Spinal manipulation and electrical dry needling as an adjunct to conventional physical therapy in patients with lumbar spinal stenosis: a multi-center randomized clinical trial.

BACKGROUND CONTEXT: Nonoperative management of lumbar spinal stenosis (LSS) includes activity modification, medication, injections, and physical therapy. Conventional physical therapy includes a multimodal approach of exercise, manual therapy, and electro-thermal modalities. There is a paucity of evidence supporting the use of spinal manipulation and dry needling as an adjunct to conventional physical therapy in patients with LSS. PURPOSE: This study aimed to determine the effects of adding thrust spinal manipulation and electrical dry needling to conventional physical therapy in patients with LSS. STUDY DESIGN/SETTING: Randomized, single-blinded, multi-center, parallel-group clinical trial. PATIENT SAMPLE: One hundred twenty-eight (n=128) patients with LSS from 12 outpatient clinics in 8 states were recruited over a 34-month period. OUTCOME MEASURES: The primary outcomes included the Numeric Pain Rating Scale (NPRS) and the Oswestry Disability Index (ODI). Secondary outcomes included the Roland Morris Disability Index (RMDI), Global Rating of Change (GROC), and medication intake. Follow-up assessments were taken at 2 weeks, 6 weeks, and 3 months. METHODS: Patients were randomized to receive either spinal manipulation, electrical dry needling, and conventional physical therapy (MEDNCPT group, n=65) or conventional physical therapy alone (CPT group, n=63). RESULTS: At 3 months, the MEDNCPT group experienced greater reductions in overall low back, buttock, and leg pain (NPRS: F=5.658; p=.002) and related-disability (ODI: F=9.921; p<.001; RMDI: F=7.263; p<.001) compared to the CPT group. Effect sizes were small at 2 and 6 weeks, and medium at 3 months for the NPRS, ODI, and RMDI. At 3 months, significantly (p=.003) more patients in the MEDNCPT group reported a successful outcome (GROC≥+5) than the CPT group. CONCLUSION: Patients with LSS who received electrical dry needling and spinal manipulation in addition to impairment-based exercise, manual therapy and electro-thermal modalities experienced greater improvements in low back, buttock and leg pain and related-disability than those receiving exercise, manual therapy, and electro-thermal modalities alone at 3 months, but not at the 2 or 6 week follow-up.

Intramuscular Electrical Stimulation to Trigger Points: Insights into Mechanisms and Clinical Applications-A Scoping Review.

Intramuscular electrical stimulation (IMES) is a modality used by clinicians to treat myofascial pain. Recent studies have shown positive results for the use of IMES on pain outcomes, yet studies investigating the potential mechanisms of IMES directly to trigger points (TrPs) are lacking. We performed a scoping review of the literature to summarize the current evidence from human and animal studies on the mechanisms of IMES to the TrP location, and to identify gaps in the existing literature. Electronic literature searches were conducted across five databases from inception to 15 August 2022, including PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Allied and Complementary Medicine Database (AMED), Scopus and Cochrane Register of Controlled Trials. Four studies met our full criteria for inclusion in this review. Three studies assessed the effects of IMES to TrPs on human subjects with MPS, and only one study used an animal model with experimentally generated TrPs. Based on the results of the included studies, IMES within a TrP region was reported to normalize muscle blood flow, decrease endplate noise of the TrP and elicit antinociceptive effects, at least partially, through engaging supraspinal descending pain inhibitory systems. At present, no clinical implications can be determined on the use of IMES to TrPs due to the limited amount and quality of the available evidence. Further studies investigating the clinical effectiveness and also underlying mechanisms of IMES to TrPs are clearly needed.

Cardiac autonomic neuropathy and physical therapy: A case report.

Cardiac autonomic neuropathy (CAN) is a complication of diabetes mellitus, which imposes significant functional limitations and at times, sudden death. In an evolving healthcare landscape, physical therapists are assuming greater clinical responsibility and thus must be aware of this potential complication and tailor the plan of care appropriately. The purpose of this case report is to highlight the need for increased awareness of CAN among physical therapists in order to improve screening, diagnosis, and treatment. A 41-year-old Spanish-speaking male with uncontrolled type 2 diabetes arrived to the emergency department (ED) with dizziness and syncope leading to an inability to walk, work, or complete community service hours. After evaluation by the ED physical therapist, the patient was admitted for further work-up and diagnosed with CAN. After a short hospital course, the patient returned home symptomatic, fell, and was re-admitted the same day. Throughout the second hospital stay, the patient's symptoms improved with robust medical management allowing physical therapy treatment and functional independence for safe discharge home. Additionally, patient-specific goals were met with the help of social work and the medical team. Clinical knowledge of CAN for the non-cardiopulmonary specialist physical therapist is lacking. As physical therapists prepare to be advanced practice providers in a rapidly evolving healthcare landscape, increasing awareness has the potential to lead to improved screening, diagnosis, and treatment of persons with CAN, a severe complication of diabetes.

Dry needling and upper cervical spinal manipulation in patients with temporomandibular disorder: A multi-center randomized clinical trial.

OBJECTIVE: To compare the effects of dry needling and upper cervical spinal manipulation with interocclusal splint therapy, diclofenac, and temporomandibular joint (TMJ) mobilization in patients with temporomandibular disorder (TMD). METHODS: One hundred-twenty patients with TMD were randomized to receive six treatment sessions of dry needling plus upper cervical spinal manipulation (n = 62) or interocclusal splint therapy, diclofenac, and joint mobilization to the TMJ (n = 58). RESULTS: Patients receiving dry needling and upper cervical spinal manipulation experienced significantly greater reductions in jaw pain intensity over the last 7 days (VAS: F = 23.696; p < 0.001) and active pain-free mouth opening (F = 29.902; p < 0.001) than those receiving interocclusal splint therapy, diclofenac, and TMJ mobilization at the 3-month follow-up. CONCLUSION: Dry needling and upper cervical spinal manipulation was more effective than interocclusal splint therapy, diclofenac, and TMJ mobilization in patients with TMD.

Dry needling as a novel intervention for cervicogenic somatosensory tinnitus: a case study.

Tinnitus is defined as conscious perception of sound in the absence of a corresponding external stimulus. A condition that affects 10 - 15% of the adult population, tinnitus may be caused by an interaction between the somatosensory and auditory system, more formally known as somatosensory tinnitus. Cervicogenic somatosensory tinnitus is a subgroup of somatosensory tinnitus involving anatomical structures and physiological mechanisms associated with the cervical spine. A limited number of studies have reported inconsistent outcomes for treating cervicogenic somatosensory tinnitus with conservative treatment strategies such as manual therapy and exercise. However, dry needling is a skilled, manual therapy intervention that has recently gained popularity among the physical therapy profession that may be useful for both evaluating and treating the condition. The following case report describes the use of dry needling to evaluate and treat a patient with cervical somatosensory tinnitus and concurrent cervicogenic headaches. Physical therapy that targeted the muscles of the upper cervical spine with dry needling resulted in a meaningful reduction in cervicogenic somatosensory tinnitus, and the improvements persisted at 1-year follow-up. Further research, including randomized control trials, is warranted to fully determine the potential of dry needling to treat cervicogenic somatosensory tinnitus.

Physical therapy treatment of a pediatric patient with symptoms consistent with a spinal cord injury without radiographic abnormality: A retrospective case report.

BACKGROUND: A spinal cord injury without radiographic abnormality (SCIWORA) is a relatively uncommon event that occurs in children following cervical trauma primarily due to sports-related injuries or physical abuse. CASE DESCRIPTION: This case report describes an 11-year-old wrestler that developed signs and symptoms consistent with a SCIWORA following neck trauma during competition. Despite all diagnostic tests being inconclusive, the patient demonstrated increased cervical, thoracic, and lumbar paraspinal tone along with pain, loss of sensation, loss of mobility, and weakness of the lower extremities. As a result, the patient was confined to a wheelchair and required maximum assistance to transfer and ambulate with a walker. The patient was referred to physical therapy nine days after the traumatic event, where he received interferential current with moist heat, myofascial release of paraspinal muscles, functional exercise, gait training, and spinal manipulative therapy targeting the cervical, thoracic, and lumbar vertebrae. OUTCOME: After 13 physical therapy treatments over 5-weeks, the patient was able to ambulate independently and perform all activities of daily living without pain or functional limitation. The following case report outlines this patient's successful journey toward recovery. CONCLUSION: This case report suggests that spinal manipulative therapy may be a safe and effective intervention when used within a multi-modal treatment strategy for patients with signs and symptoms consistent with SCIWORA. Moreover, spinal manipulative therapy may be considered a beneficial treatment in some pediatric patients. However, this report describes a single patient, and further research is required on the use of spinal manipulation in this patient population.

Dry needling strategies for musculoskeletal conditions: Do the number of needles and needle retention time matter? A narrative literature review.

Acupuncture and dry needling are both minimally invasive procedures that use thin, filiform needles without injectate for the management of a variety of neuromusculoskeletal pain conditions. While the theoretical constructs underlying the use of acupuncture and dry needling are unique, both appear to have the ability to elicit biochemical, biomechanical, endocrinological and neurovascular changes associated with reductions in pain and disability. However, optimal treatment dosage has yet to be determined, and there is a lack of consistency in the literature on the number of needles that should be inserted and the needle retention time. Therefore, the purpose of this narrative review is to further explore the importance of these two variables. While trigger point dry needling advocates single needle insertions via repetitive, quick in-and-out pistoning, most acupuncture and dry needling clinical trials have incorporated multiple needles for five to 40 min. Notably and to date, using a single needle to repeatedly prick trigger points one at a time with fast-in and fast-out pistoning maneuvers has not yet been shown to produce significant and clinically meaningful long term improvements in pain and disability in a wide array of musculoskeletal conditions. Insertion of multiple needles for typically 20-30 min durations has been shown to produce larger treatment effect sizes and longer-lasting outcomes than brief, single-needle strategies. Moreover, the number of needles and needle retention time are two variables associated with treatment dosage and must be carefully matched with specific musculoskeletal conditions and the patient's goals.

Spinal Manipulation and Electrical Dry Needling in Patients With Subacromial Pain Syndrome: A Multicenter Randomized Clinical Trial.

OBJECTIVES: To compare the effects of spinal thrust manipulation and electrical dry needling (TMEDN group) to those of nonthrust peripheral joint/soft tissue mobilization, exercise, and interferential current (NTMEX group) on pain and disability in patients with subacromial pain syndrome (SAPS). DESIGN: Randomized, single-blinded, multicenter parallel-group trial. METHODS: Patients with SAPS were randomized into the TMEDN group (n = 73) or the NTMEX group (n = 72). Primary outcomes included the Shoulder Pain and Disability Index and the numeric pain-rating scale. Secondary outcomes included the global rating of change scale (GROC) and medication intake. The treatment period was 6 weeks, with follow-ups at 2 weeks, 4 weeks, and 3 months. RESULTS: At 3 months, the TMEDN group experienced greater reductions in shoulder pain and disability (P<.001) compared to the NTMEX group. Effect sizes were large in favor of the TMEDN group. At 3 months, a greater proportion of patients within the TMEDN group achieved a successful outcome (GROC score of 5 or greater) and stopped taking medication (P<.001). CONCLUSION: Cervicothoracic and upper-rib thrust manipulation combined with electrical dry needling resulted in greater reductions in pain, disability, and medication intake than nonthrust peripheral joint/soft tissue mobilization, exercise, and interferential current in patients with SAPS. The effects were maintained at 3 months. J Orthop Sports Phys Ther 2021;51(2):72-81. Epub 28 Aug 2020. doi:10.2519/jospt.2021.9785.

Spinal manipulation and perineural electrical dry needling in patients with cervicogenic headache: a multicenter randomized clinical trial.

BACKGROUND CONTEXT: Spinal manipulation, spinal mobilization, and exercise are commonly used in individuals with cervicogenic headache (CH). Dry needling is being increasingly used in the management of CH. However, questions remain about the effectiveness of these therapies and how they compare to each other. PURPOSE: The present study aims to compare the combined effects of spinal manipulation and dry needling with spinal mobilization and exercise on pain and disability in individuals with CH. STUDY DESIGN/SETTING: Randomized, multicenter, parallel-group trial. PATIENT SAMPLE: One hundred forty-two patients (n=142) with CH from 13 outpatient clinics in 10 different states were recruited over a 36-month period. OUTCOME MEASURES: The primary outcome was headache intensity as measured by the Numeric Pain Rating Scale. Secondary outcomes included headache frequency and duration, disability (Neck Disability Index), medication intake, and the Global Rating of Change (GROC). Follow-up assessments were taken at 1 week, 4 weeks, and 3 months. METHODS: Patients were randomized to receive upper cervical and upper thoracic spinal manipulation plus electrical dry needling (n=74) or upper cervical and upper thoracic spinal mobilization and exercise (n=68). In addition, the mobilization group also received a program of craniocervical and peri-scapular resistance exercises; whereas, the spinal manipulation group also received up to eight sessions of perineural electrical dry needling. The treatment period for both groups was 4 weeks. The trial was prospectively registered at ClinicalTrials.gov (NCT02373605). Drs Dunning, Butts and Young are faculty within the AAMT Fellowship and teach postgraduate courses in spinal manipulation, spinal mobilization, dry needling, exercise and differential diagnosis. The other authors declare no conflicts of interest. None of the authors received any funding for this study. RESULTS: The 2 × 4 analysis of covariance revealed that individuals with CH who received thrust spinal manipulation and electrical dry needling experienced significantly greater reductions in headache intensity (F=23.464; p<.001), headache frequency (F=13.407; p<.001), and disability (F=10.702; p<.001) than those who received nonthrust mobilization and exercise at a 3-month follow-up. Individuals in the spinal manipulation and electrical dry needling group also experienced shorter duration of headaches (p<.001) at 3 months. Based on the cutoff score of ≥+5 on the GROC, significantly (X2=54.840; p<.001) more patients (n=57, 77%) within the spinal manipulation and electrical dry needling group achieved a successful outcome compared to the mobilization and exercise group (n=10, 15%) at 3-month follow-up. Between-groups effect sizes were large (0.94

Unilateral and Multiple Cavitation Sounds During Lumbosacral Spinal Manipulation.

OBJECTIVE: The purpose of this study was to determine from which side of the spine the popping sound (PS) emanates during side-lying, rotatory high-velocity low-amplitude (HVLA) thrust manipulation directed to the L5-S1 articulation using a time-frequency analysis. Secondary aims were to calculate the average number of PSs, the duration of lumbar thrust manipulation, and the duration of a single PS. METHODS: Thirty-four asymptomatic participants received 2 lumbar HVLA thrust manipulations targeting the right and left L5-S1 articulations. Two high sampling rate accelerometers were secured bilaterally 25 mm lateral to the midline of the L5-S1 interspace. For each manipulation, 2 audio signals were extracted and singularly processed via spectrogram calculation to obtain the release of energy over time on each side of the lumbosacral junction. RESULTS: During 60 HVLA thrust manipulations, it was measured a total of 320 PSs. Of those PSs, 176 occurred ipsilateral and 144 occurred contralateral to the targeted L5-S1 articulation; that is, the PS was no more likely to occur on the upside than the downside facet after right or left rotatory L5-S1 HVLA thrust manipulation. Moreover, PSs occurring on both sides at the same time were detected very rarely (ie, 2% of cases) with the lumbar HVLA thrust manipulations. The mean number of audible PSs per lumbosacral HVLA thrust manipulation was 5.27 (range 2-9). The mean duration of a single manipulation was 139.13 milliseconds (95% confidence interval: 5.61-493.79), and the mean duration of a single PS was 2.69 milliseconds (95% confidence interval: 0.95-4.59). CONCLUSION: Based on our findings, spinal manipulative therapy practitioners should expect multiple PSs that most often occur on the upside or the downside facet articulations when performing HVLA thrust manipulation to the lumbosacral junction (ie, L5-S1). However, whether the multiple PSs found in this study emanated from the same joint or adjacent ipsilateral or contralateral facet joints remains unknown. A single model may not necessarily be able to explain all of the audible sounds during HVLA thrust manipulation.

Psychometric properties of the Numeric Pain Rating Scale and Neck Disability Index in patients with cervicogenic headache.

BACKGROUND: Self-reported disability and pain intensity are commonly used outcomes in patients with cervicogenic headaches. However, there is a paucity of psychometric evidence to support the use of these self-report outcomes for individuals treated with cervicogenic headaches. Therefore, it is unknown if these measures are reliable, responsive, or result in meaningful clinically important changes in this patient population. METHODS: A secondary analysis of a randomized clinical trial (n = 110) examining the effects of spinal manipulative therapy with and without exercise in patients with cervicogenic headaches. Reliability, construct validity, responsiveness and thresholds for minimal detectable change and clinically important difference values were calculated for the Neck Disability Index and Numeric Pain Rating Scale. RESULTS: The Neck Disability Index exhibited excellent reliability (ICC = 0.92; [95 % CI: 0.46-0.97]), while the Numeric Pain Rating Scale exhibited moderate reliability (ICC = 0.72; [95 % CI: 0.08-0.90]) in the short term. Both instruments also exhibited adequate responsiveness (area under the curve; range = 0.78-0.93) and construct validity ( p < 0.001) in this headache population. CONCLUSIONS: Both instruments seem well suited as short-term self-report measures for patients with cervicogenic headaches. Clinicians and researchers should expect at least a 2.5-point reduction on the numeric pain rating scale and a 5.5-point reduction on the neck disability index after 4 weeks of intervention to be considered clinically meaningful.

Reliability, construct validity, and responsiveness of the neck disability index and numeric pain rating scale in patients with mechanical neck pain without upper extremity symptoms.

Objective: The purpose of this study was to examine the psychometric properties of the neck disability index (NDI) and numeric pain rating scale (NPRS) in patients with neck pain (NP) without concomitant upper extremity (UE) symptoms. Design: A secondary psychometric analysis of 107 patients with NP without UE symptoms. Test-retest reliability, construct validity, area under the curve (AUC), minimum detectable change (MDC), and minimum clinically important difference (MCID) were calculated.Results: The NDI exhibited excellent reliability (ICC = 0.88; [0.63 to 0.95]), while the NPRS exhibited moderate reliability (ICC = 0.67; [0.27 to 0.84]). The AUC for both the NDI (0.86; [0.79 to 0.93]) and NPRS (0.81 [0.73 to 0.90]) was acceptable. The MDC for the NDI was 6.9, and the MCID for the NDI was 5.5(Sn = 0.83; Sp = 0.79). For the NPRS, the MDC was 2.6, and the MCID was 1.5(Sn = 0.93; Sp = 0.64). Conclusion: The threshold for MCID for the NDI and NPRS in patients without UE symptoms is lower (NDI = 5.5; NPRS = 1.5) than that of patients with UE/radicular symptoms (NDI = 8.5 points; NPRS = 2.2). Knowledge of these cut-scores in each presentation of NP is needed for successful research and clinical treatment. Additional outcomes may be warranted for patients with UE symptoms.

Electrical dry needling as an adjunct to exercise, manual therapy and ultrasound for plantar fasciitis: A multi-center randomized clinical trial.

STUDY DESIGN: Randomized, single-blinded, multi-center, parallel-group trial. OBJECTIVES: To compare the effects of adding electrical dry needling into a program of manual therapy, exercise and ultrasound on pain, function and related-disability in individuals with plantar fasciitis (PF). BACKGROUND: The isolated application of electrical dry needling, manual therapy, exercise, and ultrasound has been found to be effective for PF. However, no previous study has investigated the combined effect of these interventions in this population. METHODS: One hundred and eleven participants (n = 111) with plantar fasciitis were randomized to receive electrical dry needling, manual therapy, exercise and ultrasound (n = 58) or manual therapy, exercise and ultrasound (n = 53). The primary outcome was first-step pain in the morning as measured by the Numeric Pain Rating Scale (NPRS). Secondary outcomes included resting foot pain (NPRS), pain during activity (NPRS), the Lower Extremity Functional Scale (LEFS), the Foot Functional Index (FFI), medication intake, and the Global Rating of Change (GROC). The treatment period was 4 weeks with follow-up assessments at 1 week, 4 weeks, and 3 months after the first treatment session. Both groups received 6 sessions of impairment-based manual therapy directed to the lower limb, self-stretching of the plantar fascia and the Achilles tendon, strengthening exercises for the intrinsic muscles of the foot, and therapeutic ultrasound. In addition, the dry needling group also received 6 sessions of electrical dry needling using a standardized 8-point protocol for 20 minutes. The primary aim was examined with a 2-way mixed-model analysis of covariance (ANCOVA) with treatment group as the between-subjects variable and time as the within-subjects variable after adjusting for baseline outcomes. RESULTS: The 2X4 ANCOVA revealed that individuals with PF who received electrical dry needling, manual therapy, exercise and ultrasound experienced significantly greater improvements in first-step morning pain (F = 22.021; P<0.001), resting foot pain (F = 23.931; P<0.001), pain during activity (F = 7.629; P = 0.007), LEFS (F = 13.081; P<0.001), FFI Pain Subscale (F = 13.547; P<0.001), FFI Disability Subscale (F = 8.746; P = 0.004), and FFI Total Score (F = 10.65; P<0.001) than those who received manual therapy, exercise and ultrasound at 3 months. No differences in FFI Activity Limitation Subscale (F = 2.687; P = 0.104) were observed. Significantly (X2 = 9.512; P = 0.023) more patients in the electrical dry needling group completely stopped taking medication for their pain compared to the manual therapy, exercise and ultrasound group at 3 months. Based on the cutoff score of ≥+5 on the GROC, significantly (X2 = 45.582; P<0.001) more patients within the electrical dry needling group (n = 45, 78%) achieved a successful outcome compared to the manual therapy, exercise and ultrasound group (n = 11, 21%). Effect sizes ranged from medium to large (0.53

The use of dry needling as a diagnostic tool and clinical treatment for cervicogenic dizziness: a narrative review & case series.

STUDY DESIGN: Narrative Review & Case Series. BACKGROUND: No "gold standard" test presently exists to confirm a diagnosis of cervicogenic dizziness, a condition whereby the neuromusculoskeletal tissues of the cervical spine are thought to contribute to imbalance and dizziness. Clusters of tests are presently recommended to provoke signs and symptoms of the condition. In this regard, dry needling may provide a valuable diagnostic tool. Targeting the musculoskeletal structures of the upper neck with dry needling may also provide a valuable treatment tool for patients that suffer from cervicogenic dizziness. While dry needling has been used to treat various musculoskeletal conditions, it has not been specifically reported in patients with cervicogenic dizziness. CASE DESCRIPTION: Three patients were screened for signs and symptoms related to cervicogenic dizziness in an outpatient physical therapy clinic. These patients presented with signs and symptoms often associated with (though not always) cervicogenic dizziness, including a positive flexion-rotation test, altered cervical range of motion, and tenderness with manual assessment of the upper cervical extensors. In addition, dry needling targeting the obliquus capitis inferior muscle was used diagnostically to reproduce symptoms as well as to treat the patients. OUTCOMES: Two of the patients reported full resolution of their dizziness and a significant improvement in their function per standardized outcome measures. While the third patient did not report full resolution of her cervicogenic dizziness, she noted significant improvement, and dry needling was helpful in guiding further treatment. Importantly, the effect of the treatment was maintained in all three patients for at least 6 months. DISCUSSION: This case series with narrative review covers various testing procedures for cervicogenic dizziness and explores the use of dry needling targeting the suboccipital muscles to evaluate and treat this patient population. The physiologic changes that occur in the periphery, the spine and the brain secondary to dry needling and their potential relevance to the mechanisms driving cervicogenic dizziness are discussed in detail.

Periosteal Electrical Dry Needling as an Adjunct to Exercise and Manual Therapy for Knee Osteoarthritis: A Multicenter Randomized Clinical Trial.

OBJECTIVES: To compare the effects of adding electrical dry needling into a manual therapy (MT) and exercise program on pain, stiffness, function, and disability in individuals with painful knee osteoarthritis (OA). MATERIALS AND METHODS: In total, 242 participants (n=242) with painful knee OA were randomized to receive 6 weeks of electrical dry needling, MT, and exercise (n=121) or MT and exercise (n=121). The primary outcome was related-disability as assessed by the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index at 3 months. RESULTS: Individuals receiving the combination of electrical dry needling, MT, and exercise experienced significantly greater improvements in related-disability (WOMAC: F=35.504; P<0.001) than those receiving MT and exercise alone at 6 weeks and 3 months. Patients receiving electrical dry needling were 1.7 times more likely to have completely stopped taking medication for their pain at 3 months than individuals receiving MT and exercise (OR, 1.6; 95% confidence interval, 1.24-2.01; P=0.001). On the basis of the cutoff score of ≥5 on the global rating of change, significantly (χ=14.887; P<0.001) more patients (n=91, 75%) within the dry needling group achieved a successful outcome compared with the MT and exercise group (n=22, 18%) at 3 months. Effect sizes were large (standardized mean differences >0.82) for all outcome measures in favor of the electrical dry needling group at 3 months. DISCUSSION: The inclusion of electrical dry needling into a MT and exercise program was more effective for improving pain, function, and related-disability than the application of MT and exercise alone in individuals with painful knee OA. LEVEL OF EVIDENCE: Level 1b-therapy. Prospectively registered February 10, 2015 on www.clinicaltrials.gov (NCT02373631).

The local twitch response during trigger point dry needling: Is it necessary for successful outcomes?

BACKGROUND: Myofascial trigger point (MTrP) injection and trigger point dry needling (TrPDN) are widely accepted therapies for myofascial pain syndrome (MPS). Empirical evidence suggests eliciting a local twitch response (LTR) during needling is essential. OBJECTIVE: This is the first review exploring the available literature, regardless of study design, on the neurophysiological effects and clinical significance of the LTR as it relates to reductions in pain and disability secondary to MTrP needling. METHODS: PubMed, MEDLINE, Science Direct and Google Scholar were searched up until October 2016 using terms related to trigger point needling and the LTR. RESULTS: and Discussion: Several studies show that eliciting a LTR does not correlate with changes in pain and disability, and multiple systematic reviews have failed to conclude whether the LTR is relevant to the outcome of TrPDN. Post needling soreness is consistently reported in studies using repeated in and out needling to elicit LTRs and increases in proportion to the number of needle insertions. In contrast, needle winding without LTRs to MTrPs and connective tissue is well supported in the literature, as it is linked to anti-nociception and factors related to tissue repair and remodeling. Additionally, the positive biochemical changes in the MTrP after needling may simply be a wash out effect related to local vasodilation. While the LTR during TrPDN appears unnecessary for managing myofascial pain and unrelated to many of the positive effects of TrPDN, further investigation is required.

CAVITATION SOUNDS DURING CERVICOTHORACIC SPINAL MANIPULATION.

BACKGROUND: No study has previously investigated the side, duration or number of audible cavitation sounds during high-velocity low-amplitude (HVLA) thrust manipulation to the cervicothoracic spine. PURPOSE: The primary purpose was to determine which side of the spine cavitates during cervicothoracic junction (CTJ) HVLA thrust manipulation. Secondary aims were to calculate the average number of cavitations, the duration of cervicothoracic thrust manipulation, and the duration of a single cavitation. STUDY DESIGN: Quasi-experimental study. METHODS: Thirty-two patients with upper trapezius myalgia received two cervicothoracic HVLA thrust manipulations targeting the right and left T1-2 articulation, respectively. Two high sampling rate accelerometers were secured bilaterally 25 mm lateral to midline of the T1-2 interspace. For each manipulation, two audio signals were extracted using Short-Time Fourier Transformation (STFT) and singularly processed via spectrogram calculation in order to evaluate the frequency content and number of instantaneous energy bursts of both signals over time for each side of the CTJ. RESULT: Unilateral cavitation sounds were detected in 53 (91.4%) of 58 cervicothoracic HVLA thrust manipulations and bilateral cavitation sounds were detected in just five (8.6%) of the 58 thrust manipulations; that is, cavitation was significantly (p<0.001) more likely to occur unilaterally than bilaterally. In addition, cavitation was significantly (p<0.0001) more likely to occur on the side contralateral to the clinician's short-lever applicator. The mean number of audible cavitations per manipulation was 4.35 (95% CI 2.88, 5.76). The mean duration of a single manipulation was 60.77 ms (95% CI 28.25, 97.42) and the mean duration of a single audible cavitation was 4.13 ms (95% CI 0.82, 7.46). In addition to single-peak and multi-peak energy bursts, spectrogram analysis also demonstrated high frequency sounds, low frequency sounds, and sounds of multiple frequencies for all 58 manipulations. DISCUSSION: Cavitation was significantly more likely to occur unilaterally, and on the side contralateral to the short-lever applicator contact, during cervicothoracic HVLA thrust manipulation. Clinicians should expect multiple cavitation sounds when performing HVLA thrust manipulation to the CTJ. Due to the presence of multi-peak energy bursts and sounds of multiple frequencies, the cavitation hypothesis (i.e. intra-articular gas bubble collapse) alone appears unable to explain all of the audible sounds during HVLA thrust manipulation, and the possibility remains that several phenomena may be occurring simultaneously. LEVEL OF EVIDENCE: 2b.

Pathoanatomical characteristics of temporomandibular dysfunction: Where do we stand? (Narrative review part 1).

Temporomandibular dysfunction (TMD) is a complicated and multifactorial condition that affects the temporomandibular joint (TMJ) and muscles of mastication, resulting in pain and disability in 5-12% of the population. The condition involves genetic, anatomic and hormonal factors and is propagated, in part, by trauma, habitual activity, psychosocial components and occlusal variation. Yet, the exact etiology of TMD is still unknown and the most strategic conservative management of the condition is still a topic of debate. The purpose of this paper, the first of a two part series, is to provide greater insight into the pathoanatomical factors associated with TMD. Consistent with Scully (2008, 2013), degenerative changes seem to disrupt the relationship between the TMJ capsule, articular disc and muscles of mastication. The resulting position of the articular disc coincides with three primary classifications of TMD: Type 1 (muscle disorders), Type 2a/b (disc displacement with and without reduction), and Type 3 (any joint pain). Given the association of the lateral pterygoid with both the joint capsule and articular disc, the superior and inferior head seem to play a key role in TMD. Both heads undergo biological changes associated with the vicious cycle, pain adaptation and integrated pain adaptation, making the muscle a key pain generator associated with TMD. Clinicians must understand the pathoanatomic features associated with TMD so as to choose appropriate treatment strategies, leading to optimal short and long-term outcomes. While the former is discussed in part 1 of this narrative review, the latter will be considered in part 2.

Conservative management of temporomandibular dysfunction: A literature review with implications for clinical practice guidelines (Narrative review part 2).

The effective management of temporomandibular dysfunction (TMD) requires a thorough understanding of the pathoanatomic factors that drive the underlying condition. After reviewing the etiology associated with TMD in Part 1 of this narrative review, the temporomandibular joint capsule, articular disc and muscles of mastication emerged as key players. (http://dx.doi.org/10.​1016/​j.​jbmt.​2017.​05.​017) Part 2 focuses on conservative treatment strategies best able to reduce the pain and disability associated with TMD. A review of the literature revealed limited support of strengthening exercises targeting the muscles of mastication. There was also limited evidence for manual soft tissue work targeting muscles of mastication, which may be specifically related to the limited accessibility of the pterygoid muscles to palpation. For the reduction of pain, there was little to no evidence supporting splint therapy and electrophysical modalities, including laser therapy, ultrasound, TENs and iontophoresis. However, for the reduction of pain and disability, non-thrust mobilization and high-velocity, low amplitude thrust manipulation techniques to the TMJ and/or upper cervical articulations that directly and indirectly target the TMJ joint capsule were generally supported in the literature. Studies that used dry needling or acupuncture of the lateral pterygoid and posterior, peri-articular connective tissue also led to significant improvements in pain and disability in patients with TMD. Thus, the most effective conservative management of TMD seems to be techniques best able to impact anatomic structures directly related to the etiology of TMD, to include the joint capsule, articular disc and muscles of mastication, specifically the superior and inferior head of the lateral pterygoid.