Influence of Catastrophism in Fibromyalgia Patients Following Dry Needling Treatment
Condition: Myofascial Pain Syndrome; Catastrophizing; Chronic Pain
MeSH terms: Fibromyalgia; Myofascial Pain Syndromes; Chronic Pain
Study type: Interventional

Summary: 
      Background: Dry needling trigger point treatment, while painful, has been demonstrated as a
      useful tool in fibromyalgia patients for decreasing pain and central sensitization. However,
      the current biopsychosocial pain paradigm indicates that fibromyalgia subjects with high
      levels of catastrophizing have negative thoughts related with perceived partner responses to
      pain, which results in an emotional and physical stress after a painful episode.

      Objective: To assess whether catastrophizing could influence the perception of pain during
      and after dry needling application.

      Study design: A singled-blind randomized controlled trial.

      Setting: Department of Medicine, Faculty of Health Sciences, Universitat Jaume I

      Methods: Female fibromyalgia patients and number and age-matched female controls will be
      recruited and randomly assigned to either a real or a simulated dry needling group. The
      Spanish version of the pain catastrophizing scale will be used to assess the catastrophizing
      level of each participant before initiating any of the planned interventions. The perceived
      pain during and immediately after the dry needling procedure will be measured using the pain
      visual analogue scale, [VAS].
    

Detailed description: 
      Fibromyalgia syndrome (FS) is currently classified as chronic widespread pain with widespread
      allodynia (Coster et al., 2008). These symptoms are accompanied by other disorders, such as
      sleep disturbance, headaches, morning stiffness, irritable bowel syndrome, interstitial
      cystitis, dyspareunia, mood disturbances and depression (Gerwin, 2005). The World Health
      Organization recognized FS as a disease in 1992, basing its decision on the diagnostic
      criteria of the American College of Rheumatology (ACR) which has recently been criticized and
      updated (Wolfe et al., 2011; Wolfe et al., 2010; Wolfe and Hauser, 2011). Depending on the
      diagnostic criteria used, the prevalence is from 2% to 8% of the population increasing with
      age, with highest values attained between 60 and 70 (Stahl, 2009). In Spain, was estimated
      that 2.4% of the population over 20 years old presents the disease, and it is higher in
      females than in males (ratio 21:1) (Cordero, 2011).

      A central sensitivity syndrome could be the most plausible explanation for chronic widespread
      pain affecting people with fibromyalgia syndrome. Although it was suggested this condition
      was the sole cause (Yunus, 2007), central sensitization of the nervous system causes the
      phenomena of hyperalgesia and allodynia in the individual suffering from chronic pain (Butler
      and Moseley, 2003) .

      The subject with chronic pain has an altered alarm system; this alteration could be initiated
      by a peripheral sensitization (Sarzi-Puttini et al., 2011) activated by the release of
      various chemical substances such as substance P, serotonin and bradykinin (Yunus, 2007).
      Myofascial trigger points (MTrPs) are able to maintain this peripheral sensitization
      (Affaitati et al., 2011; Ge et al., 2010) by triggering the spontaneous pain patterns
      experienced by a patient with fibromyalgia syndrome (Ge et al., 2011).

      MTrPs contain algogenic substances capable of generating changes in the intensity of pain.
      Differences in the concentration of these substances between healthy muscle and MTrPs (Shah
      et al., 2005) have been shown. One of the most effective techniques for the treatment of
      MTrPs is dry needling (Mayoral, 2010), because it alters the chemical environment of the
      MTrPs, thus decreasing their sensitization (Dommerholt, 2011). However, there are as until no
      few studies that have examined the effectiveness of this technique in patients with FS (Chou
      et al., 2008; Staud, 2006). Moreover, in these patients the perception of pain during and
      after treatment can be influenced not only by central sensitization, but also by psychosocial
      variables.

      Catastrophization, considered to be the basic psychological construction concerning the
      perception of pain intensity, is a cognitive and emotional process encompassing magnification
      of pain-related stimuli, feelings of helplessness, and a generally pessimistic orientation
      (Labus et al., 2003; Rodero et al., 2010). This catastrophization, understood as a set of
      negative emotions and cognitive processes, is a risk factor in fibromyalgia and leads to an
      increase in symptoms, health status warning, symptoms of helplessness and pessimism (Alegre
      de Miquel and Sellas Fernandez, 2008; Sullivan et al., 2001).

      These negative thoughts lead to alterations in the function of the descending inhibitory
      pathways that modulate pain (Wideman and Sullivan, 2011) producing an increase in the pain's
      intensity and exaggerated pain behavior (Wideman and Sullivan, 2012). Several lines of
      research suggest that this psychological construct is an indicator of poor results obtained
      from various treatments (surgical, pharmacological and psychological interventions in pain
      management) (Sullivan et al., 2009; Mankovsky et al., 2012; Sullivan et al., 2005).

      Catastrophizing is an important factor in the pathophysiological FM, which also influences
      the perception of pain and the effects of the various treatments mentioned above. Several
      studies have shown that catastrophizing increases attention at the site of injury and
      increases the fear of pain that patient refers (McMahon et al., 2013; Sullivan et al., 2001).
      However, how this psychological construct may influence both factors - the treatment
      effectiveness of MTrPs by dry needling and the perception of pain during this treatment - is
      still unknown.

      Subjects who experience high levels of catastrophizing have been demonstrated as having
      increased emotional and physical stress in response to a painful episode. It would therefore
      be interesting to analyze whether high levels of catastrophizing may influence and be related
      with high levels of perceived pain during and after dry needling treatment.

      The main objective of our study is to assess whether catastrophizing could influence the
      perception of pain during and after dry needling application.
    

Intervention name(s): Dry needling
Intervention type(s): Procedure
Intervention description(s): All the participants will be placed in a prone position on the bench. Once the subject is settled, we will localize a nodule within the palpable taut band, confirming its presence after inducing local twitch response by palpation. After placing the MTrPs, the area will be sterilized with an alcohol solution colorless spray [Skin-des. Agupunt ®]. The puncture method used in the true dry needling groups will be the Hong's fast in-fast out technique, described as the most aggressive technique in the MTrPs treatment, using a needle of 0.32 x 40 mm. The intervention will be implemented until the subject reports the presence of seven local twitch reactions to the controller.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Double (Participant, Outcomes Assessor)
Primary purpose: Treatment
Keywords: Fibromyalgia; Female; Myofascial trigger points