Discerning the Truth of What You Read

Comparison of the short-term outcomes between trigger point dry needling and trigger point manual therapy for the management of chronic mechanical neck pain: a randomized clinical trial.

Llamas-Ramos R, et al. J Orthop Sports Phys Ther. 2014 Nov;44(11):852-61. doi: 10.2519/jospt.2014.5229. Epub 2014 Sep 30.

Weblink: http://www.ncbi.nlm.nih.gov/pubmed/25269764

Abstract

Objectives: To compare the effects of trigger point (TrP) dry needling (DN) and TrP manual therapy (MT) on pain, function, pressure pain sensitivity, and cervical range of motion in subjects with chronic mechanical neck pain.

Background: Recent evidence suggests that TrP DN could be effective in the treatment of neck pain. However, no studies have directly compared the outcomes of TrP DN and TrP MT in this population.

Methods: Ninety-four patients (mean ± SD age, 31 ± 3 years; 66% female) were randomized into a TrP DN group (n = 47) or a TrP MT group (n = 47). Neck pain intensity (11-point numeric pain rating scale), cervical range of motion, and pressure pain thresholds (PPTs) over the spinous process of C7 were measured at baseline, postintervention, and at follow-ups of 1 week and 2 weeks after treatment. The Spanish version of the Northwick Park Neck Pain Questionnaire was used to measure disability/function at baseline and the 2-week follow-up. Mixed-model, repeated-measures analyses of variance (ANOVAs) were used to determine if a time-by-group interaction existed on the effects of the treatment on each outcome variable, with time as the within-subject variable and group as the between-subject variable.

Results: The ANOVA revealed that participants who received TrP DN had outcomes similar to those who received TrP MT in terms of pain, function, and cervical range of motion. The 4-by-2 mixed-model ANOVA also revealed a significant time-by-group interaction (P.001) for PPT: patients who received TrP DN experienced a greater increase in PPT (decreased pressure sensitivity) than those who received TrP MT at all follow-up periods (between-group differences: post treatment, 59.0 kPa; 95% confidence interval [C]: 40.0, 69.2; 1-week follow-up, 69.2 kPa; 95% CI: 49.5, 79.1; 2-week follow-up, 78.9 kPa; 95% CI: 49.5, 89.0).

Conclusion: The results of this clinical trial suggest that 2 sessions of TrP DN and TrP MT resulted in similar outcomes in terms of pain, disability, and cervical range of motion. Those in the TrP DN group experienced greater improvements in PPT over the cervical spine. Future trials are needed to examine the effects of TrP DN and TrP MT over long-term follow-up periods. Level of Evidence Therapy, level 1b.

Dr. Phil Gabel’s comment:

Before you read too much into the study – remember the Northwick Park Neck Pain Questionnaire is a modified Neck Disability Index (NDI) – so it is not as efficient as the NDI. In clinimetric terms – the authors would not be able to find a difference between the two studies, as the tools being used are unlikely to be sufficiently sensitive to determine changes for pain & disability.

This is a classic example of how not to design a study, or how to design a study to make it show what you want – use a tool that is not sufficiently sensitive to pick up any difference. The NDI and Northwick Park have an minimal detectable change (or MDC) of ~21% difference between variables and the Numeric Rating scale in this group can take up 45% change to be accurate [1] – so you will be hard pressed to get any difference between the two types of treatment when the measures used are so insensitive. So a predictable outcome of 'no difference'.

This would be like asking 2 people on the side of the Formula 1 track, to say which car is fastest on the main straight! Alternatively you could use a radar gun. The researchers here chose two people who left their radar guns at home. In this example, usage of the Advise Rehab software which has an MDC of ~5% (4 times more sensitive ) or the Spine Functional Index with an MDC of 7% (~3 times more sensitive), would be appropriate examples of validated radar guns.

If you are treating patients and need to show them, a third party payer (e.g. WorkCover) or an employer - that a difference has occurred and that YOU are being effective in your treatment or intervention strategy AND should continue to be paid for your services – then you need a sensitive tool that will do that for you - ideally one that has an MDC less than 10%.

The Advise Rehab software is the most sensitive and accurate method to achieve this and for first time users, Advise Rehab is offering you a limited time offer of 20%.

You can also freely access, download and use the SFI-10 (clinical) and SFI-25 (research) questionnaires here for use in your specific capacity.

1. Pool, J.J., et al., Minimal clinically important change of the Neck Disability Index and the Numerical Rating Scale for patients with neck pain. Spine (Phila Pa 1976), 2007. 32(26): p. 3047-51.

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All the best,

Doug Cary FACP
Specialist Musculoskeletal Physiotherapist (awarded by Australian College of Physiotherapy, 2009)
PhD Candidate Curtin University
Clinical Director AAP Education

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