Curr Pain Headache Rep (2014) 18:437 DOI 10.1007/s11916-014-0437-0

MYOFASCIAL PAIN (R GERWIN, SECTION EDITOR)

Dry Needling for Management of Pain in the Upper Quarter and Craniofacial Region David M. Kietrys & Kerstin M. Palombaro & Jeffrey S. Mannheimer

# Springer Science+Business Media New York 2014

Abstract Dry needling is a therapeutic intervention that has been growing in popularity. It is primarily used with patients that have pain of myofascial origin. This review provides background about dry needling, myofascial pain, and craniofacial pain. We summarize the evidence regarding the effectiveness of dry needling. For patients with upper quarter myofascial pain, a 2013 systematic review and meta-analysis of 12 randomized controlled studies reported that dry needling is effective in reducing pain (especially immediately after treatment) in patients with upper quarter pain. There have been fewer studies of patients with craniofacial pain and myofascial pain in other regions, but most of these studies report findings to suggest the dry needling may be helpful in reducing pain and improving other pain related variables such as the pain pressure threshold. More rigorous randomized controlled trials are clearly needed to more fully elucidate the effectiveness of dry needling. Keywords Dry needling . Myofascial pain . Myofascial trigger point . Craniofacial pain . Orofacial pain . Temporomandibular joint dysfunction

This article is part of the Topical Collection on Myofascial Pain D. M. Kietrys (*) Department of Rehabilitation and Movement Sciences, Rutgers, The State University of New Jersey, School of Health Related Professions, Stratford, NJ, USA e-mail: [email protected] K. M. Palombaro Institute of Physical Therapy Education, Widener University, Chester, PA, USA J. S. Mannheimer Delaware Valley Physical Therapy Associates, Lawrenceville, NJ, USA J. S. Mannheimer Rehabilitation and Regenerative Medicine, New York, NY, USA

Abbreviations MTrP DN CFP TMJ TMD

myofascial trigger point dry needling craniofacial pain temporomandibular joint temporomandibular joint disorder

Introduction Dry Needling and Myofascial Pain Dry needling is a therapeutic technique in which thin monofilament needles are inserted into muscle, ligament, tendon, subcutaneous fascia, scar tissue, peripheral nerve or neurovascular bundles, for the general purpose of reducing pain associated with neuromusculoskeletal conditions [1-3, 4••]. Unlike traditional Chinese acupuncture, dry needling does not consider movement of chi, or energy, along meridians, nor does it rely on a traditional Chinese medicine diagnosis. When dry needles are inserted into muscle tissue, the technique is sometimes referred to as “intramuscular manual therapy” or “trigger point dry needling” [1, 4••]. Dry needling may be used in the treatment of myofascial pain syndrome (MPS). MPS can occur anywhere in the body, including the craniofacial region. MPS is characterized by the presence of myofascial trigger points (MTrPs) [5]. MTrPs are a common source of pain in patients in primary care or pain clinic settings [6-8]. MTrPs develop in response to injury or trauma, muscle overuse or overload, repetitive microtrauma, or poor posture [9, 10, 11••]. MTrPs can cause local and/or referred pain and/or aggravation of existing pain [9, 12-14]. In addition, MTrPs may contribute to motor symptoms (such as weakness or dysfunctional movement patterns), autonomic phenomena,

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impaired range of motion, and increased sensitivity to stretch [9, 10, 12-19]. Active MTrPs may cause spontaneous pain, while latent MTrPs only elicit symptoms when compressed or palpated [9, 20]. MTrPs may be found locally (near the primary site of pain) or at sites distal to the pain [18, 21]. MTrPs are clinically defined as tender taut bands (or “contraction knots”) within a muscle that contain hyperalgesic zones [9, 10, 13, 20, 22]. The development of MTrPs consists of four overlapping stages [10, 23]. In the first stage, a taut band develops due to excessive acetylcholine release at the motor endplate with resultant abnormalities in endplate action potential. The taut band is due to sarcomere shortening and a heightened state of contraction [24]. In the next stage, local ischemia and hypoxia develops due to sustained sarcomere contractions. Alterations in the local chemical environment, such as increased intramuscular acidity and elevated levels of several nociceptive substances, are involved in stimulation of muscle nociceptors [25-27]. In the third stage, sensitization of peripheral nociceptors occurs, due to the release of vasoactive and algogenic substances, resulting in heightened peripheral sensitivity [10, 23]. Finally, central sensitization of the dorsal horn neurons and supraspinal structures can develop, resulting in hyperalgesia and allodynia [10, 23]. Dry needling is proposed to have physiologic effects at all stages of MTrP development. In the first stage, dry needling acts to interrupt spontaneous electrical activity by eliciting a localized twitch response and reducing the contraction in the trigger point [28]. Dry needling also stimulates mechanoreceptors [29] and diminishes availability of acetylcholine in the endplate region [30, 31]. In the ischemia and hypoxia stage of MTrP development, dry needling causes vasodilation [32] and may increase hypoxive-responsive proteins that support angiogenesis, vasodilation, and altered glucose metabolism [31, 33-35]. In addition, dry needling reduces peripheral sensitization by decreasing levels of substance P and the calcitonin gene-related peptide [31]. Finally, dry needling can mitigate central sensitization by segmental inhibition or gate control [28, 36], release of endogenous opiods [37], and activation of serotonergic and noradrenergic descending inhibitory tracts [38]. Dry Needling Technique Dry needling involves the insertion of a fine, solid filiform needle [39]. The needle penetrates the skin but does not introduce any analgesic medications [40]. When dry needling is performed on muscles, the length of the needle selected is contingent upon muscle size, with thicker muscles requiring longer and thicker needles [41]. Prior

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to inserting the needle into muscle, the clinician palpates the MTrP and cleans the overlying skin with isopropyl alcohol [40]. Studies exploring the inter-examiner reliability of identifying specific locations of MTrPs have provided conflicting results, with some studies suggesting the reliability is poor [42]. Several dry needling techniques in the context of MTrPs are noted in the literature. In one, the clinician pinches the MTrP between two fingers and inserts the needle between the two fingers about 1-2 cm from the MTrP at a 30° angle to the skin [40]. The needle is moved slowly up and down within the superficial and deep muscle fibers like a piston, with or without withdrawl from the tissue, in order to elicit a local twitch response [18, 43, 44]. Needle twirling is at times also performed adjunctively, which causes a fascial stretch [4••]. The local twitch response is a contraction of the muscle fibers in the immediate vicinity of the DN, as the result of an involuntary spinal reflex [17, 45]. Another form of DN technique involves needle insertion perpendicular to the skin, followed by movement of the needle until it meets a trigger point [46]. Needles can be also inserted so that they are left to stand independently in the tissue for 30 seconds to five minutes, with intermittent needle rotation until the abolition of a “jump sign” (a reflexive contraction in which the muscle shortens around the needle) [29, 41, 47]. The techniques described above involve inserting the needle into deeper layers of muscle. Inserting the needle deeper affects skin, fascia and muscle and has a better analgesic effect than when inserted only into the skin and superficial muscle [39, 48-50]. Optimal dosage of dry needling (frequency of sessions, duration of needle insertion, number of needles) remains unclear, and the dosage used in RCTs to date is variable [1]. Dommerholt recommends waiting 7-10 days before needling the same muscle again [4••]. A localized twitch response is often described as the desired response, although many RCTs describe a “deqi” response, defined as subjective reports of dull ache, heaviness, or other transient sensory perceptions at the site of needle insertion [1, 51]. It is also common for the patient to report referred pain in similar distributions to that described by Simons and Travel [9, 10]. Dry needling may also be administered to sites distal to local MTrPs [1]. Typically, dry needling of MTrPs is followed by stretching exercises and other interventions directed toward the patient’s impairments. The wellinformed clinician utilizes dry needling as part of a comprehensive treatment program that addresses the underlying structural, movement, and posture related problems that caused or propagated the MTrPs. Craniofacial Pain Headaches and orofacial discomfort, collectively termed craniofacial pain (CFP) can occur in any region of the

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cranium and/or facial skeleton. Muscle pain is a commonly overlooked factor in the etiology and perpetuation of CFP. The physiological mechanisms of muscle pain have been well described [9, 52]. For example, hyperactivity and pain within the masticatory muscles due to diurnal or nocturnal parafunction (bruxism and clenching) with or without the presence of an intrinsic TMJ dysfunction is commonly observed in the temporalis, masseter and medial pterygoid. Hyperactivity of the superior belly of the lateral pterygoid may contribute to anterior disc displacement within the TMJ. The etiology of CFP (with or without temporomandibular joint dysfunction) is not solely limited to local or intrinsic pathological, musculoskeletal or mechanical factors. One of the most overlooked etiological factors in CFP is referral from upper quarter structures including the cervical spine and shoulder girdle [53-63]. One example that illustrates the neuromusculoskeletal connections between the cranium, face and upper quarter region is the trigeminocervical complex. The spinal tract of the trigeminal nerve synapses with the dorsal horn of C1 – C3, thus, helping explain pain referral between the craniofacial area and upper cervical spine [64]. A dense neural interplay at the sub-occipital fossa, with interconnections between the trigeminal, facial, glosso-pharyngeal and vagus nerves, can give rise to local and referred pain and associated symptomatology [65]. Another example is referral of pain to the masseter and temporalis region from the upper trapezius or the SCM [9]. Patients with cervical radiculitis not only present with scapular and neck pain, but may also have CFP [66]. Recent publications on sleep, exercise, driving and work positions suggest that they impact the UQ and craniomandibular regions and can contribute to local and referred pain in the craniofacial region [9, 53-61, 67-72]. Functioning in awkward or constrained postures can propagate cumulative microtrauma and musculoskeletal accommodation. This can lead to the development of pathology such as spondylosis, disc degeneration or herniation, nerve root irritation, muscle hyperactivity, spasm and adaptive shortening. Such pathologies may culminate in the development of local and referred pain. For example, chronic forward head - rounded shoulder posture leads to increased sub-occipital compression and shortening of the upper trapezius and SCM, elevated electromyographic activity of the upper trapezius and a greater likelihood of local and referred pain [53, 68]. Head and neck neuromusculoskeletal disorders and referral from head and neck myofascial tissues can mimic symptoms of other pathologies in the craniofacial region, erroneously suggesting the presence of an intrinsic EENT disorder [65]. For example, while the sternocleidomastoid may refer pain to the craniofacial area, it is also known to

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give rise to a myriad of symptoms such as dizziness, vertigo, ataxia or disequilibrium, lacrimation, ptosis and reddening of the eye, nausea, syncope, tinnitus, dry paroxysmal cough, blurred vision, etc. [9]. Although parafunctional habits such as clenching and bruxism typically cause local or referred muscular symptoms, they can also cause symptoms in the sinuses, palate, gingiva, teeth, nasal or paranasal region, or the eye [9, 65]. A chronic paroxysmal dry cough may be triggered by SCM hyperactivity that irritates the superior laryngeal nerve [73]. The anterior digastric muscle can cause toothache via referred pain to the central and lateral mandibular incisors [9]. The masseter muscle can refer pain to the ipsilateral mandibular and maxillary three molars, while the temporalis can refer pain to any of the ipsilateral maxillary teeth [9]. Clinical experience of the authors suggests that some patients with myofascial causes of such symptoms may be misdiagnosed with EENT pathologies such as ear infection, migraine, Meniere’s syndrome, neuralgia, cerebellar ataxia, torticollis, toothache, tinnitus, barohypoacusis, vertigo, or a temporomandibular disorder (TMD). Thus, a comprehensive myofascial differential analysis including assessment of orofacial and cervical musculature is critical [74]. There is currently an increasing amount of evidence to suggest that referred pain from local and distal muscle can mimic the exact distribution of tension-type and migraine headaches [75-84]. Trigger point evaluation in the presence of migraine headaches has in part been linked to peripheral sensitization and supported by pressure pain mapping [82, 83, 85, 86]. Upper quarter postural dysfunction and concomitant sub-occipital, upper trapezius, sternocleidomastoid and ocular muscle trigger points are highly associated with the presence of tension-type and migraine headaches [60, 75, 76, 79, 81, 84, 87, 88]. The presence of upper quarter MTrPs correlates significantly with the location of pain in patients with migraines; the typical ram’s horn pain distribution of a unilateral migraine represents the exact same pain referral pattern as the upper trapezius [9, 82, 83]. Craniofacial pain referred from the upper trapezius has been shown to give rise to acute tension-type headaches as well as perpetuate their chronicity if not properly treated [78, 80]. The intensity, duration and frequency of headache have been shown to correlate with the extent of postural dysfunction [75]. Furthermore, the association of the upper quarter to orofacial pain and TMD is strongly supported in the literature [53-58, 60, 70-72]. Thus, examination of the patient with CFP must include an in-depth assessment of the pain distribution as well as determination of the etiology (neuromuscular and/or vascular) and perpetuating factors. When myofascial contributions to symptoms exist, techniques such as dry needling, manual therapy, therapeutic exercise, postural reeducation, and patient

Subjects 45 patients with myofascial pain and headaches for at least six months and MTrPs in orofacial or cervical region

36 patients with TMJ pain, limited opening and external pterygoid MTrP 52 patients with TMJ pain for at least six weeks and MTrPs in TMJ muscles

12 females with myofascial masseteric pain for at least sox months and mandibular hypomobility

30 patients with masseter and temporalis pain

71 patients with tinnitus and head, neck or shoulder myofascial pain

Study

Venancio et al. [11••]

Gonzalez-Perez et al. [99•]

Diracoglu et al. [97••]

Fernandez-Carnero et al. [98•]

McMillan et al. [100•]

Rocha & Sanchez [101••]

Table 1 Summary of studies of dry needling for craniofacial symptoms

All patients received two sessions at least seven days apart: • one session of deep DN (25 mm needle) • one session of “sham” DN (13 mm needle) Randomized into twogroups to determine which was received at 1st session. Randomized into three groups, each receiving three sessions over three weeks: • Procaine injection plus sham DN • DN plus sham injection • Sham DN plus sham injection Randomized into twogroups, each receiving 10 weekly sessions of: • DN • Sham (palpation)

Randomized into two groups: • Placebo (sham needling) • DN (1 session)

All patients received three sessions of DN over one week

Three groups, received one session of either: • DN • Lidocaine injection • Botulinum toxin injection

Independent Variables

After intervention, greater tinnitus relief in the DN group compared to sham

Slight increases in pain pressure threshold and decreased pain intensity and unpleasantness in all groups (up to 24 hours after each session) with no significant between group differences

Reduced Symptom Severity Index score at one week (all groups) Reduced pain with palpation (all groups) at ten minutes, 1, 4 and 12 weeks Less use of pain medications (all groups) Reduced headache intensity at 10 minutes (all groups) Reduced TMJ pain and improved mandibular range of motion at 2 weeks, 1, 2 and 6 months Improved pressure pain threshold, decreased pain intensity in the DN group at one week, with significant differences between DN and sham for pain pressure threshold Improved pressure pain threshold and improved range of motion (jaw opening) five minutes after deep DN compared to “sham” DN

Key Findings

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Table 2 Brief summary of evidence regarding effectiveness of DN at sites other than the upper quarter and craniofacial region Body Region

Brief Summary of Evidence

Low Back

Furlan et al. [103]: Cochrane systematic review of 35 randomized controlled trials (RCTs) using either acupuncture or dry needling found that pain relief and functional improvement occurred in patients with chronic low back pain as compared to a sham control. Itoh et al. [104]: Significant, short-term reduction in pain in older adults Rainey [105]: A case report described that DN paired with intramuscular electrical stimulation reduced pain and disability in low back and right posterolateral hip Huguenin et al. [106]: Improvement of running-related posterior thigh pain and hip range of motion in male runners in both placebo needling and DN groups. Mayoral et al. [107]: Significant reduction in total knee replacement post-operative pain and reduction in the need for pain medications. Tillu & Gupta [108]: Reduction of visual analogue ratings and subjective scores for plantar heel pain.

Low Back Low Back and Hip Posterior Thigh Knee (after total knee arthroplasty) Plantar heel Plantar heel Pelvic floor

Perez-Millan & Foster [109]: DN paired with electroacupuncture significantly reduced plantar heel pain and improved function. Moldwin & Foster [110] : DN is suggested as one of a number of conservative therapies to reduce MTrPs and thus treat bladder pain syndrome and interstitial cystitis

education to correct sleep, sit, driving, work and exercise positions should be implemented [58].

Evidence for Effectiveness of Dry Needling Dry Needling for Upper Quarter Myofascial Pain A 2013 systematic review and meta-analysis [89••] of effectiveness of dry needling for upper quarter myofascial pain identified 12 randomized controlled trials [18, 41, 44, 46, 47, 49, 90-95] involving participants with chronic pain in the neck, trapezius or shoulder regions. Meta-analysis of data from four studies regarding immediate effects of dry needling compared to sham or control found a large effect favoring dry needling, with between group differences in pain reduction ranging from 1.2 to 4.0 points on a 0 to 10 VAS scale. Clinically, dry needling is often used to achieve immediate reductions in pain so that additional therapeutic procedures directed toward the patient’s impairments may be implemented. Regarding the meta-analysis of data from three studies that compared dry needling to sham or placebo at four weeks, there was a large effect favoring dry needling, but conclusions about the effectiveness of dry needling compared to sham or placebo at four weeks should be made with caution. Metaanalysis of data from two studies regarding the immediate effects of dry needling compared to other procedures such as lidocaine injection or non-local acupuncture found the dry needling was not superior. One of these studies found that when localized twitch responses were induced via either dry needling or lidocaine injection, the difference in response between the two treatments was neither clinically nor statistically meaningful [91]. When a localized twitch response was

not induced, little change in pain, tenderness or range of motion was found. This suggests that the localized twitch response may be related to a successful result. Eight data sets from six studies [41, 46, 47, 49, 92, 94] entered into a meta-analysis of effects of dry needling compared to other treatments at four weeks found that dry needling was not superior, in general, to other treatments (such as laser, standard rehabilitation, lidocaine injection, acupuncture, electrical stimulation, or botulinum injection). Results of individual studies varied depending on the comparison treatment and patient population. One study found dry needling to be more effective than needling of non-tender points or acupuncture in patients with chronic neck pain [49]. The review concluded that dry needling is recommended for immediate reductions in pain in patients with chronic upper quarter myofascial pain, and cautiously recommended at four weeks. Additional studies with rigorous design and sound internal validity are needed to aid in the development of more conclusive evidence of the effectiveness of dry needling in this population. Dry Needling for Headaches and Craniofacial Pain Studies that have explored DN for headaches craniofacial pain (and not included in the Kietrys et al., systematic review of DN for upper quarter myofascial pain), are summarized in Table 1. DN has been suggested as a therapeutic option in the treatment of migraine headaches in patients with migraine headaches, which have been associated with MTrPs [88]. To date, one outcome study [11••] has explored the effectiveness of DN in patients with myofascial pain and headaches, and found favorable outcomes in patients treated with DN or lidocaine injection or botulinum toxin injection.

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Myofascial pain is a common entity in the development and perpetuation of TMD [9, 86, 96]. The four studies [97••, 98•, 99•, 100•] that have explored the effectiveness of dry needling in patients with TMJ dysfunction or involvement of TMJ muscles are summarized in Table 1. Favorable outcomes were noted in two studies of patients with TMJ pain [97••, 99•] and in two studies of patients with MTrPs in muscles of mastication [98•, 100•], although one of these studies [100•] found no superiority of dry needling compared to sham. In addition, one study of DN in patients with tinnitus [101••] found favorable outcomes in terms of reduced symptoms when dry needling was compared to sham.

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studies regarding effectiveness for dry needling and optimal technique and dosing. Compliance with Ethics Guidelines Conflict of Interest Dr. David M. Kietrys, Dr. Kerstin Palombaro, and Dr. Jeffrey S. Mannheimer each declare no potential conflicts of interest. Human and Animal Rights and Informed Consent This article does not contain any studies with human or animal subjects performed by any of the authors.

References Dry Needling for Other Regions A small number of studies have explored the effectiveness of DN in regions of the body other than the upper quarter and craniofacial region. These sites include the low back, the lower extremity, and the pelvic floor. Key finding from studies of DN in other regions is summarized in Table 2.

Conclusions In order to effective manage patients with the complex problem of craniofacial pain, it is imperative to perform a careful examination, including assessment of upper quarter MTrPs, and utilize a comprehensive treatment paradigm [58, 59, 102]. The increasing popularity of dry needling as a therapeutic intervention should be viewed in light of evidence of its effectiveness. Although additional research is needed before more definitive conclusions can be made, the evidence to date suggests that dry needling is effective, especially in the short term, for reducing pain in patients with upper quarter myofascial pain. Findings from a small number of individual studies also suggest that dry needling may be beneficial for patients with craniofacial pain associated with headache or TMJ involvement. Clearly, more rigorously designed randomized controlled trials are needed before definitive conclusions can be made about the effectiveness of dry needling for the craniofacial area as well as other regions of the body. A small but growing body of literature has suggested that dry needling leads to favorable outcomes for a number of lower body conditions. The addition of dry needling to the therapeutic process, when performed by trained practitioners, requires minimal low cost equipment and can be administered in relatively short periods of time, thus, making it an economically efficient means of reducing pain in patients with neuromusculoskeletal conditions. Clinicians interested in dry needling should continue to remain appraised of new

Papers of particular interest, published recently, have been highlighted as • Of importance •• Of major importance 1.

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