DRY NEEDLING VERSUS INTEGRATED
NEUROMUSCULAR INHIBITION TECHNIQUE ON
UPPER TRAPEZIUS MYOFASCIAL TRIGGER
POINTS
Yassmin Mamdouh Abdelaziz* ; Shimaa Taha Abulkasem**
and Abeer Abdelrahman Yamny***
* Researcher of physical therapy for Basic Science Department, Cairo University.
** Lecturer of Physical Therapy for Basic Science Department, Faculty of physical
therapy, Cairo University
*** Professor Doctor of Physical Therapy for Basic Science Department, Faculty of
physical therapy. Cairo University
ABSTRACT
Background: Active myofascial trigger points (MTrPs) are major pain
generators in myofascial pain syndrome and have a significant impact on
the quality of life, pain and functional disability in the neck. dry needling
and integrated neuromuscular inhibition technique are two effective
technique used in the treatment of active MTrPs. Objective: to compare
between the effect of dry needling and integrated neuromuscular
inhibition technique on upper trapezius active MTrPs . Subjects and
Methods: Thirty patients participated in the study and were assigned
randomly into two equal groups; group (A) receieved dry needling and
passive stretching exercise while group (B) received integrated
neuromuscular inhibition technique and passive stretching exercise
.Measurment outcome included pressure pain threshold (PPT) which
measured by digital electronic pressure algometer and neck functiona
was measured by neck function disability index (NDI) and pain intensity
was measured by visual analogue scale (VAS) that were taken at the
beginning of the treatment period as pre- test measurement and at the end
of the treatment period ( 3weeks) as a post-test measurement. Results:
Both groups showed significant improvement in PPT, NDI and VAS post
treatment compared with that pre treatment (P < 0.001); however there
was significant increase in PPT and significant decrease in NDI and VAS
of group A compared with that of group B post treatment (p < 0.001).
Conclusion: According to the findings of the study dry needling was
more effective than integrated neuromuscular inhibition technique on the
management of upper trapezius active myofascial trigger points.
Key Words: Active myofascial trigger point, dry needling, integrated
neuromuscular inhibition technique, pressure pain threshold and neck
function disability
Egypt. J. of Appl. Sci., 35 (7) 2020 45-56
INTRODUCTION
Myofascial pain syndrome (MPS) is the most common complain
between subjects. It is a musculoskeletal pain condition characterized by
local referred pain perceived as deep aching pain and by the presence of
myofascial trigger points (MTrPs) in any part of the body (Simons,
2004).
Myofascial trigger points (TrPs) develop as a result of injury,
overuse, sustained contractions, eccentric and maximal concentric
contractions of muscles, which result in shortening of muscles and local
ischemia. Any factor that puts over load on a muscles such as prolonged
posture , poor ergonomics , occupational demands, sports or recreational
activities can form a muscle trigger points because muscle used goes
beyond the boundary of muscle capacity and limits the normal recovery
(Bron and Dommerholt, 2012)
Dry needling (DN) is one of physical therapy treatment for
MTrPs which is safe and settled by several studies (Liamas et al.,
2014). The effect of DN on MTrPs of the upper trapezius muscle have
demonstrated reduced pain intensity and pain pressure threshold (PPT). It
can disrupt the neuromuscular activity dysfunctional in the muscles,
decrease muscle tone and normalize the neurochemical pathways of
muscles, increased local blood flow, restored range of motion at the
neck, and improved quality of life ( Liu et al.,2015 and Vulfsons et al.,
2012 )
Integrated neuromuscular inhibition technique(INIT) is a
manual therapy technique consisted of muscle energy techniques (MET),
ischemic compression (IC) and strain-counterstrain (SCS)( (Nagrale et
al., 2010). It was settled and found to be effective in treatment of
MTrPs and more beneficial in relieving pain , reducing stiffness, and
improving functional ability ( Jyothirmai et al., 2015, Nagrale et al.,
2010 and Sibby et al., 2009).
Santos et al., (2014) compares between dry needling and ischemic
pressure with passive stretch in the treatment of trigger points of upper
trapezius. The study found that both treatments relief pain and improve
patient’s activity but patients treated with dry needling with passive
stretching showed the best results .So, this study is going to find if adding
muscle energy technique and strain-counter strain and myofascial release
to ischemic compression (integrated neuro muscular inhibition technique)
would be more effective than dry needling in treatment of trigger points
of upper trapezius or using dry needling will still show the superiority in
the results? Aim of study: The study was conducted to answer the
following research question: Which is significantly more effective dry
needling or integrated neuromuscular inhibition technique in treatment
of active MTrPs of upper trapezius muscle.?
46 Egypt. J. of Appl. Sci., 35 (7) 2020
MATERIAL AND METHODS:
This study was conducted in the out patients clinic of the faculty of
physical therapy, Cairo University. The study was approved by research
ethical committee of faculty of physical therapy
(NO:P.T.REC/012/002474) and The patients were assigned randomly
into two groups by using block randomization according to a computer
generated randomization list and kept in numbered envelopes for
allocation concealment
Subjects:
Thirty subjects from both genders with active myofascial trigger
points in upper trapezius muscle were participate in the study .Their age
were ranged from 18-35 years old (Tali et al., 2014) The patients were
assigned randomly into two groups:
1-Experimental group (A): 15 subjects were received Dry
needling and passive stretching exercise on the upper trapezius muscle;
two times per week;for 3 weeks.
2-Experimental group (B): 15 subjects were received integrated
neuromuscular inhibition technique and passive stretching exercise on
the upper trapezius muscle; two times per week;for 3 weeks
Inclusion criterion
• All patients had active trigger myofascial trigger points (MTrPs) in
upper trapeziues muscle in the dominant side.
• The patients age ranged from 18-35years
• The patients had been choosen from both sexes .
• patient agrees not to receive additional treatment for their painful
condition during the trial (apart from NSAIDs and pain killers
• The patients body mass index < 30 kg/m²
Exclusion criteria:
• History of whiplash injury
• History of cervical spine surgery
• Cervical radiculopathy or myelopathy
• Having undergone physical therapy within the past 3 months before
the study.
• Non –rheumatologic diseases as multiple sclerosis ,thyroid
dysfunction and chronic infection.
• Rheumatologic condition as mild systemic lupus erythematosus ,
poly articular osteoarthritis ,rheumatoid arthritis and advanced
cervical spine degenrative diseases.
• Procedures:
Evaluation procedures
Patients were assessed before and after the treatment program . The
assessment procedures included the following items :
Egypt. J. of Appl. Sci., 35 (7) 2020 47
• Pressure pain threshold (PPT):
Digital Electronic pressure Algometer ;“force one gauge- model
FDI” was used to measure active Myofascial trigger point (MTrPs)
tenderness by determining the pressure pain threshold (PPT) using a
pressure transducer probe, that was placed on the Myofascial trigger
point (Fischer, 1996).
• Functional Disability Index:
● Functional disability of each patient was assessed by Disability
Index (NDI) . It is valid and reliable tool ( It is consists of 10
multiple choice questions for neck pain , where the patient select
one sentence out of six that best describe their function , higher
score 5 indicate great loss of function and lower score 0 indicate no
disability.( Macdermid et al., 2009).
● Visual analogue scale: was used to assess the intensity of pain
(Jensen et al., 1999). The VAS is a 10 cm line anchored with a ( 0 ) a
tone representing (no pain) and (10) at the other end representing (the
worst pain imaginable) it has been shown to be reliable and valid for
assessing pain intensity (Bijur et al., 2001)
Procedure:
Dry needling for upper trapezius trigger points : it was applied to
group ( A )
Patient was placed in a comfortable prone position and encouraged
to maintain complete relaxation. The selected active MTrPs was prepared
by wiping the area with alcohol pad, and a gauge needle with its plastic
guide tube in place was palced over the active MTrPs .a tapping motion
was used to advance the needle to a depth of 5 to 10 mm for 30 seconds
(Baldry, 1995).
INIT for upper trapezius trigger point: it was applied to group(B)
The patients were in supine to reduce tension in the upper trapezius
muscle .The arm in affected side was positioned in slight shoulder
abduction withe elbow bent and their hand resting on their stomach .
Using a pincer grasp , the physiotherapist moved throughout the fibres of
the upper trapezius and maked note of any active TrP .once TrP was
identified treatment begins . The first technique applied was ischemic
compression . The therapist again utilized a pincer grasp , placing the
thumb and index finger over the active TrP. Slowly , increasing levels of
pressure was applied to the trigger point, but not sustained Rather an on -
and-off pressure application was suggested , 5 seconds of pressure , 2-3
seconds release , following by a further 5 seconds of pressure , and so on
, repeated until a perceptible change was palpated
Ischemic compression was followed by the application of
positional release technique. The position of release was often produced
through positioning the muscle in a shortened / relaxed position . Ease
48 Egypt. J. of Appl. Sci., 35 (7) 2020
was defined as the point where reduction in pain of a least 70% was
produced . The patient had been in supine lying with the head side bent
towards the involved side while the therapist positioned the ipsilateral
arm in flexion , abduction and external rotation to reduce the reported
TrP pain . Once the position of ease was identified .it was held for 20-30
sec and repeated for three to five repetitions Lastly, the subjects receive
Muscle energy technique directed towards the involved upper trapezius .
Each isometric contraction for shoulder elevation (autogenic inhibition )
was held for 7-10 sec. Then isometric contraction for shoulder depression
( reciprocal inhibition ) then followed by further contralateral side
bending , flexion , and ipsilateral rotation to maintain the soft tissue
stretch. Each stretch was held for 30 sec and was repeated three to five
times per treatment session and was repeated three to five times per
treatmen session (Chaitow, 2003)
Passive stretch exercise : was received to group (A)and (B)
The patient was placed in a comfortable and relaxed sitting position with
his back supported ; one hand was placed on the side of the head
applying the stretching force, while the other hand was placed on the
patients shoulder applying shoulder stablization . The direction of
stretched force was in flexion , side bending to the opposite side and
rotation to the same side . The stretched position was sustained for 30
seconds , then a relaxation period of 30 seconds . This procedure was
repeated 3 times .
DATA ANALYSIS
Sample size:
Sample size calculation was performed prior to the study based on
data of pilot study using PPT as the primary outcome using G*POWER
statistical software (version 3.1.9.2; Franz Faul, Universitat Kiel,
Germany) [F tests- MANOVA: Repeated measures, within-between
interaction, α=0.05, power = 80%, effect size= 0.27 ] and revealed that
the appropriate sample size for this study was N=30.
Subject characteristics were compared between groups using
unpaired t-test. Chi- squared test was used for comparison of sex and
affected side distribution between groups. Normal distribution of data
was checked using the Shapiro-Wilk test for all variables. Levene’s test
for homogeneity of variances was conducted to test the homogeneity
between groups. Mixed MANOVA was performed to compare the effects
of treatment on PPT and NDI between the group A and B as between
group comparison and between pre and post treatment in each group as
within group comparison. Post-hoc tests using the Bonferroni correction
were carried out for subsequent multiple comparison. VAS was
compared between groups by Mann–Whitney U test and between pre and
post treatment in each group by Wilcoxon Signed Ranks The level of
Egypt. J. of Appl. Sci., 35 (7) 2020 49
significance for all statistical tests was set at p < 0.05. All statistical
analysis was conducted through the statistical package for social studies
(SPSS) version 25 for windows (IBM SPSS, Chicago, IL, USA).
RESULT
- Subject characteristics:
Table 1 showed the subject characteristics of both groups. There was
no significant difference between both groups in the mean age, weight,
height and BMI. (p < 0.05). Also there was no significant difference in sex
and affected side distribution between groups (p < 0.05).
Table 1. Comparison of subject characteristics between group A and B.
Group A Group B
p- value
Age (years) 25.33 ± 2.7 26.73 ± 3.76 0.25
Weight (kg) 67.53 ± 10.17 64.87 ± 8.14 0.43
Height (cm) 165.06 ± 9.51 163.8 ± 6.4 0.67
BMI (kg/m²) 24.76 ± 2.97 24.2 ± 2.95 0.61
Males/females 5/10 12/3 0.4
Right/left affected side 9/6 10/5 0.7
x , Mean; SD, Standard deviation; p value, Probability value
Effect of treatment on PPT, NDI and VAS:
Mixed MANOVA for PPT and NDI revealed that there was a
significant interaction of treatment and time (F = 19.11, p = 0.001). There
was a significant main effect of time (F = 441.04, p = 0.001). There was
a significant main effect of treatment (F = 4.53, p = 0.02).
Within group comparison
Both groups showed significant increase in PPT post treatment
compared with that pre treatment (p < 0.001). There was a significant
decrease in NDI and VAS in both groups post treatment compared with
that pre treatment (p < 0.001). (table 2).
Between group comparison
There was no significant difference between group A and B in all
variables pre-treatment (p > 0.05). There was a significant increase in
PPT of group A compared with that of group B post treatment (p >
0.001); also, there was a significant decrease in NDI and VAS of group A
compared with that of group B post treatment (p > 0.001). (table 2).
Table 2. Mean PPT and NDI pre and post treatment in group A and B.
Pre treatment Post treatment
Group
A
Group
B
Group
A
Group
B
Pre vs post
(group A)
Pre vs post
(group B)
p
value
p
valu
e
p value p value
PPT (kg/cm²)
1.55 ±
0.42
1.58 ±
0.43
0.86
3.68 ±
0.47
2.84 ±
0.35
0.001 0.001 0.001
NDI (%)
16.26 ±
4.83
15.13
± 3.73
0.47
2.4 ±
0.98
4.26 ±
0.96
0.001 0.001 0.001
x , mean; SD, standard deviation; p-value, level of significance
50 Egypt. J. of Appl. Sci., 35 (7) 2020
Table 3. Median values of VAS pre and post treatment of group A
and B:
VAS
Group A Group B
U- value p-value
Pre treatment 7 (8-6) 8 (9-7) 82.2 0.2
Post treatment 1 (1-1) 2 (2-1) 38 0.001
Z- value -3.44 -3.45
p = 0.0001 p = 0.0001
IQR, Interquartile range; U- value, Mann-Whitney test value; Z- value, Wilcoxon
signed ranks test value; p-value, level of significance
DISCUSSION
This study was conducted to compare between the effect of both dry
needling and integrated neuromuscular inhibition technique on active
myofascial trigger points of upper trapezius muscle. An underlying premise
of this study was that both these technique would be effective in improving
pain pressure threshold, neck disability index and visual analogue scale .
According to the data analysis of the current study, there were a significant
improvement of PPT, NDI and VAS of dry needling group. Also,
neuromuscular inhibition technique group showed significant increase of
PPT and significant decrease in NDI and VAS. The percent of improvement
in PPT of group A was 137% while that of group B was 80%. The percent
of decrease in NDI of group A was 85% while that of group B was 70%. In
comparison between groups post treatment revealed significant increase in
PPT and significant decrease in NDI and VAS of group (A) compared with
that of group( B).
The effect of DN on sensory component was significant decrease in
pain intensity and increase in PPT. Many studies and recent systematic
reviews on the management of MTrPs showed that DN was effective in
relieving pain and improving PPT (Kietrys et al., 2014; Tekin et al., 2013;
Tough et al., 2009, Edwards and Knowles, 2003 and Cummings and
White, 2001) It is possible that rapidly moving a needle into a MTrP might
stimulate the large diameter-sensory afferent fibers, which could lead to an
inhibition in the dorsal horn of spinal cord by blocking the pain information
generated in the MTrP’s nociceptors through a “gate control” mechanism
(Cagnie et al., 2013). Inserting a needle into the MTrP and stimulating it by
rotation is thought to decrease pain due to the rapid depolarization of the
involved muscle fibers which manifests as local twitches. After the muscle
has finished twitching, the spontaneous electrical activity subsides and the
pain and dysfunction decrease dramatically.
The effect of DN on motor component Similar to previous reports that
dry needling stimulate A-delta nerve fibers, which in turn, may activate the
enkephalinergic inhibitory dorsal horn interneurons, resulting in opioid
mediated pain suppression and pain relief (Dommerholt, 2004). For the
Egypt. J. of Appl. Sci., 35 (7) 2020 51
chemical effect of DN, some studies have demonstrated that the increased
levels of bradykinin, substance P, and other chemicals at TrP are directly
corrected by eliciting local twitch response following DN (Shah, 2008).
And also may influence the circulation. Several investigators demonstrtated
that needle insertion in the muscles increased bot skin and muscle blood
flow in the stimulated region (Cagnie et al., 2012).
The effect of DN on autonomic component was the therapeutic effects
of needling can act through the sympathetic system regulation following
needle insertion. Inhibition or blockade of the sympathetic nervous system
might be explanatory mechanism for the reduction of sympathetic response
following DN. Sympatheic system regulation is a polysynaptic reflex with
spinal and supraspinal control (Vetrugno et al., 2003). Different parts of
brain cortex, thalamus, hypothalamus, limbic system have been shown to be
involved in facilitation or inhibition of pain and the autonomic system
(Sakai et al., 2007).
Another explantion may include DN is more local and specific
because of the smaller contact point and possibility of accessing deeper
muscles and provoking LTRs more easily compared with progressive
pressure technique(Kayleigh et al., 2017).
Furthermore, our results were supported with the study investigated
the effect of DN on pain intensity and PPT in patients with myofascial pain
in the upper trapezius muscle. They observed similar improvements in pain
intensity and PPT in patients with myofascial pain in the upper trapezius
muscle. They observed similar improvements in pain intensity and PPT after
1 session of DN compared with 10 physiotherapy sess10 ns.
In contrast to our results (De Meulemeester et al., 2017) who
investigated short term and long term treatment effect of dry needling and
myofascial pain release in treating myofascial neck and shoulder pain in
women . They found that both treatment techniques lead to short term and
long term effects, but dry needling was found to be no more effective than
Myofascial pain release in treatment of myofascial neck-shoulder pain.
Regarding the effect of integrated neuro muscular inhibition technique
directly deal with muscle trigger point that aids in its deactivativation
(Chaitow, 1996) . Ischemic compression aims to slow down blood supply
then produce reactive hyperemia that aids in relieve pain and muscle tension
(muscle spasm ) by decreasing the sensitivity of painful nodules and
normalizing· length of sarcomeres in the affected TrP (Nagrale et at, 2010).
Strain counter strain improve tissue relaxation created by maintaining a
position release of TrP by mechanism of facilitating unopposed arterial
filling that decrease muscle tone which aids in modification of neural
reporting , improvement of local circulation and decreasing of pain (Nagrale
et al., 2010). MET' inhibit muscle tone by isometric contraction to the
involved muscle producing post-isometric relaxation through stimulation of
52 Egypt. J. of Appl. Sci., 35 (7) 2020
Golgi tendon organs (autogenic inhibition) and to the antagonistic muscle
group producing reciprocal inhibition in affected agonistic muscle (Nagrale
et: al., 2010 ).
Our finding were in agreement with the study (Nagrale et al., 2010)
that INIT was directed toward deactivation of TrP and inhibition of muscle
tone before stretching affected upper trapezius that aim. To equalize
shortened sarcomere so increase ROM .NDI is sensitive to change and
correlates significantly with VAS (Vernon and Mior, 1991).
Other study proved that INIT along with specific strength training is
proved to be more effective than INIT alone in reducing pain, decreasing
disability and improving range of motion in individuals with upper trapezius
trigger points (Jyothirmai et al., 2015).
CONCLUSIONS
According to our findings dry needling was more effective than
integrated neuromuscular inhibition technique in improving patients with
active myofascial trigger points on upper trapezius.
Recommendations
1- Replicate this study with greater sample size.
2- Replicate this study with greater number of sessions.
3- Follow up to know long lasting effect of dry needling and integrated
neuromuscular inhibition technique and recurrence of symptoms
4- Including less physically active , older or more progressive patients
5- Further study to be conducted to investigation the effect of dry
needling and integrated neuromuscular inhibition technique on EMG
activity
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مقارنه بین تاثیر الابر الجافه و تقنیه التثبیط العصبى العضمى المتکامل عمى
الجزء العموى من العضمه الشبه منحرفه فى حالات
متلازمه الالم المیفى العضمى
یاسمین ممدوح عبد العزیز * شیماء طه ابو القاسم** عبیر عبدالرحمن یمنى***
* باحث علاج طبیعى بقسم العموم الاساسیو .جامعو القاىره
**مدرس العلاج الطبیعى بقسم العموم الاساسیو.جامعو القاىره
***استاذ دکتور العلاج الطبیعى بقسم العموم الاساسیو .جامعو القاىره
خمفیه: یعتبر متلازمو الالم المیفى العضمى واحد من اکثر مسببات الالام الذى یتعرض لو
المریض حیث انو یؤثر عمى اعمالو الیومیو ویتسبب فى الاحساس باللام الرقبو عمى مدار
الیوم الهدف: مقارنو بین تاثیر الابر الجافو و تقنیو التثبیط العصبى العضمى المتکامل عمى
الجزء العموى من العضمو الشبو منحرفو فى حالات متلازمو الالم المیفى العضمى النتائج: تحسن
ف النتائج لکل من المجموعتین فى تحمل الالم و فى شده الالم و کفاءه الرقبو ولکن یوجد زیاده
فى تحمل الالم ونقص فى شده الالم ف المجموعو الاولى )ا( مقارنو بالمجموعو الثانیو )ب(
الخلاصه: الابر الجافو تاثیرىا اعمى من تقنیو التثبیط العصبى العضمى المتکامل عمى الجزء
العموى من العضمو الشبو منحرفو فى حالات متلازمو الالم المیفى العضمى.
الکممات الداله: الابر الجافو -تقنیو التثبیط العصبى العضمى المتکامل- متلازمو الالم المیفى
العضمى
56 Egypt. J. of Appl. Sci., 35 (7) 2020
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