Evolution of Myofascial Pain, Post-dry Needling. Repair and Measuring With Elastography, of Myofascial Tissue.

Study Overview
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Brief Summary
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This study evaluates the deep dry needling technique as a percutaneous technique included in the professional field of physiotherapy. The project quantifies a significant limit on the number of local twitch responses necessary for the favorable treatment of myofascial pain and analyzes the injury degree and/or the repair of myofascial tissue, with Elastography.

Detailed Description
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The myofascial shoulder pain caused by myofascial trigger points, is one of the main causes of medical consultation and functional disability in the general population and particularly in the amateur athlete. Nowadays, many physiotherapists all over the world, study and practice the dry needling as a therapeutic tool for the treatment of myofascial trigger points. The most used modality is the technique described by Hong: This technique introduces an acupuncture needle in the skin until reaching the dysfunctional muscle fiber. To do so, it uses maneuvers fast in and fast out of needle, until the extinction of local twitch responses or the tolerance of the patient. The local twitch response is defined as a reflex and transitory contraction of a group of muscle fibers associated with a myofascial trigger points. The technique eliminates muscle contractile activity by mechanical interruption of their muscle fibers, mechanism which finishes with the sensitization of nearby nerves and with the start of the nociceptive modulation peripheral, segmental and central. The dry needling technique, in its eagerness to obtain local twitch responses, pierces the muscle fibers both dysfunctional and normal, the fascial tissue that wraps the myofascial trigger points and also neuro-vascular structures. That is, the treatment of myofascial trigger points with dry needling, makes reference to a mechanical trauma done with a acupuncture needle. The myofascial tissue injured can suffer repair or regeneration, which is mainly due to the extension of the lesion. The process of healing of a wound is strictly regulated by multiple growth factors and cytokines, which are released into the wound. The alterations that disturb the healing process, can lead to chronic wounds that do not heal or to an excessive fibrosis. The pathobiological processes, in form of fibrosis, would present changes in stiffness and elasticity of the neo-tissue. The quantitative elastography, is shown as an effective tool to measure the amount of fibrosis, occasioned by repeated percussion of the acupuncture needle on the myofascial tissue.

Official Title
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Comparative Study, Between Dry Needling Techniques, in the Evolution of Myofascial Pain Shoulder in Athletes. Elastography as Indicator in the Repair of Myofascial Tissue, Post-dry Needling.

Conditions
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Myofascial Pain Syndromes, Dry Needling, Technique for the Treatment of the Myofascial Trigger Points, Elastography

Intervention / Treatment
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* Other: High Intensity Dry Needling
* Other: Low intensity Dry Needling
* Other: Fascial Mechanotransduction Dry Needling
* Other: Technique Placebo of Dry Needling


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Unilateral shoulder pain or referred pain pattern of the infraspinatus muscle. Pain Intensity with a minimum score of 2 on the Wong-Baker scale, using the homolateral test hand-back. Process time more than 1 and less than 10 weeks. Age of 18 years old to 49 years old. Written Informed Form. Exclusion Criteria: Conventional pharmacological treatment of NSAIDs and / or muscle relaxants, the 48 hours before or during the study. Coagulation pathology or anticoagulant therapy. Pretreatment with infiltration and / or steroid injections during the last year. Physiotherapy Pretreatment, in the cervical region or shoulder girdle during or in the last week taking part in the study. Dry needling pretreatment in the cervical region and / or shoulder girdle during or in the last month before taking part in the study. History of fracture or dislocation of the shoulder to study, in the last year. Dermatological disorders or erosions in the treatment area (infraspinatus fossa). Metals allergy such as chromium or nickel. Fibromyalgia diagnosis, myelopathy, cervical radiculopathy or neurologic disease. Fear of needles. Pregnant women. Suffering a traumatic accident of the upper extremity and / or cervical-thoracic spine during the study (it will pass to the zero week). Medical-legal litigious, by financial compensation. Drugs or alcohol abuse / consumption history. Cognitive inability to complete the health forms.

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 49 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Factorial Assignment
Masking: Double


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: High Intensity Dry Needling<br>Maneuver of Input-Output with the acupuncture needle, until the disappearance of local twitch responses or patient tolerance. | Other: High Intensity Dry Needling<br>* This technique follows the criteria established by Dr Hong C-Z. This technique is known as fast in and fast out technique and uses repeated insertion of the acupuncture needle in the myofascial trigger point, with the aim to get multiple local twitch responses. The technique ends when the local twitch responses disappear.<br>|
| Experimental: Low Intensity Dry Needling<br>Maximum 10 input-output maneuvers with acupuncture needle or maximum 3 local twitch responses or patient tolerance. | Other: Low intensity Dry Needling<br>* Technique proposed by the main investigator and based on the studies of Professor Dr. Jay P. Shah and the mechanisms of neuromodulation that transmits us the acupuncture scientific evidence.<br>|
| Experimental: Fascial mechanotransduction Dry needling<br>Maneuver of input, screwing and pulling out of the needle acupuncture. | Other: Fascial Mechanotransduction Dry Needling<br>* The Fascial Mechanotransduction Dry Needling Technique, strikes with the acupuncture needle until it reaches and pierces the myofascial trigger point. Then the acupuncture needle is rolled in the connective tissue, which causes an intense coupler that we define as needle grasp. Finally, the acupuncture needling is pulled-out twice. The screwing and the two pull-out of the acupuncture needle is performed in the infraspinatus and supraspinatus muscles and we describe it as mechanotransduction cycle. Each cycle lasts 30 seconds and the whole technique lasts 3 minutes per session.<br>|
| Sham Comparator: Placebo Dry Needling Technique<br>Technique is performed with the Park´s Sham device. | Other: Technique Placebo of Dry Needling<br>* Technique with a total duration of 3 minutes per session: To locate the myofascial trigger points of infraspinatus and supraspinatus muscles and put each bridle on them. Monitor longitudinally taut band, with index and middle fingers. Percuss with tube and needle placebo (Sham needle) on Infraspinatus. Remove the tube and needle placebo from the device. Reintroducing the placebo needle into the tube and strike on the supraspinatus. Repeat this sequence without interruption for 3 minutes. Remove the bridles and perform hemostasis with cotton. We will give end to the technique placebo of dry needling.<br>* Other names: Control Group;|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Number of input-output of acupuncture needle in the infraspinatus and supraspinatus muscles. | This outcome only used with High Intensity Dry Needling and Low Intensity Dry Needling techniques. The number of input-output of the acupuncture needle are established in each technique. The first 3 interventions are recorded with a compact sporty camera with a bracket on the head. This method allows recording, specifically, the number of input-output of the acupuncture needle. | Three interventions during 40 days. | 
| Number of local twitch response in the infraspinatus and supraspinatus muscles. | The limits of number of local twitch response are established in each technique to study. | Three interventions during 40 days. | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Active joint range of motion | This dependent variable is measured before and after each intervention. We assign the following reference: Active joint range of motion - flexion, Active joint range of motion - abduction, Active joint range of motion - internal rotation and Active joint range of motion - external rotation. | Four interventions during 40 days. | 
| Feeling of shoulder pain | This dependent variable is measured before and after each intervention. We used the hand-back test and measure the pain feeling with the Wong-Baker scale. Score 0-5 (0 = No pain, 5 = Hurts worst) | Four interventions during 40 days. | 
| Life quality related to health shoulder. | We measure the shoulder disability in the daily life activities, at work and practising sports with the questionnaire Disabilities of the Arm, Shoulder and Hand (DASH) | Two interventions during 40 days. | 
| Pressure pain threshold | This dependent variable is measured before and after each intervention. We use the electronic algometer as a measurement tool. | Four interventions during 40 days. | 
| Quality of the myofascial tissue by elastography | Check with quantitative elastography, the presence or not of fibrosis and / or repair of the myofascial tissue. | Two interventions during 40 days. A third intervention at 6 months after the second, to determine the degree of myofascial fibrosis. | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Myofascial pain., Myofascial trigger point., Infraspinatus muscle., Deep dry needling., Local twitch response., Fascial mechanotransduction., Needle grasp., Myofascial fibrosis., Elastography.