Physiotherapy

Dry needling for the treatment of poststroke muscle spasticity: a prospective case report.

Ansari, NN., Naghdi, S., Fakhari, Z., Radinmehr, H.,and  Hasson, S. (2015)

In this study, dry needling (DN) was introduced as a method of treatment for muscle spasticity in a post-stroke patient. The patient experienced muscle spasticity specifically in the pronator teres, flexor carpi radialis, and flexor carpi ulnaris muscles of the forearm, in which the DN technique was applied.

The treatment consisted a single session in which DN was applied for one minute to each muscle of study.

The outcomes measured included the Modified Modified Ashworth Scale (MMAS) muscle spasticity score, and the Hmax ratio that was collected before treatment (T0), immediately after (T1) and 15 minutes after the DN (T2).

The patient’s spasticity scores improved after the DN treatment. These scores were also maintained 15 minutes after the treatment. As a result, the patient was able to perform voluntary wrist and finger extension, which was not seen prior to the DN treatment.

Although this study is a preliminary examination on the effects of dry needling, it provides promising effects of DN for patients experiencing muscle spasticity. Further study can be used to explore the effects of dry needling more long term as well as the impact of multiple DN treatments.

Summary by Kaitlin Proksch

Dry Needling Alters Trigger Points in the Upper Trapezius Muscle and Reduces Pain in Subjects With Chronic Myofascial Pain

Lynn H. Gerber, MD., Jay Shah, MD., William Rosenberger, PhD., Kathryn Armstrong, DPT., Diego Turo, PhD., Paul Otto, BS., Juliana Heimur, BS., Nikki Thaker, BS., and Siddhartha Sikdar, PhD. (2015).

Myofascial pain syndrome (MPS) is a common issue however it carries widespread controversy in regards to the etiology and pathophysiology. As a result, the diagnosis and treatment is often debated, specificially if myofascial trigger point (MTrP) is an accurate and important aspect in the diagnosis. The study divided trigger points into three types: active (those that are a palpable, distinct nodule that is instantaneously painful upon pressure), latent (those that are not spontaneously painful and requires palpation or activity to induce pain), and resolved (no palpable nodule present).

Dry needling (DN) is comonly used to reduce pain and involves the insertion of a needle into the nodule which ultimately causes muscle twitches at the site of needle insertion.

This area of study is novel as it has been difficult to accurately measure pain and so, the study included three separate and differing measurement tools for pain. These measurements included verbal accounts, pain pressure threshold (PPT), and the Brief Pain Inventory.

The study consisted of 52 subjects with neck or shoulder girdle pain for more than 3 months. These participants received DN treatment once weekly for a period of three weeks. The researchers utilized verbal accounts of pain, the Brief Pain Inventory as well as the palpable status of the trigger point as primary measures.

It was found that participants experienced a significant reduction in pain that was found to be correlated to an improvement in palpable status of the trigger point from a state of active to either latent or resolved. This reduction in pain was seen in all three pain measurement tools. In addition to reduced pain, participants also experienced an increased range of motion in the cervical spine that is inferable to the muscle tension of the trapezius muscle.

This study provides important findings on the relation between pain and palpable status of the MTrP in regards to dry needling treatment. The study provides favourable support for the use of dry needling for trigger point disorders, specifically those in the upper trapezius muscles.

Summary by: Kaitlin Proksch

Non-Operative Treatment of Subacromial Impingement Syndrome

David S. Morrison, M.D.T., Anthony D. Frogameni, M.D., and Paul Woodworth, P.T.(1997)

This study examined the past experience with subacromial impingement syndrome in 616 patients. The aim of the study was to examine the effectiveness of non-operative treatments (manual physiotherapy approaches) of subacromial impingement syndrome.  These patients were diagnosed based on a positive impingement sign (defined as pain in the lateral region of the deltoid when the limb is elevated and the scapula is stabilized) but yet an absence of other possible abnormalities such as rotator cuff tears.

Subacromial impingement syndrome includes impingement at the coracoacromial arch involving the rotator cuff muscles. The purpose of non-operative treatment is to reduce inflammation, decrease pain, promote muscle healing and increase joint functioning.

All patients received anti-inflammatory medications in addition to the physiotherapy treatments. The treatment comprised of various steps. After the inflammation was controlled and pain was at a tolerable level, the treatment began with soft tissue stretching. Stretching was performed both at home and in the clinic until a normal range of motion was acquired. At this point, the treatment was geared towards strengthening of the shoulder muscles, with the exception of the deltoid muscle. As the shoulder was able to tolerate various sets of exercises, resistance was added in order to further promote strengthening. The structure of the program was geared towards the structural components of the joint as well as to the limitations of the disorder.

The study found that 67% of the patients experienced satisfactory results and of these, 30% had excellent results and 37% had a good result of the treatment. In terms of reoccurrence of symptoms, only 18% of those with satisfactory results experiences a reoccurrence of symptoms within the follow-up period.

The article also examined the effects of acromion morphology, degree of pain and age with treatment outcomes. It was found that those with type I acromion fared better than those with type-II or type-III acromion. In addition, those with acromioclavicular joint tenderness experienced satisfactory relief in comparison to those without this tenderness. Lastly, it was found that 73% of those under the age of 20 experienced satisfactory results compared to 64% of those between 21 and 40, 73% of those 41 to 60 years old and only 55% of those over 60 years of age.

This study provides promising results on the use of manual physiotherapy techniques in the treatment of shoulder disorders including subacromial impingement syndrome.

Summary by: Kaitlin Proksch

Role of physiotherapy in the treatment of subacromial impingement syndrome: a prospective study

Dickens, Victoria, A., Williams, James L., Bhamra, Manjit S. (2005)

The purpose of this study was to examine the effects of physiotherapy on patients with subacromial impingement syndrome in need of surgery. Seventy-three patients who had been put on a surgical list for subacromial impingement were recruited for the study. The participants were divided into two groups- one who received the physiotherapy program designed for the injury and the second group served as a control group.

The physiotherapy group consisted of an individualized program based on their current status found in the initial assessment. The program consisted of multiple approaches in clinic including joint mobilization, exercise therapy (balance and posture exercises) and occasional electrotherapy. The program often included some at-home exercises to do in between clinic appointments.

The evaluation of progress was examined with the use of the Constant Score (a standardized method) that indicated any functional recovery of the joint. The Constant Score evaluated three areas: function, pain and strength with a max cumulative score of 100 points.

The study found that eleven out of forty-five (26%) of the participants in the physiotherapy group improved significantly and did not require surgery post intervention. All patients in the physiotherapy group improve their Constant Score by an average of 20 points. The control group improved only by 0.65 points on average, all of which continued to require surgery post-intervention.

The study concluded that physiotherapy serves as an effective treatment option for subacromial impingement syndrome and should be highly considered as a go-to treatment. The programs were found to improve functional use of the shoulder and arm, decrease pain and increase strength. The physiotherapy approach therefore serves as a valuable method in subacromial impingement, possibly reducing a need for surgical interventions.

Summary by Kaitlin Proksch

The effect of additional core stability exercises on improving dynamic sitting balance and trunk control for subacute stroke patients: A randomized controlled trial

Cabanas-Valdes, Rosa, et al. (2015)

The purpose of the study was to examine the effect of core stability exercises on various abilities in individuals who had experienced a subacute stroke. The study examined the effects specifically on trunk control, dynamic sitting, standing balance, overall gait as well as activities of daily living (those included in the Barthel Index).

The study consisted of eighty patients who were randomly assigned to either the exercise group or the control group. Those in the exercise group were instructed to perform 15 minutes per day of various core stability exercises in addition to the conventional therapy both groups received.

Various scales and tests were utilized to examine the abilities. The Trunk Impairment Scale and Function in Sitting Test were used for dynamic sitting and the Berg Balance Scale, Tinetti Test, Brunel Balance Assessment and a few others were used for the balance and function abilities.

The study found that those in the core exercise group improved significantly in all areas with the exception of the Brunel Balance Assessment. The researchers concluded that the addition of the core exercises into a daily routine had significant effects for one’s ability for trunk control, dynamic sitting balance, standing balance, gait as well as daily activities.

Summary by Kaitlin Proksch

Effects of Push-ups Plus Sling Exercise on Muscle Activation and Cross-sectional Area of the Multifidus Muscle in Patients with Low Back Pain

Promising results suggesting the importance of training shoulder stabilizer muscles, in addition to lumbar stabilization exercises, as part of a holistic treatment for low back pain. The study shows that “strengthening the stabilizer muscles of shoulder joint, improves functional movement by activating the rectus abdominis and the internal and external abdominal oblique muscles. “

 Yoga for Chronic Low Back Pain: A Randomized Trial

Biochemicals Associated With Pain and Inflammation are Elevated in Sites Near to and Remote From Active Myofascial Trigger Points

Evidence of changes in the biochemicals present (e.g. the pH normalizes) at the site of a trigger point following the twitch response elicited with trigger point dry needling.

Thoracic Ring Control: A Missing Link?

Lee, LJ. Thoracic Ring Control: A Missing Link? MPA In Touch magazine, an official publication of Musculoskeletal Physiotherapy Australia, a national group of the Australian Physiotherapy Association. Issue 4, 2013: 13-16.

A unique perspective on connecting the role of the thorax with whole body performance optimization.

Dry Needling to a Key Myofascial Trigger Point May Reduce the Irritability of Satellite MTrPs

Hsieh, Y-L., Kuan, M-J., Chen, S-M., Chen, J-T., Hong, C-Z. Dry needling to a key myofascial trigger point may reduce the irritability of satellite myofascial trigger points. Am J Phys Med Rehabil 2007; 86: 397-403.

Single blinded study providing evidence that using dry needling to deactivate primary (key) myofascial trigger points (MTrPs) in muscles causing shoulder pain also inhibits activity in satellite myofascial trigger points located in the pain referral zone of the primary MTrP.

Shoulder Impingement in Tennis/Racquetball Players Treated With Subscapularis Myofascial Treatments

Ingber, R. Shoulder Impingement in Tennis/Racquetball Players Treated With Subscapularis Myofascial Treatments. Am Phys Med Rehabil 2000; 81: 679-682.

Case report showing patients with shoulder impingement syndrome who did not respond to traditional treatment and were subsequently referred for surgery were able to avoid arthroscopic surgery and return to full, pain-free function with subscapularis trigger point dry needling treatment and therapeutic stretching.