D.O.I: Msc student in Sports Physiotherapy, PT, European University Cyprus

Transcription

1 VOLUME 14.1, 2018 D.O.I: Dry needling and neuromuscular exercises in the management of chronic ankle instability. A case study Ioannou Andria 1, Stasinopoulos Dimitrios 2 1 Msc student in Sports Physiotherapy, PT, European University Cyprus 2 Chairperson / Associate Professor, Physiotherapy, Coordinator of MSc in Sports Physiotherapy Coordinator of Physiotherapy Program, Director of Cyprus Musculoskeletal and Sports Trauma Research Centre (CYMUSTREC) Physiotherapy Program, Dep. of Health Sciences, School of Sciences, European University Cyprus, Nicosia, Cyprus Abstract The aim of this case study was to evaluate the effectiveness of dry needling in treating painful trigger points (TrPs) in combination with neuromuscular exercises in a patient with chronic ankle instability. A 23-year-old amateur runner complained about 3 years of pain on the outside of the left lower limb of the ankle. She had chronic ankle instability according to history and clinical examination. Dry needling was applied at the trigger points of the peroneal muscles, gastrocnemius and soleus. The patient also attended a supervised exercise program that included neuromuscular exercises. The programme was individualized on the basis of the patient s description of pain experienced during the procedure. The patient visited the clinic five times per week for 7 weeks. The supervised neuromuscular exercise program was performed in every visit while DN was applied in 3 out of 5 sessions. Outcome measures were pain, using a visual analogue scale, function using the Foot and Ankle Ability Measure questionnaire and proprioception using the star excursion balance test. The patient was evaluated at baseline Key Words: Ankle instability, Proprioception, Dry needling, Trigger points, Neuromuscular exercises

2 32 JBE VOL. 14.1, 2018 and 1 month after the end of treatment. At the follow-up, pain was reduced, function and prpprioception were increased. The results of the study suggest that the combination of dry needling trigger points with neuromuscular exercises can improve pain, function and proprioception in a patient with chronic ankle instability. Future well-designed studies need to confirm the results of this case study. Introduction The ankle sprain is one of the most common sports injuries. About 20% of patients with acute ankle sprain will develop chronic ankle instability (CAI) (1). Chronic pain, muscle weakness, recurrent instability and degenerative arthritis are the complications of CAI (2, 3). Patients with CAI complain of a feeling that the ankle is gone, previous sprains, pain, edema and restrictions on daily and sports activities (4). The primary treatment option for these patients is conservative one. Neuromuscular exercises and patients education have short-term results in CAI (5). Patients with CAI have delayed activation of peroneal muscles (6). Repetitive sprains are a mechanism of triggering the trigger points (TrPs) within the muscles (7). TrPs in the affected muscles alter the motor control (8) and accelerate fatigue (9). Therefore, proper treatment of TrPs can effectively reduce motor disorders in the affected muscular system by preventing the spread of overload in surrounding structures (8). It is claimed that the treatment of TrPs using dry needling (DN) is an effective therapeutic approach (10). The purpose of this study is to find out the effectiveness of DN technique in treating TrPs in combination with neuromuscular exercises in a patient with CAI. CASE PRESENTATION A female amateur runner with CAI in her left ankle had 3-ankle sprains grade 2 in the last 3 years. She also had positive the drawer test and the talar tilt test. Both tests assess the ligament stability. The patient followed a supervised program of neuromuscular exercises (11). The program of the neuromuscular exercises included closed kinetic chain exercises. The patient used her body weight on a stable surface (Figure 1, 2) for the first 2 weeks (3 sets of 10 repetitions), on a unstable surface (figure 3) over the next 2 weeks (3 sets of 10 repetitions) and in the last three weeks (5-7 weeks) (3 sets of 15 repetitions) even more complex re-training exercises of neuromuscular and dynamic stabilization of the lower limb (Figures 4, 5, 6). In addition to the neuromuscular exercises, the DN of TrPs of the peroneal muscles, gastrocnemius and soleus was applied to the patient. The fast -in and

3 Dry needling and neuromuscular exercises in the management of chronic ankle instability 33 fast-out dry needle technique was used in the present study. DN was applied by one experienced physiotherapist (IA) with 2 years experience in this technique. The patient was placed in oblique position to locate TrPs in the peroneals and soleus and in prone lying for gastrocnemius (Figures 7, 8, 9). The patient visited the clinic five times a week for 7 weeks. The supervised program of neuromuscular exercises was performed every day, while DN was applied 3 times per week. She was also told to refrain from taking anti-inflammatory drugs throughout the course of the study. Patient compliance with this request was monitored using a treatment diary (12). Communication and interaction (verbal and non-verbal) between the therapist and patient was kept to a minimum, and behaviours sometimes used by therapists to facilitate positive treatment outcomes were purposefully avoided. For example, patient was given no indication of the potentially beneficial effects of the treatments or any feedback on their performance in the pre-application and postapplication measurements (12). Pain, function and proprioception were measured in this study. Pain was measured on a visual analogue scale (VAS), where 0 (cm) was least pain imaginable and 10 (cm) was worst pain imaginable. The pain VAS was used to measure the patient s worst level of pain over the previous 24 h before each evaluation, and this approach has been shown to be valid and sensitive of the VAS. Function was evaluated by The Foot and Ankle Ability Measure (FAAM) questionnaire. FAAM is a 29-questionnaire divided into 2 scales: (1) activities of Daily Living (ADL) with 21 questions and (2) sports activities (SPORTS), including 8 questions. The values are added for the scoring of each scale, 84 points for the ADL scale and 32 for the SPORTS scale13. Each grade is converted to a percentage (0-100%) to output the end result of each sub-scale. Higher scores indicate higher function (13). Finally, the star excursion balance test (SEBT) was used to evaluate the patient s proprioception. The patient maintained her balance on one leg (left) and the other leg tried to get as far as possible along the directions performing SBET. The directions that were evaluated were the anterior, posteriormedial and posterior-lateral. The examiner with a tape measure measured the distance in centimeters (cm) from the center to the point of contact. The patient was evaluated at the baseline (week 0), and 1 month after the end of the treatment.

4 34 JBE VOL. 14.1, 2018 Figure 1. Stable surface Figure 2. Stable surface Figure 3. Unstable surface Figure 4. Complex and dynamic neuromuscular exercises

5 Dry needling and neuromuscular exercises in the management of chronic ankle instability 35 Figures 5 & 6. Complex and dynamic neuromuscular exercises Figure 7. DN gastrocnemius Figure 8. DN peroneals Figure 9. DN soleus RESULTS At the end of the treatment and at the follow up there was a decline in pain and a rise in function and proprioception (Table 1). (Tables 1.1, 1.2).

6 36 JBE VOL. 14.1, 2018 Table 1.1. Pain and function VAS (cm) FAAM-ADL subscale (0-100%) FAAM-SPORTS subscale (0-100%) At the beginning of the treatment One month after the end of treatment Table 1.2. Proprioception Direction Injured leg (left) Non- injured leg (right) Anterior BT=75 AT=80 BT=90 AT=95 Postero-medial BT=73 AT=80 BT=80 AT=85 Postero-lateral BT=76 AT=82 BT=92 AT=95 BT=Before treatment, AT=After treatment Discussion The present study has looked at the effect of neuromuscular exercises and DN of TrPs in a patient with CAI; its findings have demonstrated significant improvements in terms of pain, disability and proprioception. The results obtained from this case report are novel; as to date, similar studies have not been conducted in Greece. The protocol of the case study was based on the therapist s experience according to the patient s symptoms. Personalizing a program seems to have better results in rehabilitation (14). It cannot be determined which of the 2 interventions led to the change of symptoms. Manual therapy (15), exercise therapy (15), and functional rehabilitation (16), have positive results in patients with CAI. On the other hand, bandages and braces showed no effect on the proprioception in patients with CAI (16). Only one study (11) evaluated the effectiveness of DN in TrPs

7 Dry needling and neuromuscular exercises in the management of chronic ankle instability 37 in combination with neuromuscular exercises in pain and function in patients with CAI, concluding the same conclusions as present case study. The exact therapeutic mechanism of DN at the TrPs of managing pain is still unclear (17). It can help breaking the strained muscle bundle leading to an increase in sarcomer length but also to the reduction of peripheral pain and the activation of central pain pathways (18). Neuromuscular education increases the response time of peroneals, which is delayed in patients with CAI. In addition, it is likely that the DN applied to the peroneals improved muscle neurophysiology (17). The supervision of a program, as in the present study, seems to have better clinical results than a home exercise program (14). Although the results of this study are positive cannot be generalized. Future well-designed studies are needed to confirm the short-term and long-term effects of this intervention in patients with CAI. REFERENCES 1. AL-Mohrej OA, AL-Kenani NS. Chronic ankle instability: current perspectives. Avicenna journal of medicine, 6: , Ferran N, Maffulli N. Epidemiology of sprain of the lateral ankle ligament complex. Foot and Ankle Clinics, 11:659-62, Mccriskin BJ, CAMERON KL, Orr JD, Waterman BR. Management and prevention of acute and chronic lateral ankle instability in athletic patient populations. World Journal of Orthopedics, 6:161-71, O loughlin PF, Murawski CD, Egan C, Kennedy JG. Ankle instability in sports. The Physician and sportsmedicine, 37(2):93-103, DE vries JS, Krips R, Sierevelt IN, Blankevoort L, VAN dijk CN. Interventions for treating chronic ankle instability. Cochrane database of systematic reviews, (8), p.cd004124, 2011(Online). 6. Hoch MC, Mckeon PO. Peroneal reaction time after ankle sprain: A systematic review and meta-analysis. Medicine & Science in Sports & Exercise, 46: , Simons DG. Review of enigmatic MTrPs as a common cause of enigmatic musculoskeletal pain and dysfunction. Journal of Electromyography and Kinesiology, 14:95-107, Lucas KR, Rich PA, Polus BI. Muscle activation patterns in the scapular positioning muscles during loaded scapular plane elevation: The effects of Latent Myofascial Trigger Points. Clinical Biomechanics, 25: , Ge HY, Arendt-nielsen L, Madeleine P. Accelerated muscle fatigability of latent myofascial trigger points in humans. Pain Medicine (United States), 13: , 2012.

8 38 JBE VOL. 14.1, Simons D, Travell JSL. Myofascial pain and dysfunction: The trigger point manual. Baltimore: Williams & Wilkins, Salom-moreno J, Ayuso-casado B, Tamaral-costa B, Sanchez-mila Z, Fernandez-de-las-penas C, Alburquerque-sendin F. Trigger point dry needling and proprioceptive exercises for the management of chronic ankle instability: A randomized clinical trial. Evidence based Complementary and Alternative Medicine, [online] , Vicenzino B, Collins D, Wright A. The initial effects of a cervical spine manipulative physiotherapy treatment on the pain and dysfunction of lateral epicondylalgia. Pain, 68(1):69-74, Carcia CR, Martin RL, Drouin JM Validity of the foot and ankle ability measure in athletes with chronic ankle instability. Journal of Athletic Training, 43(2): , Manias P, Stasinopoulos D. A controlled clinical pilot trial to study the effectiveness of ice as a supplement to the exercise programme for the management of lateral elbow tendinopathy. Br J Sports Med, 40: 81-85, Van der wees PJ, Lenssen AF, Hendriks EJM, Stomp DJ, Dekker J, DE bie RA. Effectiveness of exercise therapy and manual mobilisation in acute ankle sprain and functional instability: A systematic review. Australian Journal of Physiotherapy, 52:27-37, Webster KA, Gribble PA. Functional rehabilitation interventions for chronic ankle instability: a systematic review. J Sport Rehabil, 19:98-114, Dommerholt J, Fernandez-de-las-peras C. Trigger Point Dry Needling: An Evidence and Clinical-Based Approach. Trigger Point Dry Needling: An Evidence and Clinical-Based Approach, Domingo A, Mayoral O, Monterde S, Santafé MM. Neuromuscular damage and repair after dry needling in mice. Evidence-based Complementary and Alternative Medicine, , Address for correspondence: Stasinopoulos Dimitrios (phd) chairperson/ associate professor, physiotherapy, physiotherapy program, Dep. of health Sciences, School of Sciences coordinator of msc in Sports physiotherapy coordinator of physiotherapy program 6, Diogenes Str. Engomi, P.O.Box 22006, 1516, Nicosia, Cyprus Τel [f] D.Stassinopoulos@euc.ac.cy [w]