JOURNAL OF MANUAL & MANIPULATIVE THERAPY. https://doi.org/10.1080/10669817.2019.1574389
Objective: The purpose of this study was to examine the within and between group effects of segmental and distal dry needling (DN) without needle manipulation to a semi-standardized non-thrust manipulation (NTM) targeting the symptomatic spinal level for patients with non-specific low back pain (NSLBP).
Methods: Sixty-five patients with NSLBP were randomized to receive either DN (n=30) or NTM (n=35) for 6 sessions over 3 weeks. Outcomes collected included the Oswestry Disability Index (ODI), Patient Specific Functional Scale (PSFS), Numeric Pain Rating Scale (NPRS), and Pain Pressure Thresholds (PPT). At discharge, patients perceived recovery was also assessed.
Results: A 2-way mixed model ANOVA demonstrated that there was no group*time interaction for PSFS (p=0.26), ODI (p=0.57), NPRS (p=0.69), and PPT (p=0.51). There was significant within group effects for PSFS (3.1 [2.4, 3.8], p=0.018), ODI (14.5% [10.0%, 19.0%], p=0.015), NPRS (2.2 [1.5, 2.8], p=0.009), but not for PPT (3.3 [0.5, 6.0], p=0.20).
Discussion: The between group effects were neither clinically or statistically significant. The within group effects were both significant and exceeded the reported minimum clinically important differences for the outcome tools except the PPT. DN and NTM produced comparable outcomes in this sample of patients with NSLBP.
Level of evidence: 1b. Keywords:Low back pain, manual therapy, dry needling
Our above randomized clinical trial was the first clinical trial comparing DN to another manual therapy intervention for low back pain. The non-thrust manipulation (NTM) was an intervention with known treatment effect and recommended in clinical practice guidelines. Clinicians performing DN did not target MTrP but rather inserted needles at the most symptomatic levels of the lumbar spine and targeted peripheral nerve innervation zones distally. The DN technique was a basic needle insertionWITHOUT needle manipulation to the maximum needle depth or up to 50 mm. Both groups experienced significant improvements in pain and disability.
Relevance:Basic needle insertion creates a therapeutic lesion and now we have further evidence that more aggressive needling is not required for a positive clinical outcome. Not all patients are able to tolerate excessive needle manipulation that attempts to elicit and exhaust the local twitch response with MTrP dry needling. Post-needling soreness can be unreasonable with inconclusive evidence that it produces better outcomes compared to alternative techniques. Basic techniques are appropriate for patients new to DN, who have low healing potential, or for those who are strong responders. Techniques like pistoning or needle rotations may provide a stronger neuroinflammatory response and are still recommended in certain situations as it increases the overall therapeutic dosage. It may also be warranted to increase the depth of the lesion in appropriate anatomical areas in order to maximize the microcirculation effect in deeper tissue. In the trial, we standardized the depth to a maximum of 50 mm to reduce variability but in clinical practice, deeper needling may be more advantageous in certain patients. It is important to address a patient’s local symptoms, but segmental and systemic involvement cannot be ignored. The progressive sensitization and inflammatory changes occurring with injury often involves a larger nociceptive field, which is relevant clinical data. Distal needling combined with local needling is a way to address factors like segmental and systemic sensitization that are more likely to occur with chronic conditions, i.e chronic non-specific low back pain. Dr. David Griswold