for reviews published in the English language. A narrative synthesis, a risk of bias assessment, and an evaluation of the evidence confidence were performed. Eighteen reviews (nine on knee surgery, four on hip replacement, and seven on both hip/knee replacement) were included. From 44 potential preoperative prognostic factors, just 20 were judged as having high or moderate confidence for robust findings. Race, opioid use, preoperative function, neuropathic pain symptoms, pain catastrophizing, anxiety, other pain sites, fear of movement, social support, preoperative pain, mental health, coping strategies, central sensitization-associated symptoms, and depression had high/moderate confidence for an association with postoperative chronic pain. Some comorbidities such as heart disease, stroke, lung disease, nervous system disorders, and poor circulation had high/moderate confidence for no association with postoperative chronic pain. This review has identified multiple preoperative factors (i.e., sociodemographic, clinical, psychological, cognitive) associated with postoperative chronic pain after knee or hip replacement. These factors may be used for identifying individuals at a risk of developing postoperative chronic pain. Further research can investigate the impact of using such prognostic data on treatment decisions and patient outcomes.

A Closer Look at Localized and Distant Pressure Pain Hypersensitivity in People With Lower Extremity Overuse Soft-Tissue Painful Conditions: A Systematic Review and Meta-Analysis.

OBJECTIVE: The nociceptive pain processing of soft-tissue overuse conditions is under debate because no consensus currently exists. The purpose of this meta-analysis was to compare pressure pain thresholds (PPTs) in symptomatic and distant pain-free areas in 2 groups: participants with symptomatic lower extremity overuse soft-tissue conditions and controls who were pain free. METHODS: Five databases were searched from inception to December 1, 2021, for case-control studies comparing PPTs between individuals presenting with symptomatic lower extremity tendinopathy/overuse injury and controls who were pain free. Data extraction included population, diagnosis, sample size, outcome, type of algometer, and results. The methodological quality (Newcastle-Ottawa Quality Assessment Scale) and evidence level (Grading of Recommendations Assessment, Development, and Evaluation) were assessed. Meta-analyses of symptomatic, segmental related, and distant pain-free areas were compared. RESULTS: After screening 730 titles and abstracts, a total of 19 studies evaluating lower extremity overuse conditions (Achilles or patellar tendinopathy, greater trochanteric pain syndrome, plantar fasciitis, and iliotibial band syndrome) were included. The methodological quality ranged from fair (32%) to good (68%). Participants with lower extremity overuse injury had lower PPTs in both the painful and nonpainful areas, mirrored test-site, compared with controls (affected side: mean difference [MD] = -262.92 kPa, 95% CI = 323.78 to -202.05 kPa; nonaffected side: MD = -216.47 kPa, 95% CI = -304.99 to -127.95 kPa). Furthermore, people with plantar fasciitis showed reduced PPTs in the affected and nonaffected sides at segmental-related (MD = -176.39 kPa, 95% CI = -306.11 to -46.68 kPa) and distant pain-free (MD = -97.27 kPa, 95% CI = 133.21 to -61.33 kPa) areas compared with controls. CONCLUSION: Low- to moderate-quality evidence suggests a reduction of PPTs at the symptomatic area and a contralateral/mirror side in lower extremity tendinopathies and overuse conditions compared with pain-free controls, particularly in plantar fasciitis and greater trochanteric pain syndrome. Participants with plantar fasciitis showed a reduction of PPTs on the affected and non-affected sides at a segmental-related area (very low-quality evidence) and at a remote asymptomatic area (moderate-quality evidence). IMPACT: Some overuse peripheral pain conditions may be more associated with pressure pain sensitivity than others. Accordingly, examination and identification of conditions more peripherally, centrally, or mixed mediated could potentially lead to more specific and different treatment strategies.

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.

Lumbar multifidus thickness changes during active leg raising with ultrasound imaging can detect patients with chronic non-specific low back pain.

BACKGROUND: Altered lumbar multifidus (LM) activation has been found in populations with non-specific chronic low back pain (NSCLBP). OBJECTIVE: To detect differences in LM muscle thickness at rest and during active manoeuvres between patients with NSCLBP and pain-free controls and to analyze the ability of LM thickness change during the active straight leg raise (ASLR) with rehabilitative ultrasound imaging to detect patients with NSCLBP. DESIGN: Cross-sectional observational study. METHODS: Seventy volunteers (50% patients NSCLBP) were recruited. 18 B-mode images of LM at L4-L5 or L5-S1 level selecting the most symptomatic level (both sides, six at rest and three during ASLR) were collected by a blinded assessor. Differences between patients and controls in LM muscle thickness at rest, during ASLR (holding 3sec), and 5 s after ASLR were calculated. In addition, discriminant validity was evaluated by calculating the area under the receiver operating characteristic curve (ROC), sensitivity, specificity and positive and negative likelihood ratio. RESULTS: Significant LM thickness change differences during ASLR were found within and between groups: bilaterally, LM thickness change during ASLR was significantly higher in healthy controls than in NSCLBP patients. Ipsilateral LM muscle thickness change was sensitive to detect individuals with NSCLBP (ROC = 0.79-0.80). CONCLUSION: Pain-free individuals exhibited significantly greater LM thickness changes bilaterally during the ASLR compared to patients with NSCLBP. LM thickness change during the ASLR has good validity for discriminating patients with NSCLBP. Further studies should assess benefits of LM training programs in the management of these patients.

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.

Is Dry Needling Applied by Physical Therapists Effective for Pain in Musculoskeletal Conditions? A Systematic Review and Meta-Analysis.

OBJECTIVE: The main objective of this systematic review and meta-analysis was to determine the short-, medium-, and long-term effectiveness of dry needling (DN) applied by physical therapists to myofascial trigger points for the treatment of pain. METHODS: PubMed, Scopus, SportDiscus, and Web of Science databases were searched from their inception to February 2020. Randomized controlled trials that compared DN with other treatments or placebo and measured pain with a visual analog Scale or another numerical pain rating scale were included. Two authors used a personalized form to collect the following data relevant to the objectives of the review from each article independently: study design, purpose, sample size, diagnosis, characteristics of DN intervention, characteristics of placebo intervention, outcome measures, period of assessment, body region, DN technique, and number of sessions. The initial search identified 1771 articles. After the selection, 102 articles were assessed for eligibility; 42 of these articles measuring pain were used for the meta-analysis. Four meta-analyses were performed according to the follow-up period from the last reported treatment. RESULTS: This meta-analysis found a large effect to decrease pain within 72 hours (standardized mean difference [SMD] = -0.81; 95% CI = -1.21 to -0.40), a moderate effect in 1 to 3 weeks (SMD = -0.69; 95% CI = -1.02 to -0.35), a large effect in 4 to 12 weeks (SMD = -0.85; 95% CI = -1.30 to -0.40), and a large effect in 13 to 24 weeks (SMD = -0.81; 95% CI = -1.64 to -0.03). The risk of bias was generally low; however, the heterogeneity of the results downgraded the level of evidence. CONCLUSIONS: Low-quality evidence that the immediate to 72-hour (large) effect, 4- to 12-week (large) effect, 13- to 24-week (large) effect, and moderate-quality 1- to 3-week (moderate) effect suggested that DN performed by physical therapists was more effective than no treatment, sham DN, and other therapies for reducing pain. IMPACT: DN is commonly used by physical therapists to treat musculoskeletal pain, and it is very important for physical therapists to know the clinical conditions and time periods for which DN is effective in reducing pain in their patients.

Evidence of Bilateral Localized, but Not Widespread, Pressure Pain Hypersensitivity in Patients With Upper Extremity Tendinopathy/Overuse Injury: A Systematic Review and Meta-Analysis.

OBJECTIVE: The presence of altered nociceptive pain processing in patients with upper extremity tendinopathy/overuse injury is conflicting. Our aim was to compare pressure pain thresholds (PPTs) in symptomatic and distant pain-free areas between patients with upper extremity tendinopathy/overuse injury and controls. METHODS: Five databases were searched from inception to October 15, 2020. The authors selected case-control studies comparing PPTs between individuals with upper extremity tendinopathy/overuse injury and pain-free controls. Data were extracted for population, diagnosis, sample size, outcome, and type of algometer. Results were extracted by 3 reviewers. The methodological quality/risk of bias (Newcastle-Ottawa Quality Assessment Scale) and evidence level (Grading of Recommendations Assessment, Development and Evaluation approach) were assessed. Meta-analyses of symptomatic, segment-related, and distant pain-free areas were compared. RESULTS: The search identified 807 publications with 19 studies (6 shoulder, 13 elbow) eligible for inclusion. The methodological quality ranged from fair (48%) to good (37%). Patients exhibited lower bilateral PPTs than controls at the symptomatic area (affected side: MD = -175.89 kPa [95% CI = -220.30 to -131.48 kPa]; nonaffected side: MD = -104.50 kPa [95% CI = -142.72 to -66.28 kPa]) and the segment-related area (affected side: MD = -150.63 kPa [95% CI = -212.05 to -89.21 kPa]; nonaffected side: MD = -170.34 kPa [95% CI = - 248.43 to -92.25]) than controls. No significant differences in PPTs over distant pain-free areas were observed. CONCLUSION: Low to moderate quality evidence suggests bilateral hypersensitivity to pressure pain at the symptomatic and contralateral/mirror areas in patients with upper extremity tendinopathies/overuse injury. Moderate quality of evidence supports bilateral pressure pain sensitivity in the segment-related area (neck) in lateral epicondylalgia, but not in subacromial impingement syndrome. No evidence of widespread pressure pain hyperalgesia was reported. IMPACT: Early identification of people with altered pain modulation could guide clinicians in treatment strategies. This review shows that there is a complex interplay between peripheral and central pain mechanisms in upper extremity tendinopathies/overuse injuries and that there likely are different subgroups of patients with upper extremity conditions.

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.

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.