The association between dry needling-induced twitch response and change in pain and muscle function in patients with low back pain: a quasi-experimental study

doi:10.1016/j.physio.2016.05.002

Physiotherapy

Volume 103, Issue 2, June 2017, Pages 131-137

https://doi.org/10.1016/j.physio.2016.05.002 Get rights and content

Abstract

Objective

To investigate the relationship between dry needling-induced twitch response and change in pain, disability, nociceptive sensitivity, and lumbar multifidus muscle function, in patients with low back pain (LBP).

Design

Quasi-experimental study.

Setting

Department of Defense Academic Institution.

Participants

Sixty-six patients with mechanical LBP (38 men, 28 women, age: 41.3 [9.2] years).

Interventions

Dry needling treatment to the lumbar multifidus muscles between L3 and L5 bilaterally.

Main outcome measures

Examination procedures included numeric pain rating, the Modified Oswestry Disability Index, pressure algometry, and real-time ultrasound imaging assessment of lumbar multifidus muscle function before and after dry needling treatment. Pain pressure threshold (PPT) was used to measure nocioceptive sensitivity. The percent change in muscle thickness from rest to contraction was calculated to represent muscle function. Participants were dichotomized and compared based on whether or not they experienced at least one twitch response on the most painful side and spinal level during dry needling.

Results

Participants experiencing local twitch response during dry needling exhibited greater immediate improvement in lumbar multifidus muscle function than participants who did not experience a twitch (thickness change with twitch: 12.4 [6]%, thickness change without twitch: 5.7 [11]%, mean difference adjusted for baseline value, 95%CI: 4.4 [1 to 8]%). However, this difference was not present after 1-week, and there were no between-groups differences in disability, pain intensity, or nociceptive sensitivity.

Conclusions

The twitch response during dry needling might be clinically relevant, but should not be considered necessary for successful treatment.

Introduction

Dry needling is a therapeutic procedure comprising of the insertion of a thin filiform needle directly into myofascial trigger points [1]. Clinical trials examining the effectiveness of dry needling have reported immediate and short-term pain relief and functional improvement for a wide range of musculoskeletal conditions [2], [3], [4], [5], [6], [7]. Yet; recent systematic reviews have concluded that evidence for dry needling effectiveness is limited; owing to poor methodological quality and clinical heterogeneity among included trials [8], [9], [10], [11], [12], [13].

Potentially important sources of clinical heterogeneity involve the differences in dry needling technique including the role of the local twitch response [14]. A twitch response occurs when there is a brisk, involuntary contraction within the muscle being needled [15]. It is believed that the twitch response results from a spinal reflex, following the mechanical stimulation introduced by the needle [16], [17]. Studies have demonstrated both electrical and biochemical changes after eliciting twitch responses [14], [18]. The twitch response is often used to confirm the presence of trigger points which frequently drives both patient selection and treatment parameters [19]. Likewise, many practitioners assume that the elicitation of a twitch response during dry needling represents evidence of trigger point “inactivation” and is necessary for achieving a successful clinical outcome. However, few studies have examined the potential relationship between dry needling-induced local twitch response and clinical improvements [5], [16]. Moreover, the results of these studies conflict, with one reporting immediate changes in pain and range of motion only in participants experiencing twitch response [16] and the other reporting no differences in quality of life based on local twitch response and only differences in pain after 4 weeks [5]. Additionally, both of these studies exhibited important limitations such as procedures that were not standardized [16] and small sample sizes [5].

The lumbar multifidus muscle has been shown to play an important role for normal function of the lumbar spine and has been implicated clinically in patients with low back pain (LBP) [20], [21]. No prior studies have examined the effect of twitch response during dry needling on lumbar multifidus muscle function and clinical outcome in patients with LBP. Therefore, the purpose of this study was to explore the relationship between dry needling-induced local twitch response and change in pain, LBP-related disability, nociceptive sensitivity, and lumbar multifidus muscle function in patients with LBP.

Section snippets

Study design

This study was a pre-planned secondary analysis of data from a quazi-experimental study investigating changes in lumbar multifidus muscle function and nociceptive sensitivity in LBP patient responders vs non-responders after dry needling treatment [22]. The study protocol was approved by the Institutional Review Board of Brooke Army Medical Center and all participants provided written informed consent prior to study enrollment. The study entailed two visits consisting of the same procedures for

Results

Two hundred and sixty individuals were screened for study inclusion. One hundred and eighty eight were excluded, most commonly for having an ODI score of <20%. Of the 72 participants enrolled in the study, 6 individuals failed to return for the follow up visit, leaving complete data on 66 participants. The complete participant flow chart has been published elsewhere [22]. Of the 66 participants, 61 (92%) exhibited at least one twitch response (and usually more than one) during treatment.

Discussion

Although clinicians often view the elicitation of local twitch response during dry needling as a primary goal and indicator of successful treatment there is scarce evidence supporting this assertion [16], [39]. Therefore, the purpose of the current study was to explore the relationship between dry needling-induced twitch response and changes in pain, LBP-related disability, nociceptive sensitivity, and lumbar multifidus muscle function in patients with LBP. Our primary finding was that twitch

Conclusion

Local twitch response elicited on the most painful side and spinal level during dry needling appears to be related to immediately improve lumbar multifidus function, but not pain, nociceptive sensitivity, LBP-related disability, or lasting improvements in muscle function. This suggests that the local twitch response during dry needling might be clinically relevant, but that it should not be considered as a “hallmark” sign of dry needling or “necessary” for successful treatment.

Acknowledgments

This study was performed at the Center for Physical Therapy Research at the U.S. Army-Baylor University Doctoral Program in Physical Therapy, San Antonio, Texas and was approved by the Institutional Review Board of Brooke Army Medical Center.

The views expressed herein are those of the authors and do not reflect the official policy or position of BAMC, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army, Department of the Air Force,

References (40)

K. Itoh et al.
Randomized Trial of trigger point acupuncture treatment for chronic shoulder pain: a preliminary study
J Acupunct Meridian Stud
(2014)
L. Liu et al.
Effectiveness of dry needling for myofascial trigger points associated with neck and shoulder pain: a systematic review and meta-analysis
Arch Phys Med Rehabil
(2015)
Y.-L. Hsieh et al.
Spinal cord mechanism involving the remote effects of dry needling on the irritability of myofascial trigger spots in rabbit skeletal muscle
Arch Phys Med Rehabil
(2011)
M. Freeman et al.
The role of the lumbar multifidus in chronic low back pain: a review
PM R
(2010)
D.A. MacDonald et al.
The lumbar multifidus: does the evidence support clinical beliefs?
Man Ther
(2006)
J.A. Cleland et al.
Psychometric properties of selected tests in patients with lumbar spinal stenosis
Spine J
(2012)
J. Ylinen
Pressure algometry
Aust J Physiother
(2007)
K. Kiesel et al.
Measurement of lumbar multifidus muscle contraction with rehabilitative ultrasound imaging
Man Ther
(2007)
S. Koppenhaver et al.
Reliability of rehabilitative ultrasound imaging of the transversus abdominis and lumbar multifidus muscles
Arch Phys Med Rehabil
(2009)
S. Koppenhaver et al.
Rehabilitative ultrasound imaging is a valid measure of trunk muscle size and activation during most isometric sub-maximal contractions: a systematic review
Aust J Physiother
(2009)

C.-Y.J. Hsieh et al.

Interexaminer reliability of the palpation of trigger points in the trunk and lower limb muscles

Arch Phys Med Rehabil

(2000)

L. Kalichman et al.

Dry needling in the management of musculoskeletal pain

J Am Board Fam Med

(2010)

D. Dıraçoğlu et al.

Effectiveness of dry needling for the treatment of temporomandibular myofascial pain: a double-blind, randomized, placebo controlled study

J Back Musculoskelet Rehabil

(2012)

R. Llamas-Ramos et al.

Comparison of the short-term outcomes between trigger point dry needling and trigger point manual therapy for the management of chronic mechanical neck pain: a randomized clinical trial

J Orthop Sports Phys Ther

(2014)

M.J. Mejuto-Vázquez et al.

Short-term changes in neck pain, widespread pressure pain sensitivity, and cervical range of motion after the application of trigger point dry needling in patients with acute mechanical neck pain: a randomized clinical trial

J Orthop Sports Phys Ther

(2014)

L. Tekin et al.

The effect of dry needling in the treatment of myofascial pain syndrome: a randomized double-blinded placebo-controlled trial

Clin Rheumatol

(2012)

L. Chou et al.

Remote therapeutic effectiveness of acupuncture in treating myofascial trigger point of the upper trapezius muscle

Am J Phys Med Rehabil

(2011)

D.M. Kietrys et al.

Effectiveness of dry needling for upper-quarter myofascial pain: a systematic review and meta-analysis

J Orthop Sports Phys Ther

(2013)

E. Tough et al.

Effectiveness of acupuncture/dry needling for myofascial trigger point pain

Phys Ther Rev

(2011)

R. Boyles et al.

Effectiveness of trigger point dry needling for multiple body regions: a systematic review

J Man Manip Ther

(2015)

Cited by (31)

Could dry needling change the kinematics of gait in individuals with piriformis muscle syndromes? Secondary analysis of a randomized controlled trial
2024, Journal of Bodywork and Movement Therapies
Piriformis muscle syndrome (PMS) is a condition that can lead to symptoms including gluteal pain, local tenderness, and limitation of hip joint motion in daily activities, and it may have a major impact on some daily functions such as gait. We proposed that dry needling (DN) can improve the gait of individuals with PMS.
Thirty-two individuals with PMS were assigned equally and randomly to the treatment group or the wait-list control group. Subjects in the treatment group received three sessions of DN of the piriformis muscle. All participants in both groups were educated to correct their lifestyles. The outcome measures were the gait-related parameters (walking speed, peak hip flexion, peak hip extension, time to peak internal and external hip rotation, and knee sagittal range of motion), which were evaluated at baseline and after treatment. To compare different outcomes, analysis of covariance (ANCOVA) was used, with baseline as the covariance and groups as a factor.
After DN sessions, peak hip extension during gait showed a statistically significant difference [adjusted MD 1.9 (3.7–0.08), p < 0.05, d = 0.56 (0.1–1.28)] in favor of the DN group. Peak hip flexion, on the other hand, exhibited a marginal statistically significant difference [adjusted MD -3.2 (−6.51 to 0.01), p = 0.053, d = 0.44 (1.16 to −0.02)] compared to the control group.
The findings suggest that participants in DN showed significantly greater peak extension angle of the hip during walking in individuals with PMS than in the control group.
Immediate Effects of Adding Dry Needling to Thoracic Manipulation and Exercise in Cervical Range of Motion for Adults With Neck Pain: A Randomized Clinical Trial
2022, Journal of Manipulative and Physiological Therapeutics
Citation Excerpt :
Hong's “fast-in, fast-out” approach involves achieving a local twitch response attributed to a spinal reflex associated with hypersensitive motor endplates for successful DN treatment.45 More recent literature debates the necessity of eliciting a local twitch response, with some stating it is necessary to obtain clinically meaningful changes in pain and function,46,47 while others state that a local twitch response does not provide significantly greater patient outcomes.48,49 Similar to disagreement on DN technique, current literature has yet to establish consensus on parameters in regard to duration and frequency of DN treatment.50
The purpose of this study was to determine the immediate effects of adding dry needling (DN) to thoracic spine manipulation and neck-specific exercise in individuals with neck pain.
Forty-two participants with neck pain were randomized to either the true (n = 21) or sham (n = 21) DN groups, receiving treatment on the initial visit and 2 to 3 days later. Outcomes were assessed on day 1, both at baseline and immediately after the initial treatment, at the second treatment 2 to 3 days later, and at the final visit 5 to 7 days after visit 2. Primary outcomes were Neck Disability Index (NDI) (0-50) and current pain via numeric pain rating scale (0-10). Secondary outcomes were cervical range of motion, pain pressure threshold, and global rating of change.
Repeated measures analysis of covariance with baseline value as covariate revealed no significant difference in NDI scores at either follow-up time point with adjusted mean differences (95% confidence interval) of -0.11 (-2.70 to 2.48) and 0.31 (-1.96 to 2.57). There were no between-group differences in pain at any time point via Independent-Samples Median Test (P value range of .54-1.0). Secondary outcome measures were similarly not statistically different between groups except for immediate improvements in rotation to the side opposite of pain, which favored DN, with an adjusted mean difference (95% confidence interval) of 7.85 (3.54-12.15) degrees.
The addition of DN to thoracic spinal manipulation and neck-specific exercise did not affect improvements in NDI score or numeric pain rating scale but showed an increase in cervical range of motion.
Effects of dry needling of the obliquus capitis inferior on sensorimotor control and cervical mobility in people with neck pain: A double-blind, randomized sham-controlled trial
2021, Brazilian Journal of Physical Therapy
Impairments of sensorimotor control relating to head and eye movement control and postural stability are often present in people with neck pain. The upper cervical spine and particularly the obliquus capitis inferior (OCI) play an important proprioceptive role; and its impairment may alter cervical sensorimotor control. Dry needling (DN) is a valid technique to target the OCI.
To investigate if a single DN session of the OCI muscle improves head and eye movement control-related outcomes, postural stability, and cervical mobility in people with neck pain.
Forty people with neck pain were randomly assigned to receive a single session of DN or sham needling of the OCI. Cervical joint position error (JPE), cervical movement sense, standing balance and oculomotor control were examined at baseline, immediately post-intervention, and at one-week follow-up. Active cervical rotation range of motion and the flexion rotation test were used to examine the global and upper cervical rotation mobility, respectively.
Linear mixed-models revealed that the DN group showed a decrease of JPE immediately post-intervention compared to the sham group (mean difference [MD]= -0.93°; 95% confidence interval [CI]: -1.85, -0.02) which was maintained at one-week follow-up (MD= -1.64°; 95%CI: -2.85, -0.43). No effects on standing balance or cervical movement sense were observed in both groups. Upper cervical mobility showed an increase immediately after DN compared to the sham group (MD= 5.14°; 95%CI: 0.77, 9.75) which remained stable at one-week follow-up (MD= 6.98°; 95%CI: 1.31, 12.40). Both group showed an immediate increase in global cervical mobility (MD= -0.14°; 95%CI: -5.29, 4.89).
The results from the current study suggest that a single session of DN of the OCI reduces JPE deficits and increases upper cervical mobility in patients with neck pain. Future trials should examine if the addition of this technique to sensorimotor control training add further benefits in the management of neck pain.
Immediate decrease of muscle biomechanical stiffness following dry needling in asymptomatic participants
2021, Journal of Bodywork and Movement Therapies
Citation Excerpt :
The LTR is a phenomenon of involuntary contraction of the muscle fibers within and around the MTrP and is thought to correlate with DN effectiveness(Hong, 1994; Tekin et al., 2013). The clinical relevance of the LTR is debated, and may not correlate to pain or disability(Boyles et al., 2015; Koppenhaver et al., 2017; Perreault et al., 2017). However, significantly greater muscle activation was reported in participants with a LTR immediately after DN(Boyles et al., 2015).
Biomechanical muscle stiffness has been linked to musculoskeletal disorders. Assessing changes in muscle stiffness following DN may help elucidate a physiologic mechanism of DN. This study characterizes the effects of dry needling (DN) to the infraspinatus, erector spinae, and gastrocnemius muscles on biomechanical muscle stiffness.
60 healthy participants were randomized into infraspinatus, erector spinae, or gastrocnemius groups. One session of DN was applied to the muscle in standardized location. Stiffness was assessed using a MyotonPRO at baseline, immediately post DN, and 24 h later. The presence of a localized twitch response (LTR) during DN was used to subgroup participants.
A statistically significant decrease in stiffness was observed in the gastrocnemius, the LTR gastrocnemius, and the LTR erector spinae group immediately following DN treatment. However, stiffness increased after 24 h. No significant change was found in the infraspinatus group.
DN may cause an immediate, yet transitory change in local muscle stiffness. It is unknown whether these effects are present in a symptomatic population or related to improvements in clinical outcomes. Future studies are necessary to determine if a decrease in biomechanical stiffness is related to improvement in symptomatic individuals.
Impact of physical therapists’ instructions on function and the perception of post-dry needling soreness in mechanical cervical pain; a randomized clinical trial
2020, Journal of Bodywork and Movement Therapies
Citation Excerpt :
Often, clinicians aim to elicit one or more local twitch responses (LTR), which are spinal cord reflexes with analgesic effects (Hong, 1994). Whether eliciting LTRs is essential is a subject of debate (Perreault et al., 2017; Koppenhaver et al., 2017) in spite of its documented benefits (Gerber et al., 2017; Hsieh et al., 2012). Post-needling soreness is a common epiphenomenon or adverse effect of DN caused by tissue damage from repetitive needle insertions, that, at least in theory, may cause a certain degree of apprehension about DN (Brady et al., 2014; Torres et al., 2004).
To investigate the impact of physical therapists’ instructions on the perception of post dry needling (DN) soreness and function in patients with mechanical neck pain.
Seventy-five patients with neck pain were randomly assigned to three groups: “positive” group (n = 25) received positive verbal input; “negative” group (n = 25) received negative verbal input, and control group (n = 25) did not receive any input about post-needling soreness. All three groups received DN of a trigger point in the upper trapezius muscle. The subjective pain experience, pressure pain threshold (PPT), and neck disability Index (NDI) were assessed before and after DN.
Patients in all groups showed improvement in pain, PPT and NDI. There were no significant differences in pain (P = 0.41) and PPT (P = 0.68) in the positive and negative groups compared with the control group. Significant difference in function was seen with the NDI after DN of patients in the positive and negative groups compared with the control group (P = 0.011, standard error: 1.08–1.5).
Considering that the power of our study may be too low to draw more definitive conclusions, DN appears to be an effective technique to improve pain and mechanical hyperalgesia. The experience of post-needling soreness does not appear to influence the outcome of DN on pain, PPT, and NDI. Post-needling soreness does not seem to be a limiting factor in achieving acceptable outcomes, especially when clinicians offer DN within a therapeutic emphasizing a positive patient response. This study questions whether any treatments need to be offered to patients receiving DN.
Postneedling Soreness and Tenderness After Different Dosages of Dry Needling of an Active Myofascial Trigger Point in Patients With Neck Pain: A Randomized Controlled Trial
2018, PM and R
Previous studies in asymptomatic subjects have demonstrated that myofascial trigger point (MTrP) dry needling frequently is associated with postneedling soreness. However, to the authors’ knowledge, there is not any study that performs a detailed description of postneedling soreness characteristics in patients with myofascial pain. This information could help clinicians to make evidence-informed decisions considering the benefits and negative effects of different dry needling dosages.
To (1) compare the prevalence, intensity, and duration of postneedling soreness and tenderness after different dosages of deep dry needling (DDN) and (2) analyze the influence on postneedling soreness of psychological factors and other factors involved in the DDN process
1-week follow-up, double-blind randomized controlled trial.
University community.
Patients (n = 120: 34 male; 86 female) aged 18-53 years (median ± interquartile range, 21.0 ± 7.0 years) with active MTrPs in the upper trapezius.
All patients received DDN in an active MTrP. They were randomly divided into 4 groups: no local twitch responses (LTRs) elicited (control group), 4 LTRs elicited, 6 LTRs elicited, and DDN until no more LTRs were elicited.
Postneedling soreness and pressure pain threshold were assessed before treatment, during DDN procedure, and every 24 hours during 1 week.
Postneedling soreness showed a significant effect for time (F_2,006 = 173.603; P < .001, η_p² = 0.659) and a significant interaction between group and time (F_6,017 = 3.763; P = .001; η_p² = 0.111). Pressure pain threshold showed a significant effect for time (F_2,377 = 16.833; P < .001; η_p² = 0.127) and a significant interaction between group and time (F_7,130 = 2.100; P = .04; η_p² = 0.052). Psychological factors did not show relevant correlations with the intensity of postneedling soreness.
Postneedling soreness is present in most of subjects after DDN of active MTrPs. The groups in which DDN was performed eliciting LTRs exhibited greater post-needling soreness. The number of needle insertions was associated with postneedling soreness but psychological factors did not seem to play a relevant role on its perception.
NCT02190890
I

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The association between dry needling-induced twitch response and change in pain and muscle function in patients with low back pain: a quasi-experimental study

Abstract

Objective

Design

Setting

Participants

Interventions

Main outcome measures

Results

Conclusions

Introduction

Section snippets

Study design

Results

Discussion

Conclusion

Acknowledgments

J Acupunct Meridian Stud

Arch Phys Med Rehabil

Arch Phys Med Rehabil

PM R

Man Ther

Spine J

Aust J Physiother

Man Ther

Arch Phys Med Rehabil

Aust J Physiother

Arch Phys Med Rehabil

Dry needling in the management of musculoskeletal pain

J Am Board Fam Med

Effectiveness of dry needling for the treatment of temporomandibular myofascial pain: a double-blind, randomized, placebo controlled study

J Back Musculoskelet Rehabil

Comparison of the short-term outcomes between trigger point dry needling and trigger point manual therapy for the management of chronic mechanical neck pain: a randomized clinical trial

J Orthop Sports Phys Ther

Short-term changes in neck pain, widespread pressure pain sensitivity, and cervical range of motion after the application of trigger point dry needling in patients with acute mechanical neck pain: a randomized clinical trial

J Orthop Sports Phys Ther

The effect of dry needling in the treatment of myofascial pain syndrome: a randomized double-blinded placebo-controlled trial

Clin Rheumatol

Remote therapeutic effectiveness of acupuncture in treating myofascial trigger point of the upper trapezius muscle

Am J Phys Med Rehabil

Effectiveness of dry needling for upper-quarter myofascial pain: a systematic review and meta-analysis

J Orthop Sports Phys Ther

Effectiveness of acupuncture/dry needling for myofascial trigger point pain

Phys Ther Rev

Effectiveness of trigger point dry needling for multiple body regions: a systematic review

J Man Manip Ther