Further Evidence For Dry Needling In The Treatment Of Myofascial Pain

A recent systematic review by Kietrys et al (2013), provides us with level 1A evidence in support of what we as clinicians using Dry Needling for Myofascial Pain Syndrome (MPS) have known for a long time....it works!

In the meta-analysis, twelve quality RCT’s were selected which met the following inclusion criteria: human subjects, dry needling intervention group, and MPS involving the upper quarter. The methodological quality scores ranged from 23 to 40 points, with a mean of 34 points (scale range 0-48, best possible score-48) using the the MacDermid Quality Checklist.

The authors concluded:

Based on the best current available evidence, we recommend (Grade A) Dry Needling, compared to sham or placebo, for decreasing pain (immediately after treatment and at 4 weeks) in patients with upper quarter MPS. Due to the small number of high quality RCTs published to date, additional well-designed studies are needed to inform future evolution of this recommendation.
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East Meets West - Challenging Preconceptions

A 25 year old 4th level student from China came to see me a few weeks ago. He was referred from one of the campus health doctors with widespread bilateral neck and back pain with muscle tension thought to be related to long hours of study, poor posture and stress.

This would be a fairly common scenario these days given the number of wound up, stressed out students I am seeing in the clinic for various issues.

So what was different about my student from China?

He had received Acupuncture previously in China and reported some short term benefit. When I suggested we try this again, but in conjunction with specific exercise and lifestyle management advice he was receptive.

Given his subjective history where stress was a large factor, he was not sleeping and generally run down as well as objective findings of widespread muscle overactivity, generalised hypersensitivity with multiple active and latent myofascial trigger points, I thought it best to take it easy in terms of dosing treatment at the first session.

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Comparing Like With Like In The Clinical Trials - What’s The Point?

A specific type of needle has been developed by Nobuari Takakura and Hiroyoshi Yajima which allows for the blinding of both the Acupuncturist and the patient (double blinding) in Acupuncture based clinical trials.

The so called ‘active’ version of the needle is 0.16mm in diameter and only penetrates to 5mm in depth. The ‘sham’ version does not penetrate the skin at all - it penetrates some stuffing in the bottom of the guide tube and just touches the skin, enough to give some sensation or the impression of needle penetration.

This needle has been validated such that when subjects were told they would receive either ‘real’ needling or ‘placebo’ needling, they could not tell the difference between the two types of needle and were unable to determine which was which.

So when this needle is put to the test in a clinical trialcomparing ‘active’ and ‘sham’ needling do you think there is likely to be a significant difference in pain outcome measures?

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Lateral Epicondylalgia - Medical Acupuncture Based Treatment Approach

A Case Study

Introduction

Lateral epicondylalgia (LE), otherwise known as tennis elbow, is a common condition causing pain at the lateral elbow and forearm, as well as a lack of strength and function of the elbow and wrist.1 From a clinical point of view, many patients presenting with this condition are sports people. However others have developed the condition either by working in very manually orientated jobs, or in more sedentary jobs with repetitive use of computers for example. I used to approach the condition with some trepidation, as from experience LE had always been a very difficult condition to treat. However since using a primarily Medical Acupuncture (MA) based approach, my results have been more positive as the following case illustrates.

Presenting complaint

Mr. D complained of severe local tenderness at and just below the lateral epicondyle of the right elbow, associated with radiating pain through the dorsal forearm as far as the wrist. On the day of assessment his pain level was 6 on the VAS. He found certain activities involving the wrist and hand painful and ‘weak’ e.g. lifting boxes, carrying objects as well as playing golf. Mr. D mentioned that his forearm muscles felt very tight and that his wife had found very sore points when trying to assist with local massage. There was no altered sensation or paraesthesia to report and he had no neck pain or stiffness.

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Could Physios Be Needling With Better Technique?

So you’ve been on a Dry Needling course and have started treating patients using the technique. This may not hold true for all of you, but I was somewhat nervous when first starting to use needles clinically. I quickly realised the apprehension could be perceived by my patient but once I became more confident in my handling and needle insertion I perceived my patients to find the technique more comfortable and better clinical results followed.

Good assessment is key

I have found the key to effective treatment in a MSK setting is a good assessment. This means getting your hands on the patient and performing a careful and deliberate palpation assessment as well as looking at other relevant objective findings. However preceding this, a good subjective should give you a very good indication of a patient's ‘sensitivity’ and will help guide your objective assessment and subsequent treatment.

Getting dosage right

The concept of ‘dose’ is becoming recognised as crucial to good clinical outcomes. Dose may be defined as the level of sensory input provided to the CNS during the process of needling. Too much in a sensitive patient may brings about an adverse reaction which may mean an exacerbation of symptoms. Too little and there may be no therapeutic effect. The aim is to get the dose right for the patient and this is the tricky part.

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