Integration of pain sciences and dry needling to enhance ... · Cervical ROM only caused P2 neck...

Integration of pain sciences and dry needling to enhance movement and function for upper quarter

dysfunctions

Derek Clewley, PT, DPT, OCS, FAAOMPT, PhD (c)Elizabeth Lane, PT, DPT, OCS, FAAOMPT

Daniel Maddox, PT, DPT, ATC, OCS, FAAOMPTMark Milligan, PT, DPT, OCS, FAAOMPTHannah Norton, PT, DPT, OCS, FAAOMPT

DiagnosisDiagnosis

MechanismMechanism

Patient profile and body chart

Patient profile and body chart

ExaminationExamination

Central Sensitization


Yellow flagsYellow flags

NocioceptiveNocioceptive

Cervical vsShoulderCervical vsShoulder

Peripheral NeuropathicPeripheral Neuropathic

Cervical Radiculopathy

Cervical Radiculopathy

So after a long day in the trenches fighting the chiropractic board……

Patient Profile

• 60 yr old female• PMH: 10+ yr history of chronic migraines• PSH: gallbladder removal 10 yr ago• Chronic, episodic right shoulder and arm pain, worries that it will never go away completely

• NDI: 85%• Hesitant to answer 2 item depression screen

(Arroll, 2003)

• Yes to ½ fear avoidance questions (Calley, 2010)

ObjectiveNeuro Exam: Dermatome WNL, DTR 2+ B/L, Mytome WNL, ULTTA: negative

Cervical Examination: • AROM

– Flex 40, no pain, no pain with OP– Ext 40, caused P2, No P1 with OP– SB: Rt 35 Lt 30, Rt SB P2* (2/10), No P1 with OP– Rot: Rt 70 Lt 60, No pain, P2* (2/10) with Rt Rot OP

• Cervical Special Test– Spurlings: Increased P2 – Distraction: Decreased P2, no change P1 or P3– Cervical accessory: UPA Rt C6 produce P2 (3/10), capsular end feel – 1st rib: hypomobile, P2 (2/10)

Objective Examination cont.Shoulder Examination:• AROM

– ABD: P1 in mid range 70‐100, ROM WNL– HBB: P1 (6/10) at end of range, L3– Aggravation of P3 after summation of AROM

• MMT: ER 4/5 P1/P3 (+ infraspinatus test)• +Hawkins‐Kennedy 7/10 P1• Supine shoulder PROM: all WNL no pain• Shoulder accessory: hypo post glide and infglide

• Palpation: Extremely provocative for P1 at infraspinatus and teres minor (8/10)

What is it?– “Central sensitization is defined as an augmentation of responsiveness of central neurons to input from unimodal and plymodal receptors (Meyer et al. 1995).”

– What does it look like?

Mechanism Central Sensitization NocioceptivePeripheral Neuropathic


Nijs 2010 Recognition of CS in Manual Therapy. Manual Therapy 15 (2010) 135‐141.• –Nervous system changes quickly, even with acute pain• –“Top‐down mechanisms (altered sensory processing in the

brain, malfunctioning of descending anti‐nociceptive mechanisms, increased activity of pain facilitory pathways, temporal summation of second pain or wind‐up, and long‐term potentiation of neuronal synapses in the anterior cingulate cortex)

• –Bottom‐up mechanisms (increased responsiveness to a variety of peripheral stimuli including mechanical pressure) “decreased load tolerance


Woolf CJ. Central sensitization: implications for the diagnosis and treatment of pain. Pain. 2011;152:S2‐S15.• •Review• •Clinical pain is not simply the consequence of a ‘‘switching on”• of the ‘‘pain system” in the periphery by a particular pathology, but• instead reflects to a substantial extent, the state of excitability of• central nociceptive circuits. The induction of activity‐dependent• increases in synaptic function in these circuits triggered and main‐• tained by dynamic nociceptor inputs, shifts the sensitivity of the• pain system such that normally innocuous inputs can activate it• and the perceptual responses to noxious inputs are exaggerated,• prolonged and spread widely. These sensory changes represent• the manifestation of central sensitization,


•Bachasson D et al. The role of the peripheral and central nervous systems in rotator cuff disease. J Shoulder Elbow Surg. 2015; 24(8):1322‐35.•(1) exacerbate structural and functional muscle changes induced by tendon tear, •(2) compromise the reversal of these changes during surgery and rehabilitation,• (3) contribute to pain generation and persistence of pain, •(4) impair shoulder function through reduced proprioception, kinematics, and muscle recruitment, •(5) help explain interindividual differences and response to treatment


•Nijs 2010 Recognition of CS in Manual Therapy. Manual Therapy 15 (2010) 135‐141.–Is CS characteristic of the medical diagnosis?*–Does the patient exhibit at least a few consistent signs of CS?**–Does the patient exam support CS? ***


•Smart et al. 2011. Clin J Pain 27:655‐663–Pain disproportionate to the nature and extent of injury or pathology–Disproportionate, nonmechanical, unpredictable pattern of pain provocation in response to multiple/nonspecific aggravating/easing factors–Strong association with maladaptive psychosocial factors (eg, negative emotions, poor self‐efficacy, maladaptive beliefs, and pain behaviors, altered family/work/social life, medical conflict) –Diffuse/nonanatomic areas of pain/tenderness on palpation


Srbely J Rehabil Med 2010;42:463‐468. Dry needle stimulation of myofascial trigger points evokes segmental anti‐nociceptive effects.


•Tsaai c‐T. Remote effects of dry needling on the irritability of the myofascial trigger point in the upper trapezius muscle. American Journal of Physical Medicine and Rehabilitation. 2010;89:133‐140.•Dry needling applied to distal trigger points has an inhibitory effect on proximal trigger points through a proposed mechanism of diffuse noxious inhibitory control, a supraspinal mechanism‐ i.e. breaks the neural circuit responsible for the muscle trigger point


•Nijs J. Treatment of central sensitization in patients with ‘unexplained’ chronic pain: what options do we have? Expert opinion on pharmacotherapy. 2011–Manual therapy has been shown to have short term central analgesic effects–Manual therapy may also “serve as a peripheral source of nociceptive input to the CNS and thus will sustain the process of central sensitization.”

Mechanism Central Sensitization

Nocioceptive

Cervical vsShoulder

Peripheral Neuropathic

YES NO

Usually intermittent and sharp with movement/mechanical provocation; may be a more constant dull ache or throb at rest

Pain variously described as burning, shooting, sharp, or electric‐shock‐like

Pain localized to the area of injury/dysfunction (with/without some somatic referral)

Pain in association with other dysesthesias(eg, crawling, electrical, heaviness)

Clear, proportionate mechanical/anatomic nature to aggravating and easing factors

Night pain/disturbed sleep

Antalgic postures/movement patterns

Description by Smart:

Mechanism Central Sensitization

Nocioceptive Peripheral Neuropathic

CERVICAL SHOULDER

Cervical ROM only caused P2 neck pain (not shoulder P1 or UE P3)

+ Hawkins‐Kennedy (Sn 0.75 Sp 0.44)

No change in shoulder pain with Spurling’sor distraction

Weakness in ER MMT (Sn 0.19 Sp 0.69)

No shoulder or UE symptoms with cervical mobility testing

Pain with shoulder AROM. Painful arc(Sn 0.67 Sp 0.47)

3/3 for Park (2005) Test‐item cluster: +LR 10.56

Mechanism Peripheral Neuropathic


Nocioceptive

Description by Smart:

• History of nerve injury, pathology, or mechanical compromise

• Pain referred in a dermatomal or cutaneous distribution

• Pain/symptom provocation with mechanical/movement tests (eg, Active/Passive, Neurodynamic) that move/load/compress neural tissue

Mechanism Peripheral Neuropathic


Nocioceptive

• Test‐item cluster for cervical radiculopathy by Wainner

Test ‐LR +LR Jane

Spurling’s A 0.58 3.5 Negative

Distraction 0.62 4.4 Negative

ULTT A 0.12 1.3 Negative

Rotation < 60 0.23 1.8 Negative

Mechanisms are not mutually exclusive Mechanism

Central SensitizationPeripheral NeuropathicNocioceptive

What does the evidence show us about treatment targeting central

sensitization?

• Pain Neuroscience Education• Manual Therapy• Exercise Intervention• Dry Needling?

Pain Neuroscience Education

• GOAL: Address deleterious behaviors related to inappropriate pain beliefs– Meeus 2010: one 30‐minute educational session was found to reduce

• GOAL: Reduce potential negative effect on descending pain inhibitory mechanisms– Seminowicz 2006

• GOAL: Improve movement and exercise performance– Moseley 2004– Moseley 2005– Nijs 2008

DM2

DM2 Insert info from Louww SR as wellDaniel Maddox, 8/22/2015

Manual Therapy• GOAL: Prevent transition to a centrally sensitized state or

lessen nociceptive input that may sustain a centrally sensitized state– Staud 2002– Vierck 2006– Nijs 2006

• GOAL: Invoke Centrally‐mediated Hypoalgesia– Sterling 2001– George 2006– Bender 2007– Schmid 2008– Coronado 2012– De Oliveira 2013

Exercise

• GOAL: Decrease Pain, Perhaps Partially via Centrally‐Mediated Hypoalgesia– Dupree Jones 2006– Bender 2007– Nijs 2012

• GOAL: Decrease Fatigue, Improve Sleep, and Improve Mood– Dupree Jones 2006

Dry Needling?

• GOAL: Decrease nociceptive input that may sustain a centrally sensitized state

– See previously discussed mechanisms of CS and previously discussed evidence for DN in managing peripheral nociceptive pain

• Do we have evidence to suggest that dry needling may act on central mechanisms?

– Tsai 2009– Srbely 2010– Cagnie 2013

What does the evidence show us about treatment targeting Peripheral

Nociceptive Pain?

• Modailities• Pain Neuroscience Education• Manual Therapy and Exercise intervention• Dry Needling?

Modalities

• GOAL: Decrease pain, Decrease Inflammation, Improve Function, Return to Activity – Cryotherapy

• Algafly A, George K 2007

– Transcutaneous Electrical Nerve Stimulation• DeSantana et al

– Traction• Childs et al 2010• Raney et al 2009

Pain Neuroscience Education

• Goal: Prevention of chronic symptoms using Fear‐Avoidance Model‐ Crombez et al 2012

See previously mentioned evidence for pain control.

Manual Therapy

• Goal: Decrease Pain, Improve ROM, Improve Strength

• Cervical Spine – Childs et al 2010

• Shoulder– Bang and Deyle 2000– Cleland et al 2004 – Lieber et al 2001– Mintken et al 2010– Boyles et al 2009

Manual Therapy and Exercise• Goals: Decrease pain, Increase Function, Increase Strength

• Shoulder– Walker et al 2008– McClatchie et al 2008

• Cervical Spine– Bronfort et al 2001– Hoving et al 2002– Jull et al 2002– Evans et al 2002– Chiu et al 2005– Franca et al 2008– Martel et al 2011

Dry Needling

• Removal of nociceptive input – Dommerholt 2011

• Decrease of chemicals associated with pain– Shah 2008

• See previously discussed mechanisms of CS and previously discussed evidence for DN in managing peripheral nociceptive pain

Nocioceptive Treatment

• Exercise• Manual Therapy• Modalities

Exercise

PHYSICAL THERAPY INTERVENTIONSEXERCISE

SYSTEMATIC REVIEWS: • Moderate quality evidence for short and long term benefit for pain and function versus a control or compared to surgical intervention• Kuhn et al, Kromer et al, Lombardi et al

RANDOMIZED CONTROLLED TRIALS: • Exercise supervised by PT was superior to placebo and equally effective as SAD• Specific exercise for SIS decreases need for surgery and improves function vsgeneral exercise approach

• Program of exercise only as effective as manual therapy and exercise in reduction of pain and function short and long term

• Reduced costs for the exercise only group• Kromer et al, Brox et al, Holmgren et al

INEFFECTIVE: US, IFC, Pre‐tensioned tape

SHORT TERM: LLLT

Passive Modalities

Manual Therapy

• Improved ROM and strength in the manual therapy / exercise AND exercise only group

• Favored manual therapy

Bang J Orthop Sports Phys Ther 2007

• Systematic review: decreasing pain

Camarinos J Man Manip Ther 2009

• Thoracic thrust• Short term benefit for pain

Boyles Manual Therapy 2007

• Single arm CPR• Short term reduction in pain

Mintken Phys Ther 2010

• 6 sessions of PT with manual therapy = CSI• Less overall healthcare exposure and costs

Rhon Ann Intern Med 2014

Soft tissue directed interventions

• Association of trigger points and subacromial impingement syndrome

• Infraspinatus, Teres Major, Upper Trapezius, Deltoid most common

Bron, Dommerholt et al. 2011

• Manual trigger point interventions decreased pain and improved function

Bron, de Gast et al. 2011

Background and Significance

APTA & AAOMPT recognize dry needling within the scope of PT practice

APTA Dry Needling Resource Paper low number of studies as primary intervention

23 RCTs

Quality of trials overall poor

DRY NEEDLING


• TrPs in the levator scapula, supraspinatus, infraspinatus, subscapularis, pectoralis major, and biceps brachii• Decreased Pain Pressure Thresholds• Demonstrated increased TrPs in symptomatic shoulders

Hidalgo‐Lozano Exp Brain Res 2010Hidalgo‐Lozano Exp Brain Res 2010

• Within subject within session design bilateral shoulder pain• TDN to Infraspinatus• Side that received TDN had increased shoulder IR ROM, increased PPT, decreased pain

Hsieh Am J Phys Med Rehabil 2007Hsieh Am J Phys Med Rehabil 2007

DRY NEEDLING


• Acupuncture• Case series• Within session improvements (ROM, strength, Pain assessed)

Osborne Acupunct Med 2010Osborne Acupunct Med 2010

• Shoulder pain• Compared corticosteroid with acupuncture • Both groups had significant improvement pain and function but not between

Johansson Fam Pract 2011Johansson Fam Pract 2011

DRY NEEDLING

2nd visit• 5 questions:1. How did you feel after last visit? I was a little sore that

night but I felt better. I haven’t had any numbness at all or shoulder pain

2. How do you feel now? I am 98% better. 3. How is sleeping, reading, driving (SE * signs)? They are

95% better. I am only having a little stiffness in my neck

4. How are OE * signs? Very little tenderness to palpation, no reproduction with shoulder ROM with OP. Still had P2 with cervical motions as in IE.

5. Show me your HEP: Performed correctly

Dry Needling demo or vid?

• Derek

Re‐test

• Rx 1: Dry Needling to infraspinatus and teresminor, 1 each mms, multiple LTRs. Patient reported reproduction of P1 and P3 with each of muscle needled.

• Retest: AROM shoulder. No production of P1 with any motion and no P3 with MMT ER. No change in P2 with cervical motions.

And now the rest of the story

• At 2 month follow up:– NDI 2%– GROC +7 “ A Very Great Deal Better”– NPRS 0/10

• Algafly AA, George KP. The effect of cryotherapy on nerve conduction velocity, pain threshold and pain tolerance. Br J Sports Med. 2007;41(6):365–369

• Crombez G1, Eccleston C, Van Damme S, Vlaeyen JW, Karoly P. Fear‐avoidance model of chronic pain: the next generation. Clin J Pain. 2012 Jul;28(6):475‐83.

• Bang MD, Deyle GD: Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impingement syndrome. J Orthop Sports Phys Ther. 2000;30(3):126‐137

• Liebler EJ, Tufano ‐Coors L, Douris P et al: The effect of thoracic spine mobilization on lower trapezius strength• testing. J Manual Manipulative Ther. 2001;9(4):207 ‐212.• Mintken PE, Cleland JA, Carpenter KJ, Bieniek ML, Keirns M, Whitman JM. Some Factors Predict Short‐Term Outcomes in Individuals

with Shoulder Pain Receiving Cervicothoracic Manipulation: A Single‐Arm Trial. Phys Ther. 2010; 90(1): 26‐42.• Boyles RE, Ritland BM, Miracle BM, Barclay DM, Faul MS, Moora JH, Koppenhaver SL,fckLRWainner RS. The short‐term effects of

thoracic spine thrust manipulation on patients with shoulder impingement syndrome. Manual Therapy. 2009; 14: 375‐380.• Bronfort G, Evan R, Nelson B, Aker PD, Goldsmith CH, Vernon H. A randomized clinical trial of exercise and spinal manipulation for

patients with chronic neck pain. Spine 2001;26(7):788‐99.• Hoving JL, Koes BW, de Vet HCW, van der Windt DAWM, Assendelft WJJ, van Mameren H, et al. Manual therapy, physical therapy, or

continued care by a general practitioner for patients with neck pain. A randomized controlled trial. Ann Int Med 2002;136:713‐22.• Jull G, Trott P, Potter H, Zito G, Niere K, Shirley D, et al. A randomized controlled trial of exercise and manipulative therapy for

cervicogenic headache. Spine 2002;27(17):1835‐43.• DeSantana JM, Walsh DM, Vance C, Rakel BA, Sluka KA. Effectiveness of transcutaneous electrical nerve stimulation for treatment of

hyperalgesia and pain. Curr Rheumatol Rep. 2008;10: 492–499.• Walker MJ, Boyles RE, Young BA, Strunce JB, Garber MB, Whitman JM, Deyle G, Wainner RS. The effectiveness of manual physical

therapy and exercise for mechanical neck pain. Spine. 2008; 33:2371‐2378.• McClatchie L, Laprade J, Martin S, Jaglal SB, Richardson D, Agur A. Mobilizations of the asymptomatict cervical spine can reduce signs of

shoulder dysfunction in adults. Man Ther. 2008; doi: 10.1016/j.math.2008.05.006.• Raney N, Petersen EJ, Smith TA, Cowan JE, Rendeiro DG, Deyle GD, Childs JD. Development of a clinical prediction rule to identify

patients with neck pain likely to benefit from cervical traction and exercise. Eur Spine J 2009;18:382‐391• Dommerholt J. Dry needling—peripheral and central considerations. Journal of Manual and Manipulative Therapy. 2011;19(4):223–237.• Shah JP, Gilliams EA. Uncovering the biochemical milieu of myofascial trigger points using in vivo microdialysis: an application of muscle

pain concepts to myofascial pain syndrome. J Bodyw Mov Ther. Oct 2008;12(4):371‐384

References

References

• Wainner, R. S., Fritz, J. M., Irrgang, J. J., Boninger, M. L., Delitto, A., & Allison, S. (2003). Reliability and diagnostic accuracy of the clinical examination and patient self‐report measures for cervical radiculopathy. Spine, 28(1), 52‐62.

• Smart, K. M., Blake, C., Staines, A., & Doody, C. (2011). The Discriminative validity of “nociceptive,”“peripheral neuropathic,” and “central sensitization” as mechanisms‐based classifications of musculoskeletal pain. The Clinical journal of pain, 27(8), 655‐663.

• Smart, K. M., Blake, C., Staines, A., Thacker, M., & Doody, C. (2012). Mechanisms‐based classifications of musculoskeletal pain: part 1 of 3: symptoms and signs of central sensitisation in patients with low back (±leg) pain. Manual therapy, 17(4), 336‐344.

• Smart, K. M., Blake, C., Staines, A., Thacker, M., & Doody, C. (2012). Mechanisms‐based classifications of musculoskeletal pain: part 2 of 3: symptoms and signs of peripheral neuropathic pain in patients with low back (±leg) pain. Manual therapy, 17(4), 345‐351.

• Smart, K. M., Blake, C., Staines, A., Thacker, M., & Doody, C. (2012). Mechanisms‐based classifications of musculoskeletal pain: Part 3 of 3: Symptoms and signs of nociceptive pain in patients with low back (±leg) pain. Manual therapy, 17(4), 352‐357.

• Bron, C., Franssen, J., Wensing, M., & Oostendorp, R. A. (2007). Interrater reliability of palpation of myofascial trigger points in three shoulder muscles. Journal of Manual & Manipulative Therapy, 15(4), 203‐215.

• Hidalgo‐Lozano, A., Fernández‐de‐las‐Peñas, C., Díaz‐Rodríguez, L., González‐Iglesias, J., Palacios‐Ceña, D., & Arroyo‐Morales, M. (2011). Changes in pain and pressure pain sensitivity after manual treatment of active trigger points in patients with unilateral shoulder impingement: a case series. Journal of bodywork and movement therapies, 15(4), 399‐404.

• Osborne, N. J., & Gatt, I. T. (2010). Management of shoulder injuries using dry needling in elite volleyball players. Acupuncture in Medicine, 28(1), 42‐45.

• Dommerholt, J., Mayoral del Moral, O., & Gröbli, C. (2006). Trigger point dry needling. Journal of Manual & Manipulative Therapy, 14(4), 70E‐87E.

• Dommerholt, J. (2011). Dry needling‐peripheral and central considerations. Journal of Manual & Manipulative Therapy, 19(4), 223‐227.

• Bron, C., De Gast, A., Dommerholt, J., Stegenga, B., Wensing, M., & Oostendorp, R. A. (2011). Treatment of myofascial trigger points in patients with chronic shoulder pain: a randomized, controlled trial. BMC medicine, 9(1), 8.

Integration of pain sciences and dry needling to enhance ... · Cervical ROM only caused P2 neck...

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