Dry Needling for Somatic Pain (Trigger Points): on the "Efficacy of specific needling techniques in the treatment of myofascial pain syndrome"

SITE NOTES:

still reviewing meta data.
this study is in review.
posted temporarily for discussion purposes.


Efficacy of specific needling techniques in the treatment of myofascial pain syndrome
Candice Brunham
Kelly McNabney
Jody Wiebe
Jeff Norwood
Research Supervisors:
Dr. Darlene Reid
Dr. Babak Shadgan

Needling Intervention + Adjunct Therapy vs Adjunct Therapy vs Control
• Comparison of superficial DN + stretching vs stretching vs control (Edwards & Knowles, 2003):
– No significant difference between
groups immediately post
treatment
– Superficial DN + stretch favoured
at follow up for increase in PPT

Discussion – Needling vs Needling Intervention
• No trends seen due to heterogeneity
of studies
– Study by Irnich et al (2002)
found acupuncture
to be significantly more effective than DN
– Ceccherelli et al (2002)
found deep
acupuncture to be more effective than
superficial acupuncture
– Birch & Jamison (1998)
found relevant acupuncture to be more effective than irrelevant acupuncture
• Future studies comparing needling
techniques are needed to determine
the most effective technique

Discussion – Needling vs
Other Intervention
• Studies which favoured lidocaine injection
over DN techniques involved only one
treatment session
• Study by Ga et al (2007)
which favoured
IMS over lidocaine injection had 3
treatments over 3 weeks
• The form of dry needling may play a role in
treatment efficacy
• Study by Ilbuldu et al (2004)
favoured
laser over DN, but subjects received a
greater number of laser treatments

Implications for Practice
• Best practice involves a structured
interdisciplinary approach including
physical and cognitive behavioral strategies
• The national institute of health (USA)
consensus statement on  acupuncture
(1997) concluded that it may be useful as
an adjunct treatment

• This review indicates a need for future
investigation of dry needling therapies as
part of a comprehensive program
Conclusions
• No clear evidence that Dry Needling techniques are more efficacious than placebo, sham, or alternative treatment techniques
• No clear recommendations can be made regarding
the most effective needling technique or optimal
length and frequency of treatment
• Results suggest that multiple treatment sessions are
more effective on pain outcomes than single
treatment sessions
• Level of evidence does not exceed moderate



Acknowledgements:
Dr. Darlene Reid, Dr. Babak Shadgan,
Charlotte Beck, Dr. Angela Busch, &
Meredith Wilso

RSD

[Case:
Complex Regional Pain Syndrome
( Reflex Sympathetic Dystrophy )

This is a constellation of symptoms springing from increased sympathetic tone at one or more extremities. Pain, erythema, and edema are seen. Lymphedema and fascial strains may be noted along the extremities. This may occur after blunt force Trauma, a crush or fall injury, or surgery.

We see a sympathetic overload. Changes in tissue circulation occur. Tender points, tissue changes, or vertebral rotations are noted over T5-7, T10-L2. Motor and tissue changes may be seen along C4-T1 or L1-S3. Compensatory patterns over unaffected areas may be noted.

The complex is fairly responsive to Reflexive De-Afferentation Techniques, OMT, and manual drainage techniques.

www.manual.blogspot.com]

A Case to Study: Neuro-MyoFascial Trigger Points, Cervical Somatic Dysfunction

chief complaint:
constant, moderately severe
neck and shoulder pain,
with primary limitation of cervical flexion,
x 2 weeks, with increased intensity x 1 day,
precluding ability to do common office tasks.
Persistent aching to pounding severe pain was what crippled ability to do even standard deskwork.
No sudden falls or known recent physical trauma traceable as possible trigger events.
Areas highlighted in red correspond to neuro-myofascial adhesions and active trigger point distribution. The NMTPs formed a reverb circuit.

What are the primary lesions?
Treatment modes recommended?
Does Trigger-Point Needling and Infiltration Work?

MMG Homepage? Click here.

Athletic Injuries Galore

Just finished taking care of someone with
a hardly walkable, fairly unswollen knee.
In other words, it will look normal to most.

Primary inciting injury inversion fall, medial knee caught fall on concrete June 2011.
Main complaint: moderately severe, constain pain, marked by sharp spikes that accompany sudden limb weakness, limiting stair descent more than walking.
Pes anserinus and infrapatellar bursitis as primaries.
Medial collateral and coronary ligaments sprained.
Iliotibial band bursitis, too.
Conclusion:
cheerdancing IS a competitive sport,
cheerdancers are atheletes,
these are real injuries.

Brother @Rheysonn Cornilla, i'm sad i missed out on Zark's burgers today.

Mind body medicine workshops

How do we maximize the mindbody connection in treatment?
Wondering who else would be interested in joining a pilot class for Mind-Body Mobilization?
Basic precepts for the intervention techniques:
How do we rapidly shift to parasympathetic healing mode, and what to do with once there.
Will include, at a minimum, synthesized R.D.T. work, OMT, N.L.P., & clinical Hypnosis.
Rheysonn, we gotta talk soon, bro.
Email me suggestions, please, everyone.

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A Primary Spine Care Pratitioner Network in the Philippines?

The Establishment of a Primary Spine Care Practitioner and its Benefits to Health Care Reform in the United States Murphy DR, Justice BD, Paskowski IC, Perle SM, Schneider MJ Chiropractic & Manual Therapies 2011, 19:17 (21 July 2011)

http://www.chiromt.com/content/pdf/2045-709X-19-17.pdf

Thought the community might benefit from access to this article.

Email us feedback!

Rheysonn
Dionne
Harold
Strix

Would you believe that clinical research is important?

An example of why clinical research is important to the practicing doctor

by Henry Davld Nava Dlmaano on Saturday, July 9, 2011 at 3:33pm

A longtime friend of mine, whom I'll refer to here as P.A., happens to be consulting me for chronic low back pain with radiating pain/numbness/pins-&-needles sensation to both left & right legs.  The symptoms started over a year ago (nearly two years now), particularly for the left leg & back.  Now, her right leg also has symptoms.  She happens to be a year older than me, is athletic, does gym & other physical activities, has a healthy lifestyle with no vices.  

She's never had any major trauma, but she was part of the Judo team back when she was a college student.  No medical problems other than this one.  taking her cue from my prior advice, she's had an MRI scan done for her lower back at National Kidney Transplant Institute (she spent about P9k for it, about as much as you'd spend if you had it done here in Cebu City).  What it revealed was L4-L5 and L5-S1 bilateral foraminal stenosis stemming from degenerative disc disease & facet joint hypertrophy of the same levels.  So I've advised her to consider surgery, especially since she's symptomatic for nerve impingement for over a year now (going past the 1-year mark is normally not a good idea, as recovery of nerve function following decompressive surgery is significantly poorer if you've allowed the nerve under impingement to remain so for more than a year).  Her main setback is the cost of undergoing surgery; so right now, she's managing the BACK pain symptoms using acupuncture.

Here's a transcript of our most recent conversation via live chat:

P.A.

The doc here at the acupuncture clinic says that with the [acupuncture] treatment we should be able to address the injury [she means the degenerative spine disease], not just the pain -- and I may not need surgery. Is that possible?

 

H.D.

he's going to REVERSE the degenerative process with acupuncture? hmm.  seems like i'm going to have to give you a crash course on clinical medical research methodology here.  Hold on to your seat.

okay.  well, you can always try going alternative while you're waiting for a shot at definitive surgery.  i don't know the PROVEN clinical impact of acupuncture (OTHER THAN for pain relief) well enough to vote for or against that claim.  but the good thing is, you can always ask your acupuncturist for HARD CLINICAL RESEARCH DATA that proves acupuncture can do what he says it can do -- remove the need for surgical decompression.  and by "remove the need for surgery", i don't mean just the short-term effects; we measure the clinical benefit of surgery in terms of YEARS (with 2-year post-operative follow-ups being the MINIMUM requirement for efficacy surveillance).  so i guess you'd want to see hard data from THOUSANDS of acupuncture patients with the SAME DISEASE AS YOU -- and you'd want to see how acupuncture can save their impinged nerves without them having to later undergo surgery anyway (as compared to patients who DON'T undergo acupuncture AND instead have surgical treatment for their radiculopathies).

without clinical research data like that to convince you about the SAFETY & EFFICACY PROFILE of the treatment in question, i'd say the claim that acupuncture can CURE YOU TOTALLY is about as good as saying MX3 or Circulan can cure you totally.  (we always say that the first precept of medical practice is "first, do no harm".  treatments don't always work; but even if they don't, the least you can do is make sure the patient doesn't end up with a complication in the process of treatment. hence, the need for research data that can prove SAFETY, and preferably, EFFICACY of the treatment.  take your acupuncture for example: it's both safe & effective for controlling your back pain, or any other type of pain -- and THAT'S PROVEN BY RESEARCH.  but the question here is: can it safely & effectively cure degenerative lumbar radiculopathy without the need for later surgery?)

now here's what you need to do: ask your acupuncturist for STUDIES (yes, more than one research) that are "clinical trials" or "prospective clinical cohorts" with "adequately powered samples" & "clinical outcome measures that are blinded".  (nevermind what that means -- if the research has any of these features, it will likely declare itself as having such.)

in particular, you'd like the research data to have the ff features:

> LARGE clinical trial or LARGE prospective cohort (preferably a multi-center study);

> must be something that actually compares ACUPUNCTURE versus SURGICAL DECOMPRESSION as treatments;

> must include patients that actually have lumbosacral RADICULOPATHY -- patients that are strictly screened for, and fit the clinical description of, a patient suffering from lumbosacral nerve impingement due to narrowed canals (no more, no less);

> must have at least 2 years' worth of post-treatment ff-up data (each patient is regularly checked up for 2 years right after the treatment protocol is FINISHED -- not 2 years after the symptoms start, or, not 2 years after the patient enters the study pool);

> the sample of patients at the END of the study must relatively be equivalent to the sample at the BEGINNNING (i.e., not many patients were lost to ff-up during the entire duration of the study -- about 80% of the original patients should still be accounted for at the end, in order for the study to be credible);

> there must be NO TREATMENT CROSS-OVERs -- where patients undergoing acupuncture later cross over to the surgery side, or patients who had surgery cross over to the acupuncture side;

> treatment success must be measured by ANY OR ALL of the ff CLINICAL OUTCOME MEASUREMENT TOOLS -- the VAS score for pain (back pain AND leg pain), the Roland-Morris Disability Questionnaire for degenerative spine disease, the Oswestry Disability Index for back pain, and maybe even the SF-36 questionnaire (these are all world-accepted VALIDATED TOOLS for evaluating clinical functionality of patients with back problems; any other means of measuring or defining "treatment success" just won't cut it);

> outcome measurement (as mentioned above) must be "blinded" -- i.e., the research person doing the measurement(s) over the entire ff-up period MUST NOT KNOW if the patient he/she is evaluating is a patient belonging to the acupuncture group or the surgery group (in order to prevent BIAS TO TREATMENT EFFECTS from occurring on the part of the evaluator);

> the complication rates of both acupuncture & surgical decompression must be reported in detail -- and remember that "failure of primary treatment" is in itself a complication (e.g., you get the acupuncture, symptoms are relieved for a while, but then they come back, and you eventually need surgery for it).  [note also that there are other complications to consider: risk of getting an infection from bacteria or viruses; risk of delay of definitive treatment; risk of developing chronic pain which is non-responsive to any treatment; risk of paralysis; even risk of dying from a procedure, although that's actually close to nil, even for spine surgery.]

if your acupuncturist can show you at least 3 studies [i wouldn't want to settle for just ONE study, i'd like to at least base my decisions on a consensus of 3 studies] which meet all these requirements, then you have my vote for going alternative instead of having the surgery.  i know it seems too technical; but you see, saving patients' lives is a technical task to begin with -- which is why the research & evidence-gathering involved is also quite technical.  think of it as proof that we doctors don't take our patients' problems lightly.  ^_^

and besides, any medical practitioner who knows what he/she is doing should also intimately know the hard basis for whatever he/she does.  if you don't know the hard science behind your practices, how would you be sure that your practices are SAFE & EFFECTIVE, right?  (by "science", i am referring to the scientific method of research.)  this is, to a large extent, what you pay good money for -- to make sure that your medical care provider actually knows his/her stuff.  because why would any patient bother spending good money on a practitioner who doesn't really know if what he's doing is rational or not?

bottom line: is it possible for him to do what he says acupuncture can do? yes -- but he has to first show some hard evidence that it really can.

P.A.

what he said was that I MAY not need surgery, not that I definitely won't need it.  in any case, it's good for the pain so that's what I keep going back for :)

when he told me that what I said was that I am definitely getting another MRI before surgery if only so we can see if there has been any improvement to my back.

H.D.

what he's implying is that you may not FEEL THE NEED to have surgery done if you are kept pain-free (which is most likely true for any patient -- no symptoms, no need for any further treatment).  but the question that you have to ask him is, can he guarantee that you're nerves won't get damaged from progressive degenerative compression just the same, EVEN THOUGH THE ACUPUNCTURE KEEPS YOU PAIN-FREE?  because i'm pretty sure that no amount of acupuncture (or any other treatment offering mere symptomatic, non-decompressive releif) can reverse the degenerative changes in your spine that are causing nerve compression.

i'll make him a bet. get the MRI after his treatment is done. if it shows any improvement in the size of your foraminal canals [compared to the first MRI scans from last month], i'll pay for the MRI. but if it doesn't show any change, he pays for it. deal

i'm serious with that bet. i say put your money where your mouth is.

P.A.

hahaha ... I'll have to tell him that first. :D

 

H.D.

for the sake of image uniformity, you have to get the MRI repeat scan also in NKTI, where you had the first one done.

although essentially, from the standpoint of orthopedics, you don't need a repeat MRI -- not unless your symptoms grow worse and/or you end up waiting maybe more than a year from the first MRI scan before you have any surgery done. if your symptoms don't worsen, we can assume that the involved levels of your lumbar spine are status quo. although it's highly likely that the canals will get narrower over time. how much time till things worsen PARTLY depends on how much load you place on your back.

P.A.

I will surely do that. the equipment is good and the price is even better :)

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Paper Mastery

The moment you know everything there is to learn
about that one thing you say you've mastered,
i'd like to congratulate you, because,
right then, you're already
20% there!

You can walk again!

Okay, now that we've fixed your back, now that you can walk again,
here are a few guidelines we've found most useful to tell patients:

1. Hydrate! Fascia is a colloidal structure in terms of behaviour. The better your fluid status is, the more useful fascial sliding we'll get.
2. Walking is good. Swimming is great.
3. Whatever it is, take it easy.
4. Resist the tempation to run, jog, leap, and go up and down large flights of stairs, at least for two weeks after our last treatment.
5. Sugar sucks up water and feeds inflammation. Avoid it for at least three days.
6. Never sit down for more than 45 minutes straight. Get up. Stretch. Unwind.
7. Turmeric, fish body oils, flax seed oil: these are your anti-inflammatory friends. An alkaline vitamin C will help. Red hot chilli peppers, if you can tolerate them, will do wonders for you.
8. Get your greens. Go by color. Deeper, darker greens are best.
9. Shift all your salt to unadulterated natural sea salt. Iodized salt in the Philippines is pure sodium plus pure chloride plus iodine. More sodium isn't a good idea. Real sea salt has trace magnesium and calcium that will really help.
10. When in doubt, don't invent. Ask me about whatever it is i can help you with.
11. Weight loss for the portly is a necessity. Gradual continued fat loss is best. Rapid weight loss is traumatic to your system, And is likely not a sustainable change.
12. Release unproductive emotions. Seek and stock up on grattitude, love, and laughter.
13. Don't take my word on any of this. Take it for testing, and prove us right.

www.manualmed.blogspot.com

What is "Tensegrity?"

@TranceDoctor:
How is it that we can heal with our hands?
dionne-thehealingparadigms.blogspot.com/2011/06/tensegrity-power.html?spref=fb

"the kitchen is all foreplay!"
(Chef Ed Quimson)

"the thrust is automatic
when you've set is up right"
(S. Toledo, D.BT, D.OI)

"great idea!"
(@iamstrix)

Help Wanted

@iamstrix:
the Manual Medicine Group
needs the best Occupational Therapist
still in the philippines
to join us for clinics.
www.manualmed.blogspot.com

Elbow Pain?

Free assessments for tennis elbow
or pain on the outer elbows.
Conducted by university professor, clinician.
Mail us. strix02@yahoo.com

posted from Bloggeroid

Fix Scoliosis!

How to correct lumbar primary scoliosis lesions without thrust techniques, and with more permanent results.
An evolving dialogue and practice forum for my colleagues and students is also at:
www.manualmed.blogspot.com
http://yfrog.com/h2vojqp

posted from Bloggeroid

@iamstrix:
Because of cultural sitting differences,
the japanese knee replacement needs to be able to bend to 135°.
The caucasian knee needs only 90° to be funtional for normal activities of daily living.

The Emmett Technique is in the Philippines?

Weekend Workshop! Ask us about it!

Ask us about great group discounts!

The Emmett Technique Body Pressure Therapy

Doers and Do-nots

Heard of the latest fashion scandal?

Basically, a fashion designer substituted his tags
for off-the-rack tags on department store clothes he passed off for his own, at a price upgrade of tens of thousands a piece. He got caught because he forgot to unstitch one of the rtw labels.

Today, passing by
a wall at eastwood where fashion critics and columnists have their faces plastered, i am strangely taken back to the notion that

some people talk,
and some people do.

In an ideal world, we all walk our talk.
Ideally, we are so good at what we do, so overflowing with passion for it, that we lead our fields by example, by results.
It would then be great if those exceptional at what they do could also teach well.
It would be great if every clinician could be a good academician.
It would be great if every academician knew how to do well what they teach.

Too often, however, those who can't do
just adore criticizing what they don't really grasp.
Often, those who can do things aren't able to share their knowledge.
Often, those who can't do things are particularly good at talking.

I wonder if we could all stop cursing and criticizing the darkness.
I wonder if we could start looking for the light, head for it, and describe the journey so others might take up a similar path.

May we more often walk our talk, say what we mean, and mean what we say.

www.manualmed.blogspot.com

Pain has many names

I hope we always remember to check for emotional content. So much of pain is colored by personal perception. We would be remiss as caretakers of the body if we did not notice the mental and emotional burdens our patients carry.