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ORIGINAL ARTICLE
Abstract
Objectives: To determine (1) whether the shear modulus in upper trapezius muscle myofascial trigger points (MTrPs) reduces acutely after dry
needling (DN), and (2) whether a change in posture from sitting to prone affects the shear modulus.
Design: Ultrasound images were acquired in B mode with a linear transducer oriented in the transverse plane, followed by performance of shear-
wave elastography (SWE) before and after DN and while sitting and prone.
Setting: University.
Participants: Women (NZ7; mean age SD, 4617y) with palpable MTrPs were recruited.
Intervention: All participants were dry needled in the prone position using solid filament needles that were inserted and manipulated inside the
MTrPs. SWE was performed before and after DN in the sitting and prone positions.
Main Outcome Measure: MTrPs were evaluated by shear modulus using SWE.
Results: Palpable reductions in stiffness were noted after DN and in the prone position. These changes were apparent in the shear modulus map
obtained with ultrasound SWE. With significant main effects, the shear modulus reduced from before to after DN (P<.01) and from the sitting to
the prone position (P<.05). No significant interaction effect between time and posture was observed.
Conclusions: The shear modulus measured with ultrasound SWE reduced after DN and in the prone position compared with sitting, in agreement
with reductions in palpable stiffness. These findings suggest that DN and posture have significant effects on the shear modulus of MTrPs, and that
shear modulus measurement with ultrasound SWE may be sensitive enough to detect these effects.
Archives of Physical Medicine and Rehabilitation 2013;94:2146-50
2013 by the American Congress of Rehabilitation Medicine
From 1996 to 2006, U.S. residents more than tripled their Dry needling is a technique used by a variety of clinicians in the
spending on prescription analgesics, from $4.2 to $13.2 billion.1 treatment of myofascial pain and motor dysfunction. A fine-gauge,
Since myofascial pain has a lifetime prevalence of 85% many solid filament needle is inserted into discrete focal points of taut
chronic pain disorders and syndromes of the musculoskeletal bands within muscle and manipulated until local twitch responses
system can be explained by the presence of localized, hyperirri- (LTRs) are elicited. The LTR is an involuntary spinal reflex
table nodules in taut bands of skeletal muscle called myofascial contraction of muscle fibers within a taut band and occurs during
trigger points (MTrPs).2 These trigger points are tender on needling of a taut band. This LTR elicited by dry needling is
palpation and cause pain, restricted range of motion, and associated with pain relief and a palpable reduction of muscle
substantial motor dysfunction. The etiology of MTrPs is suggested stiffness.4 Despite the clinical efficacy of dry needling for allevi-
to be due to motor endplate dysfunction.2,3 ating the symptoms of MTrPs, objective quantification of the
severity of MTrPs in terms of muscle stiffness has not been possible.
No commercial party having a direct financial interest in the results of the research supporting The literature has shown that 2- and 3-dimensional ultrasound
this article has conferred or will confer a benefit on the authors or on any organization with which
the authors are associated.
imaging can be used for visualizing MTrPs and their associated
0003-9993/13/$36 - see front matter 2013 by the American Congress of Rehabilitation Medicine
http://dx.doi.org/10.1016/j.apmr.2013.04.021
Quantification of stiffness in myofascial trigger points 2147
characteristics.5-10 Recently developed ultrasound shear-wave over the region of interest on the upper trapezius muscle, and the
imaging technology measures the shear-wave propagation transducer was manipulated until the muscle fibers appeared
through soft tissues, thereby allowing for the objective quantifi- parallel. The boundaries of the transducer were then marked on
cation of the soft tissue stiffness in real time by means of the shear the skin to standardize the transducer position. Once a clear image
modulus (in kilopascals). It would be useful if this technology was acquired in B mode, supersonic shear imaging mode was used
could provide a means for quantifying the muscle stiffness asso- to obtain the shear modulus map of the muscle for the region of
ciated with MTrPs. Although this technology has been applied to interest. Three elastography images were acquired in 5 seconds
healthy human skeletal muscles,11,12 the applicability of the before and immediately after dry needling in 2 subject postures:
technology to MTrPs and its treatment with dry needling is (1) while subjects sat upright in a high backed chair, shoulders
unknown. Hence, we performed a preliminary study to provide relaxed with arms supported by armrests; and (2) in the prone
insights into the applicability of the ultrasound shear-wave position with arms resting alongside their trunk. From each elas-
imaging technology in assessing the efficacy of dry needling on tography image, the spatial average of the shear modulus (kPa) in
muscle stiffness that is associated with MTrPs. an 8-mm circular area was determined, and the values were
We expected that the shear modulus in the trapezius muscle averaged across 3 measurements in each condition.
would be reduced acutely as a result of dry needling. In clinical
practice, the upper trapezius muscle is palpated with the patient in Dry needling
the sitting, supine, or prone position. Since neuromuscular excit-
ability is reduced in the supine position compared with the sitting All subjects were dry needled in the prone position using a slow-
position,13 we also expected that the shear modulus in the trape- velocity technique. A solid filament needle with guide tubeb
zius muscle would be reduced with a change in posture from the (0.250mm) was inserted into the trigger point in the upper
sitting to the prone position. trapezius muscle. The needle was manipulated up and down
The primary and secondary objectives of this preliminary study (sweeps) inside the trigger point 10 times in an effort to stan-
were as follows: (1) to compare the shear modulus of the upper dardize the dry needling protocol. Several LTRs were elicited.
trapezius muscle with MTrPs before and after dry needling, and
(2) to compare the shear modulus of the upper trapezius muscle
between the prone and sitting positions, using ultrasound shear- Statistical analysis
wave elastography.
The dependent variable was the shear modulus of the upper
trapezius muscle. The effects of time (before and after dry
Methods needling) and posture (sitting and prone) were analyzed using
a 2-way repeated analysis of variance (ANOVA). An alpha value
Study population less than .05 was considered significant. Mean data are presented.
The new findings of the preliminary study are that the shear
List of abbreviations:
modulus of the upper trapezius muscle with MTrPs was signifi-
ANOVA analysis of variance
cantly reduced after dry needling and in the prone position, in
LTR local twitch response
agreement with reductions in palpable stiffness. These findings
MTrPs myofascial trigger points
support that shear-wave elastography could quantitatively detect
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2148 R.M. Maher et al
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Quantification of stiffness in myofascial trigger points 2149
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