Expert Review of Neurotherapeutics
ISSN: 1473-7175 (Print) 1744-8360 (Online) Journal homepage: http://www.tandfonline.com/loi/iern20
Dry needling for headaches presenting active trigger points César Fernández-de-las-Peñas PT, PhD, DMSc & María L. Cuadrado MD, PhD To cite this article: César Fernández-de-las-Peñas PT, PhD, DMSc & María L. Cuadrado MD, PhD (2016): Dry needling for headaches presenting active trigger points, Expert Review of Neurotherapeutics, DOI: 10.1586/14737175.2016.1152889 To link to this article: http://dx.doi.org/10.1586/14737175.2016.1152889
Accepted author version posted online: 10 Feb 2016.
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=iern20 Download by: [222.79.109.29]
Date: 19 February 2016, At: 12:42
Dry needling for headaches presenting active trigger points AUTHORS
Downloaded by [222.79.109.29] at 12:42 19 February 2016
César Fernández-de-las-Peñas
1,2
PT, PhD, DMSc; María L. Cuadrado
3,4
MD, PhD
INSTITUTIONS
1 Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain.
2 Cátedra de Investigación y Docencia en Fisioterapia: Terapia Manual y Punción Seca, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain.
3 Headache Unit, Department of Neurology, Hospital Clínico San Carlos, Madrid, Spain.
4 Department of Medicine, Universidad Complutense, Madrid, Spain.
Corresponding author César Fernández de las Peñas Facultad de Ciencias de la Salud Universidad Rey Juan Carlos Avenida de Atenas s/n 28922 Alcorcón, Madrid SPAIN
Telephone number: + 34 91 488 88 84 Fax number: + 34 91 488 89 57
E-mail address: [email protected]
Key words: Dry needling, headache, trigger points.
1
Definition of Dry Needling Therapeutic management of headaches mainly includes pharmacological and physical therapy approaches [1-3]. In the last decade, there has been an increasing interest in the use of dry needling (DN) for the treatment of headache as well as for neck and shoulder pain syndromes [4]. The American Physical Therapy Association (APTA) defined DN as a “skilled intervention using a thin filiform needle to penetrate the skin and stimulate trigger points (TrPs), muscles, and connective tissue for the treatment of
Downloaded by [222.79.109.29] at 12:42 19 February 2016
musculoskeletal disorders” [5]. Although acupuncture and DN share many similarities [6], they differ in many aspects, particularly the fact that DN inserts the needle into the muscle and not in standardized acupuncture points [7]. The most commonly accepted DN approach is the “fast-in and fast-out” technique described by Hong [8]. This technique consists of the insertion of the needle penetrating the skin into a TrP until a local twitch response is obtained. The local twitch response is a sudden contraction of muscle fibres in a taut band [7]. Hong advocated that local twitch responses should be elicited during DN for a successful technique [8]. Once the first local twitch response is obtained, the needle is moved up and down, usually 3 to 5 mm, in vertical motions with no rotations at approximately 1Hz. The time of application will depend on the irritability of the TrP [7]. This assumption is supported by one study observing an immediate drop in the concentrations of some neurotransmitters, including calcitonin gene related peptide and substance P and several cytokines and interleukins in the extracellular fluid of the local TrP milieu after the insertion of a needle [9].
2
Scientific Evidence for Dry Needling Recent meta-analyses have found that trigger point dry needling (TrP-DN) may be effective for the treatment of upper quarter pain syndromes. In their meta-analysis, Kietrys et al concluded that TrP-DN can be recommended (grade A), compared to sham or placebo needling for decreasing pain at short-term in patients suffering from upper quarter myofascial pain immediately after and at a 4-week follow-up [10]. However, the 2
heterogeneity of the studies was high (I =86%) and the majority of the studies included
Downloaded by [222.79.109.29] at 12:42 19 February 2016
in the meta-analysis had relatively small sample sizes. Although the overall effect size was large (standardized mean difference, SMD: 1.06), the 95% confidence interval was wide (95%CI 0.05 to 2.06) suggesting imprecision of the results [10]. A recent metaanalysis conducted by Liu et al also found that TrP-DN was effective immediately after (SMD: 1.91; 95% I 0.073 to 3.10) and at medium term (SMD: 1.07, 95%CI 0.27 to 1.87) compared with control or sham needling for the management of TrPs associated with neck and shoulder pain [11]. In their systematic review, France et al found some evidence to support the use of DN in treating cervicogenic and tension-type headache [12]. This review included one clinical study on tension-type headache, one including a miscellaneous of patients presenting with myofascial head pain and a third case report centered in cervicogenic headache [12]. Interestingly, the results of this last study suggested that the addition of DN to conventional physiotherapy approaches rather than DN alone was a useful therapeutic strategy. Nevertheless, the inconsistency of the interventions between the studies, the points receiving the needling intervention, the heterogeneity of the samples, and the lack of appropriate control groups limited the conclusions. As a result, the review concluded that further research with stronger methodological design was clearly required. 3
Dry Needling in Headaches: Clinical Reasoning / Research Directions The rationale for applying DN in headaches relates to the etiologic role of TrPs in these pain conditions. TrPs are defined as hypersensitive tender spots located in a taut band of skeletal muscles that are painful on mechanical stimulation and give rise to a referred pain [13]. Several muscles, e.g., upper trapezius, sternocleidomastoid, splenius capitis, or suboccipital muscles of the cervical spine can refer pain to the head mimicking headache. Active TrPs provoke spontaneous pain and are responsible for
Downloaded by [222.79.109.29] at 12:42 19 February 2016
some of the patient’s symptoms, while latent TrPs do not cause spontaneous pain. There is clear scientific evidence supporting the role of active TrPs in tension-type, migraine, and cervicogenic headache [14]; although their relevance is slightly different depending on the headache disorder. For instance, TrPs are seemingly more related to tension-type headache than migraine [15]. The exact mechanism by which TrP-DN exerts its therapeutic effects remains to be elucidated, and both mechanical and neurophysiological mechanisms have been proposed [16]. Essentially, the application of TrP-DN on individuals with headaches may reduce both peripheral and central sensitization by removing a prolonged source of peripheral nociceptive inputs, by modulating spinal efficacy in the dorsal horn and by activating central inhibitory pain pathways [17]. All these effects are apparently initiated when active TrPs receive the needling intervention. Therefore, an accurate diagnosis of active TrPs should be conducted during clinical examination of patients with headache with the aim that the needling is introduced in the proper therapeutic target [18]. In fact, a recent study found that local lidocaine injections applied into TrPs in the peri-cranial muscles could be considered as an effective alternative treatment for individuals with episodic tension-type headache [19].
4
There is a need for further studies investigating the effectiveness of DN in patients with headaches. In order to be valid and clinically significant, future studies should contemplate the following recommendations: 1, an accurate identification of active TrPs is required; 2, the needling must be placed into active TrPs; 3, DN should be applied within a multimodal approach in conjunction with other therapies; 4, both active and placebo interventions mimicking DN must be compared with the aim of eliminating any
Downloaded by [222.79.109.29] at 12:42 19 February 2016
placebo effect [20].
Financial and competing interests disclosure The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
5
REFERENCES 1. Fernández-de-las-Peñas C, Cuadrado ML. Physical therapy for headaches. Cephalalgia Dec 9 pii: 0333102415596445 (2015) 2. Fernández-de-las-Peñas C, Cuadrado ML. Therapeutic options for cervicogenic headache. Expert Rev Neurother 14, 39-49 (2014) 3. Freitag FG, Schloemer F. Medical management of adult headache. Otolaryngol
Downloaded by [222.79.109.29] at 12:42 19 February 2016
Clin North Am 47, 221-37 (2014)
4. Kietrys DM, Palombaro KM, Mannheimer JS. Dry needling for management of
pain in the upper quarter and craniofacial region. Curr Pain Headache Rep 18, 437 (2014)
5. APTA. Description of dry needling in clinical practice: an educational resource paper. Alexandria, VA, USA: APTA Public Policy, Practice, and Professional Affairs Unit (2013) 6. Zhou K, Ma Y, Brogan MS. Dry needling versus acupuncture: the ongoing debate. Acupunct Med 33, 485-90 (2015) 7. Dommerholt J, Fernandez-de-las-Peñas C. Trigger point dry needling: an evidence and clinical- based approach. 1st ed. London: Churchill Livingstone: Elsevier (2013) 8. Hong CZ. Lidocaine injection versus dry needling to myofascial trigger point: The importance of the local twitch response. Am J Phys Med Rehabil 73, 256263 (1994) 9. Shah JP, Phillips TM, Danoff JV, Gerber LH. An in-vivo microanalytical technique for measuring the local biochemical milieu of human skeletal muscle. J Appl Physiol 99, 1977-84 (2005)
6
10. Kietrys DM, Palombaro KM, Azzaretto E, Hubler R, Schaller B, Schlussel JM, Tucker M. Effectiveness of dry needling for upper-quarter myofascial pain: a systematic review and meta-analysis. J Orthop Sports Phys Ther 43, 620-34 (2013) 11. Liu L, Huang QM, Liu QG, Ye G, Bo CZ, Chen MJ, Li P. Effectiveness of dry needling for myofascial trigger points associated with neck and shoulder pain: a systematic review and meta-analysis. Arch Phys Med Rehabil 96, 944-55 (2015)
Downloaded by [222.79.109.29] at 12:42 19 February 2016
12. France S, Bown J, Nowosilskyj M, Mott M, Rand S, Walters J. Evidence for the use of dry needling and physiotherapy in the management of cervicogenic or tension-type headache: A systematic review. Cephalalgia 34, 994-1003 (2014) 13. Simons DG, Travell J, Simons LS. Travell and Simons’ myofascial pain and dysfunction: the trigger point manual, Vol. 1, 2nd edn. Baltimore: Williams & Wilkins (1999) 14. Fernández-de-las-Peñas C. Myofascial Head Pain. Curr Pain Headache Rep 19, 28 (2015) 15. Alonso-Blanco C, de-la-Llave-Rincón AI, Fernández-de-las-Peñas C. Muscle trigger point therapy in tension-type headache. Expert Rev Neurother 12, 315-2 (2012) 16. Cagnie B, Dewitte V, Barbe T, Timmermans F, Delrue N, Meeus M. Physiologic effects of dry needling. Curr Pain Headache Rep 17, 348 (2013) 17. Dommerholt J. Dry needling: peripheral and central considerations. J Man Manip Ther 19, 223-7 (2011)
7
18. Robbins MS, Kuruvilla D, Blumenfeld A, et al. Trigger point injections for headaches disorders: expert consensus methodology and narrative review. Headache 54, 1441-59 (2014) 19. Karadaş Ö, Gül HL, Inan LE. J Lidocaine injection of pericranial myofascial trigger points in the treatment of frequent episodic tension-type headache. J Headache Pain 14, 44 (2013) 20. Madsen MV, Gøtzsche PC, Hróbjartsson A. Acupuncture treatment for pain:
Downloaded by [222.79.109.29] at 12:42 19 February 2016
systematic review of randomised clinical trials with acupuncture, placebo acupuncture and no acupuncture groups. BMJ 338, a3115 (2009)
8
ISSN: 1473-7175 (Print) 1744-8360 (Online) Journal homepage: http://www.tandfonline.com/loi/iern20
Dry needling for headaches presenting active trigger points César Fernández-de-las-Peñas PT, PhD, DMSc & María L. Cuadrado MD, PhD To cite this article: César Fernández-de-las-Peñas PT, PhD, DMSc & María L. Cuadrado MD, PhD (2016): Dry needling for headaches presenting active trigger points, Expert Review of Neurotherapeutics, DOI: 10.1586/14737175.2016.1152889 To link to this article: http://dx.doi.org/10.1586/14737175.2016.1152889
Accepted author version posted online: 10 Feb 2016.
Submit your article to this journal
Article views: 44
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=iern20 Download by: [222.79.109.29]
Date: 19 February 2016, At: 12:42
Dry needling for headaches presenting active trigger points AUTHORS
Downloaded by [222.79.109.29] at 12:42 19 February 2016
César Fernández-de-las-Peñas
1,2
PT, PhD, DMSc; María L. Cuadrado
3,4
MD, PhD
INSTITUTIONS
1 Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain.
2 Cátedra de Investigación y Docencia en Fisioterapia: Terapia Manual y Punción Seca, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain.
3 Headache Unit, Department of Neurology, Hospital Clínico San Carlos, Madrid, Spain.
4 Department of Medicine, Universidad Complutense, Madrid, Spain.
Corresponding author César Fernández de las Peñas Facultad de Ciencias de la Salud Universidad Rey Juan Carlos Avenida de Atenas s/n 28922 Alcorcón, Madrid SPAIN
Telephone number: + 34 91 488 88 84 Fax number: + 34 91 488 89 57
E-mail address: [email protected]
Key words: Dry needling, headache, trigger points.
1
Definition of Dry Needling Therapeutic management of headaches mainly includes pharmacological and physical therapy approaches [1-3]. In the last decade, there has been an increasing interest in the use of dry needling (DN) for the treatment of headache as well as for neck and shoulder pain syndromes [4]. The American Physical Therapy Association (APTA) defined DN as a “skilled intervention using a thin filiform needle to penetrate the skin and stimulate trigger points (TrPs), muscles, and connective tissue for the treatment of
Downloaded by [222.79.109.29] at 12:42 19 February 2016
musculoskeletal disorders” [5]. Although acupuncture and DN share many similarities [6], they differ in many aspects, particularly the fact that DN inserts the needle into the muscle and not in standardized acupuncture points [7]. The most commonly accepted DN approach is the “fast-in and fast-out” technique described by Hong [8]. This technique consists of the insertion of the needle penetrating the skin into a TrP until a local twitch response is obtained. The local twitch response is a sudden contraction of muscle fibres in a taut band [7]. Hong advocated that local twitch responses should be elicited during DN for a successful technique [8]. Once the first local twitch response is obtained, the needle is moved up and down, usually 3 to 5 mm, in vertical motions with no rotations at approximately 1Hz. The time of application will depend on the irritability of the TrP [7]. This assumption is supported by one study observing an immediate drop in the concentrations of some neurotransmitters, including calcitonin gene related peptide and substance P and several cytokines and interleukins in the extracellular fluid of the local TrP milieu after the insertion of a needle [9].
2
Scientific Evidence for Dry Needling Recent meta-analyses have found that trigger point dry needling (TrP-DN) may be effective for the treatment of upper quarter pain syndromes. In their meta-analysis, Kietrys et al concluded that TrP-DN can be recommended (grade A), compared to sham or placebo needling for decreasing pain at short-term in patients suffering from upper quarter myofascial pain immediately after and at a 4-week follow-up [10]. However, the 2
heterogeneity of the studies was high (I =86%) and the majority of the studies included
Downloaded by [222.79.109.29] at 12:42 19 February 2016
in the meta-analysis had relatively small sample sizes. Although the overall effect size was large (standardized mean difference, SMD: 1.06), the 95% confidence interval was wide (95%CI 0.05 to 2.06) suggesting imprecision of the results [10]. A recent metaanalysis conducted by Liu et al also found that TrP-DN was effective immediately after (SMD: 1.91; 95% I 0.073 to 3.10) and at medium term (SMD: 1.07, 95%CI 0.27 to 1.87) compared with control or sham needling for the management of TrPs associated with neck and shoulder pain [11]. In their systematic review, France et al found some evidence to support the use of DN in treating cervicogenic and tension-type headache [12]. This review included one clinical study on tension-type headache, one including a miscellaneous of patients presenting with myofascial head pain and a third case report centered in cervicogenic headache [12]. Interestingly, the results of this last study suggested that the addition of DN to conventional physiotherapy approaches rather than DN alone was a useful therapeutic strategy. Nevertheless, the inconsistency of the interventions between the studies, the points receiving the needling intervention, the heterogeneity of the samples, and the lack of appropriate control groups limited the conclusions. As a result, the review concluded that further research with stronger methodological design was clearly required. 3
Dry Needling in Headaches: Clinical Reasoning / Research Directions The rationale for applying DN in headaches relates to the etiologic role of TrPs in these pain conditions. TrPs are defined as hypersensitive tender spots located in a taut band of skeletal muscles that are painful on mechanical stimulation and give rise to a referred pain [13]. Several muscles, e.g., upper trapezius, sternocleidomastoid, splenius capitis, or suboccipital muscles of the cervical spine can refer pain to the head mimicking headache. Active TrPs provoke spontaneous pain and are responsible for
Downloaded by [222.79.109.29] at 12:42 19 February 2016
some of the patient’s symptoms, while latent TrPs do not cause spontaneous pain. There is clear scientific evidence supporting the role of active TrPs in tension-type, migraine, and cervicogenic headache [14]; although their relevance is slightly different depending on the headache disorder. For instance, TrPs are seemingly more related to tension-type headache than migraine [15]. The exact mechanism by which TrP-DN exerts its therapeutic effects remains to be elucidated, and both mechanical and neurophysiological mechanisms have been proposed [16]. Essentially, the application of TrP-DN on individuals with headaches may reduce both peripheral and central sensitization by removing a prolonged source of peripheral nociceptive inputs, by modulating spinal efficacy in the dorsal horn and by activating central inhibitory pain pathways [17]. All these effects are apparently initiated when active TrPs receive the needling intervention. Therefore, an accurate diagnosis of active TrPs should be conducted during clinical examination of patients with headache with the aim that the needling is introduced in the proper therapeutic target [18]. In fact, a recent study found that local lidocaine injections applied into TrPs in the peri-cranial muscles could be considered as an effective alternative treatment for individuals with episodic tension-type headache [19].
4
There is a need for further studies investigating the effectiveness of DN in patients with headaches. In order to be valid and clinically significant, future studies should contemplate the following recommendations: 1, an accurate identification of active TrPs is required; 2, the needling must be placed into active TrPs; 3, DN should be applied within a multimodal approach in conjunction with other therapies; 4, both active and placebo interventions mimicking DN must be compared with the aim of eliminating any
Downloaded by [222.79.109.29] at 12:42 19 February 2016
placebo effect [20].
Financial and competing interests disclosure The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
5
REFERENCES 1. Fernández-de-las-Peñas C, Cuadrado ML. Physical therapy for headaches. Cephalalgia Dec 9 pii: 0333102415596445 (2015) 2. Fernández-de-las-Peñas C, Cuadrado ML. Therapeutic options for cervicogenic headache. Expert Rev Neurother 14, 39-49 (2014) 3. Freitag FG, Schloemer F. Medical management of adult headache. Otolaryngol
Downloaded by [222.79.109.29] at 12:42 19 February 2016
Clin North Am 47, 221-37 (2014)
4. Kietrys DM, Palombaro KM, Mannheimer JS. Dry needling for management of
pain in the upper quarter and craniofacial region. Curr Pain Headache Rep 18, 437 (2014)
5. APTA. Description of dry needling in clinical practice: an educational resource paper. Alexandria, VA, USA: APTA Public Policy, Practice, and Professional Affairs Unit (2013) 6. Zhou K, Ma Y, Brogan MS. Dry needling versus acupuncture: the ongoing debate. Acupunct Med 33, 485-90 (2015) 7. Dommerholt J, Fernandez-de-las-Peñas C. Trigger point dry needling: an evidence and clinical- based approach. 1st ed. London: Churchill Livingstone: Elsevier (2013) 8. Hong CZ. Lidocaine injection versus dry needling to myofascial trigger point: The importance of the local twitch response. Am J Phys Med Rehabil 73, 256263 (1994) 9. Shah JP, Phillips TM, Danoff JV, Gerber LH. An in-vivo microanalytical technique for measuring the local biochemical milieu of human skeletal muscle. J Appl Physiol 99, 1977-84 (2005)
6
10. Kietrys DM, Palombaro KM, Azzaretto E, Hubler R, Schaller B, Schlussel JM, Tucker M. Effectiveness of dry needling for upper-quarter myofascial pain: a systematic review and meta-analysis. J Orthop Sports Phys Ther 43, 620-34 (2013) 11. Liu L, Huang QM, Liu QG, Ye G, Bo CZ, Chen MJ, Li P. Effectiveness of dry needling for myofascial trigger points associated with neck and shoulder pain: a systematic review and meta-analysis. Arch Phys Med Rehabil 96, 944-55 (2015)
Downloaded by [222.79.109.29] at 12:42 19 February 2016
12. France S, Bown J, Nowosilskyj M, Mott M, Rand S, Walters J. Evidence for the use of dry needling and physiotherapy in the management of cervicogenic or tension-type headache: A systematic review. Cephalalgia 34, 994-1003 (2014) 13. Simons DG, Travell J, Simons LS. Travell and Simons’ myofascial pain and dysfunction: the trigger point manual, Vol. 1, 2nd edn. Baltimore: Williams & Wilkins (1999) 14. Fernández-de-las-Peñas C. Myofascial Head Pain. Curr Pain Headache Rep 19, 28 (2015) 15. Alonso-Blanco C, de-la-Llave-Rincón AI, Fernández-de-las-Peñas C. Muscle trigger point therapy in tension-type headache. Expert Rev Neurother 12, 315-2 (2012) 16. Cagnie B, Dewitte V, Barbe T, Timmermans F, Delrue N, Meeus M. Physiologic effects of dry needling. Curr Pain Headache Rep 17, 348 (2013) 17. Dommerholt J. Dry needling: peripheral and central considerations. J Man Manip Ther 19, 223-7 (2011)
7
18. Robbins MS, Kuruvilla D, Blumenfeld A, et al. Trigger point injections for headaches disorders: expert consensus methodology and narrative review. Headache 54, 1441-59 (2014) 19. Karadaş Ö, Gül HL, Inan LE. J Lidocaine injection of pericranial myofascial trigger points in the treatment of frequent episodic tension-type headache. J Headache Pain 14, 44 (2013) 20. Madsen MV, Gøtzsche PC, Hróbjartsson A. Acupuncture treatment for pain:
Downloaded by [222.79.109.29] at 12:42 19 February 2016
systematic review of randomised clinical trials with acupuncture, placebo acupuncture and no acupuncture groups. BMJ 338, a3115 (2009)
8
