Research Review By Dr. Ceara Higgins©

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Date Posted:

January 2014

Study Title:

Effectiveness of Dry Needling for Upper Quarter Myofascial Pain: A Systematic Review and Meta-Analysis

Authors:

Kietrys DM, Palombaro KM, Azzaretto E et al.

Author's Affiliations:

Rutgers, The State University of New Jersey; Widener University, PA; NovaCare Rehabilitation, PA & NJ; Comber Physical Therapy, VA; Sports Care of America, NJ, USA

Publication Information:

Journal of Orthopaedic & Sports Physical Therapy 2013; 43(9): 620-34.

Background Information:

Patients commonly present to primary care or pain clinics with myofascial trigger points – MTrPs/TrPs (defined as localized taut band-like areas in muscle that typically contain hyperalgesic zones). Myofascial trigger points can cause localized and/or referred pain or tenderness, aggravation of existing pain, autonomic phenomena, motor dysfunction, impaired range of motion, and/or sensitivity to stretch. Palpation of a TrP or insertion of a needle can (and often does) elicit a localized twitch response.

In dry needling, an acupuncture-like needle is inserted into MTrPs and left in until the trigger point is considered to be “inactivated”. This is typically followed by stretching exercises.

There is still a great deal of debate about the mechanism by which dry needling works. Current theories include localized twitch responses interrupting motor end plate noise which causes an analgesic effect, relaxation of actin-myosin bonds, stimulation of Alpha-delta nerve fibers which activate the enkephalinergic inhibitory dorsal horn interneurons and cause opioid mediated pain suppression, and disruption of the reverberatory circuits in the central nervous system.

The purpose of this study was to explore the effectiveness of dry needling in the treatment of MTrPs in the upper quadrant according to the current literature.

Pertinent Results:

12 articles met the study’s inclusion criteria. Although the exclusion criteria varied across studies, they generally included contraindications for needling and alternative musculoskeletal diagnoses. Participants in all included studies were generally adults, with symptom duration ranging from 3 to 63 months, and of both genders.

Dry-needling compared to sham or control, immediate effects:
Four studies were included in this meta-analysis, with three of the four showing favorable results for dry-needling. However, the study that showed the most significant treatment effect (6) used the patient’s uninvolved side as the control and the other two studies (11, 12) that favored dry-needling over sham needling showed large treatment effects but had raw between-group effect sizes of questionable clinical relevance.

Dry-needling compared to sham or control at 4 weeks:
Three studies were included in this meta-analysis with two of the three studies (9, 12) favoring dry-needling over sham needling. These conclusions must be considered with caution due to the 95% confidence interval, which crosses the line of no difference and may negate the large overall effect size. The study by Ilbuldu et al. (7), which favored sham laser treatment included a low number of subjects and was unclear as to blinding of the examiners. Therefore, the results must be considered with caution.

Dry-needling compared to other treatments, immediate effects:
Two studies were included in this meta-analysis. The study by Hong & Simons (5) compared dry-needling to lidocaine injections while the study by Irnich et al. (8) compared dry-needling to nonlocalized acupuncture. Both studies favored the other treatment but were also of questionable clinical significance due to the raw between-group effect sizes falling below 2 points on the VAS.

Dry-needling compared to other treatments at approximately 4 weeks:
Six studies were included in this meta-analysis. Of these, 2 studies included 2 other treatment groups that were entered separately to provide a total of 8 data sets. Two studies by DiLorenzo et al. (3) and Itoh et al. (9) favored dry-needling over rehabilitation and dry-needling of non-tender points over acupuncture, respectively. Other studies all favored the other treatment over dry-needling, but only the study by Kamanli et al. (10), which used botuminum toxin injections and lidocaine injections, showed clinically significant raw between-group effect sizes. Other studies favoring treatments other than dry-needling did not show clinically significant between-group raw numbers when dry-needling was compared to laser, and intramuscular stimulation.

Clinical Application & Conclusions:

Although there have been limited studies published to date, and despite the considerable limitations of this meta-analysis, there is still significant support for the use of dry-needling for the treatment of myofascial trigger points as compared to sham treatments for immediate pain relief and moderate support for the use of dry-needling to treat trigger points compared to sham treatments at 4 weeks. However, it would appear that lidocaine injections are superior to dry-needling for reduction of pain associated with myofascial trigger points both immediately and at 4 weeks. Additional research on the effectiveness of dry-needling is needed.

Study Methods:

The authors included randomized control trials, published in English, with: a control or comparison group, human subjects, dry needling intervention group, and participants with myofascial symptoms in the upper quadrant. Articles were found through searches of OvidSP Medline, HealthStar, and PubMed. A hand search of the references from the articles found was then performed.

All retained articles were scored by at least three different evaluators using the Evaluation Guidelines for Rating the Quality of an Intervention Study (MacDermid Quality Checklist) to assess for internal validity. Four separate meta-analyses were performed using pain on a visual analog scale (VAS) as an outcome measure. These included:
  1. Dry needling compared to sham or control, immediate effects;
  2. dry-needling compared to sham or control at 4 weeks;
  3. dry needling compared to other treatments, immediate effects; and
  4. dry needling compared to other treatments at approximately 4 weeks.
Studies comparing dry-needling to both other treatments and sham or control were entered separately into each meta-analysis as warranted. A minimum change of 2 points on the 0-10 point VAS was considered as clinically meaningful.

Study Strengths / Weaknesses:

Strengths:
By following the initial electronic search with a hand search of the references of those articles, the authors were able to identify additional references (however, they only used one search term [dry-needling] which may have resulted in some articles being overlooked). In addition, the use of a minimum 2 point change on the VAS to indicate a significant change in pain levels ensures that the changes are large enough to be more definitive.

Weaknesses:
In all meta-analyses the results should be interpreted with caution due to the small number of studies available and differences in inclusion criteria. In some cases, most notably the studies using the subject’s uninvolved side and using intramuscular stimulation as controls, the choice of control group must be considered as a possible weakness. Using the MacDermid Quality Checklist may also be a weakness, as its reliability has not been well established. Further, the lack of analysis of any outcome measure other than the VAS and methodological limitation of the included studies must also be considered as significant limitations to the study. The study also has limited external validity due to the wide variety of ages included in the different studies and the variance in the diagnosis and/or causes of the upper quadrant pain experienced by the study subjects. Finally, descriptions of dry-needling often emphasize the potential importance of obtaining a localized twitch response during treatment. Of the 12 studies included, only 8 studies clearly identified whether a localized twitch response was stimulated, or even desired, during dry-needling.

Additional References:

  1. Ay S, Evcik D, Tur BS. Comparison of injection methods in myofascial pain syndrome: a randomized controlled trial. Clin Rheumatol 2010; 29: 19-23.
  2. (2) Chu J. Does EMG (dry needling) reduce myofascial pain symptoms due to cervical nerve root irritation? Electromyogr Clin Neurophysiol 1997; 37: 259-272.
  3. DiLorenzo L, Traballesi M, Morelli D et al. Hemiparetic shoulder pain syndrome treated with deep dry needling during early rehabilitation: a prospective, open-label, randomized investigation. Journal of Musculoskeletal Pain 2004; 12: 25-34.
  4. Ga H, Choi J-H, Park C-H, Yon H-J. Dry needling of trigger points with and without paraspinal needling in myofascial pain syndromes in elderly patient. Journal Altern Complement Med 2007; 13: 617-624.
  5. Hong C-Z. Trigger point injection: dry needling vs lidocaine injection. Am Journal Phys Med Rehabil 1994; 73: 256-263.
  6. Hsieh Y-L, Kao M-J, Kuan T-S et al. Dry needling to a key myofascial trigger point may reduce the irritability of satellite MTrPs. Am Journal Phys Med Rehabil. 2007; 86: 397-403.
  7. Ilbuldu E, Cakmak A, Disci R, Aydin R. Comparison of laser, dry needling, and placebo laser treatments in myofascial pain syndrome. Photomed Laser Surg 2004; 22: 306-311.
  8. Irnich D, Behrens N, Gleditsch JM et al. Immediate effects of dry needling and acupuncture at distant points in chronic neck pain: results of a randomized, double-blind, sham-controlled crossover trial. Pain 2002; 99: 83-89.
  9. Itoh K, Katsumi Y, Hirota S, Kitakoji H. Randomised trial of trigger point acupuncture compared with other acupuncture for treatment of chronic neck pain. Complementary Therapies in Medicine 2007; 15: 172-179.
  10. Kamanli A, Kaya A, Ardicoglu O et al. Comparison of lidocaine injection, botulinum toxin injection, and dry needling to trigger points. Rheumatol Int 2005; 25: 604-611.
  11. Tekin L, Akarsu S, Durmus O et al. The effect of dry needling in the treatment of myofascial pain syndrome: a randomized double-blinded placebo-controlled trial. Clin Rheumatol 2013; 32(3): 309-15.
  12. Tsai C-T, Hsieh L-F, Kuan T-S et al. Remote effects of dry needling on the irritability of the myofascial trigger point in the upper trapezius muscle. Am Journal Phys Med Rehabil 2010; 89: 133-140.