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THE EFFECTIVENESS OF DRY NEEDLING ON THE REDUCTION OF PROXIMAL UPPER QUARANT PAIN USING COHEN'S d: A SYSTEMATIC REVIEW.

INTRODUCTON

The management of Pain continues to be a mayor focus in physical therapy clinics and varying therapeutic interventions are employed. There are conflicting reports in the literature that DN of myofascial trigger points (MTrPs) or trigger points (TrPs) is efficacious in reducing spinal pain. The mechanism by which DN reduces pain is also not fully elucidated. The application of DN (thin filiform needles) employs different techniques, including but not limited to winding, several stabbings (pistonings) of the needle into the site, inserting the needle into the site for a certain amount of time and electrical dry needling (EDN). Irrespective of the technique of application, pain reduction of varying degrees may be observed as demonstrated in the literature. Also, Acupuncture and DN may have different philosophies but procedure of inserting the needle into the body is essentially the same and both are targeting pain reduction essentially. How effective DN is may be dependent on the statistical analysis used, p-value or effect size. There is argument in the literature that p-value that measures statistical significance may not be enough when measuring clinical effectiveness of an intervention. In differentiating between effect size and p-value, Sullivan and Feinn [37] stated that "a P value can inform the reader whether an effect exists, the P value will not reveal the size of the effect". In arguing the need for effect size in reporting quantitative study, Cohens [38] stated that "The primary product of a research inquiry is one or more measures of effect size, not p values". Effect size is defined as the magnitude of the difference between groups, whereas the absolute effect size is the difference between the average, or mean, outcomes in two different intervention groups [37]. If DN has a clinical effect, using p-value to measure the effect may not be enough.

The development of MTrPs and subsequent pain formation is complex. It is speculated that MTrP is developed due to increased release of acetylcholine (ACh) from motor endplates and Ca[2.sup.+] resulting in continuous state of localized shortening and contractures of sarcomeres (muscle contraction) [8]. There is localized hypertonicity which then begin to cause ischemia and hypoxia [9], and subsequently, chemicals (such as bradykinin, prostaglandins, serotonin, calcitonin gene-related peptide (CGRP) and substance P) responsible for the propagation of pain and inflammation are released. In addition, several inflammatory cytokines, such as tumor necrosis factor-a (TNF- a), interleukin-lb (IL-1B), interleukin-6 (IL-6), and interleukin-8 (IL-8) are released [9]. High level of H+ ions and adenosine triphosphate (ATP) [10], are released resulting in low pH which further propagates the action of ACh (inhibition of acetylcholinesterase). The continuous presence of factors of pain and inflammation results in sensitization of the sensory afferent nerve fibers of the muscle and this may explain the point tenderness of MTrPs [10, 11, 12]. Eventually, this may lead to central sensitization of the dorsal horn neurons (which is an increase of the excitability of neurons within the central nervous system) causing pain hypersensitivity. The question is, why is DN able to mediate pain reduction in MTrPs and other tissues?

If DN has effects on pain control, what is the best way the effects can be measured to determine clinical efficacy? The use of p-value is being challenged as it may not give a clear clinical effects magnitude. Therefore, the purpose of this review is to evaluate the effect of DN treatment on proximal quadrant pain and using Cohen's d as an outcome.

METHODS

Databases, including Pubmed, Embase and PEDro databases were accessed October--November 2016 for articles published not more than 10 years at the time of the search . The randomized control trial articles were selected with inclusion criteria including intervention of DN into the trapezius muscles, clinical trials, musculoskeletal pain in proximal upper quadrant (neck, cervical, shoulder, scapular, upper back, and upper thorax), and studies that compared the effects of DN to alternative treatments pain reduction, sham DN, or pure control. Study quality was evaluated using PEDro criteria. The PEDro is a 10-point scale for assessing internal validity (higher scores indicating higher quality). PEDro risk of bias assessment was used. Information taken from the articles includes population, intervention group, comparison group(s), and post-intervention and follow up pain outcomes (VAS). Clinical trial quality was evaluated for each article and data was extracted for comparison. Outcome measures used for comparison is Cohen's d which measures the effect size of the study. Effect size was measured by taking the difference between two means, or mean (group 1)--mean (group 2) / standard deviation. Cohen classified effect sizes as small (d =0.2), medium (d =0.5), and large (d > 0.8).

RESULTS

Eleven randomized clinical trials were assessed in this systematic review (Table 1). The mean PEDro score of the studies was 6.5 with a range of 4 - 8. Using Cohen's d to measure the efficacy of DN treatment, DN had a large effect and more superior for pain control in five studies compared to the controls/interventions (ES range of 0.81 to 17.46; CI of 0.08 - 1.50 and 15.19 - 19.50 respectively) [31,32,6,7,36]; moderate effect in one study which was not significant (ES of 0.52; CI: -0.15 - 1.8) [33]; and trivial/small effect which was also not significant, in two studies (ES of 0.07 to 0.23; CI: -0.86 1.00 and -0.18 - 0.63) [5,35]. In three studies, DN appeared to be less effective but insignificant, when compared to the control.or other interventions (ES range of -0.32 to -0.14; CI of -0.18 - 0.63 and -0.89 - 0.60 respectively). Besides having a large effect size in favor of DN in study 2, DN appeared less effective (but not significant) versus STT post-intervention and OMT at both post-intervention and follow up (ES range of -0.61 to -0.23; CI of -1.41 - 0.23 and -1.03 - 0.58.) [31] (Figure 1).

DISCUSSION

This review determines the effects of DN on upper quadrant pain and using Cohen's to measure outcomes unlike the popular p-value that has been used to measure statistical significance. Statistical significance may not give the effects or magnitude of effects of an intervention [37]. This study presented the results of the study in categories of large, moderate or small effects. It is important to compare some of the results of the studies using the p-value and Cohen's d. Some of the studies presented confusing results using p-value or Cohen's d. For example, the study of Llamos-Ramos, R., et al [5], presented statistical significance of p-value of p <0.01 to 0.001 and using Cohen's d and the same data, the results favor DN to Trp MT but at a trivial level that is not significant. On the other hand, Mejuto-Vazquez, M. [6], study presented p-value of statistical significance of p <0.001, and using Cohen's d, DN resulted in large effect compared to the control and this large effect size is significant. In this study, we can see where p-value and Cohen's d for measurement of outcomes tend to agree in some of the studies. This is true of the study of Pecos-Martin, D [7] that presented a p <0.001 and using Cohen's d, a large effect with significance is also reported. There was no main difference between DN of TrPs of upper trapezius muscles and DN of TrPs plus paraspinal muscles (p<0.05) but using Cohen's d, DN of TrPs of upper trapezius plus paraspinal muscle produced small effect (not significant) but in favor of the DN TrPs plus paraspinal muscles. Using Cohen's d to measure the efficacy of DN treatment, DN had a large effect and more superior for pain control in five studies compared to the controls/interventions (ES range of 0.81 to 17.46; CI of 0.08 - 1.50 and 15.19 - 19.50 respectively) [31,32,6,7,36]. Moderate effect in one study which was not significant (ES of 0.52; CI: - 0.15 - 1.8) [33]. Of the eleven articles reviewed we have trivial/small effect, also not significant, in two studies (ES of 0.07 to 0.23; CI: 0.86 - 1.00 and -0.18 - 0.63) [5,35]. Three of the eleven studies favored control and other interventions over DN but the differences were not significant. The application of DN for upper quadrant pain is seen in these reviews to be positive for pain control. Using Cohen's d for magnitude of effects of intervention may be more useful clinically as there might be a difference between statistical significance and outcome measures like Cohen's d that gives a magnitude of the difference and whether that difference is significant or not looking at the CI. What is not clear is the mechanism with which DN controls pain, and this is not covered in this study. The application of DN (thin filiform needles) employs different techniques, including but not limited to winding, several stabbings of the needle into the site (sometimes referred to as "pistoning"), inserting the needle into the site for a certain amount of time and electrical dry needling (EDN) in some cases.

Irrespective of the technique of application, pain reduction of varying degrees may be observed as demonstrated by this current review. Also, Acupuncture and DN may have different philosophies but the procedure of inserting the needle into the body is essentially the same and both are targeting pain reduction essentially.

DISCUSSION

This review determines the effects of DN on upper quadrant pain and using Cohen's to measure outcomes unlike the popular p-value that has been used to measure statistical significance. Statistical significance may not give the effects or magnitude of effects of an intervention [37]. This study presented the results of the study in categories of large, moderate or small effects. It is important to compare some of the results of the studies using the p-value and Cohen's d. Some of the studies presented confusing results using p-value or Cohen's d. For example, the study of Llamos-Ramos, R., et al [5], presented statistical significance of p-value of p <0.01 to 0.001 and using Cohen's d and the same data, the results favor DN to Trp MT but at a trivial level that is not significant. On the other hand, Mejuto-Vazquez, M. [6], study presented p-value of statistical significance of p <0.001, and using Cohen's d, DN resulted in large effect compared to the control and this large effect size is significant. In this study, we can see where p-value and Cohen's d for measurement of outcomes tend to agree in some of the studies. This is true of the study of Pecos-Martin, D [7] that presented a p <0.001 and using Cohen's d, a large effect with significance is also reported. There was no main difference between DN of TrPs of upper trapezius muscles and DN of TrPs plus paraspinal muscles (p<0.05) but using Cohen's d, DN of TrPs of upper trapezius plus paraspinal muscle produced small effect (not significant) but in favor of the DN TrPs plus paraspinal muscles. Using Cohen's d to measure the efficacy of DN treatment, DN had a large effect and more superior for pain control in five studies compared to the controls/interventions (ES range of 0.81 to 17.46; CI of 0.08 - 1.50 and 15.19 - 19.50 respectively) [31,32,6,7,36]. Moderate effect in one study which was not significant (ES of 0.52; CI: - 0.15 - 1.8) [33]. Of the eleven articles reviewed we have trivial/small effect, also not significant, in two studies (ES of 0.07 to 0.23; CI: 0.86 - 1.00 and -0.18 - 0.63) [5,35]. Three of the eleven studies favored control and other interventions over DN but the differences were not significant. The application of DN for upper quadrant pain is seen in these reviews to be positive for pain control. Using Cohen's d for magnitude of effects of intervention may be more useful clinically as there might be a difference between statistical significance and outcome measures like Cohen's d that gives a magnitude of the difference and whether that difference is significant or not looking at the CI. What is not clear is the mechanism with which DN controls pain, and this is not covered in this study. The application of DN (thin filiform needles) employs different techniques, including but not limited to winding, several stabbings of the needle into the site (sometimes referred to as "pistoning"), inserting the needle into the site for a certain amount of time and electrical dry needling (EDN) in some cases.

Irrespective of the technique of application, pain reduction of varying degrees may be observed as demonstrated by this current review. Also, Acupuncture and DN may have different philosophies but the procedure of inserting the needle into the body is essentially the same and both are targeting pain reduction essentially.

CONCLUSION

Using Cohen's d to measure the efficacy of DN treatment, of the eleven studies reviewed, DN had a large effect and more superior for pain control in five studies compared to the controls/interventions, moderate effect in one study which was not significant and trivial/small effect, not significant was observed in two studies. However, p-value and Cohen's d as measures of outcomes do not totally not see results or outcomes at the same lenses. Cohen's d may probably be better in looking for clinical significance and the magnitude of such significance.

With the positive effect of DN treatment on pain reduction, one can deduce that patients with pain treated by DN can have an increase in function and ultimately improved quality of life. DN as a modality is new in physical therapy. Chronic pain, such as upper quadrant pain or trapezius pain that may not respond to the traditional physical therapy (heat, exercise, and massage) may be relieved with DN treatment and therapists need to consider this new modality when treating chronic pain.

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Felix Adah and Min Huang

University of Mississippi Medical Center, School of Health Related Professions, Department of Physical Therapy, Jackson, MS, USA

Caption: Fig. 1 * Effect Size | Confidence Interval (Lower & Upper)
Study Summary Table 1.

Article                 Population

1. Aridici, R.          36 patients (29 females) age 18-
2016                    73 with chronic mechanical neck
8/10                    pain involving the upper trapezius

2. Campa-Moran, I.      36 patients (29 females) age 18-
2015                    73 with chronic mechanical neck
7/10                    pain involving the upper trapezius

3. Cerezo-Tellez, E.    130 patients (no gender specified)
2016                    with non specific neck pain in the
6/10                    cervical region (trapezius,
                        cervical multifidi, splenius
                        cervicus, and levator scapulae)

4. Ga, H. 2007 6/10     40 patients (36 females) age 63-
4. Ga, H. 2007          90 with myofascial pain
6/10                    syndrome of the upper trapezius

5. Llamas-Ramos, R.     94 patients (62 females) (mean 31
2014                    yrs age) with chronic idiopathic
8/10                    mechanical neck pain

6. Mejuto-Vazquez, M.   17 patients (9 females) (mean 25
2014                    yrs age) with acute(<7 days)
8/10                    mechanical, idiopathic, unilateral
                        neck pain

7. Myburgh, C.          77 female patients age 25-46 with
2012                    and without neck/shoulder pain
7/10                    were observed with respect to
                        self-reported pain

8. Pecos-Martin, D.     72 patients (58 females) age 18-
2015                    42 with unilateral neck pain for
8/10                    >3 months

9. Rayegani, S. M.      28 patients (no gender specified)
2014                    age 20-46 with the diagnosis of
4/10                    myofascial pain syndrome of
                        upper trapezius for at least 2
                        months

10. Segura-Orti, E.     34 patients (25 females) (mean 33
2016                    yrs age) with active trigger points
6/10                    in the upper trapezius

11. Ziaeifar, M.        33 patients (no gender specified)
2014                    age 20-48 with active trigger
4/10                    points in the upper trapezius

Article                 Intervention   Comparison     Outcome
                        Group(s)       (Control       (Pain)
                        (Includes      or w/o
                        DN)            DN)

1. Aridici, R.          DN:            HPPT:          Visual
2016                    n = 30         n = 31         Analog Scale
8/10                                                  (VAS)

2. Campa-Moran, I.      DN-S:          STT:           Visual
2015                    n = 12         n = 12         Analog Scale
7/10                                   OMT:           (VAS) (0-
                                       n = 12         100 mm)

3. Cerezo-Tellez, E.    DN-S:          Stretching     Visual
2016                    n = 64                        Analog Scale
6/10                                   n = 64         (VAS)

4. Ga, H. 2007 6/10     DN:            DN +           Visual
4. Ga, H. 2007          n = 18         IMS:           Analog Scale
6/10                                   n = 22         (VAS)

5. Llamas-Ramos, R.     DN:            TrP MT:        11 point
2014                    n = 47         n = 47         numeric pain
8/10                                                  rating scale
                                                      (0=no
                                                      pain,10=max
                                                      pain)

6. Mejuto-Vazquez, M.   DN:            Control:       11 point
2014                    n = 9          n = 8          numeric pain
8/10                                                  rating scale
                                                      (0=no
                                                      pain,10=max
                                                      pain)

7. Myburgh, C.          DN:            SDN:           Self-reported
2012                    n = 17         n = 20         pain (NRS-
7/10                                                  101 eleven
                                                      point pain
                                                      rating scale)

8. Pecos-Martin, D.     DN:            Sham           Visual
2015                    n = 36         DN:            Analog Scale
8/10                                   n = 36         (VAS)

9. Rayegani, S. M.      DN:            PT: Heat,      Visual
2014                    n = 14         Ultrasoun      Analog Scale
4/10                                   d, Tens,       (VAS)
                                       Stretching

                                       n = 14

10. Segura-Orti, E.     DN + 8         SCS:           Visual
2016                    reps           n = 8          Analog Scale
6/10                    shoulder       Sham           (VAS) (0-
                        shrugs/        SCS: n =       100 mm
                        abduction      6
                        +
                        stretching:
                        n = 10

11. Ziaeifar, M.        DN:            TCT:           Visual
2014                    n = 16         n = 17         Analog Scale
4/10                                                  (VAS)

Article                 Post                Follow Up

1. Aridici, R.          1 week              4 weeks
2016                    DN: 4.58 (1.85)     HTTP: 5.93 (1.98)
8/10                    HPPT: 4.20          DN: 6.25 (1.99)
                        (2.05)

2. Campa-Moran, I.      Post treatment 2    DN-S: 13.3
2015                    DN-S: 36.0          (3.9 to 22.7)
7/10                    (24.0 to 48.0)
                        STT: 30.1 (18.0     STT: 34.3
                        to 42.1)            (24.9 to 43.7)
                        OMT: 23.0
                        (10.8 to 35.0)      OMT: 9.4
                                            (0.03 to 18.8)

3. Cerezo-Tellez, E.    DN-S: -4.81         6 months
2016                    (0.2)               DN-S: -4.08 (0.25)
6/10                    Stretching: -1.57   Stretching:
                        (0.17)              -1.60 (0.25)

4. Ga, H. 2007 6/10     DN: 3.82 (2.47)     N/A
4. Ga, H. 2007          DN + IMS: 3.11
6/10                    (2.01)

5. Llamas-Ramos, R.     DN: 1.9 (1.4)       1 week
2014                    TrP MT: 2.2         DN: 1.3 (1.1)
8/10                    (18)                TrP MT: 1.6 (1.5)
                                            2 weeks
                                            DN: 0.9 (0.8)
                                            TrP MT: 1.0 (1.1)

6. Mejuto-Vazquez, M.   DN: 3.8 (1.9)       2 weeks
2014                    Control: 5.5        DN: 2.0 (1.7)
8/10                    (2.1)               Control: 4.6 (2.1)

7. Myburgh, C.          48 hours            N/A
2012                    DN: 3.41 (2.31
7/10                    to 4.53)
                        SDN: 4.60 (3.62
                        to 5.58)

8. Pecos-Martin, D.     1 week              1 month
2015                    DN: 2.6 (1.8)       DN: 2.1 (1.6)
8/10                    Sham DN: 5.3        Sham DN: 5.1 (1.5)
                        (1.6)
9. Rayegani, S. M.      1 week              N/A
2014                    DN Rest: 1.8
4/10                    (1.5)
                        DN Activity: 2.8
                        (2.2)

10. Segura-Orti, E.     3 weeks             N/A
2016                    DN: 17.7 (14.7)
6/10                    SCS: 18.6 (10.3)
                        Sham SCS: 12.3
                        (9.3)

11. Ziaeifar, M.        1 week              N/A
2014                    DN: 1.34 (1.93)
4/10                    TCT: 3.05
                        (2.27)

Article                 Effect Size         Effect Size
                        Post                Follow Up

1. Aridici, R.          ES = -0.19          ES = -0.16
2016                    CI lower = -0.70    CI lower = -0.66
8/10                    CI upper = 0.31     CI upper = 0.34

2. Campa-Moran, I.      ES (DN-             ES (DN-S/STT) = 1.27
2015                    S/STT) = -0.28      CI lower = 0.35
7/10                    CI lower = -1.07    CI upper = 2.09
                        CI upper = 0.54     ES (DN-S/OMT) = -
                                            0.23
                        ES (DN-S/OMT)       CI lower = -1.03
                        = -0.61             CI upper = 0.58
                        CI lower = -1.41
                        CI upper = 0.23

3. Cerezo-Tellez, E.    ES = 17.46          ES = 9.92
2016                    CI lower = 15.19    CI lower = 8.60
6/10                    CI upper = 19.50    CI upper = 11.11

4. Ga, H. 2007 6/10     ES = -0.32          N/A
4. Ga, H. 2007          CI lower = -0.94
6/10                    CI upper = 0.31

5. Llamas-Ramos, R.     ES = 0.19           1 week ES = 0.23
2014                    CI lower = -0.22    CI lower = -0.18
8/10                    CI upper = 0.59     CI upper = 0.63
                                            2 week ES = 0.10
                                            CI lower = -0.31
                                            CI upper = 0.51

6. Mejuto-Vazquez, M.   ES = 0.85           ES = 2.09
2014                    CI lower = -0.18    CI lower = 0.82
8/10                    CI upper = 1.8      CI upper = 3.15

7. Myburgh, C.          ES = 0.52           N/A
2012                    CI lower = -0.15
7/10                    CI upper = 1.17

8. Pecos-Martin, D.     ES = 1.57           ES = 1.93
2015                    CI lower = 1.04     CI lower = 1.36
8/10                    CI upper = 2.01     CI upper = 2.47

9. Rayegani, S. M.      Rest ES = -0.20     N/A
2014                    CI lower = -0.94
4/10                    CI upper = 0.54
                        Activity ES = -
                        0.14
                        CI lower = -0.89
                        CI upper = 0.60

10. Segura-Orti, E.     ES (DN/SCS) =       N/A
2016                    0.07
6/10                    CI lower = -0.86
                        CI upper = 1.00

                        ES (DN/Sham
                        SCS) = -0.41
                        CI lower = -1.41
                        CI upper = 0.63

11. Ziaeifar, M.        ES = 0.81           N/A
2014                    CI Lower = 0.08
4/10                    CI Upper = 1.50

Article                 Conclusion

1. Aridici, R.          Post/Follow up:
2016                    HPPT > DN
8/10                    Trivial (NS)

2. Campa-Moran, I.      Post: STT > DN-S
2015                    Small (NS)
7/10                    OMT > DN-S
                        Moderate (NS)
                        Follow up:
                        DN-S > STT
                        Large (DN*)
                        OMT > DN-S
                        Small (NS)

3. Cerezo-Tellez, E.    Post/Follow up:
2016                    DN-S > Stretching
6/10                    Large (DN*)

4. Ga, H. 2007 6/10     DN + IMS > DN
4. Ga, H. 2007          Small (NS)
6/10

5. Llamas-Ramos, R.     Post:
2014                    DN > Trp MT
8/10                    Trivial (NS)
                        Follow up:
                        DN > TrP MT
                        Small/Trivial (NS)

6. Mejuto-Vazquez, M.   Post:
2014                    DN > Control
8/10                    Large (NS)
                        Follow up:
                        DN > Control
                        Large (DN*)

7. Myburgh, C.          DN > SDN
2012                    Moderate (NS)
7/10

8. Pecos-Martin, D.     Post/Follow up:
2015                    DN > Sham DN
8/10                    Large (DN*)

9. Rayegani, S. M.      Rest:
2014                    PT > DN
4/10                    Small (NS)
                        Activity:
                        PT > DN
                        Trivial (NS)

10. Segura-Orti, E.     DN > SCS
2016                    Trivial (NS)
6/10
                        Sham SCS > DN
                        Small (NS)

11. Ziaeifar, M.        DN > TCT
2014                    Large (DN*)
4/10

DN: Dry Needling; ES: Effect Size; CI: Confidence Interval; DN*: Dry
Needling is Significant; NS: Not Significant; HPPT: High Powered Pain
Threshold Ultrasound; DN-S: Dry Needling plus Stretching; STT: Soft
Tissue Technique; OMT: Orthopedic Manual Therapy; IMS: Intramuscular
Stimulation; TrP
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Author:Adah, Felix; Huang, Min
Publication:Journal of the Mississippi Academy of Sciences
Article Type:Report
Date:Apr 1, 2018
Words:5059
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