Effectiveness of Dry Needling in Chronic Neck Pain.
Condition: Neck Pain
MeSH terms: Neck Pain
Study type: Interventional

Summary: 
      Objectives: To investigate the effect of combining real or placebo dry needling with
      therapeutic exercise in self-reported pain, pressure pain sensitivity, neck disability,
      global rating of change (GROC) scale, muscle viscoelastic properties (muscle tone and
      stiffness) and left/right discrimination ability in adults with chronic non-specific neck
      pain.

      Design: Quantitative, experimental, longitudinal, prospective, and single blinded study.

      Subjects: Participants aged between 18 and 60 years, and with non specific neck pain of at
      least 3 months of evolution.

      Methods: Participants will be randomly allocated in four groups: a) isolated use of a home
      based therapeutic exercise (TE) program (TE Group); b) combination of the exercise program
      and the use of deep dry needling (DN) in neck shoulder muscles with active or latent
      myofascial trigger points (MTrPs) in order to elicit local twitch responses (LTR) (TE + local
      DN Group); c) therapeutic exercise combined with DN applied distally from the muscle areas
      with MTrPs and, therefore, without, eliciting LTRs (TE + distal DN Group); and d) therapeutic
      exercise program combined with placebo DN (TE + placebo DN Group).
    

Detailed description: 
      All groups will be instructed by a physiotherapist in the performance of protocol of
      neck-shoulder exercises. This program will be carried out at home for at least three days a
      week during three months. The exercise protocol includes active mobilization, stretching and
      strengthening (concentric/eccentric, isotonic, and isometric) exercises. All participants
      will be given a booklet with a detailed description of every single exercise.

      Those participants included in any of the DN groups will undergo 3 sessions of treatment (1
      session per week during 3 consecutive weeks). In each session, the physiotherapist in charge
      of the intervention will assess the presence of active or latent MTrPs in severa neck
      shoulder muscles. The selected muscles have been previously described as having a higher
      prevalence of MTrPs in adults with chronic neck pain: a) scalene muscles; b) levator
      scapulae; c) splenius cervicis; d) cervical multifidus; and e) upper trapezius trapezius. The
      location of the trigger points will be carried out following the recommendations and
      guidelines described in the literature.

      Those in the TE + local DN group will receive deep DN, using a fast-in fast-out technique, as
      described by Hong. The needle, once inserted in the muscle with a 10 to 20 mm depth, will be
      mobilized in a quick ascending and descending motion, in order to evoke the so-called LTRs. A
      minimum of 3 to 6 LTRs will be elicited in each muscle.

      For patients in the TE + distal DN group, the deep DN intervention will be carried out in
      those muscles with MTrPs, but at a remote location from the MTrP area. The same evaluation
      and intervention protocol previously described for the TE + local DN group will be carried
      out. The main difference is that, in this group, DN will not elicit LTRs. Instead, DN will be
      applied at a minimum distance of 1-1.5 cm from the MTrP locus.

      Finally, in the TE + placebo DN group, the therapeutic exercise program will be combined with
      DN using using a Dong Bang placebo needle, similar to the Streitberger placebo needle. These
      needles are designed with a retractable system. Therefore, these placebo needles evoke
      mechanical stimulation without piercing the skin; hence, patients experience a pressure
      sensation similar to that of a "real" needle.
    

Intervention name(s): Local Dry needling and exercise; Distal Dry needling and exercise; Sham dry needling and exercise; Exercise
Intervention type(s): Other; Other; Other; Other
Intervention description(s): Deep dry needling will be applied bilaterally in the locus of active or latent myofascial trigger points of several neck shoulder muscles (scalene muscles, levator scapulae, splenius cervicis, multifidus cervicis and upper trapezius). The presence of active or latent myofascial trigger points will be assessed according to the diagnostic procedures described by Travell and Simons. The dry needling intervention technique will be the fast in-fast out Hong technique, with a minimum of 3 to 6 local twitch responses to be elicited.
Patients will perform a home based therapeutic neck exercises program.; Patients in this group will undergo deep dry needling at a remote spot from the locus of the myofascial trigger point. As a result no local twitch response should be elicited. As in the previous group, dry needling will be carried out in the same assessed muscles (scalene muscles, levator scapulae, splenius cervicis, multifidus cervicis and upper trapezius) with active or latent myofascial trigger points, according to the diagnostic procedures described by Travell and Simons. The intervention technique chosen for these participants will be to insert the needle in a location in the same muscle, but far away (at least 1 to 1.5 cm) from the location of the myofascial trigger point. Likewise, the needle will be inserted without the intention to evoke local twitch responses. Therefore, the entry and exit of the needle will be performed in a slower fashion.
Patients will perform a home based therapeutic neck exercises program.; Patients in this group will undergo sham-placebo dry needling. For that purpose, placebo dry needling will be carried out in the same muscles previously described (scalene muscles, levator scapulae, splenius cervicis, multifidus cervicis and upper trapezius) with active or latent myofascial trigger points. The intervention technique will be carried out in the locus of the trigger point but using placebo needles. For this placebo group, a simulation needle procedure using a Dong Bang placebo needle, similar to the Streitberger needle, will be used. The placebo needles evoke mechanical stimulation without piercing the skin; hence, patients experience a pressure sensation similar to that of a "real" needle.
Patients will perform a home based therapeutic neck exercises program.; Patients will perform a home based therapeutic neck exercises program.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Outcomes Assessor)
Primary purpose: Treatment
Keywords: neck pain; randomized control trial; trigger points; dry needling; physical therapy; placebo; therapeutic exercise