Reviewed by Jerome Thomas, SPT, Tyler Tice, PT, DPT, OCS, ATC

Dry needling is an innovative treatment technique utilized by various healthcare practitioners such as physical therapists, physicians, and chiropractors. Dry needling is implemented by inserting needles into painful areas of muscle perceived to have motor abnormalities in an attempt to restore normal muscle function and alleviate higher levels of pain. These painful areas of muscle are more commonly referred to as myofascial trigger points by clinicians.

There is a growing body of new evidence and research that reinforces the clinical effectiveness of dry needling for various musculoskeletal conditions such as low back pain. However, there have been limited studies that evaluate the effect of dry needling on soft tissue stiffness after its application. This randomized controlled trial utilized ultrasound shear-wave elastography (SWE), technology that quantifies soft tissue elasticity by sending sound waves into the desired soft tissue area. Vibrations move faster through the areas of soft tissue that are more stiff and less elastic. The primary aim of this study is to compare the effects of dry needling and sham dry needling (control group), on lumbar muscle stiffness in individuals with low back pain.

There were several outcomes assessed at the end of this randomized controlled trial: self-reported pain using the numerical pain rating scale (NPRS), LBP-related disability using the Oswestry Disability Index (ODI), self-reported changes using the Global Rating of Change, as well as lumbopelvic active range of motion. The participants in this study were currently experiencing low back pain between the ages of 18 and 65. Current low back pain for the participants was defined as pain between the 12th rib and the buttocks region as well as an ODI score of at least 10%.

Following the baseline evaluation and outcome assessment, 60 participants were randomized to either receive dry needling or sham dry needling. Therefore, there were 30 participants in the dry needling group and 30 participants in the sham treatment group. Treatment was performed by an experienced physical therapist trained in dry needling and blinded to all outcomes. Treatment was applied to a total of four sites on both the lumbar multifidi and erector spinae, muscles of the low back region. During each insertion of the needle, a ‘pistoning’ (in and out motion) technique was used in an attempt to elicit a local twitch response. Each participant was instructed to perform a double knee-to-chest maneuver 6 times for 5–10 seconds to alleviate residual soreness.

The results of the study showed that the resting erector spinae muscle stiffness was lower in individuals that received dry needling than in those that received sham dry needling 1 week after treatment. Additionally, individuals that received dry needling reported statistically larger overall improvements using the Global Rating of Change scale, as well as statistically significant improvements in pain levels utilizing the numerical pain rating scale (NPRS). No serious adverse events were reported throughout the course of this randomized controlled trial.

 Clinical Application:

Dry needling can be utilized as an effective intervention for individuals with low back pain to attenuate muscular stiffness in the low back region, as well as provide improvements in pain levels. Dry needling can be a useful intervention to help reduce the activity of myofascial trigger points, decrease hypersensitivity of taut bands in skeletal muscle, as well as restore normal muscle function during routine functional activities.

References:

Koppenhaver SL, Weaver AM, Randall TL, et al. Effect of dry needling on lumbar muscle stiffness in patients with low back pain: A double blind, randomized controlled trial using shear wave elastography. J Man Manip Ther. 2022;30(3):154-164.

Reviewed by Jerome Thomas, SPT, Tyler Tice, PT, DPT, OCS, ATC

Patellofemoral pain syndrome (PFPS) is a chronic musculoskeletal condition characterized by persistent anterior knee pain. This condition is sometimes referred to as “runner’s knee” because it is common in individuals who participate in sports or recreational activities. However, patellofemoral pain syndrome can also occur in nonathletes as the increased pain levels and stiffness can make it difficult to climb up stairs, kneel down, and other activities of daily living.

Often times, a multimodal approach is utilized to treat individuals with PFPS. However, there is very little evidence to support the idea that the current multimodal approach for treatment of PFPS leads to successful clinical outcomes. A research study by Brown et al. on patients with PFPS, showed that only 46% of patients’ knees were pain-free at discharge. Based on the failures of the current multimodal treatment approach, there has been a strong recommendation from the International Patellofemoral Pain Research Retreats to clinically subgroup patients with PFPS and deliver targeted treatments. This prospective crossover intervention categorized patients with PFPS into 3 subgroups to assess whether targeted treatments would show clinical benefits over a multimodal approach.

The participants for this study were between the ages of 18 and 40, attending a physical therapy outpatient clinic at a university hospital with a clinical diagnosis of PFP. Various assessment tools were utilized to categorize the patients with PFPS: quadriceps and hip abductor muscle strength in the form of manual muscle tests, patella glide test, quadriceps length, gastrocnemius length, and the foot posture index. Based on these PFPS criteria, the participants were classified into 1 of 3 subgroups: strong, weak and tight, or weak and pronated feet.

All 61 patients in this crossover intervention study were given 6 weeks of multimodal treatment. The multimodal treatment included thermotherapy (heat application), transcutaneous electrical neural stimulation (TENS), stretching, as well as hip and knee strengthening. 21 patients responded positively to this treatment approach but 40 patients were non-responders to this approach. The 40 PFPS non-responders were then given an additional 6 weeks of targeted treatment based upon one of the three subgroups they were classified within. The intervention program for the “strong” subgroup was targeted at improving neuromuscular control and coordination ability using proprioceptive exercises. In the “weak and tight” subgroup, the exercise program consisted of closed kinetic chain (CKC) muscle strengthening and stretching and weight management advice. Lastly, the “weak and pronated foot” subgroup had an intervention program that included CKC strengthening exercises and foot orthoses.

Pain during activity measured using a visual analog scale (VAS) was the primary outcome measure of this study. The perception of recovery scale (PRS) was also utilized where patients rated themselves from “worse than ever” to “completely recovered” on a 7-point scale. The results of the study showed that 72.5% (29 patients) of the 40 PFPS non-responders demonstrated recovery after targeted treatment approaches. Recovery was measured through improved pain intensity (VAS) scores at rest and during activity, as well as significantly improved PRS scores. The findings of this intervention study suggest that targeted interventions based on subgroups provide a more effective treatment strategy for patients with PFPS.

Clinical Application:

Patients with PFPS who do not respond positively to the current multimodal treatment approach may benefit from a more targeted treatment. Targeted subgroups used to classify PFPS patients as “strong,” “weak and tight,” or “weak and pronated foot” provide a blueprint for targeted interventions that can improve clinical outcomes. Below is a graphic that outlines the targeted interventions for each subgroup:

References:

Yosmaoğlu HB, Selfe J, Sonmezer E, et al. Targeted Treatment Protocol in Patellofemoral Pain: Does Treatment Designed According to Subgroups Improve Clinical Outcomes in Patients Unresponsive to Multimodal Treatment?. Sports Health. 2020;12(2):170-180. doi:10.1177/1941738119883272

Brown J. Physiotherapists knowledge of patellofemoral pain syndrome. Br J Ther Rehabil. 2000;7:346-353.

Reviewed by Jerome Thomas, SPT, Tyler Tice, PT, DPT, OCS, ATC

Utilization of total knee arthroplasty (TKA) procedures in the United States has skyrocketed in recent years. According to Cram et. al (2012), the annual volume of TKA surgeries among Medicare beneficiaries increased 161.5% between 1991 and 2010. In this research article, Cram and his colleagues proposed that this dramatic advancement in TKA surgeries could be due to the fact that the TKA procedure is highly reliant on subjective criteria, therefore lending itself to potential over-utilization. Determining whether a TKA surgery is advisable for a patient requires evidence-based appropriateness criteria; however, these specific criteria have never formally been developed for patients undergoing TKAs. The aim of this cohort study is to determine if the current TKA appropriateness criteria is valid and accurately predicts whether a patient should opt for a TKA surgery.

As previously mentioned, there has been no formal appropriateness criteria for TKA procedures in the United States. The most commonly recommended and studied approach is the RAND/UCLA method developed by Escobar and his colleagues in Spain. Escobar et. al constructed their TKA appropriateness algorithm based on several variables: symptom behavior, age, extent of radiographic arthritis, prior medical history, knee joint mobility and stability, and functional status. These researchers in Spain then tested their algorithm against 775 TKA patients and determined their appropriateness based on their specialized criterion. The purpose of this cohort study was to modify Escobar’s system for US TKA patients and analyze its validity in determining whether a patient is a good candidate for a TKA procedure.

For the cohort study, 216 subject data sets were derived from 4,796 possible patients enrolled in the Osteoarthritis Initiative (OAI). In order to assess severity of knee arthritis for each patient, the KL radiographic grading system was utilized: 1 indicated mild (1 to 33%) narrowing, 2 indicated moderate (34–66%) narrowing and 3 indicated severe (67 to 100%) narrowing. The WOMAC Physical Function scale evaluates the functional status of each patient and how their symptoms impact their function:0 = none, 1=mild impairment, 2= moderate impairment, 3=severe impairment, 4=extreme impairment. Additionally, patients were categorized as limited when they had either less than 0° to 90° of knee motion or greater than 5 millimeters of medial or lateral gapping during stress testing.

The results of the cohort study were based on the modifications of Escobar’s appropriateness algorithm. Of 175 subjects with complete data sets, 77 were classified as appropriate TKA surgeries. The majority of patients that were deemed appropriate for TKA surgeries had intense or severe symptoms that impacted functional status, KL arthritis scores of 4 (severe knee joint narrowing), and were greater than 55 years of age. Many patients struggle with the ultimate decision of undergoing a TKA surgery so the researchers of this cohort study wanted to provide evidence-based criteria for patients to aid in their choice.

Clinical Application:

The patient population that are most likely to be deemed appropriate for TKA surgeries are those with intense/severe symptoms that impact functional status, KL arthritis scores of 4 (severe knee joint narrowing shown on radiographic images), and greater than 55 years of age. Other important variables that must be considered before a TKA procedure include psychological readiness for the surgery and the recommendations of all members of the patient’s healthcare team.

References:

Cram P, Lu X, Kates SL, Singh JA, Li Y, Wolf BR. Total knee arthroplasty volume, utilization, and outcomes among Medicare beneficiaries, 1991–2010. JAMA. 2012; 308(12):1227–36.

Escobar A, Quintana JM, Arostegui I, Azkarate J, Guenaga JI, Arenaza JC, et al. Development of explicit criteria for total knee replacement. Int J Technol Assess Health Care. 2003; 19(1):57–70.

Riddle DL, Jiranek WA, Hayes CW. Use of a validated algorithm to judge the appropriateness of total knee arthroplasty in the United States: a multicenter longitudinal cohort study. Arthritis Rheumatol. 2014;66(8):2134-2143.

Reviewed by Austin Mowrey PT, DPT

Introduction:  

Hamstring injuries are common in many sports that require repetitive acceleration and deceleration, including football, soccer, and basketball. There is also a correlation between hamstring mobility and pelvic, knee and low back pain. The aim of this study was to compare foam rolling and proprioceptive neuromuscular facilitation (PNF) to address hamstring mobility deficits.  

Methods and Interventions:  

This study consisted of 80 subjects over 18 years old with no history of hypermobility, hamstring injuries in the past 6 months, a diagnosed orthopedic problems or surgery in the lower limb, back pain or spine surgery, and systemic and neurological disorders. The sample consisted of 53 men and 27 women with an average age of 22.82 years. Subjects were randomly assigned to receive PNF treatment or foam rolling treatment. Hamstring mobility was assessed using a modified sit-and-reach test before interventions, during interventions and 2 minutes after interventions. The subject’s discomfort was also measured using the BORG RPE scale at the end of the intervention.  

The PNF group consisted of 29 men and 11 women with an average age of 22.48. The PNF stretching protocol was performed with each participant in a long sitting position on a plinth. The participant was asked to perform a maximal isometric hamstring muscle contraction for 5 seconds followed by 5 seconds if relaxation and 20 seconds of stretching (30 seconds total). Each participant underwent four repetitions of the PNF stretching in which hamstring length was recorded at baseline, at the end of first repetition, and at the end of the protocol.  

The foam roll group consisted of 24 men and 16 women with an average age of 22.50. For the foam rolling protocol, each participant assumed the long sitting position on a firm and even surface by placing their arms backward and transferring their weight to their palms. The foam roller was placed bilaterally under their hamstrings and slowly moved back forth from the ischial tuberosity and the popliteal fossa for two minutes. Hamstring length was recorded at baseline, 30 seconds from the start of the intervention and at the end of the protocol.  

Results:  

Baseline measurements of hamstring flexibility demonstrated no significant differences between each group, but both groups had statistically significant increase in hamstring flexibility during the interventions and after the intervention. The PNF group demonstrated a 56% total gain of hamstring mobility after the first bout of PNF stretching and the rest during the last three bouts. The foam roll group demonstrated 47% of the total gain after 30 seconds of foam rolling and the rest during the last 90 seconds. When comparing PNF stretching vs foam rolling for hamstring mobility, PNF stretching demonstrated statistically significant results during and after the interventions. There were no statistically significant results when comparing the participants’ perceived exertion between groups or with increased effort and flexibility gained.  

Conclusion:  

The PNF group and foam rolling both experienced statistically significant increase in flexibility in their hamstrings during and after both interventions. When comparing the two groups, the PNF group had significant increase in hamstring flexibility compared to the foam rolling group, but both groups had similar sensation of perceived exertion.  

Take Home Message: 

It is important for clinicians to consider patients’ needs, body size, demographics and goals when deciding on the appropriate intervention. This study concludes that PNF stretching and foam rolling are both effective to improve hamstring flexibility, but PNF is more effective for the population studied. Further research should be performed to assess the duration of the physiological changes noted in this study.  

Reference:  

Pérez-Bellmunt A, Casasayas-Cos O, Ragazzi P, Rodríguez-Sanz J, Hidalgo-García C, Canet-Vintró M, Caballero-Martínez I, Pacheco L, López-de-Celis C. Foam Rolling vs. Proprioceptive Neuromuscular Facilitation Stretching in the Hamstring Flexibility of Amateur Athletes: Control Trials. International Journal of Environmental Research and Public Health. 2023; 20(2):1439. https://doi.org/10.3390/ijerph20021439 

Reviewed by Jerome Thomas, SPT, Tyler Tice, PT, DPT, OCS, ATC

Manual therapy is one of the most common interventions utilized by physical therapists and generally refers to passively applying mechanical forces to the superficial body in order to receive a therapeutic effect. Manual therapy is often implemented in combination with other modalities and interventions to provide a comprehensive, multi-modal approach to musculoskeletal management. Additionally, manual therapy has shown superior clinical outcomes for numerous musculoskeletal disorders in the research that has been conducted on this intervention. However, new evidence in the field of physical therapy has led to a paradigm shift in the way that manual therapy can be utilized. Researchers in physical therapy are asking this pivotal question: Do some specific groups of individuals receive greater therapeutic benefits from manual therapy compared to others?

The International Association for the Study of Pain (IASP) outlines three major pain classifications: nociceptive, nociplastic, and neuropathic. Nociceptive pain is a protective mechanism, caused by physiological activation of pain receptors and is usually attributed to actual tissue damage such as stubbing your toe. Nociplastic pain is often described as increased sensitivity to pain due to the impaired functioning of the pain-processing systems in the central nervous system. This type of pain presentation is commonly seen in chronic conditions such as fibromyalgia. Lastly, neuropathic pain arises from nerve damage or irritation and can often be characterized as shooting, burning, or stabbing pain. There is a prevalent hypothesis that categorizing patients based on these three major pain presentations will allow physical therapists to better tailor their manual therapy techniques for improved patient outcomes.

This detailed study was a consensus-based survey design between the expert clinicians on manual therapy, with group members evaluating one of the three major pain presentations. These group members were tasked with developing an optimal manual therapy treatment framework for each specific pain presentation. These expert clinicians or stakeholders in this study all exhibited high levels of training and experience using manual therapy interventions in clinical practice. Each specific manual therapy framework would outline specific treatment protocols that could be modified based on the patient’s signs and symptoms. As expected, there are both differences and similarities between the theoretical frameworks of the three IASP mechanism-based pain classifications.

The experts came away with several conclusions concerning each specified theoretical framework. The neuropathic and nociplastic frameworks recommended a graded application scheme, with less aggressive techniques early in treatment to monitor patient response; the nociceptive framework recommended approaches that are more aggressive once the patient’s symptoms are improved. For the neuropathic and nociplastic frameworks, it was recommended that you attempt to reconceptualize the pain experience for these patients and create an environment that limits fear and catastrophizing. Additionally, there was an emphasis on “increasing space” for the neuropathic framework as nerve movement increases blood flow in nerve-related conditions.

Clinical Application:

All three frameworks recommended selecting a therapeutic manual therapy approach based on the patient’s unique pain presentation. Patients with neuropathic pain will benefit from graded application of manual therapy and techniques that aim to increase nerve movement for improved blood flow. Patients with nociplastic pain will generally benefit from a reconceptualized view of their pain experience along with less aggressive techniques early on in their treatment plan. Patients with nociceptive pain can be introduced to more aggressive techniques as their symptoms improve; techniques should be selected with the goal of increasing pain-free active range of motion.

Reference:

Cook, C. E., Rhon, D. I., Bialosky, J., Donaldson, M., George, S. Z., Hall, T., … & Puentedura, E. J. (2023). Developing Manual Therapy Frameworks for Dedicated Pain Mechanisms. JOSPT Open, 1(1), 1-15.

Reviewed by Jerome Thomas, SPT, Tyler Tice, PT, DPT, OCS, ATC

Achilles tendinopathy is a very common, overuse injury of the lower extremity that often affects athletes and highly-active individuals that engage in activities such as running, jumping, and other recreational-related tasks. Achilles tendinopathy can consequently become detrimental to a patient’s activity levels and overall functional capacity as many patients may begin to decrease their activity in response to pain or decline in function. There are a very limited number of randomized controlled trials and established treatment protocols for Achilles tendinopathy, despite various forms of modalities and exercise utilized for this patient population. This prospective, randomized controlled trial attempted to evaluate the efficacy of utilizing the Pain-Monitoring Model in combination with a continued, tendon-loading training regimen for patients with Achilles tendinopathy.

In this study, 38 patients with Achilles Tendinopathy were divided into two separate treatment groups: an exercise training group (n=19) and an active rest group (n=19) that was not allowed to perform any physical activity for the first 6 weeks of rehabilitation. However, both treatment groups were rehabilitated with an identical, progressive Achilles tendon-loading program for 12 weeks to 6 months.  As previously mentioned, the exercise training group was allowed to continue loading activities for the Achilles tendon in accordance with the Pain-Monitoring Model in the same timeframe that the active rest group was restricted .

Guidelines for the Pain-Monitoring Model were modified by Silberngael et al. in their 2001 study. According to their guidelines for the pain-monitoring model, pain was not allowed to reach level 5 on the VAS where a 0 indicated no pain and a 10 indicated the worst pain imaginable. Pain after the exercises were allowed to reach a 5 on the VAS but should have subsided by the following morning. Additionally, pain and stiffness in the Achilles tendon were not allowed to increase from week to week. Treatment protocol consisted of a progressive, four-phase program that incorporated the following exercises: 2-legged, 1-legged, eccentric, and fast-rebounding toe raises. Phase 3 allowed the patients to transition to more plyometric-style movements if the subsequent phases were handled with no pain in the tendon insertion or increased morning stiffness. The primary outcomes utilized for the conclusion of this randomized controlled trial were the VISA-A-S score, which was a specialized Achilles assessment questionnaire, as well as pain with hopping measured with the VAS scale.

The results of the trial showed that both treatment groups showed significant improvements in VISA-A-S score and hopping pain in comparison to baseline measurements at 6 weeks, 3 month, 6 month, and 12 month evaluations. More importantly, this study could not demonstrate any negative findings or implications for allowing the patients in the exercise training group to continue Achilles tendon-loading activities in accordance with the Pain-Monitoring Model. Therefore, early implementation of strengthening exercises for the Achilles tendon and plantar flexor complex, as well as moderated activities such as running and jumping, can be utilized to reduce symptoms and improve functional capacity in patients with Achilles tendinopathy. In previous literature, it had been recommended that patients with Achilles tendinopathy take a rest period from the activities that were pain-provoking. However, this study demonstrates that those same activities can be continued as long as the patient with Achilles tendinopathy  is following the protocols set by the Pain-Monitoring Model.

Clinical Application:

Based on this study, we can use the Pain Monitoring Model as a guide to help determine the appropriate amount of activity and exercise for the proper amount of loading to the Achilles tendon with Achilles tendinopathy without “overdoing it”. Below is a graphic that simplifies the explanation of this model:

Reference:

Silbernagel KG, Thomeé R, Eriksson BI, Karlsson J. Continued sports activity, using a pain-monitoring model, during rehabilitation in patients with Achilles tendinopathy: a randomized controlled study. Am J Sports Med. 2007 Jun;35(6):897-906. doi: 10.1177/0363546506298279. Epub 2007 Feb 16. PMID: 17307888.