A mixed-methods survey of physiotherapists who practice acupuncture and dry needling in Ontario, Canada: practice characteristics, motivations, and professional outcomes.

BACKGROUND: Physiotherapists (PTs) across the globe are increasingly incorporating filiform needling techniques (e.g., acupuncture, dry needling) into their clinical toolkits; and, the evidence base for these complementary therapies is becoming progressively more robust. However, to date, little is known about needling PTs themselves. METHODS: Using a cross-sectional survey design, PTs authorized to perform needling therapies in Ontario, Canada were recruited for anonymous participation (n = 2061) in an online survey. The survey asked providers about their demographics and practice characteristics, rationale for and views about therapeutic needling, and their related clinical and professional outcomes. The response rate was 20.7% (n = 426), and 22.3% (n = 95) of respondents provided textual responses to an open-ended qualitative question. RESULTS: While study respondents' demographic features appear similar to their broader professional population, Ontario's needling PTs are less likely to work in public sector settings. Most completed training in medical acupuncture rather than dry needling, and typically used needling in over one-third of patient visits. Almost all endorsed needling as an effective musculoskeletal treatment, the primary factor informing their adoption of the practice. While many viewed traditional Chinese medical theories as a useful explanatory framework, most relied on biomedical epistemology to drive their needling work. A majority of respondents reported that the inclusion of needling within their clinical toolkits had improved their likelihood of achieving excellent clinical results, helped support patient recruitment and retention, and heightened their professional satisfaction. While a few reported earning a higher income as a result, most reported that their clinical use of needling in addition to other PT modalities reduced their physical fatigue after a day's work. CONCLUSIONS: This study represents a first scholarly investigation into the motivations, training backgrounds and practice patterns of PTs who use acupuncture or dry needling. Additional research from other jurisdictions is needed to evaluate the transferability of study findings.

The treatment effect of intramuscular stimulation on carpal tunnel syndrome: A blinded randomized trial on 75 patients.

BACKGROUND: Carpal tunnel syndrome (CTS) is a disorder with a prevalence of about 5.8% for females and 0.6% for males. This study aims to determine whether intramuscular stimulation (IMS) to the pronator teres muscle subsequently reduces the severity of clinical parameters and the diameter of the median nerve. METHODS: Seventy-five individuals with a cross-sectional diameter of the median nerve of more than 2 mm were included in this randomized clinical trial. Thirty-seven individuals received IMS to the pronator teres muscle with a depth of up to 45-50 mm. The 38 individuals in the control group received an acupuncture needle at Li11 with a depth of 4-5 mm. Both groups had 7 treatments within 7 weeks. The primary outcome was the cross-section of the median nerve in the carpal tunnel. Additionally, Phalen's test, Tinel's sign, VAS for pain intensity, and pincer grip strength were measured. RESULTS: Both IMS subjects and controls showed significant reductions in the cross-section of the median nerve from baseline to follow-up (p < 0.001 and p = 0.002 respectively). The IMS group had the largest change, but the difference in change between the groups was not significant (p = 0.39). On all clinical tests, IMS subjects showed significant improvement from baseline compared with the control group (largest p = 0.002). CONCLUSION: In this study we found that IMS to the pronator teres muscle significantly improved all clinical variables measured, compared with the group receiving acupuncture. Furthermore, the cross-section of the median nerve reduced over time for both groups. IMS may be a low-risk alternative while patients are waiting for surgery. TRIAL REGISTRATION: Clinicaltrials. gov Identifier: NCT01102868. Retrospectively registered: March 29th, 2010.

Intramuscular stimulation as a novel alternative method of pain management after thoracic surgery.

BACKGROUND: The purpose of this study was to determine whether electrical twitch-obtaining intramuscular stimulation (ETOIMS) can be an alternative to intravenous patient-controlled analgesia (IV-PCA) for postoperative pain management in pneumothorax patients undergoing single-port video-assisted thoracoscopic surgery (VATS). METHODS: This preliminary prospective randomized study was conducted between March 2017 and July 2017. A total of 26 patients undergoing single-port VATS were randomly assigned to two groups: the ETOIMS group (n=12), which received intramuscular stimulation prior to chest tube insertion toward the end of procedure, and the IV-PCA group (n=14), which received continuous infusion of fentanyl with a basal rate of 10 µg/mL/h. To measure postoperative pain, visual analogue scale (VAS; range, 0-10) was used as the primary endpoint. RESULTS: Baseline characteristics were not different between the two groups. According to the linear mixed model, there was statistical difference in the serial VAS score between the two groups (P=0.007). The ETOIMS group showed a significantly lower VAS score compared with the IV-PCA group, especially at postoperatively hour 8, day 1, and day 2. CONCLUSIONS: We showed that ETOIMS may be a safe, effective, and simple alternative for pain management after single-port VATS.

Effect of dry needling on cubital tunnel syndrome: Three case reports.

This case series describes three patients who presented with right medial elbow pain managed unsuccessfully with conservative treatment that included medication, massage, exercise therapy, ultrasound therapy, neurodynamic mobilization, and taping. Diagnosis of cubital tunnel syndrome was based on palpatory findings, a positive elbow flexion test, and a positive Tinel's sign. Conventionally, the intervention for this entrapment has been surgical decompression, with successful outcomes. This is potentially a first-time description of the successful management of cubital tunnel syndrome with dry needling (DN) using a recently published DN grading system. The patients were seen twice a week for 2 weeks with immediate improvements noted in all the outcome measures after the first treatment session. At discharge, they were pain-free and fully functional, which was maintained up to a 6-month follow-up.

Effect of dry needling on radial tunnel syndrome: A case report.

This case report describes a 45-year-old male who presented with chronic right lateral elbow pain managed unsuccessfully with conservative treatment that included anti-inflammatory medication, injection, massage, exercise, bracing, taping, electro-physical agents, and manual therapy. Diagnosis of radial tunnel syndrome (RTS) was based on palpatory findings, range of motion testing, resisted isometrics, and a positive upper limb neural tension test 2b (radial nerve bias). Conventionally, the intervention for this entrapment has been surgical decompression, with successful outcomes. This is potentially a first-time report, describing the successful management of RTS with dry needling (DN) using a recently published DN grading system. Immediate improvements were noted in all the outcome measures after the first treatment, with complete pain-resolution maintained at a 6-month follow-up. A model is proposed describing the mechanism by which DN could be used to intervene for nerve entrapment interfaces.

Effect of dry needling on myofascial pain syndrome of the quadratus femoris: A case report.

This case report describes a 40-year-old male who presented with posterior thigh pain managed unsuccessfully with massage therapy, chiropractic adjustments, and physical therapy. The diagnosis of myofascial pain syndrome (MPS) involving the quadratus femoris (QF) was purely clinical, based on palpatory findings and ruling out other conditions through deductive reasoning. This is potentially a first time report, describing the successful management of MPS of the QF with dry needling (DN) using a recently published DN grading system. Immediate improvements were noted in all the outcome measures after the first treatment, with complete pain-resolution maintained at a 4-month follow-up.

Immediate Effects of Paraspinal Dry Needling in Patients with Acute Facet Joint Lock Induced Wry Neck.

INTRODUCTION: Acute facet joint lock induced wry neck (AFJL-WN) is common among adult population and it is primarily managed by medications and physiotherapy. However, the immediate recovery from pain and movements restriction caused by AFJL-WN is not documented in favour of existing interventions. AIM: To evaluate the immediate effects of paraspinal dry needling (PSDN) on acute neck pain and movement deficit in patients with AFJL-WN. MATERIALS AND METHODS: A total of 21 patients with AFJL-WN were treated with single session of PSDN for 12-15 minutes. The Visual Analog Scale (0-100mm) and Hand Held Goniometer were used to assess the immediate, 24 hours and 1 week follow-up neck pain and cervical spine's range of motion respectively. The mean and standard deviation was used to make inferences. RESULTS: Immediately after PSDN the pain score was reduced and cervical spine range of motion have improved. The 24 hours and 1 week follow-up pain and range of motion scores have shown the sustained improvement without deteriorations. CONCLUSION: PSDN is effective method to achieve pain free neck movements in patients with AFJL-WN.

Intramuscular stimulation of tibialis anterior in human subjects: the effects of discharge variability on force production and fatigue.

Continuous intramuscular stimulation of tibialis anterior (TA) was used to test the hypothesis that irregular trains of stimuli can increase force production and offset the magnitude of fatigue when compared with a continuous train of regular stimuli at an identical mean frequency (19 or 24 Hz). To achieve this, tungsten microelectrodes were inserted into the muscle belly into the motor point of the tibialis anterior muscle of able-bodied individuals (aged 19-50) and stimulated at current intensities ranging from 5 to 7 mA. The motor point was stimulated with a continuous train of regular stimulation at either 19 or 24 Hz (n = 11) or until the force declined below 25% of the peak force at the onset of stimulation. For the first seven subjects, no fatigue was exhibited, and thus, we simply compared the forces generated by the regular and irregular segments of the continuous train (120 sec for each segment). For four additional subjects, we delivered a higher frequency train (24 Hz) that elicited some fatigue. Once the force had declined below 25% of the initial peak force (which took between 140 and 210 sec), the continuous irregular train was integrated. Interestingly, for those subjects who exhibited muscular fatigue, force always began to rise again once the irregularity was incorporated into the continuous regular train of stimulation at the identical mean frequency (24 Hz). We conclude that incorporating irregularity into continuous trains of stimuli offers a significant advantage to the human neuromuscular system during both fatigued and nonfatigued states and could offer benefits to therapies such as functional electrical stimulation (FES).

Effect of fascia dry needling on non-specific thoracic pain - A proposed dry needling grading system.

This case report describes a 42-year-old female who presented with complaints of diffuse pain in her thoracic paraspinal region from T2 to T7. Physical examination revealed tenderness, increased turgor and restriction of her superficial fascia. A potential first time description of successful management utilizing fascia dry needling is described in this report with improvements noted in pain, range of motion, and functional activities. The patient was discharged from physiotherapy after four treatment sessions, and a follow-up after 3 months revealed that she was pain free and fully functional. A grading system (Sudarshan and Murugavel Dry Needling Grading Scale©) is proposed describing the various grades of dry needling to guide clinical reasoning and decision-making.

The Effectiveness of Trigger Point Dry Needling for Musculoskeletal Conditions by Physical Therapists: A Systematic Review and Meta-analysis.

Study Design Systematic review and meta-analysis. Background An increasing number of physical therapists in the United States and throughout the world are using dry needling to treat musculoskeletal pain. Objective To examine the short- and long-term effectiveness of dry needling delivered by a physical therapist for any musculoskeletal pain condition. Methods Electronic databases were searched. Eligible randomized controlled trials included those with human subjects who had musculoskeletal conditions that were treated with dry needling performed by a physical therapist, compared with a control or other intervention. The overall quality of the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation. Results The initial search returned 218 articles. After screening, 13 were included. Physiotherapy Evidence Database quality scale scores ranged from 4 to 9 (out of a maximum score of 10), with a median score of 7. Eight meta-analyses were performed. In the immediate to 12-week follow-up period, studies provided evidence that dry needling may decrease pain and increase pressure pain threshold when compared to control/sham or other treatment. At 6 to 12 months, dry needling was favored for decreasing pain, but the treatment effect was not statistically significant. Dry needling, when compared to control/sham treatment, provides a statistically significant effect on functional outcomes, but not when compared to other treatments. Conclusion Very low-quality to moderate-quality evidence suggests that dry needling performed by physical therapists is more effective than no treatment, sham dry needling, and other treatments for reducing pain and improving pressure pain threshold in patients presenting with musculoskeletal pain in the immediate to 12-week follow-up period. Low-quality evidence suggests superior outcomes with dry needling for functional outcomes when compared to no treatment or sham needling. However, no difference in functional outcomes exists when compared to other physical therapy treatments. Evidence of long-term benefit of dry needling is currently lacking. Level of Evidence Therapy, level 1a. J Orthop Sports Phys Ther 2017;47(3):133-149. Epub 3 Feb 2017. doi:10.2519/jospt.2017.7096.

Position Statement of the Israeli Society for Musculoskeletal Medicine on Intramuscular Stimulation for Myofascial Pain Syndrome-A Delphi Process.

OBJECTIVE: To develop consensus on a position paper on the use of intramuscular stimulation (IMS) for the treatment of myofascial pain syndrome (MPS) by physicians in Israel. METHODS: The Israeli Society of Musculoskeletal Medicine ran a modified Delphi process to gather opinions from a multidisciplinary expert panel. Eight experts in the treatment of MPS were chosen and asked to participate, and six participated. The position paper was iterated three times. RESULTS: After three iterations, general consensus was reached by all six experts. The general statement that was agreed on was: "IMS is one of the preferred treatments for myofascial pain syndrome. The treatment is evidence-based, effective, safe, and inexpensive. The position of the Israeli Society of Musculoskeletal Medicine is that the treatment should be taught and used by all primary care physicians and those physicians in other areas of medicine who deal with pain in their work." CONCLUSIONS: The position paper is a basis for clinical work and education programs for physicians interested in a better understanding and ability to treat patients with a musculoskeletal complaint or manifestation of disease.

Electrical Intramuscular Stimulation in Osteoarthritis Enhances the Inhibitory Systems in Pain Processing at Cortical and Cortical Spinal System.

OBJECTIVE: To determine if in knee osteoarthritis (KOA), one session of active electrical intramuscular stimulation (a-EIMS) compared with sham causes an effect on the motor cortex excitability parameters [motor evoked potential (MEP; the primary outcome), short intracortical inhibition (SICI), intracortical facilitation (ICF) and cortical silent period (CSP)] and pain measurements [pain pressure threshold (PPT); visual analog scale (VAS) and change in numerical pain scale (NPS0-10 ) during the conditioned pain modulation (CPM)-task]. This study also set out to determine if serum brain-derived neurotrophic factor (BDNF) mediates the effect of treatment on the cortical spinal system as assessed by MEP and PPT. DESIGN: Randomized clinical trial. SUBJECTS AND METHODS: Women with KOA, 50-75-years old received a 30-min session of either sham (n = 13) or a-EIMS (n = 13) with 2 Hz. The pain measures and excitability parameters were measured before and immediately after a-EIMS or sham. RESULTS: The a-EIMS group compared with sham decreased the MEP by 31,67% [confidence interval (CI) 95%, 2.34-60.98]. For the secondary outcomes, the a-EIMS reduced the ICF and increased the CSP but not changed the SICI. The a-EIMS improved the pain reported on VAS, the PPT, and the score of the NPS (0-10) during the CPM-task The BDNF was negatively correlated with the PPT (r = -0.56). CONCLUSIONS: The serum BDNF revealed an inverse relationship with PPT independent of the treatment group. These results suggest that a-EIMS enhanced the corticospinal inhibitory systems in cortical and infracortical pain processing sites most likely by bottom-up regulation mechanisms.

Improvement in clinical outcomes after dry needling in a patient with occipital neuralgia.

The primary purpose of this case report is to outline the diagnosis, intervention and clinical outcome of a patient presenting with occipital neuralgia. Upon initial presentation, the patient described a four-year history of stabbing neck pain and headaches. After providing informed consent, the patient underwent a total of four dry needling (DN) sessions over a two-week duration. During each of the treatment sessions, needles were inserted into the trapezii and suboccipital muscles. Post-intervention, the patient reported a 32-point change in her neck disability index score along with a 28-point change in her headache disability index score. Thus, it appears that subsequent four sessions of DN over two weeks, our patient experienced meaningful improvement in her neck pain and headaches. To the best of our knowledge, this is the first case report describing DN to successfully improve clinical outcomes in a patient diagnosed with occipital neuralgia.

L'objectif principal de cet exposé de cas est de souligner le diagnostic, l'intervention et le résultat clinique d'un patient souffrant de névralgie cervico-occipitale. Lors de la présentation initiale, la patiente a décrit des antécédents de douleur aiguë dans le cou et de céphalées pendant quatre ans. Après avoir fourni le consentement éclairé, la patiente a subi un total de quatre séances de piqûres sèches sur une période de deux semaines. Au cours de chaque séance de traitement, des aiguilles lui ont été insérées dans le trapèze et les muscles sousoccipitaux. Après l'intervention, la patiente a signalé un changement de 32 points à l'index d'incapacité cervicale avec un changement de 28 points à l'index d'incapacité liée aux céphalées. Par conséquent, il semble qu'à la suite des quatre séances de piqûres sèches réparties sur deux semaines, notre patiente a connu une amélioration remarquable concernant ses douleurs cervicales et ses céphalées. À notre connaissance, il s'agit du premier exposé de cas décrivant des piqûres sèches qui améliorent avec succès les résultats cliniques chez un patient ayant reçu un diagnostic de névralgie cervico-occipitale.

The Effect of Intramuscular Stimulation on Otalgia due to Myofascial Pain Syndrome by Contraction of Trapezius Muscle

There are several causes of otalgia, specifically primary otalgia, which originates inside the ear, and referred otalgia, which originates outside the ear. In a rare case, otalgia may result from myofascial pain syndrome (MPS) due to a contraction of cervical muscles. The author of this study reports a case in which otalgia caused by MPS due to contraction of the trapezius muscle was treated with intramuscular stimulation (IMS). A 48-year-old female patient with otalgia for two weeks was otolaryngologically tested and no anomaly was found. A pain clinic consultation was requested and severe contraction of the trapezius muscle was observed by history taking, visual inspections and palpation. She was successfully returned to the normal state with two sessions of IMS.

Spinal subarachnoid hematoma as a complication of an intramuscular stimulation : case report and a review of literatures.

Intramuscular stimulation (IMS) is widely used to treat myofascial pain syndrome. IMS is a safe procedure but several complications have been described. To our knowledge, spinal subarachnoid hematoma has never been reported as a complication of an IMS. The authors have experienced a case of spinal subarachnoid hematoma occurring after an IMS, which was tentatively diagnosed as intracranial subarachnoid hemorrhage because of severe headache. Patient was successfully treated with surgery. Here, we report our case with a review of literature.

Spinal Subarachnoid Hematoma as a Complication of an Intramuscular Stimulation : Case Report and a Review of Literatures

Intramuscular stimulation (IMS) is widely used to treat myofascial pain syndrome. IMS is a safe procedure but several complications have been described. To our knowledge, spinal subarachnoid hematoma has never been reported as a complication of an IMS. The authors have experienced a case of spinal subarachnoid hematoma occurring after an IMS, which was tentatively diagnosed as intracranial subarachnoid hemorrhage because of severe headache. Patient was successfully treated with surgery. Here, we report our case with a review of literature.

A systematic review of the effectiveness and safety of intramuscular stimulation therapy

Intramuscular stimulation (IMS) therapy has been used widely ever since Gunn introduced the effect of IMS in his study in 1980. Usually IMS has been based on Cannon's radiculopathic model, known for its effectiveness in chronic pain relief. In this study we systematically review the effectiveness and safety of IMS. In order to accomplish a systematic review, we searched for IMS-related studies through 12 bibliographical databases and 19 studies were included (4 randomized controlled trials (RCTs), 2 non-RCTs and 13 case reports/studies). Study selection was conducted independently by two researchers based on title and abstract. As a result, most included studies of 16 showed significant improvement in range of motion, decrease of drug consumption as well as pain relief after IMS treatment; the other 3 studies reported adverse events. In terms of the effectiveness of IMS, the results of intervention were good, so we concluded that IMS therapy is a useful method of pain treatment; with respect of safety, few adverse events that could have been caused by IMS were observed. However, it is not certain that there was a causal relationship between IMS and the adverse events that were reported due to a lack of evidence. Therefore, clinicians who have sufficient knowledge and experience of IMS will have to perform the procedure after thorough clinical examinations to determine its appropriateness for target patients. This study provided meaningful data on the current state of IMS treatment. We expect that the result of this study will stimulate further more extensive research on IMS.

Successful treatment of spasmodic dysphonia using IMS :A case report

Spasmodic dysphonia is a voice disorder that's characterized by intermittent, involuntary tightening or constriction of the larynx during phonation.This paper describes the case of a 45-yr-old female who suffered from phonation difficulties along with posterior and anterior neck pain.She was diagnosed with adductor type spasmodic dysphonia, which is a chronic disorder involving hyperadduction of the vocal mechanism and a resultant vocal arrest.The neural innervation of the intrinsic laryngeal musculature and the cervical nerves too may well be amenable to intramuscular stimulation therapy.

Successful treatment of spasmodic dysphonia using IMS :A case report

Spasmodic dysphonia is a voice disorder that's characterized by intermittent, involuntary tightening or constriction of the larynx during phonation.This paper describes the case of a 45-yr-old female who suffered from phonation difficulties along with posterior and anterior neck pain.She was diagnosed with adductor type spasmodic dysphonia, which is a chronic disorder involving hyperadduction of the vocal mechanism and a resultant vocal arrest.The neural innervation of the intrinsic laryngeal musculature and the cervical nerves too may well be amenable to intramuscular stimulation therapy.

Perirenal Hematoma Induced by Acupuncture and Intramuscular Stimulation / 대한신장학회지

Acupuncture therapy has been widely performed by staffs of oriental medicine in Korea, and intramuscular stimulation (IMS) therapy has been introduced recently and used for controlling myofascial pain in the field of orthopedics, rehabilitation, and pain clinics. To penetrate human tissues, relatively long needles are used in both procedures and these these may have some risks to puncture blood vessels. However, there were few reports about sequelae or complications after such procedures in Korean literatures. Recently, we experienced two cases of perirenal hematoma in patients without blood coagulation abnormalities (one case induced by acupuncture in oriental medicine clinic, and the other case induced by IMS in orthopedic clinic and was also accompanied by perirenal abscess).