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Trigger point needling for myofascial pain

PainSci » bibliography » Couto et al 2013
Tags: treatment, muscle pain, acupuncture, injections, dry needling, muscle, pain problems, manual therapy, modalities, controversy, debunkery, traditional Chinese medicine, vitalism, medicine

Four articles on PainSci cite Couto 2013: 1. The Complete Guide to Trigger Points & Myofascial Pain2. The Complete Guide to Chronic Tension Headaches3. The Complete Guide to Neck Pain & Cricks4. Complete Guide to Frozen Shoulder

PainSci notes on Couto 2013:

This study was conducted based on the premise that sticking needles in trigger points is an effective treatment for pain, and they wanted to find out which method works better: dry needling or wet needling (lidocaine injection). That’s a bit of dodgy way to start, but they did compare both types to a proper sham (a deactivated electroacupuncture device that patients were told was “a high-frequency, low-intensity stimulation and that they would most likely feel no sensation from it.”)

They worked with 70 female patients who had “experienced limitations in their routine activities due to MPS … as confirmed by an independent examiner” and excluding eliminating a variety of other common diagnoses. The primary outcomes measured were pain, sensitivity to pressure, and pain-killer usage over several weeks of treatment (plus some secondary measures, like sleep quality, that seem highly vulnerable to confounding factors).

It should be noted that the positive results here are at odds with some reviews published since that have concluded that there is no benefit (e.g. see Cagnie, Kietrys).

All the women improved, including those who received only a sham (as they always do), but the researchers concluded that dry needling produced the greatest improvement.

After a week, the improvement in pain compared to sham was detectable but trivial. Needling gained a little ground each week, until those patients were enjoying a stastically and clinically significant lead over the other groups: about one point better on a 10-point scale than wet needling, a couple points better than the sham. Results were similar with pressure tolerance and pain-killer usage.

How clinically significant the difference was is debatable. It’s not enough of a difference to seem like a “powerful” treatment, and that’s the damning-with-faint-praise problem that afflicts so many “positive” studies of pain treatments.

The other concern I have about is that it was a fairly large, relatively long-term study, which is both a strength and a weakness. Such a complex study presents plenty of opportunities for p-hacking, for statistical jiggery pokery … and the text is overflowing with assumptions that betray a strong bias in favour of needling. These authors clearly were looking for a “win,” and so I just flat out don’t trust the conclusion.

original abstract Abstracts here may not perfectly match originals, for a variety of technical and practical reasons. Some abstacts are truncated for my purposes here, if they are particularly long-winded and unhelpful. I occasionally add clarifying notes. And I make some minor corrections.

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 (LTrP-I) 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.

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