Dry needling bij aspecifieke acute lage rugpijn vincent wijburg, master OMT,
[email protected], Kortenhoef
Waarom een case report schrijven voor Fysiopraxis ‘dry needling bij aspecifieke acute lage rugpijn’
• Innovatie; Directe pijnvermindering bij 15 ALBP cliënten • Voorstel;
DN vermelden in KNGF richtlijn LBP 2012
• Voorbeeld; Behandelplan met dry needling bij ALBP • Discussie; Effectiviteit behandelplan met dry needling • Promotie; Dry needling in Nederland
Dry needling bij aspecifieke acute lage rugpijn Fysiopraxis november 2012
De KNGF richtlijn en de Nederlandse Huisartsen Genootschap standaard stellen dat bij acute lage rugpijn alleen adviseren en geruststellen zinvol is. De NVMT richtlijn vult aan dat in specifieke gevallen een manipulatie geïndiceerd kan zijn. Zou de in 2007 KNGF erkende en relatief nieuwe behandeltechniek ‘dry needling’(DN) kunnen helpen bij acute lage rugpijn?
KNGF richtlijn 2005 lage rugpijn Normaal beloop • Uitleg tijdslijn • Actief blijven
Afwijkend beloop • • • •
Kennis en inzicht vergroten Opbouw activiteiten Adequaat omgaan Bio-psychosociale factoren
KNGF richtlijn 2005 lage rugpijn therapie • Oefentherapie heeft geen meerwaarde bij patiënten met (sub)acute lage rugpijn, wel bij chronisch. • Tractie en biofeedback zijn niet zinvol bij chronische lage rugpijn. Het is onbekend of massage, elektrotherapie (inclusief TENS), ultrageluid en laser al dan niet zinvol zijn bij patiënten met lage rugpijn. Met betrekking tot de praktijk wordt geadviseerd terughoudend te zijn met het hanteren van deze verrichtingen.
American Academy of Physical Medicine and Rehabilitation Vol. 4, 394–401, June 2012
Is It Time to Rethink the Typical Course of Low Back Pain? Ronald Donelson, MD, MS, Greg McIntosh, MSc, Hamilton Hall, MD, FRCSC
•
Objective: (1) Are LBP recurrences common? (2) Do episodes worsen with multiple recurrences? (3) Does
pain change location in any recognizable pattern during an episode? • • • •
Design: Single-page self-administered questionnaire. Setting: Thirty clinical practices (primary care, physical therapy, chiropractic, and surgical spine) in North America and Europe. Patients: A convenience sample of 589 respondents with LBP. There were no exclusions based on type of LBP, history of onset, or comorbidities. Methods: The survey was distributed during patients’ assessment or initial treatment at their respective clinics. The survey queried the following: (1) the severity of original versus most recent episodes based on the following: pain intensity, interference with leisure and
work activities, duration of episodes, and most distal extent of pain; and (2) changes in pain location within episodes.
•
Results: question 1, a previous episode was reported by 73%; of those, 66.1% reported their first episode lasted _3 months,
54% reported _10 episodes, and 19.4% reported _50 episodes. question 2, of those with recurrences, 61.1% reported that at least one of the survey domains was worse in recent episodes (P _ .01) and only 36.9% reported that they were better; 20.5% were worse in all domains, whereas 8.6% were better or the same. question 3, the pain location changed during the episode in 75.6%; of these, 63.2% reported that their pain first spread distally before retreating proximally during recovery; there was a strong trend toward those reporting worsening episodes also reporting proximal-to-distal-to-proximal changes in pain location during their episodes (r _ 0.132, P _ .06).
•
Conclusion: Recurrent LBP episodes were common and numerous. Recurrences often worsened over time. It seems inappropriate to characterize the typical course of LBP as benign and favorable.
Mogelijke verklaring van aspecifieke acute lage rugpijn
Disfunctioneren van bewegingssystemen/ segmenten als gevolg van bijvoorbeeld musculaire sprain, strain, verrekking, distorsie, verkramping, verdraaiing, motorische stoornis LMTrP’s => AMTrP’s AMTrP’s
Een stoornis waar spierweefsel sterk bij betrokken is. Spierblessure = myofasciaal pijnsyndroom?
Waarom zou dry needling kunnen helpen bij aspecifieke acute lage rugpijn Rationale
• • • •
Musculaire sprain => aMTrP’s Myofasciale pijn en hypomobiliteit Spierontspanning na local twitch respons Flush out ontstekingsmediatoren
• • • •
Travell and Simons Gunn Laboratorium Elastosonografie, EMG, Ontstekingsmediatoren, aMTrP’s Case reports/ RCT’s/ Reviews
Dry needling niet effectief bij aspecifieke acute lage rugpijn
• • • • • •
HNP protusie/ prolaps/ radiculair syndroom Arthrogene sprain (-itis) Grote weefsel schade (contusio, ruptuur, fractuur) Hypersensitisatie perifeer, CZS Psychosomatisch Onbegrepen beeld
Welke patiënten met aspecifieke acute lage rugpijn kunnen baat hebben bij dry needling ‘Clinical Prediction Rule’
• Musculaire sprain, strain, verrekking, verkramping, overbelasting, verkeerde belasting • Palpabele strakke band met lokale pijn in musculatuur
• Patroon herkenning myofasciaal pijn syndroom
Richtlijn niet gevolgd => ALBP DN => Fysiopraxis artikel ALBP patiënten gedurende 8 maanden • • • • • • • • •
N= 15 8 vrouw Gemiddeld 45 jaar Onset 0 - 21 dagen Eenzijdige lage rug/ bil/ hamstring 1e zitting NPRS afname 50 % - 80 % Gemiddeld 3 zittingen Geen recidieven Geschreven met feedback Frank Timmermans
Fysiopraxis afwijzing • • • • •
DN is niet opgenomen in het beroepsprofiel fysiotherapeut Niet klassiek zoals UG, IF, TENS Geen evidence voor dry needling Bemoeienis LBP richtlijn 2012 Wel goede geluiden uit het veld gehoord over dry needling
Herschrijven opnieuw indienen • • • •
DN wel in het beroepsprofiel en evidence based Nieuwe richtlijn niet bespreken Opbouwende input Adri Apeldoorn en redactie Fysiopraxis Veranderingen, aanpassingen, N=15 N=1 Case report
VAS score comparison between US guided: Dry Needling and Wet Needling (n=44) (shoulder) Baseline comparison of VAS scores in two groups 9 8 7
VAS
6 5
Group A Group B
4 3 2 1 0 before
immediately after
24 hours after
Bubnov RV: The use of trigger point dry needling under ultrasound guidance for the treatment of myofascial pain (technological innovation and literature review). Lik Sprava 2010, 5-6:56-64.
Bijvoorbeeld een musculoskeletal therapeutisch behandelplan met dry needling bij ALBP
• 1e zitting; dry needling, mobilisaties, huiswerk rekken, richtlijn advies • 2e zitting; idem, ( HVLAT ?)
• 3e zitting; dry needling?, actief stabilisatie oefentherapie, neuromusculaire re-educatie, functioneel trainen
• 4e zitting; evaluatie, idem , controle afspraak na een maand?
Discussie • (ALBP) Dry needling evidence based practice ?
• Kosteneffectiviteit ?
Veel verschillende voorbeelden van levels of evidence
J Am Board Fam Med. 2010 Sep-Oct;23(5):640-6.
Dry needling in the management of musculoskeletal pain. Kalichman L, Vulfsons S.
Myofascial pain is a common syndrome seen by family practitioners worldwide. It can affect up to 10% of the adult population and can account for acute and chronic pain complaints. In this clinical narrative review we have attempted to introduce dry needling, a relatively new method for the management of musculoskeletal pain, to the general medical community. Different methods of dry needling, its effectiveness, and physiologic and adverse effects are discussed. Dry needling is a treatment modality that is
minimally invasive, cheap, easy to learn with appropriate training, and carries a low risk. Its effectiveness has been confirmed in numerous studies and 2 comprehensive systematic reviews. The deep method of dry needling has been shown to be more effective than the superficial one for the treatment of pain associated with myofascial trigger points. However, over areas with potential risk of significant adverse events, such as lungs and large blood vessels, we suggest using the superficial technique, which has also been shown to be effective, albeit to a lesser extent. Additional studies are needed to evaluate the effectiveness of dry needling. There also is a great need for further investigation into the development of pain at myofascial trigger points.
Effectiviteit dry needling bij (A)LBP Acupuncture and dry-needling for low back pain Furlan AD, van Tulder MW, Cherkin D, Tsukayama H, Lao L, Koes BW, Berman BM Published Online: February 16, 2011, Cochrane lib.
Thirty-five RCTs covering 2861 patients were included in this systematic
review. There is insufficient evidence to make any recommendations about acupuncture or dry-needling for acute low-back pain. For chronic
low-back pain, results show that acupuncture is more effective for pain relief than no treatment or sham treatment, in measurements taken up to three months. The results also show that for chronic low-back pain, acupuncture is more effective for improving function than no treatment, in the short-term. Acupuncture is not more effective than other conventional and "alternative" treatments. When acupuncture is added to other conventional therapies, it relieves pain and improves function better than the conventional therapies alone. However, effects are only small. Dry-needling appears to be a useful adjunct
to other therapies for chronic low-back pain.
Effectiviteit dry needling bij myofasciaal pijnsyndroom RCT Clin Rheumatol. 2012 Nov 9.
The effect of dry needling in the treatment of myofascial pain syndrome:
blinded placebo-controlled trial.
a randomized double
Tekin L, Akarsu S, Durmuş O, Cakar E, Dinçer U, Kıralp MZ.
dry needling is more effective than sham dry needling in the treatment of myofascial pain syndrome (MPS). This was a prospective, double-blinded, randomized-controlled
The objective of this study was to test the hypothesis that
study conducted in an outpatient clinic. Thirty-nine subjects with established myofascial trigger points were randomized into two groups: study group (N = 22) and placebo group (N = 17). Dry needling was applied using acupuncture needles, and sham dry needling was applied in the placebo group. The treatment was composed of six sessions which were performed in 4 weeks; the first four sessions were performed twice a week (for 2 weeks) and the last two, once a week (for 2 weeks). The visual analog scale (VAS) and Short Form-36 (SF-36) were used. When compared with the initial values, VAS scores of the dry needling group following the first and sixth sessions were significantly lower (p = 0.000 and p < 0.000, respectively). When VAS scores were compared between the groups, the first assessment scores were found to be similar, but the second and third assessment scores were found to be significantly lower in the dry needling group (p = 0.034 and p < 0.001, respectively). When SF-36 scores of the groups were compared, both the physical and mental component scores were found to be significantly increased in the dry needling group, whereas
The present study shows that the dry needling treatment is effective in relieving the pain and in improving the quality of life of patients with MPS only those of vitality scores were found to be increased significantly in the placebo (sham needling) group.
Paraspinal Stimulation Combined With Trigger Point Needling and Needle Rotation for the Treatment of Myofascial Pain: A Randomized Sham-controlled Clinical Trial. Couto C, de Souza IC, Torres IL, Fregni F, Caumo W. Clin J Pain. 2013 Apr 25. •
Abstract BACKGROUND: There
are different types and parameters of dry needling (DN) that can affect its efficacy in the treatment of pain that have not been assessed properly. OBJECTIVE:: To test the hypothesis that either
multiple deep intramuscular stimulation therapy (MDIMST) or TrP lidocaine injection (LTrPI) is more effective than a placebo-sham for the treatment of myofascial pain syndrome (MPS) and
that MDIMST is more effective than LTrP-I for improving pain relief, sleep quality, and the physical and mental state of the patient. METHODS:: Seventy-eight females aged 20 to 40 who were limited in their ability to perform active and routine activities due to MPS in the previous 3 months were recruited. The participants were randomized into 1 of the 3 groups as follows: placebo-sham, LTrP-I, or MDIMST. The treatments were provided twice weekly over 4 weeks using standardized MDIMST and LTrP-I protocols. RESULTS: There was a significant interaction (time vs. group) for the main outcomes. Compared with the sham-treated group, MDIMST and LTrP-I administration improved pain scores based on a visual analog scale, the pain pressure threshold (P<0.001 for all analyses), and analgesic use (P<0.01 for all analyses). In addition, when comparing the active groups for these outcomes, MDIMST resulted in better improvement than LTrP-I (P<0.01 for all analyses). In addition, both active treatments had a clinical effect, as assessed by a sleep diary and by the SF-12 physical and mental health scores.
CONCLUSIONS: This study highlighted the greater
efficacy of MDIMST over the placebo-sham and LTrP-I and indicated that both active treatments are more effective than placebo-sham for MPS associated with limitations in active and routine activities.
Dry needling = Evidence Based
Kosteneffectiviteit dry needling • Behandelplan met DN kosteneffectiever dan zonder DN ? Diagnosecode xx26, DN code zou handig voor statistiek => Software leverancier.
• Daling aantal zittingen per patiënt Tijdwinst, kosten, zorgverzekeraars, particuliere patiënten
• Klinisch geen recidieven gezien (n=15) Daling ziekteverzuim => economische winst ONDERZOEK NODIG
Promotie van dry needling • Veilig •
Anatomie, Hygiëne
• Effectief •
Indicatiegebied/ klinisch redeneren/ keten denken / MPS/ biomechanisch middel
• Rapportage •
Specifiek aantal keer dry needling vermelden binnen totaal zittingen
• Case reports •
Pijn hoofd, nek, schouder, arm, KANS, RSI, bil, been, ischias, artrosepijn
concluderend/ samengevat
Dry needling bij aspecifieke acute lage rugpijn • Gunstig natuurlijk verloop aspecifieke acute lage rugpijn is onzeker • ALBP = spiertrauma = myofasciale pijn = DN indicatie • Dry needling bij ALBP = 50% / 80 % VAS afname 1e zitting • DN bij myofasciale pijnsyndroom is evidence based • Klinisch geen recidieven na DN ALPB => kosteneffectief
• Meer en beter onderzoek is nodig
Hartelijk dank voor uw aandacht Gaarne uw vragen
