Clin Rheumatol DOI 10.1007/s10067-013-2448-3

ORIGINAL ARTICLE

Comparison of dry needling and physiotherapy in treatment of myofascial pain syndrome Seyed Mansoor Rayegani & Masume Bayat & Mohammad Hasan Bahrami & Seyed Ahmad Raeissadat & Elham Kargozar

Received: 15 July 2013 / Revised: 18 November 2013 / Accepted: 25 November 2013 # Clinical Rheumatology 2013

Abstract To compare the effects of dry needling and physiotherapy in treatment of myofascial pain syndrome, a randomized controlled trial was performed on 28 patients with myofascial pain syndrome (MPS) of upper trapezius muscle in the Physical Medicine and Rehabilitation Center of Shohadaye Tajrish Hospital from April 2009 to April 2010. After matching the age, sex, duration of symptoms, pain severity, and quality of life measures, subjects were randomly assigned into two subgroups of case (dry needling) and control (physiotherapy). One week and 1 month after receiving standard therapeutic modalities, outcomes and intragroup and intergroup changes in pain severity, pressure pain of trigger point (TP), and quality of life measures were evaluated and compared. After 1 month, both the physiotherapy and dry needling groups had decreased resting, night, and activity pain levels (p 0.4 >0.1 >0.1 >0.8 >0.4 >0.6 >0.4 >0.4 >0.2 >0.8

1.5±1.4 1.8±1.5

32±10 9.6±8.4 2.9±2.8 2.7±0.7 4.7±3.2 26.6±7.2 77.5±20.8 46.4±32.3 52.2±19.1 72±14.7 58.5±10.5 67.8±25.3

PT group Needling group

38.6±4.2 9.8±9.6 3.6±2.6 4.1±9.2 6.5±2.1 25.5±8.2 72.5±19.8 41.3±44.3 47.1±20.4 60.1±17.6 66.4±16.2 71.4±17.9

Activity pain

Age Symptom duration (months) Rest pain Night pain Activity pain TP pressure pain Physical functioning Role physicala Bodily pain General health Vitality Social functioning

Night pain

P value

Rest pain

Needling group N =14

Treatment group Characteristic

PT group N =14

Table 2 Patients’ scales in 1-week follow-up session

Treatment group Characteristics

TP pressure pain

Table 1 Demographic characteristics of both groups in pretreatment visit

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Chart 1 Patients’ VAS measures in 1-month follow-up

functioning, role limitation due to physical problems and social functioning (p 0.1). Results of the 1-month follow-up are shown in Charts 1, 2 and 3.

Discussion In this study, we gained significant improvement in pain and some scales of quality of life in both treatment groups. No significant difference was observed between the results of both groups. We found no significant change in SF-36 scales of the needling group in the 1-week follow-up visit. We think that this finding could be due to the characteristics of SF-36 questionnaire. Because this form evaluates the subject’s condition in the last 4 weeks, no significant change can be expected only 1 week afterward. In contrast, in the PT group, we found significant improvement in patients’ quality of life, just 1 week after the last treatment session. As mentioned, longer treatment course (about 3 weeks) in this set of patients can explain it. In this study, no significant change was observed in some SF-36 scales (role limitation due to emotional problems, Chart 2 Patients’ pressure pain and quality of life scales in 1-month follow-up

mental health, general health, and vitality). Because these scales are mainly related to the subjects’ psychological condition, we concluded that the patients’ pain levels have not affected their psychiatric condition at least in the 1-month follow-up period. Up to the time of preparing this article, no similar trial of comparing these two methods was carried out in this field, or at least, we did not have access to it. We could find some trials in evaluating the effect of either physiotherapy or dry needling in MPS. It is shown that therapeutic ultrasound is a useful clinical tool for the treatment of trigger points and myofascial pain syndrome [10]. In the study by Gam et al., ultrasound alone has not been effective, but adding exercises has caused pain reduction [12]. There are also studies evaluating the effect of trigger point dry needling, which have shown its positive effects [16–19]. In a study by Ay et al., the effects of local anesthetic injection on myofascial pain syndrome of the neck muscles were compared with dry needling methods. After the 12-week followup, no significant differences were observed between the groups. This study showed that exercise associated with anesthetic or dry needling injections was effective in decreasing pain in MPS patients [17]. In another study with 45 subjects with MPS and headache, the effect of dry needling was compared to different substances injection. This study indicated that all three methods (dry needling, lidocaine injection, and mixture of lidocaine and corticosteroid injection) were effective in reducing pain level of these patients [19]. One positive aspect of our study was that we compared two well-known treatment methods of MPS. PT is a time consuming and expensive treatment and needs special equipment, whereas needling is a simple straight forward method and needs no sophisticated equipment. The requirements of needling are a cheap syringe needle and a skilled physician. Furthermore, we included the SF-36 questionnaire in our study which was relatively new. Since both treatment methods are studied separately and showed to be efficient, we did not encounter the ethical conflicts in this study.

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Chart 3 CONSORT 2010 flow diagram

Probable action mechanism of dry needling in MPS is mechanical destruction of dysfunctional end plates [3, 32]. These end plates cause a sustained contraction of muscle fiber by continuous acetylcholine release. Deactivation of these end plates terminates the muscle fiber contraction and nociceptive input to the CNS [2]. For needling, we applied syringe needle, whereas using an acupuncture needle is more conventional. Both methods are mentioned by Travell and Simons [3]. Theybelieve that although needles thinner than 25 gauged (near to acupuncture needle) are less traumatic to tissue and so cause lesser discomfort, these are more prone to bending and losing true direction by the contraction knots. Also, these needles provide less tactile feedback to the practitioner [3]. The exact action mechanism of ultrasound on TPs is not clear. If probe is applied on TP with enough pressure, it may effect through pressure-release mechanism [3]. The other proposed mechanism is termination of local energy crisis. According to this hypothesis, continuous muscle fiber activity increases the metabolic rate, tissue ischemia, and pain [2]. Generally, none of these proposed theories is definite enough.

This makes it difficult to come to a final conclusion, and so choosing the best option is a dilemma. We thought that in such a condition, the best way is the easiest. We encountered some problems in our study. First, was the low number of participants. Another inevitable factor which might have made some alterations in the results is that the follow-up visits did not happen at exactly the same time in both groups. This was basically due to different treatment durations. Dry needling was accomplished in just one session, while PT lasted 10 sessions. In such a condition, it was not possible to plan the follow-up visits at exactly the same time. So patients of the physiotherapy group received their last follow-up visit at about 2 months from the start of treatment, while this happened at exactly 1 month in the needling group. Also, subjects of the physiotherapy group were exposed to a therapist for 10 sessions, but this happened just once in the needling group. This passage of time might have an independent effect in subsiding the patients’ symptoms. Also, compared with one treatment session, several sessions might have at least some placebo effects. Subjects in the needling group also applied ice and

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capsaicin cream to the needling site. This may have a synergistic effect with needling [33]. Also, the lack of longer follow-up is another limitation of this study.

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Conclusion

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We concluded that both the methods PT and dry needling are effective in treatment of upper trapezius myofascial pain syndrome. However, considering the time and expense, dry needling is preferred. Since this study is the first trial in comparing these two methods, and regarding the high prevalence of this syndrome, we suggest more research in this field.

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Disclosures None.

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References

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Comparison of dry needling and physiotherapy in treatment of myofascial pain syndrome.

To compare the effects of dry needling and physiotherapy in treatment of myofascial pain syndrome, a randomized controlled trial was performed on 28 p...
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