Dry needling in neurologic patients

[pablofisio]

Has anyone tried out invasive trigger point therapy (dry needling) with neurologic patients? I know of articles and research about treatment of pain in neurologic patients (shoulder pain in hemiplegic patients) but I haven´t seen anything published for treating spasticity or increasing ROM. Does anybody know some study about this?

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[kayebaker83]

Hello!
Sorry i am not able to answer your question but i did not that you knew of articles of post stroke acupuncture for pain. Do you have the references for these or in fact anything on acupuncture and stroke patients? I have been looking everywhere and have had no luck!
Thank you !
K x

[Rajul vasa]

Does Acupuncture Have Additional Value to Standard Poststroke Motor Rehabilitation?
Frank Kai-Hoi Sze, FRCP; Eric Wong, MA; Xiang Yi, MD Jean Woo, FRCP

From the Department of Medicine and Geriatrics (F.K.-H.S.), Shatin Hospital, Hong Kong; Centre for Clinical Trials and Epidemiological Research (E.W.) and Department of Medicine and Therapeutics, Prince of Wales Hospital (J.W.), Chinese University of Hong Kong, Hong Kong; and Department of Acupuncture and Moxibustion (X.Y.), Nanjing Municipal Traditional Chinese Medicine Hospital, Nanjing, China.


Correspondence to Dr Frank Kai-hoi Sze, Department of Medicine and Geriatrics, Shatin Hospital, 33 A Kung Kok St, Ma On Shan, N.T. Hong Kong, China. E-mail [email protected]

Background and Purpose— A significant number of patients remain severely disabled after stroke despite rehabilitation with standard treatment modalities. Acupuncture has been reported as an alternative modality. This study aims to examine whether acupuncture has additional value to standard poststroke motor rehabilitation.

Methods— A prospective randomized controlled trial (RCT) was carried out in a stroke rehabilitation unit in Hong Kong. One hundred six Chinese patients with moderate or severe functional impairment were included at days 3 to 15 after acute stroke. They were stratified into the moderate and the severe groups before randomization into the control arm receiving standard modalities of treatment, which included physiotherapy, occupational and speech therapy, and skilled medical and nursing care, and the intervention arm receiving in addition traditional Chinese manual acupuncture. A mean of 35 acupuncture sessions on 10 main acupoints were performed over a 10-week period. Outcome measures included Fugl-Meyer assessment, Barthel Index, and Functional Independence Measure, respectively, at weeks 0, 5, and 10, performed by blinded assessors.

Results— At baseline, patients in each arm were comparable in all important prognostic characteristics. No statistically significant differences were observed between the 2 arms for any of the outcome measures at week 10 or outcome changes over time.

Conclusions— Traditional Chinese manual acupuncture on the body has no additional value to standard poststroke motor rehabilitation.

[neurospast]

The research quoted might be a little out of focus of the subject since one have to understand that the benefits of acupuncture might be of a complete different modality: Most research medication versus acupuncture look at benefits which have to do with modalities as balancing bloodpressure and alike so more in the way if a stroke patient in GENERAL will rehabilitate faster with acupuncture than without. The research mentioned, is this within Traditional Chinese Medicine(TMC acupuncture) or Medical Acupuncture? The way of thinking is very different and therefor the choice of points regarded as essential for the outcome of the treatment different.
To my experience acupuncture with a painful hemi shoulder when looked at in a neuromusculoskeletal way can be rather beneficial: look at range of movement of the neck, shoulder, positioning of the shoulder, head. Use triggerpoints to rebalance rest tone and so on. In genral it is not a good idea to needle a muscle in spasm for obvious reasons: If you provoke a spasm how does the needle look like? If though one would needle e.g. Lv3 it might have some effect on spasticity. But first of all you have to know the background of the spasticity, has it purely a neurological background or also a musculoskeletal?
Research of acupuncture in general has been very poor and therefor the chance to find a good research (which can stand the test) on something as specific as rehab and acupuncture is doughtful.

[neurospast]

I had another look at research and unfortunately nothing comes to my mind which can help you. But it might be a good idea just to have a look at the different websides of acupuncture organisations like BAC (which has an article), BMAS etc. Look at website bandolier.
In general I have found that the idea is to add a sensoric stimulus which is proven to be effective in stroke rehabilitation. This stimulus could well be acupuncture at pooints which are known to give a central stimulation of the brain. It would work in the way as an anti depresent which is (to my opinion essential) known to have effect on the rehab time (quantitative) and quality of rehab. Central effects are well studied at this time of MRI and other scans.
Cheers!

[BillOst]

Pablo
When I trained in medical acupuncture I was taught that an intact nervous system was necessary for acupuncture to be succesful, I have found this to be true when treating "neurological" pain due to CNS lesion but where the pain is local - eg hand pain due to OA you have a good chance of helping, especially when the pain predates the neurological syndrome. Best wishes
Bill

[MrPhysio+]

Hi,
Dry needling is a subject of interest to me. Most of my experience to date has been with musculoskeletal problems, however I am finding that some neuro applications with pain syndromes have been helped significantly. Patchy improvement has been noted in cases of CRPS (chronic regional pain syndrome), and treatment resistant peripheral nerve pain, plus chronic fibromyalgic type pains. Quite a number of patients with increased muscle tone problems have reported an ease of there persistent resting tension of muscle post dry needling. I do not use traditional acupuncture points, but the sports medicine dry needling approach. Recent literature reports are indicating that there is very little difference between traditional massage points and random needling points for conditions such as OA knee pain. More research is needed, as the physiology is not fully understood.
MrPhysio+

[neurospast]

Dear BillOst,
i am wondering what is meant with an intact nervous system. this would for example mean that people with e.g. Ms would not benefit from acupuncture whic after my experience is not true. I do understand that we, physios, in general use medical acupuncture but it seems to me that since there is little prove of anything we do statements like acupuncture doesn't help if the nervous system isn't intact. The problem arises to my opinion if there are leasions within e.g. the lymbic system but even then when it comes to pain I have had some very good responses. I think that a lot of statements are made to easily (as I am doing here) and a lot of research has to be done prior to make these statements. A good idea to my opinion would be that be people share outcomes and discuss why they think the outcome is as so.
MRI scans have proven that acupuncture can activate parts of the brain but thsi is mostly the limbic system so it makes sense to me that if there is a leasion in this sector of the brain the chances of a good response are doughtful.
Cheers Roel

[pablofv]

There are some research for treating pain in neuro patients (Di Lorenzo et al) but regarding treating spasticity there is treatment technique called DNHS (dry needling hypertonia and spasticity) that show effects of dry needling on hypertonia and spasticity. There is a published study in J Mus Pain in 2004 by Herrero P, Mayoral O. The tecnhique registered as DNHS has some more evidence but it is only in Spanish, so if you don´t know Spanish is impossible to understand. There is a recent publication (now in press) in the national Spanish Physiotherapy Journal (Fisioterapia). Most of the articles can be accesed in the official web DNHS | but I think that the English version is not working (this web is very recent and is being contructed...). In 2010 a course was ran in Toledo by Herrero P for physios and there was shown the effect on patients with spasticty and hypertonia but also with movement disorders. I hope this helps...

[MrPhysio+]

Hi Pablofv,
Interesting stuff. Since my last post on here I have used dry needling for pain control and muscle relaxation more than I had previously. Research has indeed confirmed more benefits from needling in osteoarthritis and some other conditions. The type of patients I treat do not present with true spasticity therefore I do not have personal experience in this area of needling.
Cheers,
MrPhysio+

[Termy]

Do you use deep or superficial dry needling in this case? What about patients with strong blood thinning medicines? (which is the case with a lot of stroke patients)

[pablofv]

Do you use deep or superficial dry needling in this case? What about patients with strong blood thinning medicines? (which is the case with a lot of stroke patients)

I use deep dry needling techniques, adapting the intensity of the technique to patient´s confort and characteristics. In case of patients having these kind of medicines I take as a reference if they can be infiltrated with BOTOX, because dry needling uses a kinf of needle which is not so aggresive like needles used for BOTOX. If there is no possibility to have this reference I first make superficial dry needling or a very low intensity technique for the first day and I asess results. Apart from that, I haven´t never had problems by this cause although they were taking blood thinning medicines, perhaps some bruise

It is important you follow some criteria specific for neurologic patients, like waiting the "neural relaxation" after the local twitch response or the GIS (global increase of spastic response or global muscular activity). Read Aidimo - La russite de votre projet immobilier "Publicaciones" section, there is a paper in English about this

A Case Study Looking at the Effectiveness
of Deep Dry Needling for the Management of Hypertonia
Pablo Herrero Gallego
Orlando Mayoral del Moral
ABSTRACT. Backgrounds: The patient is a four-year-old child with spastic tetraparesia.
Findings: A decrease in spasticity was observed in all the muscles being treated with deep dry
needling, measured with the Modified Ashworth Scale [MAS]. There was also a gain in passive
range of movement in the thumb.
Conclusions: Treatment with deep dry needling decreased resistance to passive movement. It is
difficult to determine whether decreased resistance to passive movement measured with the MAS
is due to changes in viscoelastic properties or to decreased spasticity. Since we treat trigger points,
it is possible that improvement in MAS scores could be more due to changes in the viscoelastic
properties than in spasticity. doi:10.1300/J094v15n02_09 [Article copies available for a fee from The
Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: <[email protected]>
Website: <http://www.HaworthPress.com> © 2007 by The Haworth Press, Inc. All rights reserved.]

[MrPhysio+]

Hello Termy,
I use both superficial and deep needling for my patients. It is generally felt that patients using strong blood thinners should not receive needling due to the possibility of uncontrolled bleeding.
Lower grade blood thinners do not seem to cause problems. My patients are asked if they have had recent problems with bruising or if they have problems ceasing blood flow if they receive cuts. If the patients are okay, I needle if appropriate.
My clinic rarely has stroke patients, therefore the needling question does not occur.
Hope this answers your questions.
MrPhysio+

[Termy]

Interesting. I use dry needling myself, but I've only used it so far on patients with musculoskeletal pain and tensions (trigger points), not neurological patients.