TREATMENT OF CHRONIC MECHANICAL NECK PAIN IN AN OUTPATIENT ORTHOPEDIC SETTING Clinical Problem Solving II Allison Walsh
PATIENT OVERVIEW Age: 22 years Gender: Female Chief Complaint: Cervical pain, cervicogenic headaches, upper thoracic pain Onset of Symptoms: 2 years ago, insidious onset Pain Level: Ranges from 2/10 to 7-8/10 Aggravating Factors: Turning head, driving, reading Medication: Prescribed anti-inflammatory meds and muscle relaxers Imaging: X-rays unremarkable
PATIENT EXAMINATION FINDINGS Posture: Mild thoracic kyphosis, rounded shoulders and forward head in sitting Palpation: Tautness and tenderness to palpation at cervical paraspinals, suboccipitals, scalenes bilaterally, and thoracic paraspinals and upper trapezius on the right Joint Mobility: Hypomobile PA glides C3-C5, T2-T4 and unilateral glides to the right C3-C5 Neck Disability Index: 28/50 (severe disability) Cervical ROM:
ASSESSMENT: ICF HEALTH CONDITION: Chronic Mechanical Neck Pain BODY STRUCTURE & FUNCTION: Cervical Pain Decreased Cervical ROM Decreased joint mobility of spine Tautness/TTP cervical and upper thoracic musculature Poor posture ACTIVITY LIMITATIONS: Unable to sit for prolonged periods Difficulty sleeping Difficulty driving Difficulty reading Lifting heavy objects PARTICIPATION RESTRICTIONS: Decreased performance on a student Unable to perform fully as nanny Environmental Factors: On summer break from school, flexible work schedule Personal Factors: Sedentary lifestyle, lack of motivation
ASSESSMENT Goals: Short Term (3 weeks): 1. Increased cervical AROM rotation bilaterally to 70 with c/o pain less than 2/10 2. Frequency of headaches no more than 2x/week Long Term (6 weeks): 1. Read for 30 minutes without c/o cervical pain 2. Drive for 30 minutes without c/o cervical pain 3. Frequency of headaches no more than 1x/week Prognosis: Fair-Good Strengths: Age Absence of comorbidities Barriers: Long duration of symptoms Sedentary lifestyle
TREATMENT PLAN Patient will be seen 2x week for 6 weeks for the following: Manual Therapy: Deep tissue massage, passive stretching, pressure release Low and high grade PA mobilizations to cervical and thoracic spine High grade unilateral glides at cervical for improved right rotation Gentle passive cervical ROM and contract-relax techniques Therapeutic Exercise: Progression of cervical retractions Cervical ROM and strengthening Scapular retractions/stabilization Patient Education: Postural awareness Book position when reading Lifting techniques
PATIENT OUTCOMES After 4 weeks of therapy, patient demonstrated the following: Persistent trigger points Limited cervical AROM Flexion 45, Extension 40 Lateral flexion left 25, right 20 Left rotation 65, right 45 Slight improvement in cervical pain, frequency of headaches, and posture NO GOALS WERE MET Patient states that she has been prescribed dry needling.
BACKGROUND: TRIGGER POINT DRY NEEDLING Skilled intervention that uses a thin filiform needle to penetrate the skin and stimulate/inactivate underlying myofascial trigger points by eliciting local twitch responses Alleviation spontaneous electrical activity Reduction of nociceptive, inflammatory, and immune related chemicals Relaxation/decreased irritability of taut band Restored local circulation Reduced local and referred pain Improved range of motion
FOR A YOUNG ADULT PATIENT WITH CHRONIC MECHANICAL NECK PAIN, IS TRIGGER POINT DRY NEEDLING MORE EFFECTIVE THAN MANUAL THERAPY IN RELIEVING SYMPTOMS? Clinical Question
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. Llamas-Ramos, R., Pecos-Martín, D., Gallego-Izquierdo, T., Llamas- Ramos, I., Plaza-Manzano, G., Ortega-Santiago, R., & Fernandez-De- Las-Penas, C. (2014). journal of orthopaedic & sports physical therapy, 44(11), 852-861. Article 1
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 (LLAMAS-RAMOS ET AL., 2014) Design: Randomized clinical trial Level of Evidence: 1b, PEDro - 8/10 Purpose: To compare the short-term effects of trigger point dry needling and trigger point manual therapy in individuals with chronic mechanical neck pain and active trigger points in the upper trapezius muscle. Outcome Measures: Primary: Pain - 0-10 Visual Analog Scale Disability - Northwick Park Neck Pain Questionnaire (NPQ) Secondary: Pressure Pain Threshold - Mechanical Algometer Cervical AROM - CROM device
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 (LLAMAS-RAMOS ET AL., 2014) Methods: Inclusion Criteria: Chronic idiopathic mechanic neck pain Upper trapezius trigger point Exclusion Criteria: Whiplash, previous cervical surgery, cervical radiculopathy or myelopathy, fibromyalgia, PT in the past year, fear of needles, or contraindication to dry needling.
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 (LLAMAS-RAMOS ET AL., 2014) Methods: 2 treatments, 1x/week Intervention Group (DN): Trigger point dry needling of upper trapezius Treating only 1 unilateral trigger point Fast in and fast out technique, no rotation After 1 st twitch response, needle is moved up and down at 1 Hz for 25-30 seconds Comparison Group (MT): Trigger point manual therapy 1. Pressure Release x 3 2. Stretching of taut band muscle fibers 3. Passive stretch of upper trapezius - 45 seconds 1 2 3
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 (LLAMAS-RAMOS ET AL., 2014) Methods: Assessment Baseline Post-intervention (1 day after 2 nd treatment) Follow-up 1 week post treatment Follow-up 2 weeks post treatment Results: Participants: 94 subjects 47 intervention group (2 lost to followup) 47 comparison group (1 lost to followup) Age: 31 +/- 3 years Gender: 66% female Duration of symptoms: 7 +/- 2.7 months Pain intensity (0-10): 6.2 +/- 1.3 NPQ (0-36): 18 +/- 7 (severe disability) No adverse events reported
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 (LLAMAS-RAMOS ET AL., 2014) Statistically significant differences: p<0.125 Results: Post-intervention, 1 wk follow-up, 2 wk follow-up: Standardized mean difference SMD: Pain Intensity (MCID 2.1) small = 0.2; medium = 0.5; and large = Within groups: Large improvement in both (SMD>2.8) DN -5.3 +/- 0.4 MT 0.8. -5.2 +/- 0.4 Between groups: No significant difference (p=.516) Neck Disability NPQ (MCID-25% reduction) Within groups: Large improvement in both (SMD>2.8) DN -13.7 +/- 1.5 (72%) MT -12.8 +/- 1.4 (72%) Between groups: No significant difference (p=.411) Cervical AROM (MDC 5-10) Within group: Large improvement in both (SMD>1.4) DN 6.5 +/- 1.7 MT 5.6 +/- 1.5 Between groups: No significant difference (0.139<p<0.917) Pressure Pain Threshold (MDC 47.2) Within group: Large improvement in both: DN 138.1 +/- 10.3 MT 59.2 +/- 10.2 Between groups: Significant difference (p<0.001)
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 (LLAMAS-RAMOS ET AL., 2014) Conclusion: 2 sessions of either trigger point manual therapy or trigger point dry needling were similarly effective for decreasing pain and improving function and cervical range of motion. Statistically significant between group difference for changes in pressure pain threshold in favor of the group that received trigger point dry needling. Impact on function? Precursor?
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 (LLAMAS-RAMOS ET AL., 2014) Limitations: Only one trigger point in the upper trapezius was treated, only 2 sessions Only collected data at a short-term follow-up of 2 weeks. Not consistent with typical multimodal approach in PT Not a control group, improvements due to the passage of time? Relevance to Patient: This study would suggest that two sessions of trigger point dry needling would not have provided any more pain relief or cervical range of motion in the short term for my patient than current treatment. More sessions? Long-term effects? Treating ALL trigger points?
EFFECTIVENESS OF DRY NEEDLING FOR CHRONIC NON-SPECIFIC NECK PAIN: A RANDOMIZED, SINGLE BLINDED, CLINICAL TRIAL Cerezo-Téllez, E., Torres-Lacomba, M., Fuentes-Gallardo, I., Perez-Muñoz, M., Mayoral-del-Moral, O., Girbes, E. L.,... & Falla, D. (2016).PAIN. Article 2
EFFECTIVENESS OF DRY NEEDLING FOR CHRONIC NON-SPECIFIC NECK PAIN: A RANDOMIZED, SINGLE BLINDED, CLINICAL TRIAL (CEREZO-TÉLLEZ ET AL., 2016) Design: Randomized clinical trial Level of Evidence: 1b, not yet on PEDro Purpose: To evaluate the effectiveness of deep dry needling in people with chronic nonspecific neck pain attributed to myofascial pain syndrome with active myofascial trigger points in their cervical muscles. Outcome Measures: Primary: Pain - 0-10 Visual Analog Scale Secondary: Pressure Pain Threshold - Mechanical Algometer Cervical AROM - CROM device Cervical Strength - Dynamometer Disability - Neck Disability Index
EFFECTIVENESS OF DRY NEEDLING FOR CHRONIC NON-SPECIFIC NECK PAIN: A RANDOMIZED, SINGLE BLINDED, CLINICAL TRIAL (CEREZO-TÉLLEZ ET AL., 2016) Methods: Inclusion Criteria: Chronic non-specific (mechanical) neck pain greater than 6 months Myofascial Pain Syndrome Exclusion Criteria: Major trauma, pregnancy, widespread pain, inflammatory/neurological/hormonal/psychiatric disorders, upper extremity tendinopathy, fibromyalgia, certain medication use within one week of the study or contraindication to dry needling
EFFECTIVENESS OF DRY NEEDLING FOR CHRONIC NON-SPECIFIC NECK PAIN: A RANDOMIZED, SINGLE BLINDED, CLINICAL TRIAL (CEREZO-TÉLLEZ ET AL., 2016) Methods: 4 treatments, 2x/week over 2 weeks Intervention Group (DDN): Deep dry needling Treat every trigger point Fast in and fast out technique Seek 4-5 twitch responses Passive stretching Performed after dry needling Comparison Group: Passive stretching Same for both groups 36 seconds x 4
EFFECTIVENESS OF DRY NEEDLING FOR CHRONIC NON-SPECIFIC NECK PAIN: A RANDOMIZED, SINGLE BLINDED, CLINICAL TRIAL (CEREZO-TÉLLEZ ET AL., 2016) Methods: Assessments A0 Baseline A1 Day after second treatment A2 Day after all four treatments A3 Follow-up 15 days post treatment A4 Follow-up 30 days post treatment A5 Follow-up 3 months post treatment A6 Follow-up 6 months post treatment Results: Participants: 128 subjects (no loss to follow-up) 64 intervention 64 comparison Age: 50 +/- 16 years Duration of symptoms: At least 6 months (average not stated) Pain intensity (0-10): 5.1 +/- 1.5 NDI: 34/50 ( severe disability) No adverse events Requested subjects seek no external treatment during 6 month time period
EFFECTIVENESS OF DRY NEEDLING FOR CHRONIC NON-SPECIFIC NECK PAIN: A RANDOMIZED, SINGLE BLINDED, CLINICAL TRIAL (CEREZO-TÉLLEZ ET AL., 2016) Results: Subjective pain intensity: clinically meaningful improvement with DDN only Post-intervention (A2): -4.81 ± 0.20 in the DDN group -1.57 ± 0.17 in the control group 6 month follow-up (A6): -4.08 ± 0.25 in the DDN group and -1.60 ± 0.25 in the control group Significant between group difference: 2.48 (p<0.00000) VAS Pain Scale MCID 2.1 MDC 1.3
EFFECTIVENESS OF DRY NEEDLING FOR CHRONIC NON-SPECIFIC NECK PAIN: A RANDOMIZED, SINGLE BLINDED, CLINICAL TRIAL (CEREZO-TÉLLEZ ET AL., 2016) Pressure Pain Threshold (MCID 1.13) Neck Disability Index: (MCID 10) DDN Control Graph shows R trapezius Cervical Active ROM (MDC 10) Control DDN Cervical Strength (MCID 15 N) Graph shows change in cervical rotation AROM Graph shows change in cervical rotation strength
EFFECTIVENESS OF DRY NEEDLING FOR CHRONIC NON-SPECIFIC NECK PAIN: A RANDOMIZED, SINGLE BLINDED, CLINICAL TRIAL (CEREZO-TÉLLEZ ET AL., 2016) Conclusion: Deep dry needling with passive stretching applied to participants with chronic nonspecific neck pain was associated with better and clinically meaningful results for pain, mechanical hyperalgesia, range of cervical motion, neck muscle strength, and neck disability when compared with passive stretching only in the short-term and at 6-month follow-up. Limitations: Difficulty controlling external interventions; however, none were registered. Differences in technique of passive stretching by 2 different physical therapists. Differences in treatment time between groups (DDN > comparison).
EFFECTIVENESS OF DRY NEEDLING FOR CHRONIC NON-SPECIFIC NECK PAIN: A RANDOMIZED, SINGLE BLINDED, CLINICAL TRIAL (CEREZO-TÉLLEZ ET AL., 2016) Relevance to Patient: At least four sessions of dry needling, treating all identifiable trigger points, & seeking 4-5 twitch responses may have a positive effect on my patient s pain, cervical ROM, strength and perceived disability. Could not conclude that dry needling would be more effective than manual therapy, as passive stretching alone is not likely to have as strong of an impact as a comprehensive manual therapy approach.
CONCLUSION: IS DRY NEEDLING MORE EFFECTIVE THAN MANUAL THERAPY FOR A YOUNG ADULT PATIENT WITH CHRONIC MECHANICAL NECK Article PAIN? 1 (Llamas- Ramos et Al) Short-term effects likely similar, long-term effects unknown. May need to consider other factors: Certification needed Insurance coverage Prescription from physician Article 2 (Cerezo-Téllez et Al) therapist Dry needling is effective but may not be better than comprehensive manual therapy HOWEVER, minimal progress made with conventional therapy Recommend dry needling as an adjunct to manual therapy and therapeutic exercise Further research with stronger design needed. Cost effective Time efficient Wear & tear on
REFERENCES Cerezo-Téllez, E., Torres-Lacomba, M., Fuentes-Gallardo, I., Perez-Muñoz, M., Mayoral-del-Moral, O., Girbes, E. L.,... & Falla, D. (2016). Effectiveness of dry needling for chronic non-specific neck pain: a randomized, single blinded, clinical trial. PAIN. Llamas-Ramos, R., Pecos-Martín, D., Gallego-Izquierdo, T., Llamas-Ramos, I., Plaza-Manzano, G., Ortega-Santiago, R.,... & Fernandez-De-Las-Penas, C. (2014). 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. journal of orthopaedic & sports physical therapy, 44(11), 852-861. http://www.aaompt.org/documents/dryneedlinginptclinicalpracticeeducationalresourc epaper.pdf http://www.rehabmeasures.org/lists/rehabmeasures/dispform.aspx?id=1117
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