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

Background

Trigger point dry needling (TDN) is commonly used to treat musculoskeletal pain related to myofascial trigger points (MTrPs). To date, no systematic review of high-quality randomised controlled trials (RCTs) investigating TDN to multiple body regions exists.

Purpose

The aim of this review is to determine the effectiveness of TDN based on high-quality RCTs for all body regions.

Methods

To ensure thorough reporting, Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed as the methodological basis for this systematic review. PubMed, Physiotherapy Evidence Database (PEDro), Cinahl, Cochrane and reference lists were searched for the years 2000–2014 and the terms ‘TDN’, ‘dry needling NOT trigger point’, ‘functional dry needling’ and ‘intramuscular manual therapy’. Inclusion criteria: RCTs with PEDro scores 6–10 investigating TDN. Exclusion criteria: duplicates, non-human participants, non-English language, exclusive focus on acupuncture or medicinal injections. Three investigators searched databases, applied criteria, read and assigned PEDro scores to every RCT. Nineteen studies met the criteria. As compared to either baseline or control groups, significant differences were found for pain (14 studies), range of motion (ROM) (five studies) and at least one item on function and quality of life measures (six studies).

Limitations

This review was limited by inclusion criteria, timeframe, language and databases searched.

Conclusion

The majority of high-quality studies included in this review show measured benefit from TDN for MTrPs in multiple body areas, suggesting broad applicability of TDN treatment for multiple muscle groups. Further high-quality research is warranted to standardise TDN methods to determine clinical applicability.     

Noninvasive ventilation and exercise tolerance in heart failure: A systematic review and meta-analysis

Background:

Patients with heart failure (HF) usually develop exercise intolerance. In this context, noninvasive ventilation (NIV) can help to increase physical performance.

Objective:

To undertake a systematic review and meta-analysis of randomized controlled trials that evaluated the effects of NIV on exercise tolerance in patients with HF.

Method:

Search Strategy: Articles were searched in the following databases: Physiotherapy Evidence Database (PEDro), Scientific Electronic Library Online (SciELO), and MEDLINE. Selection Criteria: This review included only randomized controlled trials involving patients with HF undergoing NIV, with or without other therapies, that used exercise tolerance as an outcome, verified by the distance travelled in the six-minute walk test (6MWT), VO₂peak in the cardiopulmonary test, time spent in testing, and dyspnea. Data Collection and Analysis: The methodological quality of the studies was rated according to the PEDro scale. Data were pooled in fixed-effect meta-analysis whenever possible.

Results:

Four studies were selected. A meta-analysis including 18 participants showed that the use of NIV prior to the 6MWT promoted increased distance, [mean difference 65.29 m (95% CI 38.80 to 91.78)].

Conclusions:

The use of NIV prior to the 6MWT in patients with HF may promote increased distance. However, the limited number of studies may have compromised a more definitive conclusion on the subject.     

Dietary interventions for fecal occult blood test screening: Systematic review of the literature

OBJECTIVE

To determine whether dietary restrictions enhance the specificity of guaiac-based fecal occult blood tests (FOBTs) when screening for colorectal cancer.

DATA SOURCES

PubMed-MEDLINE, the Cumulative Index to Nursing and Allied Health Literature, and Cochrane databases were searched.

STUDY SELECTION

English-language case series, cohort studies, randomized controlled trials (RCTs), and meta-analyses were selected. Studies that did not include dietary manipulation or the use of guaiac-based FOBTs available in North America were excluded.

SYNTHESIS

Ten case series, 5 cohort studies, 4 RCTs, and 1 meta-analysis were critically appraised. All studies used Hemoccult, Hemoccult II, or Hemoccult SENSA tests. Data from case series involving challenge diets showed no increase in positive FOBT results from high-peroxidase vegetables, but results varied with red-meat challenges depending on the amount of meat consumed and the test used. Case series, cohort studies, and RCTs comparing FOBT results during restricted versus unrestricted diets consistently showed no differences in positive FOBT results.

CONCLUSION

Most of the evidence evaluating the effect of dietary restrictions on FOBT results is dated and of suboptimal quality. However, 4 RCTs and a meta-analysis of these data do not support dietary restrictions when screening for colorectal cancer. Because patient adherence can be an issue with FOBTs, and dietary restrictions can affect adherence in some populations, it is reasonable to abandon these recommendations without fear of substantially affecting specificity.     

Exercise for Fall Risk Reduction in Community-Dwelling Older Adults: A Systematic Review

Purpose:

To evaluate the influence of exercise on falls and fall risk reduction in community-dwelling older adults and to present an updated synthesis of outcome measures for the assessment of fall risk in community-dwelling older adults.

Method:

A systematic review was performed, considering English-language articles published from 2000 to 2006 and accessible through MEDLINE, CINAHL, PEDro, EMBASE, and/or AMED. Included were randomized controlled clinical trials (RCTs) that used an exercise or physical activity intervention and involved participants over age 50. Screening and methodological quality for internal validity were conducted by two independent reviewers.

Results:

The search retrieved 156 abstracts; 22 articles met the internal validity criteria. Both individualized and group exercise programmes were found to be effective in reducing falls and fall risk. The optimal type, frequency, and dose of exercise to achieve a positive effect have not been determined. A variety of outcome measures have been used to measure fall risk, especially for balance.

Conclusions:

Falls and fall risk can be reduced with exercise interventions in the community-dwelling elderly, although the most effective exercise variables are unknown. Future studies in populations with comorbidities known to increase fall risk will help determine optimal, condition-specific fall-prevention programmes. Poor balance is a key risk factor for falls; therefore, the best measure of this variable should be selected when evaluating patients at risk of falling.     

RECURRENT HAMSTRING INJURY: CONSIDERATION FOLLOWING OPERATIVE AND NON‐OPERATIVE MANAGEMENT

Purpose/Background:

Hamstring injuries are common at all levels of sport, however recurrence rates are disproportionate compared to other soft tissue injuries. Age and previous injury are supported in the literature as risk factors for hamstring injury; nonetheless, debate exists regarding modifiable risk factors. Restoration of peak torque length using lengthening eccentrics and core stability interventions appear to reduce incidence of re‐injury. The purpose of this clinical commentary is to review examination techniques and rehabilitation considerations in order to identify important risk factors to reduce recurrence after hamstring strain and total rupture.

Discussion/Relation to Clinical Practice:

Novel clinical examination techniques both at time of acute injury and prior to return to sport may provide valuable prognostic information. Restoration of core stability, neuromuscular control and lengthening eccentric hamstring interventions are proposed key components to reduce hamstring re‐injury.

Levels of Evidence:

Level 5     

THE EFFECTS OF CONVENTIONAL PHYSICAL THERAPY AND ECCENTRIC STRENGTHENING FOR INSERTIONAL ACHILLES TENDINOPATHY

Study Design:

Single‐blind, randomized, clinical trial.

Background:

The effect of eccentric training for mid‐portion Achilles tendinopathy is well documented; however, its effect on insertional Achilles tendinopathy is inconclusive. The primary purpose of this study was to investigate the effect of eccentric training on pain and function for individuals with insertional Achilles tendinopathy.

Methods:

All patients received a 12‐week conventional strengthening protocol. Patients who were randomly assigned to the experimental group received additional eccentric exercises. Patients completed the Short Form‐36 Health and Bodily Pain Surveys, the Foot and Ankle Outcomes Questionnaire, and the Visual Analog Scale at initial evaluation, after 6 weeks of therapy, and at 12 weeks after therapy.

Results:

Thirty‐six patients (20 control and 16 experimental; average age 54 years; 72% women) completed the study. Both groups experienced statistically significant decreases in pain and improvements in function. No statistically significant differences were noted between the groups for any of the outcome measures.

Conclusion:

Conventional physical therapy consisting of gastrocnemius, soleus and hamstring stretches, ice massage on the Achilles tendon, and use of heel lifts and night splints with or without eccentric training is effective for treating insertional Achilles tendinopathy.

Level of Evidence:

Level 2     

Usage evaluation of the Physiotherapy Evidence Database (PEDro) among Brazilian physical therapists

BACKGROUND:

It is unclear whether the Physiotherapy Evidence Database (PEDro) is widely and equally used by physical therapists in Brazil. As PEDro is considered a key resource to support evidence-based physical therapy, analyses of PEDro usage could reflect the extent of dissemination of evidence-based practice.

OBJECTIVE:

To describe the usage of PEDro among the five regions of the World Confederation for Physical Therapy (WCPT) and, in more detail, in the South American region and Brazil over a 5-year period.

METHOD:

PEDro home-page sessions and the number of searches performed were logged for a 5-year period (2010-2014). Absolute usage and relative usage were calculated for each region of the WCPT, each country in the South American region of WCPT, and each Regional Council (CREFITO) in Brazil.

RESULTS:

Europe had the highest absolute and relative usage among the five regions of the WCPT (971 searches per million-population per year), with the South American region ranked 4th in absolute terms and 3rd in relative terms (486). Within the South American region, Brazil accounted for nearly 60% of searches (755). Analysis at a national level revealed that usage per physical therapist in Brazil is very low across all CREFITOs. The highest usage occurred in CREFITO 6 with 1.3 searches per physical therapist per year.

CONCLUSIONS:

PEDro is not widely and equally used throughout Brazil. Strategies to promote PEDro and to make PEDro more accessible to physical therapists speaking Portuguese are needed.     

The Effects of Open versus Closed Kinetic Chain Exercises on Patients with ACL Deficient or Reconstructed Knees: A Systematic Review

Background

There is no consensus among the existing published evidence as to whether closed kinetic chain (CKC) or open kinetic chain (OKC) exercises should be the intervention of choice following an anterior cruciate ligament (ACL) injury or reconstruction. The commonly held belief has been that OKC exercises cause increased strain on the ACL as well as increased joint laxity and anterior tibial translation.

Objective

To investigate the effects of OKC and CKC exercises on the knees of patients with ACL deficiency or reconstruction.

Data Sources

MEDLINE, ProQuest Medical Library, and CINAHL

Study Selection

Six articles were chosen for inclusion in the systematic review. The authors narrowed 50 articles down to 6 by review of titles and abstracts. Included articles were randomized controlled trials written in English, published during 2000-2008, that evaluated the effects of OKC and CKC exercises on ACL deficient or reconstructed knees.

Data Extraction

Quality of the included studies was defined by the PEDro scale¹, which has been found to be reliable.²

Data Synthesis

Scores on the PEDro scale¹ ranged from 4-6/10. One article found positive significant effects with inclusion of OKC exercises in the rehabilitation program and another found significant benefits with combining OKC and CKC exercises. CKC exercises alone were not found by any studies to be superior to OKC exercises.

Conclusion

These studies reveal favorable results for utilization of both open and closed kinetic chain exercises for intervention with ACL deficient or reconstructed knees. However, further research needs to be completed.     

COMPARISON OF ECCENTRIC AND CONCENTRIC EXERCISE INTERVENTIONS IN ADULTS WITH SUBACROMIAL IMPINGEMENT SYNDROME

Background

Researchers have demonstrated moderate evidence for the use of exercise in the treatment of subacromial impingement syndrome (SAIS). Recent evidence also supports eccentric exercise for patients with lower extremity and wrist tendinopathies. However, only a few investigators have examined the effects of eccentric exercise on patients with rotator cuff tendinopathy.

Purpose

To compare the effectiveness of an eccentric progressive resistance exercise (PRE) intervention to a concentric PRE intervention in adults with SAIS.

Study Design

Randomized Clinical Trial

Methods

Thirty‐four participants with SAIS were randomized into concentric (n = 16, mean age: 48.6 ± 14.6 years) and eccentric (n = 18, mean age: 50.1 ± 16.9 years) exercise groups. Supervised rotator cuff and scapular PRE''s were performed twice a week for eight weeks. A daily home program of shoulder stretching and active range of motion (AROM) exercises was performed by both groups. The outcome measures of the Disabilities of the Arm, Shoulder, and Hand (DASH) score, pain‐free arm scapular plane elevation AROM, pain‐free shoulder abduction and external rotation (ER) strength were assessed at baseline, week five, and week eight of the study.

Results

Four separate 2x3 ANOVAs with repeated measures showed no significant difference in any outcome measure between the two groups over time. However, all participants made significant improvements in all outcome measures from baseline to week five (p <  0.0125). Significant improvements also were found from week five to week eight (p < 0.0125) for all outcome measures except scapular plane elevation AROM.

Conclusion

Both eccentric and concentric PRE programs resulted in improved function, AROM, and strength in patients with SAIS. However, no difference was found between the two exercise modes, suggesting that therapists may use exercises that utilize either exercise mode in their treatment of SAIS.

Level of evidence

Therapy, level 1b     

A systematic review of the effects of pilates method of exercise in healthy people

Cruz-Ferreira A, Fernandes J, Laranjo L, Bernardo LM, Silva A. A systematic review of the effects of Pilates method of exercise in healthy people.

Objective

To evaluate evidence for the effectiveness of the Pilates method of exercise (PME) in healthy people.

Data Sources

Published research was identified by searching Science Direct, MEDLINE, PubMed, SPORTDiscus, PEDro, Cochrane Central Register of Controlled Trials, CINAHL, and Web of Science.

Study Selection

Research studies published from inception to May 7, 2011 were selected for evaluation. Two reviewers independently applied the inclusion criteria to selected potential studies. Studies were included if they were published in a peer-reviewed journal, written in the English language, conducted as a randomized controlled trial (RCT) or quasi-RCT in healthy people, had an inactive and/or exercise control group(s), included key study outcomes, and used the PME as the study intervention in at least 1 study arm.

Data Extraction

Two reviewers independently extracted data (study, design, subjects, intervention, key outcomes results), applied the Physiotherapy Evidence Database (PEDro) scale to assess the method quality of selected studies, and determined the strength of the evidence using the best evidence synthesis grading system.

Data Synthesis

Sixteen studies met the inclusion criteria. PEDro scale values ranged from 3 to 7 (mean, 4.1), indicating a low level of scientific rigor. The outcomes studied most often were flexibility, muscular endurance, strength, and postural alignment. The PME appears to be effective in improving flexibility (strong evidence), dynamic balance (strong evidence), and muscular endurance (moderate evidence) in healthy people.

Conclusions

There was strong evidence to support the use of the PME at least to the end of training to improve flexibility and dynamic balance and moderate evidence to enhance muscular endurance. Future RCTs should focus on the components of blinding, concealed allocation, subject adherence, intention-to-treat analysis, and follow-up designs.     

Effectiveness of Interventions of Specific Complaints of the Arm, Neck, and/or Shoulder: 3 Musculoskeletal Disorders of the Hand. An Update

Huisstede BM, van Middelkoop M, Randsdorp MS, Glerum S, Koes BW. Effectiveness of interventions of specific complaints of the arm, neck, and/or shoulder: 3 musculoskeletal disorders of the hand. An update.

Objectives

To provide an evidence-based overview of the effectiveness of conservative and surgical interventions for trigger finger, Dupuytren's, and De Quervain's diseases.

Data Sources

The Cochrane Library, PEDro, PubMed, Embase, and CINAHL were searched to identify relevant studies.

Study Selection

Two reviewers independently applied the inclusion criteria to select potential relevant studies from the title and abstracts of the references retrieved by the literature search. Relevant (Cochrane) reviews and randomized controlled trials (RCTs) were included.

Data Extraction

Two reviewers independently extracted the data and performed a methodologic quality assessment.

Data Synthesis

A best-evidence synthesis was performed to summarize the results of the included trials. One Cochrane review (trigger finger) and 13 RCTs (trigger finger [6], Dupuytren's [4], De Quervain's [3]) were included. The trials reported on physiotherapy (De Quervain's), steroid injections (trigger finger, De Quervain's), surgical treatment (trigger finger, De Quervain's), and a postsurgical treatment (Dupuytren's). For trigger finger, moderate evidence was found for the effectiveness of steroid injections in the short-term (1-4wk) but not for long-term outcomes. Limited evidence was found for the effectiveness of staples compared with sutures in skin closure and for intermittent compression after surgery to treat Dupuytren's disease. For other interventions, no evidence was found.

Conclusions

Indications for effectiveness of some interventions for trigger finger, Dupuytren's, and De Quervain's diseases were found. Because only a few RCTs were identified, it is difficult to draw firm conclusions. High-quality RCTs are clearly needed in this field.     

DRY NEEDLING IN SUBJECTS WITH MUSCULAR TRIGGER POINTS IN THE LOWER QUARTER: A SYSTEMATIC REVIEW

Background

Trigger points, which have been defined as highly localized, hyperirritable locations in a palpable taut band of skeletal muscle fibers, have been identified with a variety of musculoskeletal conditions. The incidence of trigger point pain is high, with studies showing them as the primary source of pain in 30-85% of patients presenting in a primary care setting or pain clinic. Dry needling has emerged as a possible intervention for trigger points, but its effectiveness has not yet fully been determined.

Purpose

To assess and provide a summary on the current literature for the use of dry needling as an intervention for lower quarter trigger points in patients with various orthopedic conditions.

Study Design

Systematic review

Methods

CINAHL, NCBI-PubMed, PEDro, SPORTDiscus, Cochrane Library, and APTA''s PTNow were searched to identify relevant randomized controlled trials. Six studies meeting the inclusion criteria were analyzed using the PEDro scale.

Results

Four of the studies assessed by the PEDro scale were deemed ‘high’ quality and two were ‘fair’ quality. Each of the six included studies reported statistically significant improvements with dry needling for the reduction of pain intensity in the short-term. Only one study reported a statistically significant improvement in short-term functional outcomes; however, there was no maintenance of improved function at long-term follow-up. Furthermore, none of the studies reported statistically significant changes regarding the effect of dry needling on quality of life, depression, range of motion, or strength.

Conclusion

A review of current literature suggests that dry needling is effective in reducing pain associated with lower quarter trigger points in the short-term. However, the findings suggest that dry needling does not have a positive effect on function, quality of life, depression, range of motion, or strength. Further high quality research with long-term follow-up investigating the effect of dry needling in comparison to and in conjunction with other interventions is needed to determine the optimal use of dry needling in treating patients with lower quarter trigger points.

Levels of Evidence

1     

Effectiveness of Aquatic Exercise for Musculoskeletal Conditions: A Meta-Analysis

Objective

To investigate the effectiveness of aquatic exercise in the management of musculoskeletal conditions.

Data Sources

A systematic review was conducted using Ovid MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Embase, and The Cochrane Central Register of Controlled Trials from earliest record to May 2013.

Study Selection

We searched for randomized controlled trials (RCTs) and quasi-RCTs evaluating aquatic exercise for adults with musculoskeletal conditions compared with no exercise or land-based exercise. Outcomes of interest were pain, physical function, and quality of life. The electronic search identified 1199 potential studies. Of these, 1136 studies were excluded based on title and abstract. A further 36 studies were excluded after full text review, and the remaining 26 studies were included in this review.

Data Extraction

Two reviewers independently extracted demographic data and intervention characteristics from included trials. Outcome data, including mean scores and SDs, were also extracted.

Data Synthesis

The Physiotherapy Evidence Database (PEDro) Scale identified 20 studies with high methodologic quality (PEDro score ≥6). Compared with no exercise, aquatic exercise achieved moderate improvements in pain (standardized mean difference [SMD]=−.37; 95% confidence interval [CI], −.56 to −.18), physical function (SMD=.32; 95% CI, .13–.51), and quality of life (SMD=.39; 95% CI, .06–.73). No significant differences were observed between the effects of aquatic and land-based exercise on pain (SMD=−.11; 95% CI, −.27 to .04), physical function (SMD=−.03; 95% CI, −.19 to .12), or quality of life (SMD=−.10; 95% CI, −.29 to .09).

Conclusions

The evidence suggests that aquatic exercise has moderate beneficial effects on pain, physical function, and quality of life in adults with musculoskeletal conditions. These benefits appear comparable across conditions and with those achieved with land-based exercise. Further research is needed to understand the characteristics of aquatic exercise programs that provide the most benefit.