Journal Club October 2016: Impact of Needle Diameter on Long-Term Dry Needling Treatment of Chronic Lumbar Myofascial Pain Syndrome

Whether it is in the inpatient or outpatient setting, myofascial pain is a common problem that all physiatrists will eventually see in their medical career. The following study conducted by Wang et al. 2016 examined the impact of needle diameter on lumbar myofascial pain. Specifically, the researchers were looking to identify whether the diameter of a dry-needle had an effect on myofascial pain. The article was originally published in the American Journal of Physical Medicine and Rehabilitation. Through a web search, on the database PUBMED, the article was obtained to read.

This was a double-blinded study. Wang et al. 2016 separated 48 patients with a history of lumbar myofascial pain into one of three groups. Each group corresponded to a specific dry-needle diameter. The three groups examined were: 0.25 mm, 0.5mm, and 0.9mm.

The primary outcomes used were the visual analog score (VAS) and the short form health survey (SF-36). Patients rated their pain before treatment and three months after treatment. Secondary outcomes examined included: pain intensity after treatment and whether the patient would consider undergoing the same treatment again if needed.

The researchers determined that dry-needling as a practice improved patient’s pain scores over a three month period regardless of needle diameter. They also determined that the efficacy of the larger diameter needle (0.9mm) improved over the course of three months in comparison to the other two diameter sizes. Patient’s willingness to return for another treatment improved as time went on with the larger diameter needle.

In conclusion, dry-needling and the diameter of the needle both play an important role in the treatment of myofascial pain.  

Discussion Points:

1) What is myofascial pain syndrome? How is it diagnosed?

2) What is dry needling therapy? Can you think of any other forms of alternative medicine that have been used to treat myofascial pain?

3) What is the difference between a tender point and a trigger point? Could dry needling also be used as a treatment modality for tender points?

4) Do you think the diameter of the needle could play a role in other treatment modalities (trigger points, nerve blocks, etc.) for chronic pain?

5) Do you think the VAS score is an accurate way to measure pain? Do you think another scale could be used or designed to better measure a patient’s pain level?

6) How can this study be used to further improve treatment for myofascial pain?

7) What type of future research could be designed based on this new study?

8) With this new information, how will you incorporate this information into your own medical practice?

LEARN MORE by downloading the article:

Journal Article October 2016

Journal Discussion Questions October 2016

 

Journal Club September 2016: Effects of Ramelteon on Sleep Disturbance After TBI

Article title: Pilot Study on the Effect of Ramelteon on Sleep Disturbance After Traumatic Brain Injury: Preliminary Evidence From a Clinical Trial.

Author: Lequerica A, Jasey N, Portelli Tremont JN, Chiaravalloti ND

Journal: Arch Phys Med Rehabil. 2015 Oct;96(10):1802-9. doi: 10.1016/j.apmr.2015.05.011. Epub 2015 May 28.

Discussion:

Many people with Traumatic Brain Injury (TBI) report sleep disorders, leading to anxiety, depression, and fatigue. These issues are associated with deficits in neurobehavioral, cognitive, and occupational issues. Currently used medications used to treat sleep disorders further complicate cognitive functioning. Benzodiazepines, Tricyclic antidepressant, Trazodone, and anti-histamines carry their own cognitive, sedating, or poor memory effects.

The suprachiasmatic nucleus of the hypothalamus regulates circadian rhythm, and Ramelteon (TAK-375) is a neurohormone that targets melatonin receptors in this nucleus. While Ramelteon is indicated for long-term management of insomnia, and it has minimal chance for addiction, few trials have studied its role in treating insomnia. Clinical trials showed promising results, but Ramelteon’s use in treating sleep disorder in TBI had not yet been studied.

This study tested Ramelteon’s use in treating sleep disorders after TBI. There were 18 participants, each with TBI for at least a month before enrollment. In addition to meeting inclusion criteria, they were screened for other confounding conditions and medications, and discontinued use of other sleep medications for 2 weeks before the study.

The study used a double-blind, placebo controlled crossover design. Participants were grouped into Ramelteon or placebo groups for the first of the study, at which point they were switched into the opposite group for the second half. Electronic accelerometers (actigraphs) were worn to track “sleep onset latency (SOL), number of awakenings, wake time after sleep onset, and total sleep time (TST)”. Participants kept a sleep log, had CNS vital signs recorded, and were measured with the Pittsburgh Sleep Quality Index and Brunel Mood Scale.

Ramelteon was found to significantly increase total sleep time. It was also found to increase time needed to fall asleep, yet this time was not clinically significant. Likely due to the mechanism of action regulating circadian rhythm, those on Ramelteon also  went to bed earlier. The study found promising benefit for the use of Ramelteon in treating sleep disorders in TBI. Use of polysomnography instead of actinography would provide more detailed data. Additionally, further research would benefit from a larger sample size.

 

Discussion Points:

1: What is the role of the physiatrist in treating TBI?

2: Who else plays a role in treating TBI?

3: Why are sleep disorders particularly troubling for TBI patients?

4: What are some of the side effects with medications currently used to treat sleep disorders?

5: Why was it important to use a double-blind, placebo-controlled crossover design?

6: In addition to use of the actinography, what are some other ideas for how sleep variables can be measured?

7: What benefit would there be if a study recruited participants with more recent injuries?

8: What other methods could be used to manage sleep disorders in TBI?

LEARN MORE by downloading the article::

Article - Link to Full Article