Research Review By Dr. Ceara Higgins©

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Date Posted:

July 2017

Study Title:

Dry Needling Versus Cortisone Injection in the Treatment of Greater Trochanteric Pain Syndrome: A Noninferiority Randomized Clinical Trial

Authors:

Brennan KL, Allen BC, Munoz Maldonado Y

Author's Affiliations:

Baylor Scott & White Health, Temple, Texas, USA.

Publication Information:

Journal of Orthopaedic & Sports Physical Therapy 2017; 47(4): 232-239.

Background Information:

Greater trochanteric pain syndrome (GTPS), formerly called greater trochanteric or subgluteal bursitis, is characterized by chronic, intermittent pain and tenderness to palpation over the lateral aspect of the hip (5). The change in clinical terminology reflects contemporary research indicating that contractile tissues are more commonly involved than the bursa and that overt inflammation is uncommon (2). It is estimated that GTPS affects 10-25% of the population, with a higher incidence in women and patients with coexisting low back pain, osteoarthritis, iliotibial band tenderness, and obesity (5). GTPS is a generic term which may include several disorders including: bursitis, gluteal tears, external coxa saltans (“snapping hip”), and trigger points in the lateral hip region (10). Traditionally, GTPS has been treated with cortisone injections into the lateral hip, directly targeting the bursa. However, as the etiology of GTPS has been revealed in more detail, the culprit is not always the bursa, rendering this treatment approach questionable (1).

The adverse effects of steroid injections are poorly quantified (3), but there have been clinically significant side effects documented that include osteonecrosis (12), osteomyelitis (13), hallucinations (11), and death (3). Dry needling (DN) is the insertion of filament needles to stimulate and desensitize trigger points in musculature, and has been found to have potential in treating soft tissue injury and neuromyofascial pain with minimal risks (4). Previous research has shown that analgesic (steroid) injection is not superior to DN in other body regions (8). As such, if DN is equally or more effective than cortisone injection in the treatment of GTPS, it would provide a treatment option for patients with a better safety profile.

This study aimed to examine whether DN is equally effective when compared to cortisone injection for the reduction of lateral hip pain and the improvement of function in patients with GTPS.

Pertinent Results:

The two groups showed similar baseline characteristics. Individuals in the cortisone injection group received one treatment, while individuals in the DN group received 3-7 treatments.

At 6 weeks, there were no differences in numeric pain-rating scores or average and weighted Patient-Specific Functional Scale (PSFS) scores between the two groups. In a mixed-effects model using time and treatment as co-variables, the interaction between time and treatment was significant, but the type of treatment was not significant in either outcome measure. Medication intake for hip pain was no different between groups at any time during the study. Therefore, we can conclude that DN and cortisone injections were equally effective in the treatment of GTPS in these study groups.

Clinical Application & Conclusions:

We do not fully understand the mechanism by which DN is effective in reducing pain and improving function, but research has shown biochemical, neurologic, vascular, and clinical changes associated with the use of DN (4). DN has been shown to be effective in the treatment of trigger points (MTrP), with improvements in pain and function demonstrated with needling of active MTrPs (7). A similar effect has even been demonstrated with needling of remote, latent MTrPs, even in other neurologic segments (14).

Both DN and injection of a substance such as lidocaine or cortisone can cause a local twitch response (LTR) and a study by Hong (9) concluded that elicitation of a LTR is more important than the choice of DN or an injection in the treatment of MTrPs.

Steroid injections have potentially detrimental side effects, particularly with repeated injections. As well, steroid injections are contraindicated for individuals with certain medical conditions and not all patients respond positively. As a result, identification of treatment alternatives that are equally effective and have minimal side effects can offer valuable clinical advantages.

In this study, cortisone injections and DN provided equivalent pain relief and reduction in functional limitations, while cortisone injections showed more adverse effects than DN and have significantly more contraindications. As practitioners, we should strive to provide patients with the best and safest possible care for their condition. Based upon this, DN would be the preferable treatment option for GTPS compared with cortisone injections. (EDITOR’S NOTE: the time a patient may have to devote to receiving treatment may also be a factor in their decision-making. DN may take a number of treatments to provide benefit, while cortisone injection is normally performed only once).

Study Methods:

43 patients being treated at the orthopaedic department of the Baylor Scott & White Health, Roney Bone and Joint Institute between May 2013 and July 2015 were recruited for this study. 21 were placed in the DN group and 22 in the cortisone injection group, with a total of 50 hips being observed. Patients were randomized in blocks to reduce the variability between treatment groups and reduce bias (6). As patients could identify their treatment group, there was no blinding. Patients were selected based on the criteria outlined below.

Inclusion Criteria:
  • 18 years of age or older
  • Having lateral hip pain (anywhere from the iliac crest to the mid iliotibial band)
  • Having an active email account
Exclusion Criteria:
  • Low back pain associated with hip pain
  • Motor and/or sensory impairment consistent with radiculopathy
  • Active infection or malignancy of the hips
  • Connective tissue disease
  • Lack of proficiency in spoken English
  • Pregnancy
Outcome measures for this study included the numeric pain-rating scale (NPRS: scored 0-10) and the Patient-Specific Functional Scale (PSFS: 0-10). The PSFS allows patients to identify up to 5 tasks that they find most limited by a specific body part and assign a score to each task ranging from 0 (unable to perform activity) to 10 (able to perform activity at the same level as before the injury or condition). The final scores were then weighted, with the weights calculated as the number of times the repeated function appeared, divided by the total number of functions the patient listed. As well, medication intake for pain, sex, age, and body mass index were collected as co-variables. All outcome measures were taken at baseline and at 1, 3, and 6 weeks after the initial treatment by a third-party research coordinator.

Dry needling treatment began at the first visit. The exact location of needle insertion and the number of penetrations within the region of the involved posterolateral hip were determined by the treating therapist. All patients were treated by the same investigator, who had 4 years of experience in DN. The therapist also determined the number of follow-up treatments, all within 6 weeks of initiation and DN was the only form of treatment received by this group.

Individuals in the cortisone injection group received their injection during their first visit with the exact location and technique of the injection being determined by the provider. All injections were performed by 1 of 3 orthopaedic surgeons or 1 of 2 physician assistants, with the number of follow-up visits within 6 weeks of initiating the study again determined by the provider. As in the DN group, cortisone injection was the only treatment received by this group.

Study Strengths / Weaknesses:

Strengths:
  • As no adjunct treatment was permitted during the study, we got as clear an indication as possible regarding the effectiveness of DN as a stand-alone treatment.
Weaknesses:
  • No sham DN procedure was applied (keep in mind the tremendous difficulty in blinding patients for this sort of procedure).
  • There was no non-treatment group, so the placebo effect cannot be ruled out as a contributing factor in these results (this could apply to both the DN or cortisone interventions, to be clear).
  • A single provider performed all DN, while multiple providers performed the cortisone injections. This creates an issue with inherent variability in the treatment application within the cortisone injection group, but not the DN group.
  • This study used a small sample size. A larger sample would allow for smaller confidence intervals and increased statistical robustness.
  • The study only addressed changes over a 6-week interval. Therefore, we cannot make inferences about the effectiveness or differences in the treatment outcomes over a longer time period.

Additional References:

  1. Alvarez-Nemegyei J, Canoso JJ. Evidence-based soft tissue rheumatology: III: trochanteric bursitis. J Clin Rheumatol 2004; 10: 123-124.
  2. Anderson TP. Trochanteric bursitis: diagnostic criteria and clinical significance. Arch Phys Med Rehabil 1958; 39: 617-622.
  3. Brinks A, Koes BW, Volkers AC, et al. Adverse effects of extra-articular corticosteroid injections: a systematic review. BMC Musculoskelet Disord 2010; 11: 206.
  4. Cagnie B, Dewitte V, Barbe T, et al. Physiologic effects of dry needling. Curr Pain Headache Rep 2013; 17: 348.
  5. de Abreu Venancio R, Alencar FG, Zamperini C. Botulinum toxin, lidocaine, and dry0needling injections in patients with myofascial pain and headaches. Cranio 2009; 27: 46-53.
  6. Efird J. Blocked randomization with randomly selected block sizes. Int J Environ Res Public Health 2011; 8: 15-20.
  7. Fernandez-Carnero J, La Touche R, Ortega-Santiago R, et al. Short-term effects of dry needling of active myofascial trigger points in the masseter muscle in patients with temporomandibular disorders. J Orofac Pain 2010; 24: 106-112.
  8. Ga H, Choi JH, Park Ch, et al. Acupuncture needling versus lidocaine injection of trigger points in myofascial pain syndrome in elderly patients – a randomized trial. Acupunct Med 2007; 25: 130-136.
  9. Hong CZ. Lidocaine injection versus dry needling to myofascial trigger point. The importance of the local twitch response. Am J Phys Med Rehabil 1994; 73: 256-263.
  10. Pavkovich R. effectiveness of dry needling, stretching, and strengthening to reduce pain and improve function in subjects with chronic lateral hip and thigh pain: a retrospective case series. Int J Sports Phys Ther 2015; 10: 540-551.
  11. Pecos-Martin D, Montanez-Aguilera FJ, Gallego-Izquierdo T, et al. Effectiveness of dry needling on the lower trapezius in patients with mechanical neck pain: a randomized controlled trial. Arch Phys Med Rehabil 2015; 96: 775-781.
  12. Samala RV, Ciocon JO. Steroid-induced hallucination following intra-articular administration: a case report and brief review. J Am Med Dir Assoc 2011; 12: 609-610.
  13. Simons DG, Hong CZ, Simons LS. Endplate potentials are common to midfiber myofascial [sic] trigger points. Am J Phys Med Rehabil 2002; 81: 212-222.
  14. Tough EA, White AR, Cummings TM, et al. Acupuncture and dry needling in the management of myofascial trigger point pain: a systematic review and meta-analysis of randomized controlled trials. Eur J Pain 2009; 13: 3-10.