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Journal of Back and Musculoskeletal Rehabilitation 28 (2015) 173–179 DOI 10.3233/BMR-140547 IOS Press

Efficacy of dry needling for treatment of myofascial pain syndrome Yacov Fogelmana,∗ and John Kentb a

Leumit Health Services and Institute of Pain Medicine, Rambam Health Care Campus and Technion, Rappaport School of Medicine, Haifa, Israel b Maccabi Health Services and Rambam School of Pain Medicine, Haifa, Israel

Abstract. Myofascial pain is a major cause of musculoskeletal regional pain. Myofascial pain, which is a high-prevalence but eminently treatable condition, is almost universally underdiagnosed by physicians and undertreated by physical therapy modalities. Large numbers of patients can be left suffering in chronic pain for years. Dry needling, also referred to as Intramuscular Stimulation, is a method in the arsenal of pain management which has been known for almost 200 years in Western medicine, yet has been almost completely ignored. With the increase in research in this field over the past two decades, there are many high-quality studies that demonstrate dry needling to be an effective and safe method for the treatment of myofascial pain when diagnosed and treated by adequately-trained physicians or physical therapists. This article provides an overview of recent literature regarding the treatment of myofascial pain syndrome, evidence for the efficacy of dry needling as a central component of its management, and a glimpse at developments in recent imaging methods to aid in the treatment of these problems. Keywords: Myofascial pain syndrome, dry needling, intramuscular stimulation, trigger point

1. The burden of pain in medical practice Myofascial pain (MFP) is a common source of musculoskeletal pain presenting in primary care. Musculoskeletal pain is a major cause of morbidity [1] whose prevalence is high and increases with age. It is the single most common reason for patients presenting with pain complaints to their physician [2]. A growing number of individuals in our population have musculoskeletal pain that affects their daily activities and function. It has a significant impact on their quality of life. The prevalence of MFP in pain management centers is high. In a comprehensive pain centre study on 283 consecutive patients, two physicians independently reported MFP as the primary diagnosis in 85% of cases [3]. Gerwin examined 96 patients in another pain centre study and found MFP to be the primary cause of pain in 74% of cases, and 93% of ∗ Corresponding author: Yacov Fogelman, Institute of Pain Medicine, Rambam Health Care Campus and Technion, Rappaport School of Medicine, Haifa, Israel. E-mail: [email protected]

cases had at least part of their complaint caused by MFP [4]. However, musculoskeletal pain often goes undiagnosed by both physicians and physiotherapists, leading to chronic conditions [5,6].

2. Definition and mechanisms of myofascial pain Myofascial pain is a regional pain syndrome characterized in part by a trigger point (TrP) in a taut band (TB) of skeletal muscle and its associated referred pain. A key to understanding myofascial pain syndrome is the recognition of specific pain patterns generated by a particular muscle, whose associated dysfunction may be easily detected by weakness and reduced range of motion. Sir Thomas Lewis [7] was already mapping these characteristic pain patterns with his student Jonas Kellgren in the 1930s. The patient’s pain complaint is often referred to a segmentallyrelated area distant from the muscle itself, and not in a recognizable traditional dermatomal pain pattern. The segmental pain is localized or regional rather than gen-

c 2015 – IOS Press and the authors. All rights reserved ISSN 1053-8127/15/$35.00 

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eralized (as in the case of fibromyalgia), and the referred pain patterns are consistent and reproducible. Active TrPs are typified by tender spots in taut muscular bands, and pressure on them reproduces the patient’s pain in typical patterns for each TrP [8]. The term “Trigger Point” (TrP) was first coined by Travell et al. [9], to describe a tender nodule within a group of muscle fibers. These sensitive TrPs can cause significant pain as well as motor dysfunction of the muscle [10]. TrPs are not always sensitive and can also be found in the muscles that are rigid only [11]. The physiological mechanism underlying the development of rigid muscle bundles (taut bands, TBs) and TrPs has not been sufficiently elucidated until the last decade [12]. Recent literature supports the notion that the altered activity of the motor endplate – the neuromuscular junction – is responsible [13]. Travell’s “Energy Crisis” model postulates that TrPs form at the neuromuscular junction, where local hypoxia increases the demand for ATP, changes Ca++ reuptake, upregulates acetylcholine (ACh) receptor activity, and decreases acetylcholinesterase activity. The pain which develops after the creation of these hardened muscle nodules is thought to be caused by the release of inflammatory mediators such as bradykinin and potassium ions in the microcirculation. These substances activate peripheral nociceptors and also induce the release of calcitonin gene-related peptide (CGRP) from motor nerve endings, which in turn increases endplate activity that enhances sensory nerve activation [14]. TrPs may develop in response to acute overload, chronic repetitive strain, poor static posture, non-ideal sleeping positions and incorrect ergonomic habits. These TrPs can cause significant pain and interfere with muscle function. Exercise under ischemic conditions and eccentric muscle exercise (muscle contraction during lengthening) result in persistent muscle pain. Muscle that is maximally eccentrically contracted shows evidence of muscle fiber distraction similar to changes seen in exercised ischemic muscle. Women with work-related trapezius myalgia have a deficiency of cytochrome C oxidase, suggestive in energy crisis within the muscle [15]. In addition, MFP is often exacerbated by mental and social stress and it is suggested that psychophysiological mechanisms play an important role in the development and maintenance of chronic pain states [16]. Passatore and Roatta [17] advocate that stress may facilitate the development of chronic pain states, irrespective of their origin. Since the 1970s, one of the leading proponents of dry needling therapy has been Gunn in Canada [18].

Based upon observations of the treatment on thousands of patients, he proposed a model that MFP syndrome may be caused by peripheral segmental nerve dysfunction or radiculopathy, i.e., a functional disturbance in the peripheral nerve innervating the muscle. He based his treatment model on accepted neurophysiological principles that underlie the variety of pathologies found by Cannon et al. [19]. Cannon’s Law of Denervation relates to somatosensory afferent supersensitization, whereby functional denervation of a muscle results in lowered thresholds to stimulation. As a result the denervated muscle becomes extremely sensitive, as measured by a dramatic increase in ACh receptors throughout the muscle and not just at the motor endplate. This sensitivity results in muscle contraction and shortening (in the absence of nerve stimulus), as well as pain and the development of TrPs in the affected muscle and others involved at that vertebral segment. Stimulation of these denervated muscles has been shown experimentally to dramatically decrease the ACh sensitivity [20] and thus the chronic contraction of the muscle. Muscle contraction of the paravertebral Multifidi of an involved segment can cause narrowing of the intervertebral foramen, resulting in irritation and dysfunction of the dorsal root ganglion within it. Gunn coined the phrase IMS (Intramuscular Stimulation) – a method for treating MFP by inserting acupuncture needles into affected peripheral muscles as well as the paravertebral Multifidi of the involved spinal segment. This treatment of the affected spinal segment, of muscles innervated by both the anterior primary ramus as well as the posterior primary ramus of the peripheral nerve, has been acknowledged to increase the efficacy of dry needling as a modality. If myofascial pain is left untreated, it may become an irritative focus and send persistent pain impulses via sensory neurons to the spinal cord. The spinal reflex loop that is constantly bombarded with peripheral noxious stimuli may result in spinal cord central sensitization which is characterized by the facilitated release of nociceptive neurotransmitters in the dorsal horn; lowered threshold for synaptic activation of interneurons, and; resulting amplification and perpetuation of noxious input over several adjacent vertebral levels above and below the irritative focus [21]. This condition may affect sensory, motor and autonomic components of the hyperactive and hyperexcitable spinal segments. It is here that a critical difference may be noticed, marking the different etiologies of pain of myofascial origin from that of fibromyalgia. While the above-

Y. Fogelman and J. Kent / Efficacy of dry needling for treatment of myofascial pain syndrome

mentioned central sensitization is a direct effect of peripheral overload, it is often fairly easy to reverse these changes by treatment of the peripheral muscle and fascia. Conversely, the etiology of fibromyalgia can be seen to be that of a predisposing tendency to central sensitization that may often be triggered by peripheral trauma, but which is located in the central nervous system and generally requires treatment at that level, since manipulation or vigorous needling of the peripheral tissues results in wind-up phenomenon and worsening of the fibromyalgia pain. Interestingly, it has been shown that more gentle treatment of the peripheral tissues does provide some relief of fibromyalgia pain [22]. However, the characteristic pattern of the pain of fibromyalgia is widespread, or generalized (not segmental), and is accompanied by subjective functional symptoms that have been included in the new diagnostic criteria of this disorder, according to the American College of Rheumatology [23].

3. Treatment of myofascial pain Dry needling is a very old treatment modality, documented as used by physicians since the 1820s [24] and including its recommendation by Sir William Osler, the father of modern western medicine [25]. The scientific basis for its use in treatment of myofascial pain was grounded in the work of Kellgren, who methodically mapped out the specific pain patterns caused by each painful muscle, in experiments using the injection of hypertonic (6%) saline in healthy subjects [26]. In 1938 he also demonstrated the use of 1% procaine anaesthetic injected into muscle TrPs to alleviate the pain [27]. His pioneering work was continued by Travell and Rinzler [28]. Travell and Simons’ “Trigger Point Manual” is still the gold standard as the evidence-based source for management of myofascial pain. Experienced practitioners of Travell and Simons’ original techniques of anaesthetic injection and stretch with vapocoolant spray have moved towards dry needling as an effective treatment [29–31]. In 1979 the renowned Czech physician Karel Lewit demonstrated quite elegantly that the effect of the injection is not due to the substances injected but to the mechanical stimulation of the needle itself [32]. Since then the practice of dry needling for the treatment of TrPs, without injecting pharmaceutical substances became commonplace. Gunn, as mentioned above, has demonstrated excellent results in treating neck pain [33], shoulder pain [34], knee pain [35], leg pain [36] and

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low back pain [37–39]. Patients with peripheral isolated muscle pain have been found to obtain relief from needling other muscles innervated by the same spinal segment [40].

4. Treatment alternatives Various methods have also been used to deactivate TrPs, including ultrasound [41], manual pressure release [42], cold spray and stretch and injection of local anaesthetic [43]. The use of vapocoolant spray has declined in recent years, in line with concerns about releasing fluorocarbons into the atmosphere. Dry needling (no substance injected) may be carried out either superficially or with deeper insertion [44]. Dry needling or IMS is also called “Western acupuncture” but bears no relationship to the Chinese therapy. While IMS uses the same needles, they are inserted into TrPs and taut bands as a facilitator or “artificial nerve” to generate a twitch response and subsequent reflex relaxation of the muscle, completely unrelated to oriental meridians or lines of energy. High-quality research and review articles in the literature have been relatively scarce until the last 20 years, and the number of new articles appearing is rising rapidly. In the treatment of myofascial problems of the neck and shoulder, the results of IMS may be more favorable than lidocaine injection, 6 months after treatment [45,46], and at least as good as physiotherapy in relation to upper Trapezius pain [47]. Paraspinal dry needling of the Multifidi muscle group has been shown to be more effective than sham needling or lidocaine injection in pain relief, return of function and B-symptoms in young women [48]. A double-blind placebo-controlled trial of IMS vs. sham needling in 49 subjects showed very significant differences between the two treatment groups in both visual analog scale reports, as well as Short Form-36 reports [49]. Dry needling while still under anaesthesia has been shown to reduce post-operative pain in patients undergoing total knee arthroplasty [50]. The use of dry needling, as opposed to medications or other modalities, is the subject of several recent reviews [51–53].

5. Challenges in research There are manifest difficulties in performing randomized, controlled double-blind studies to demon-

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strate the efficiency of dry needling. One of the main difficulties that exist is in performing a study with sham treatment compared with standard therapy. Many studies compare the efficacy of dry needling to a control group that did not receive any treatment. The methodological problems in these studies are due to several reasons. Firstly, although TrPs were wellidentified, it may not be clear if the cause of the pain is solely due to that particular contracted muscle. Secondly, in a large number of studies examining the efficacy of dry needling, the sample size was small, which increases the likelihood of false negative results. In addition, therapeutic interventions were significantly different between the various studies in parameters like location, depth of needling, number of treatments and frequency [54]. In a recent systematic review, 15 RCT studies were examined for the effectiveness of dry needling. In that review it was not possible to reach positive or negative conclusions due to studies’ limitations. The conclusion of the reviewers was that dry needling is a safe procedure in skilled hands of appropriate trained therapists. Indeed, Gerwin has demonstrated that the key to improving the methodology hinges on adequately-trained therapists who can consistently identify TrPs and taut bands, with good inter-rater reliability [55]. Some studies have attempted to quantify the effects of dry needling as a stand-alone therapy, rather than as an adjunct capacity in which it is routinely used in clinical practice. Thus, it is possible that the effectiveness of dry needling was underestimated. Treatment outcomes may be improved by the addition of dry needling to stretching exercises in patients with chronic head, neck, shoulder, and back pain, but this is also true of stretching and other therapies such as ultrasound and laser. The absence of a “no treatment” or “stretching alone” control arm made it impossible to assess what contribution, if any, dry needling made to patient outcomes [56,57]. A Cochrane Systematic review including 35 RCT studies and covering 2861 patients surveyed the effectiveness of acupuncture and dry needling in treating low back pain [58]. The objectives of this systematic review were to determine the effects of acupuncture for subacute and chronic non-specific low back pain, and dry needling for MFP syndrome in the lowback region, compared to no treatment, sham therapies and other therapies. Although dry needling appeared to be a useful adjunct to other therapies for chronic lowback pain, no clear recommendations could be made because of small sample sizes and poor methodolog-

ical quality of many of the studies. Another systematic review aimed to review the current evidence on dry needling, by conducting a systematic literature review [59]. Only three studies met the tough conditions set by two independent reviewers of this article. In these three studies the sample size was small and the methodological problems were many. Data from one study indicated that dry needling for treatment of myofascial pain was more effective in reducing pain than no treatment. Two other studies provided conflicting data when compared dry needling of muscle TrPs compared to needling elsewhere in the muscle. Four other studies that included a placebo group did not demonstrate the superiority of dry needling treatment over the placebo group. Since marked statistical heterogeneity was present, the authors emphasized the need for larger double blind controlled studies. A recently published systematic review from Korea reached the same conclusion [60]. In spite of the positive results of individual studies, the level of evidence supporting the efficacy and effectiveness of dry needling for several conditions remains insufficient because of high risk of bias in the included studies. 6. Imaging of myofascial trigger points One of the major problems that prevent the common acceptance of TrPs by the medical community is the lack of imaging methods that allow objective visual inspection of the painful nodes in the muscle, that until now have been diagnosed solely by palpation. Reliable methods for identifying TrPs should permit better diagnosis, more accurate treatment, and improved evaluation of treatment outcome. Two recent studies introduced imaging methods that allow the visualization of TrPs. Sikdar et al. [61] introduced an ultrasound imaging technique, sonoelastography, enabling visualization of muscular tissue containing TrPs. They simultaneously applied external vibration in order to differentiate tissue stiffness and ultrasound color variance mode to image the relative distribution of the vibration amplitude in the myofascial tissue. Results of this study are very encouraging since for the first time there appears to be a reliable noninvasive device that may objectify the diagnosis of muscle TrPs, facilitating further research in in this field [62]. However, it is unlikely that any imaging method will be useful in the everyday clinical setting, since the basis of treatment is found in a directed physical examination of the patient, the finding of involved muscles and autonomic epiphenomena in the same spinal segment, and inexpensive, brief therapeutic intervention.

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7. Conclusion Dry needling, acknowledged but generally disregarded for decades by mainstream medicine, has recently found increasing use in the comprehensive management of myofascial pain. As a treatment modality it is easy to learn and integrate into everyday clinical practice. Based on a thorough history and physical examination combined with a new perspective on the anatomy that health professionals did not learn in their basic training, this technique generally does not require further investigation or imaging in order to start treatment, which is cheap, minimally invasive, and carries a low risk. Dry needling is easily combined with other treatment modalities in the management of chronic musculoskeletal pain, particularly where the shortened muscles are deep and not easily accessible by other methods. Until recently, the level of evidence supporting the effectiveness of dry needling has been criticized, primarily because of concerns about a lack of precision and a high risk of bias of the included studies. These concerns are being laid to rest with more recent research and meta-analyses of the data. Rigorous largescale clinical observational trials are needed to evaluate the clinical utility of this technique, particularly with regard to functional outcome, in addition to its ability to decrease pain over the short and long term. With the introduction of the sonoelastography and other imaging methods, we should see a further refinement in our understanding of the pathophysiology of this syndrome. In tertiary pain centers these imaging techniques will facilitate the guided treatment of refractory cases. Currently, the biggest challenge that must be faced is in the basic training of health professionals (particularly physicians) in the identification of muscles and soft tissue as generators of pain. This subject must return as part of the basic curriculum in Anatomy, and be stressed throughout pre-clinical and clinical training. At present, many countries offer extensive post-graduate practical training of academicallytrained health professionals in the identification, clinical examination and treatment by Intramuscular Stimulation. In the hands of primary health care providers, use of this technique will enable us to deal with a significant component of the incredible burden of chronic pain suffered by so many people in our clinical practices.

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Efficacy of dry needling for treatment of myofascial pain syndrome.

Myofascial pain is a major cause of musculoskeletal regional pain. Myofascial pain, which is a high-prevalence but eminently treatable condition, is a...
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