Efficacy of Ultrasound-Guided Dry Needling Therapy and Exercise in Piriformis Muscle Syndrome
Condition: Piriformis Muscle Syndrome; Dry Needling; Ultrasonography; Ultrasound Guided Dry Needling; Exercise Treatment
MeSH terms: Piriformis Muscle Syndrome; Syndrome
Study type: Observational [Patient Registry]

Summary: 
      Piriformis muscle syndrome (PMS) is a neuromuscular disorder that can cause symptoms of hip
      joint motion limitation, buttock pain and tenderness, and numbness radiating to the back of
      the thigh due to compression or irritation of the sciatic nerve.In the etiology of PMS
      myofascial trigger points are the most common cause and also hypertrophy in the piriformis
      muscle tissue, inflammation, trauma, anatomical variations of the piriformis muscle or
      sciatic nerve may also cause the development of PMS . Physical examination supports the
      diagnosis of PMS and may help to eliminating competing diagnoses. Multiple physical
      examination maneuvers have been identified to help diagnose but no physical examination
      maneuver is diagnostic for PMS. Compression and deep palpation may also exacerbate buttock or
      gluteal pain. Electrodiagnostic tests are usually normal in FMS and useful in excluding other
      conditions such as lumbosacral radiculopathy .There is no gold standard treatment option for
      PMS, conservative treatment and lifestyle changes remain the mainstays for the treatment.
      Piriformis muscle stretching is the form of an exercise technique in physiotherapy method
      that is generally used for those patients. The exercises focused on relaxing the priformis
      muscle to increase the resting length of the muscle and reduce the potential sciatic nerve
      compression because of this thigtness. Dry needling (DN) therapy is a treatment method where
      myofascial trigger points are stimulated using acupuncture needles or injection needles .DN
      can be applied according to the anatomical landmark method or under the guidance of
      ultrasound (US) and fluoroscopic imaging. US guidance is important in the management of PMS,
      which allows imaging of specific deep muscle groups and avoids complications such as
      procedural pain and damage of neurovascular structures . There are no randomized controlled
      studies other than case series on the use and frequency of application of the US-guided DN
      technique in PMS. The aim of this study is to compare the effectiveness of dry needling
      treatment applied to the piriformis muscle once a week for a total of 3 times under US
      guidance and 3-week exercise program treatment in PMS. The secondary outcomes of this study
      is to evaluate and compare the effect of these treatment modalities on Visuel Analg Scale
      (VAS) scores ,Oswestry Disability Index (ODI), lower extremity functional scale (LEFS) and
      (Douleur Neuropathique 4 Questionare ) DN4 scores in PMS patients at 3 months follow up.
    

Detailed description: 
      In this observational study, between January 2022 and April 2023, after excluding other hip,
      lumbar, sacroiliac region and lower extremity pain etiology diagnoses, 44 patients aged 18-70
      years who are clinically diagnosed with PMS are planned to be included in the study. The
      diagnosis is based on patient's history and physical examination, bearing positive FAIR test
      and/or tenderness or trigger point at the priformis muscle area and/or revealing the pain
      with maneuvers; such as Freiberg's maneuver , Beatty's maneuver and Pace's maneuver . The
      demographic data (age, sex, occupation, body mass index scores), the side of the pain will be
      noted. Each patient in the study will receive and sign an informed consent form.The patients
      will divide into two groups ; group 1 (n:22)will have DN treatment to the piriformis muscle
      once a week for a total of 3 times under US guidance, all patients in group 2 (n:22) will
      have exercise programme for 3 weeks. Overall pain severity will measure by using visual
      analogue scale (VAS). Pain disability will assess with the Oswestry Disability Index (ODI)
      questionnaire, Physical function will rate with Lower Extremity Functional Scale (LEFS).
      Presence and severity of neuropathic pain will evaluate according to Douleur Neuropathique 4
      questionnare (DN4). To identify the outcomes of the treatment modalities, pre-treatment,
      post-treatment 1st month and 3th-month scores will be used. Patients with comorbidities that
      prevented interventional treatment (e.g., inflammatory diseases, uncontrolled diabetes
      mellitus, uncontrolled hypertension, malignancy, pregnancy, and severe psychiatric
      disorders), patients with other diagnoses that may cause hip and leg pain (e.g.,lumbar disc
      herniation, sciatic nerve injury history, sacroiliac and hip joint pathologies) those aged
      under 18 years old and patients who did not accept interventional or physical therapy
      modalities are going to exclude from the study.
    

Intervention name(s): ultrasound guided dry needling
Intervention type(s): Procedure
Intervention description(s): Dry needling was applied in the intervention room with sterile conditions the patient in the prone position.The low frequency (2-5 MHz) transducer is placed in the gluteal region in a slightly oblique position and sonographic scanning is started. First, the large mountain shadow of the iliac crest and gluteus maximus muscle is sonographically visualized in the midline. Then the transducer is shifted inferiorly until the sciatic notch is visualized. When the sciatic notch, sciatic nerve and the pear-shaped piriformis muscle above it are visualized, the patient's knee is flexed and the leg is rotated internally and externally, and the typical sliding motion of the piriformis muscle is observed. After the target point is determined, a 22 G spinal needle is applied from lateral to medial or from medial to lateral with in plane technique. The needle is inserted and withdrawn several times until the switch response in the piriformis muscle is observed and extinguished
Other intervention name(s): exercise programme
Observational model: Case-Only
Time perspective: Prospective
Sampling method: Probability Sample
Study population: 
        The patients were divided into two groups as those who will accept DN treatment (Group 1
        -n: 22) and those who will have physical exercise treatment (Group 2- n: 22). All patients
        in group 1 will have DN treatment to the piriformis muscle once a week for a total of 3
        times under US guidance.
      
Keywords: piriformis muscle syndrome; pain; dry needling; exercise; ultrasound; neuralgia; interventional ultrasonography; physical therapy modalities