Trigger Point Pathophysiology
Myofascial trigger points (MTrPs) are defined as “hyperirritable spots in skeletal muscle that are also associated with hypersensitive palpable nodules in taut bands” (1). The tenderness associated with this pain is restricted solely to the taut band instead of the entire muscle (1). MTrPs can develop in any muscle of the body due to either “sudden injury, muscle, overload, or repetitive microtrauma” (4). Upon compression of MTrPs, pain is elicited in that point as well as along a referral pattern from that point of origin (1,3,4). Autonomic phenomena can also follow this MTrP compression, such as localized sweating, vasoconstriction or vasodilation, and pilomotor activity (1,4). These additional effects of MTrP compression are important for differentiating from other muscle tender points, which in contrast “only cause local pain upon compression” (1). Trigger points are described as being active or latent (1,3). Active MTrPs can produce spontaneous referred pain and often generate clinical symptoms as well (3,4). Latent MTrPs are usually asymptomatic but can produce referred pain due to either compression, stretch, or overload of the involved tissues (3,4). In addition to these referral patterns, latent MTrPs are believed to modify muscle activation patterns, ultimately affecting strength of the muscle as well as range of motion achieved (3). Many factors have been associated with activating MTrPs, such as poor posture and physical or social conditions leading to vitamin deficiencies (1,4). The primary belief behind MTrP pathophysiology is that these hyperirritable spots are caused by an excessive release of acetylcholine (Ach) from the motor endplates (1). This prolonged release of Ach leads to “chronic shortening and contractures of sarcomeres, coupled with decreased circulation leading to hypoxia and local ischemia” (1). In response, inflammatory mediators – such as prostaglandins, bradykinins, and histamine – are also released, sensitizing the sensory afferent fibers of the muscle, likely causing the point tenderness of MTrPs (1). The influx of inflammatory mediators produces hypersensitivity of nociceptors, leading to both peripheral sensitization (localized at the site of injury) and central sensitization (especially at the dorsal horn neurons) (1).
Increasing Utilization of Dry Needling
Dry needling (also known as functional dry needling, intramuscular manual stimulation, or intramuscular needling) is a treatment technique used by physical therapists around the world since the 1980’s (1,2). Although not typically taught in entry-level education, many certification programs and continuing education courses have emerged to teach clinicians this innovative technique (1,3). With this increase of dry needling utilization in clinical practice, the American Physical Therapy Association (APTA) and the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT) have both published position statements supporting the use of dry needling by physical therapists (1).
Dry Needling Methods
Dry needling (DN) is described as using a fine needle to penetrate the skin, subcutaneous tissues, and muscle with the purpose to “mechanically disrupt the tissue without the use of an anesthetic” (2,5). In a more expansive view, DN can be utilized to target muscles, ligaments, tendons, subcutaneous fascia, scar tissue, peripheral nerves, bones, and neurovascular bundles (3). Prior to utilizing the technique, clinicians must identify the appropriate patients and screen for absolute or relative contraindications that could lead to adverse effects (1).
|Patient with needle phobia
An unwilling patient
Patient who is unable/unwilling to give consent
History of abnormal reaction to needling/injection
In a medical emergency
Patient on anticoagulant therapy/has thrombocytopenia
In an area/limb with lymphoedema
|an area/limb with lymphoedema
Abnormal bleeding tendencies
Severely compromised immune system (e.g. HIV, cancer, hepatitis, etc.)
Altered psychological status
Allergy to metals or latex
Needling near a surgical site within 4 months of surgical procedure
Anatomic considerations (over pleura and lungs, nerves, organs, implants, etc. )
After screening for these possible eliminations, the clinician must then confirm that the patient is an ideal candidate for the DN technique. The patient should possess the following qualities: “1) a physical therapy diagnosis that will reasonably improve with DN; 2) the ability to understand what is being done and why; 3) the ability to effectively communicate his or her own response to treatment; 4) the ability to lie still during treatment; and 5) the ability to provide informed consent according to clinical guidelines” (1). It is critical to obtain signed informed consent from the patient following a discussion explaining the purpose, methods, and risks associated with DN (1). The patient should be positioned in either supine, prone, or sidelying with the targeted tissues exposed and pillows or bolsters for assisting the patient positioning. The positioning should allow the patient to relax. Completing DN in a seated position is not recommended due to the risks of syncope occurring. Although several studies have deemed routine disinfection of visibly clean skin prior to needling unnecessary, the current standards of care recommend preparing the skin with 70% isopropyl alcohol and the clinician wearing gloves during the treatment. After disinfection of the area, the clinician identifies the MTrP using palpation and utilizes either the pincer grip to lift the skin or flat palpation to take up the slack of the skin. The sterile, disposable, solid filament needle is then inserted directly through the skin, or using a guide tube that is immediately removed, with a depth sufficient enough to penetrate the MTrP (1).
Once the needle is inserted into the MTrP, the practitioner has several technique variations to employ. The clinician may use a slow, steady pistoning motion in and out of the muscle with the needle (termed dynamic DN). The needle could also be left unbothered, also known as in situ (termed static DN). Another variation involves the needle being rotated several revolutions to draw the surrounding fascia or soft tissue around the needle as well. If the clinician decides to utilize the static technique, intramuscular electrical stimulation (IES) could augment the treatment. Since previous studies have proven IES to produce muscle relaxation and increase local blood circulation, the addition could lead to a greater decrease in muscle tone and improvements of motor recruitment, as long as contraindications of IES are ruled out (1).
Throughout the intervention, the practitioner should note the gauge, or diameter, and the length of the needles and ensure that the needle parameters are appropriate for the targeted muscles. A 0.30 x 50mm needle is appropriate for most muscles, but various other gauges and lengths are available for tissues of varying depths and sizes – such as a 0.30 x 75mm for the psoas or a 0.20 x 25 mm for the forearm muscles (1,3). If a patient is having their first experience with DN, and have given informed written consent, then treating only 1-2 muscles could be the best practice. After becoming accustomed to the intervention, the clinician could treat 3-4 muscles or more in following sessions as appropriate (1).
To gain the most benefits from DN, several authors believe that the intervention should elicit a localized twitch response (LTR) (1,4,5). This muscular response to the needle is thought to interrupt the motor end plate noise, which in turn elicits an analgesic effect (1,4). Following DN, which rarely exceeds 10 minutes, the involved tissues are then stretched and instructed through neuromuscular re-education of new movement patterns (1,4).
Physiology Behind Dry Needling
The scientific basis behind DN are summarized by several different models of thought, the most frequently utilized being the trigger point model, credited to the research of Janet Travell (1). These MTrPs are specifically targeted and inactivated by DN under the belief that the sensory, motor, and autonomic abnormalities will be relieved (1). It is suggested that DN produces both local and central nervous system responses to restore homeostasis at the MTrP site, ultimately reducing the presence of both peripheral and central sensitization (2). The DN is thought to improve the flow of acetylcholinesterase and relax the actin-myosin bonds of the taut bands (1). This cascade of events decreases the release of Ach and inflammatory mediators – such as bradykinin, calcitonin gene- related peptide, and substance P – which were responsible for the shortening of muscle, hypersensitivity and reduction of pain threshold associated with MTrP (1,4). DN also stimulates the alpha-delta nerve fibers, activating the enkephalinergic inhibitory dorsal horn interneurons as well as producing opioid-mediated pain reduction (4). Therefore, DN subsequently utilizes both the gate control theory as well as descending central mechanisms to achieve analgesia (2,4). Another theory behind DN is that it aids chronic injuries by disrupting the cyclic inflammatory process and re-stimulating the inflammatory cycle with a natural “reset” (6). This newly “injured” tissue restores the healing process and encourages new tissue formation (6).
Effects on Pain Research
Because of the invasive technique of DN, it is difficult for researchers to execute double-blinded, randomized controlled clinical trials, which severely limits the quality of evidence that can be conducted (1). Despite this limitation, Gattie et al collected several studies that compared DN to sham needling or control and examined their effects on pain, pressure pain threshold (PPT), and function outcomes immediately and long-term. Most of the studies, although being of low-quality, suggested a moderate effect of DN over control/sham in reducing pain and improving PPT immediately and after 12 weeks. In these same studies, the authors suggested a small effect in favoring DN over sham/control in reducing pain after 6 months. Gattie et al also examined studies that compared DN to other treatments and observed their effects on pain. There was moderate-quality evidence to suggest small effect favoring DN in reducing pain and low-quality evidence support a moderate effect favoring DN in improving PPT. It is important to note that not all of these studies utilized corrective exercise in addition to the variables being observed (2).
Halle et al conducted a single-blind randomized clinical trial to determine if the addition of DN to a rehabilitation protocol after shoulder stabilization surgery was more effecting in improving range of motion (ROM), pain, and functional outcome scores. These dependent variables were assessed for the 39 enrolled patients at baseline (4 weeks post-operative) and at 8 weeks, 12 weeks, and 6 months post-operative. The 19 patients in the DN group received standard rehabilitation and weekly DN treatments between 4- and 8-weeks post- operative, while the control group received “sub- therapeutic” passive ROM during the DN treatment time. Aside from the statistically significant improvement in shoulder flexion ROM in the control group at the 6-month follow up, there were no significant differences in the outcomes between the two groups, with both groups showing improvement over time (3).
Kietrys et al conducted a systematic review and meta-analysis to explore the evidence regarding the effects of DN on pain reduction of patients with upper-quarter myofascial pain. Of the twelve studies collected and included in their analysis, three studies suggested a large effect favoring DN over sham/control having immediate effects on pain suppression, with one studying being clinically meaningful. Three studies also suggested a large effect favoring DN over sham/control in controlling pain at 4 weeks, although caution should be used due to the 95% confidence interval (CI) crossing the line of no difference. Two studies compared DN to other treatments and assessed their immediate effects on pain, suggesting a moderate effect favoring other treatment over DN. However, these studies were of questionable clinical meaningfulness due to their raw between- group effect sizes. Six studies suggested a small overall effect favoring other treatment over DN in improving pain at 4 weeks, with the 95% CI crossing the line of no difference (4).
Effects on Performance Research
Gattie et al found that there was low-quality evidence to suggest a small effect favoring DN over sham/control in improving functional outcomes both immediately and long-term. When compared to other treatments, very low-quality evidence suggested that there was no effect of DN, despite one study reporting that DN lead to functional outcome improvements (2).
Dembowski et al completed a case report on an 18- year-old collegiate pole vaulter that sustained an acute hamstring strain and had a history of multiple strains on his uninvolved extremity. In his initial examination, the athlete demonstrated limited knee active ROM, weakness, tenderness to palpation, and dysfunction according to the Selective Functional Movement Assessment (SFMA), consistent with a diagnosis of a grade 2 hamstring strain. He completed a physical therapy rehabilitation program three times per week for 3 weeks, focusing on progressive eccentric strengthening, and was instructed to perform a home exercise program as well. Due to the presence of MTrPs, he received a session of DN once per week after completing his exercises for that day without any adverse effects. The patient demonstrated improvements at every consecutive visit, completing an equal active straight leg raise, having no AROM deficits, and improving his SFMA. On day 20, at the time of his return to sport assessment, the physical examination was unremarkable, with him able to meet specific functional criteria, particularly eccentric strength within 10% of the uninvolved extremity, as well as completing several sport specific functional tests. At his follow-up examinations, there was no reported new injuries, deficits present, and he was fully participating in pole vaulting (5).
Another case report published by Patrick et al investigated a multimodal approach to conservatively manage a chronic ulnar collateral ligament (UCL) injury in a collegiate baseball pitcher. The athlete presented to outpatient physical therapy 6 weeks post-injury and platelet- rich plasma (PRP) injection. In his initial examination, he was diagnosed with a grade I and “borderline” grade II UCL sprain as well as reports of increased pain, strength deficits of both upper and lower extremities, motor recruitment deficits of scapulothoracic musculature, and significant disability measured by the Disability of the Arm, Shoulder, and Hand (DASH) outcome assessment. During the first 4 weeks, the athlete completed pain-free ROM and shoulder/scapula stabilizationexercises to strengthen the involved upper extremity (UE). Although achieving full strength in his UE at this point, he was still unable to complete a throwing program pain free. For weeks 5 and 6 after initial evaluation, he received a weekly DN session in addition to his rehabilitation exercises to initiate another acute inflammatory response, suppress pain, and promote healing of the sprained ligament. Palpation discovered MTrPs in his forearm flexor musculature, which received DN connected to IES to elicit the LTR. The injured, avascular UCL tissue received DN with the pistoning technique to reset the extracellular healing process. A follow-up MRI after the second DN session confirmed significantly decreased tears and laxity along with no edema. For weeks 7-12, the rehabilitation shifted its focus to strengthening of the kinetic chain utilized in the throwing biomechanics as well as neuromuscular reeducation to correct altered patterns in his throwing mechanics. After treatment, he reported significantly lower pain levels, displayed improvements in strength, proper pitching form, and decreased disability scores on the DASH assessment. At the start of the following season, the athlete returned to sport at 6 months post-injury with no pain at full speed (6).
Short et al also documented a case report upon a 29-year-old National Basketball Association player that sustained a contact injury during a professional game, resulting in an acute avulsion of the rectus abdominis and adductor longus from the pubic symphysis as well as partial tears of the adductor brevis and pectineus. After undergoing surgical repairs of the injuries, the athlete was led through 3 phases of rehabilitation – acute, subacute, and return-to-sport reconditioning – until he met return-to-play criteria that included a reduction in pain, normalization of ROM and strength, improvements on outcome questionnaires, reduction of movement asymmetries, and pain-free running and sport participation. The acute phase utilized various interventions – such as cryotherapy, pneumatic compression, open-kinetic-chain exercises, ROM, and progressive weight-bearing activities – to promote proper healing of the surgical repairs. Thesubacute phase (weeks 1 through 3 post-operative) consisted of additional manual therapy techniques, progressive strengthening, and motor control in multiple planes of movement. During this phase, on days of increased soreness, the athlete received DN in areas of increased tone and tenderness found within the adductor longus, rectus abdominis, and related regional musculature. Upon test-retest, he reported a clinically significant decrease in pain, decrease in soreness following ROM activities, and an improvement in ROM achieved according to visual observation. Phase 3 treatment implemented active mobility drills, progressive strengthening exercises in preparation for competition, and advanced plyometric and agility activities. Manual therapy and DN were reduced during this phase, only being utilized if impairments were presented possibly relating to mobility restrictions and/or increased pain. He was able to return to in-season competition at 5 weeks post-operation, with improvements observed in pain rating, the Copenhagen Hip and Groin Outcome Score, mobility, strength, the Functional Movement Screen, the Y Balance Test, and sport performance metrics. At his 2-year follow-up, he remained an active professional basketball player and had not experienced any complications or reinjuries (7).
As stated previously, it is difficult for research to conduct high-quality clinical trials to determine the effectiveness of DN due to its invasiveness. Additionally, the research that has been published is contradictory, with no true consensus on the effect size DN has on pain reduction and its effect on improving performance. However, several cases do Further evidence should still be conducted to elaborate upon the benefits of DN. But when collaborated upon with corrective exercise and analysis of movement patterns, DN could play a pivotal role in an athlete’s recovery and return to peak performance.
Trigger Point Pathophysiology Myofascial trigger pointi (MTrPs) ni kufafanuliwa kama <unk> spots hyperirritable katika misuli ya mifupa ambayo pia ni kuhusishwa na nodules hypersensitive palpable katika bendi tight <unk> (1). Ugonjwa huu unaathiri tu sehemu ya misuli iliyo ngumu badala ya misuli yote. MTrPs inaweza kuendeleza katika misuli yoyote ya mwili kutokana na ama <unk>madhara ya ghafla, misuli, overload, au microtrauma ya mara kwa mara<unk> (4). Wakati wa compression ya MTRP, maumivu ni elicited katika hatua hiyo kama vile pamoja na muundo wa rufaa kutoka hatua hiyo ya asili (1,3,4). Mfumo wa MTP unaweza pia kufuatia msongamano huu wa MTP, kama vile jasho la mahali, vasoconstriction au vasodilation, na shughuli ya pilomotor. Athari hizi za ziada za MTrP compression ni muhimu kwa kutofautisha kutoka kwa pointi nyingine za misuli, ambayo kinyume chake <unk> husababisha maumivu ya ndani tu wakati wa compression <unk> (1). Trigger pointi ni ilivyoelezwa kama kuwa hai au latent (1,3). MTPs zinaweza kusababisha maumivu ya spontaneous na mara nyingi hutokeza dalili za kliniki pia. MTPs za latent ni asymptomatic lakini zinaweza kusababisha maumivu ya kumbukumbu kutokana na compression, stretch, au overload ya tishu zinazohusika. Kwa kuongezea mifumo hii ya rufaa, MTRPs ya siri inaaminika kubadilisha mifumo ya uanzishaji wa misuli, hatimaye kuathiri nguvu ya misuli na pia wigo wa mwendo uliopatikana. Kuna sababu nyingi zinazohusiana na kuamsha MTP, kama vile msimamo mbaya na hali za mwili au kijamii zinazoongoza kwa upungufu wa vitamini. Kwa sababu ya hali ya MTRP, sehemu hizi za hyperirritable zinasababishwa na kutolewa kwa acetylcholine (A) kutoka kwa mwisho wa motor. Hii kutolewa kwa muda mrefu wa Ach inaongoza kwa <unk>mzito kufupisha na contractures ya sarcomeres, pamoja na kupungua kwa mzunguko wa damu na kusababisha hypoxia na ischemia ya ndani <unk> (1). Katika majibu, mediators uchochezi - kama vile prostaglandins, bradykinins, na histamine - pia ni iliyotolewa, sensitizing nyuzi sensory afferent ya misuli, pengine kusababisha uhakika uchungu wa MTrPs (1). Mzunguko wa mediators inflammatory inazalisha hypersensitivity ya nociceptors, na kusababisha wote sensitization peripheral (localized katika tovuti ya jeraha) na sensitization kuu (hasa katika neurons pembe ya mgongo) (1). "Kutumia ""Dry needling"" (au ""functional dry needling,"" ""intramuscular manual stimulation,"" au ""intramuscular needling"") ni mbinu ya matibabu inayotumiwa na wataalamu wa matibabu duniani kote tangu miaka ya 1980." Ingawa si kawaida kufundishwa katika elimu ya kiwango cha kuingia, mipango mingi ya vyeti na kozi za elimu ya kuendelea zimeibuka kufundisha madaktari mbinu hii ya ubunifu (1,3). Kwa kuongezeka kwa matumizi ya sindano kavu katika mazoezi ya kliniki, Chama cha Tiba ya Kimwili cha Amerika (APTA) na Chuo cha Amerika cha Tiba ya Mwongozo wa Orthopedic (AAOMT) vimechapisha taarifa za msimamo zinazounga mkono matumizi ya sindano kavu na wataalamu wa matibabu ya kimwili. Kwa kawaida, dawa ya kupasua ni kutumia sindano ndogo kupenya ngozi, tishu subcutaneous, na misuli kwa kusudi la <unk> mechanically kuvuruga tishu bila matumizi ya anesthetic <unk> (2,5). Kwa mfano, DNA inaweza kutumika kwa kuelekeza misuli, ligaments, tendons, fascia subcutaneous, tishu scar, neva za pande zote, mifupa, na bundles neurovascular. Kabla ya kutumia mbinu hii, madaktari lazima kutambua wagonjwa sahihi na screen kwa ajili ya contraindications kamili au jamaa ambayo inaweza kusababisha athari mbaya. Mgonjwa mwenye hofu ya sindano: mgonjwa ambaye hawezi kutoa idhini yake kwa matibabu ya sindano, ambaye ana athari mbaya kwa sindano, ambaye ana ugonjwa wa thromboembolism, ambaye ana ugonjwa wa lymphedema, ambaye ana ugonjwa wa lymphedema, ambaye ana ugonjwa wa lymphedema. HIV, kansa, hepatitis, na kadhalika.) Ugonjwa wa akili: Madhara ya nywele, nywele, nywele, nywele, nywele, nywele, nywele, nywele, nywele, nywele, nywele, nywele, nywele, nywele, nywele, nywele, nywele, nywele, nywele, nywele, nywele, nywele, nywele, nywele, nywele, nywele, nywele, nywele, nywele, nywele, nywele, nywele, nywele, nywele, nywele, nywele, nywele, nywele, nywele, nywele, nywele, nywele. Baada ya kuchunguza kwa ajili ya kuondolewa haya uwezekano, daktari lazima kisha kuthibitisha kwamba mgonjwa ni mgombea bora kwa ajili ya mbinu DN. Mgonjwa anapaswa kuwa na sifa zifuatazo: (1) utambuzi wa matibabu ya kimwili ambayo itaboresha kwa sababu ya DN; (2) uwezo wa kuelewa nini kinachotengenezwa na kwa nini; (3) uwezo wa kuwasiliana kwa ufanisi majibu yake mwenyewe kwa matibabu; (4) uwezo wa kukaa bila kusonga wakati wa matibabu; na (5) uwezo wa kutoa idhini ya ufahamu kulingana na miongozo ya kliniki. Ni muhimu kupata idhini ya mgonjwa iliyoandikwa baada ya mazungumzo ya kuelezea kusudi, mbinu, na hatari zinazohusiana na DN. Mgonjwa anapaswa kuwekwa ama katika supine, prone, au sidelying na tishu lengo wazi na mto au bolsters kwa kusaidia mgonjwa nafasi. Msimamo huo unapaswa kumruhusu mgonjwa apumzike. Kukamilisha DN katika nafasi ya kukaa haipendekezi kutokana na hatari ya syncope kutokea. Ingawa utafiti kadhaa umeona kuwa disinfection ya kawaida ya ngozi safi kabla ya kuingiza sindano ni ya lazima, viwango vya sasa vya utunzaji vinapendekeza kuandaa ngozi na 70% isopropyl pombe na daktari kuvaa glavu wakati wa matibabu. Baada ya kuua vimelea, daktari hutambua MTP kwa kutumia palpation na hutumia ama grip pincer kuinua ngozi au palpation gorofa kuchukua up slack ya ngozi. Kisha, sindano ya sterili, ya kutumiwa mara moja, ya nyuzi ngumu huingizwa moja kwa moja kupitia ngozi, au kwa kutumia bomba la kuongoza ambalo huondolewa mara moja, kwa kina cha kutosha kupenya MTP. Mara baada ya sindano kuingizwa katika MTrP, mtaalamu ana tofauti kadhaa za mbinu ya kutumia. Daktari anaweza kutumia mwendo wa polepole, thabiti wa pistoning ndani na nje ya misuli na sindano (inaitwa DN ya nguvu). Pia, sindano inaweza kuachwa bila kusumbuliwa, inayoitwa in situ (inaitwa DN ya kimya). Tofauti nyingine inahusisha sindano kugeuzwa mara kadhaa ili kuchora fascia au tishu laini inayozunguka sindano pia. Kwa mfano, kama daktari anaamua kutumia mbinu ya static, intramuscular umeme stimulation (IES) inaweza kuongeza matibabu. Kwa kuwa utafiti wa awali umeonyesha kuwa IES inazalisha kupumzika kwa misuli na kuongeza mzunguko wa damu wa ndani, kuongeza kunaweza kusababisha kupungua kwa nguvu za misuli na kuboresha kuajiri kwa magari, kwa muda mrefu kama contraindications za IES zimekataliwa. Wakati wa upasuaji, daktari anapaswa kuzingatia kipimo, au kipenyo, na urefu wa sindano na kuhakikisha kwamba vigezo vya sindano ni sahihi kwa misuli inayolengwa. Inchi ya 0.30 x 50mm ni sahihi kwa misuli mingi, lakini vipimo vingine mbalimbali na urefu zinapatikana kwa tishu za kina na ukubwa tofauti, kama vile 0.30 x 75mm kwa psoas au 0.20 x 25mm kwa misuli ya mkono wa mbele. Ikiwa mgonjwa ana uzoefu wao wa kwanza na DN, na wamewapa idhini ya maandishi, basi kutibu misuli 1-2 tu inaweza kuwa mazoezi bora. Baada ya kuhitimu na upasuaji, daktari anaweza kutibu misuli mitatu au zaidi katika vikao vifuatavyo kama inavyostahili. Kwa sababu ya faida kubwa ya DN, wataalamu wengi wanaamini kwamba hatua hiyo inapaswa kusababisha majibu ya twitch (LTR) ya eneo. Msaada wa misuli kwa sindano hufikiriwa kuvunja kelele ya mwisho wa motor, ambayo kwa upande wake husababisha athari ya analgesic (1,4). Baada ya muda wa dakika 10 au zaidi, tishu zinazohusika zinafupishwa na kuelekezwa kupitia elimu ya neuromuscular ya mifumo mpya ya harakati. "Kutumia ""Dry needling"" ni njia ya kuelezea hali ya mwili ya mtu, na kwa sababu ya kutegemea utafiti wa Janet Travell, kuna mifano kadhaa ya ""trigger point"" ambayo ni muhimu sana kwa matibabu ya matibabu ya matibabu ya matibabu." MTPs hizi ni maalum lengo na inactivated na DN chini ya imani kwamba sensory, motor, na autonomic abnormalities itakuwa kuondolewa. Kwa hivyo, kuna uwezekano kwamba DNA inazalisha majibu ya mfumo wa neva wa ndani na wa kati ili kurudisha homeostasis katika tovuti ya MTRP, na hatimaye kupunguza uwepo wa unyeti wa pande zote mbili za pande zote mbili. Kwa mfano, kuna uwezekano wa kuimarisha mtiririko wa acetylcholinesterase na kuondoa vifungo vya actin-myosin kwenye mishipa ya nyongeza. Mzunguko huu wa matukio hupunguza kutolewa kwa Ach na wajumbe wa uvimbe kama vile bradykinin, peptide inayohusiana na jeni la calcitonin, na dutu P, ambayo ilikuwa na jukumu la kufupisha misuli, unyeti wa juu na kupunguzwa kwa kizingiti cha maumivu kinachohusiana na MTRP. Katika kesi ya kupumua, nyuzi za neva za alpha-delta huchochea interneurons za pembe ya nyuma ya enkephaline, na pia hupunguza maumivu ya opioid. Kwa hiyo, DN baadaye hutumia nadharia ya kudhibiti lango na vilevile utaratibu wa chini wa kati ili kufikia analgesia (2,4). Nadharia nyingine nyuma ya DN ni kwamba inasaidia majeraha ya muda mrefu kwa kuvuruga mchakato wa uchochezi wa mzunguko na kuchochea tena mzunguko wa uchochezi na <unk>reset<unk> ya asili (6). Tambo hii mpya "iliyoharibiwa" inarudisha mchakato wa uponyaji na kuhamasisha malezi ya tishu mpya (6). Kwa sababu ya mbinu ya uvamizi wa DN, ni vigumu kwa watafiti kutekeleza majaribio ya kliniki ya blinded, randomized, ambayo hupunguza sana ubora wa ushahidi ambao unaweza kufanywa. Pamoja na upungufu huu, Gattie na wenzake walikusanya masomo kadhaa ambayo yalilinganisha DN na udongo wa udongo au udhibiti na kuchunguza athari zao juu ya maumivu, kizingiti cha maumivu ya shinikizo (PPT) na matokeo ya kazi mara moja na kwa muda mrefu. Utafiti wa utafiti wa kawaida, ingawa ni wa ubora wa chini, ulionyesha athari ya wastani ya DN juu ya udhibiti wa kudhibiti na kupunguza maumivu na kuboresha PPT mara moja na baada ya wiki 12. Katika utafiti huo huo, waandishi walipendekeza athari ndogo katika kupendelea DN juu ya udhibiti wa udanganyifu katika kupunguza maumivu baada ya miezi sita. Gattie et al pia alichunguza masomo ambayo yalilinganisha DN na matibabu mengine na kuchunguza athari zao juu ya maumivu. Kuna ushahidi wa ubora wa wastani unaoonyesha athari ndogo inayopendelea DN katika kupunguza maumivu na ushahidi wa ubora wa chini unaunga mkono athari ya wastani inayopendelea DN katika kuboresha PPT. Ni muhimu kutambua kwamba si masomo yote ya matibabu ya mazoezi ya mazoezi ya mazoezi ya mazoezi ya mazoezi ya mazoezi ya mazoezi ya mazoezi ya mazoezi ya mazoezi ya mazoezi ya mazoezi ya mazoezi ya mazoezi ya mazoezi ya mazoezi ya mazoezi ya mazoezi ya mazoezi ya mazoezi ya mazoezi ya mazoezi ya mazoezi ya mazoezi ya mazoezi ya mazoezi ya mazoezi ya mazoezi ya mazoezi ya mazoezi ya mazoezi ya mazoezi ya mazoezi ya mazoezi ya mazoezi. Halle na wenzake walifanya jaribio la kliniki la randomized moja-blind ili kuamua kama kuongeza DN kwa itifaki ya ukarabati baada ya upasuaji wa utulivu wa bega ilikuwa na athari zaidi katika kuboresha kiwango cha mwendo (ROM), maumivu, na alama za matokeo ya kazi. Kwa mujibu wa utafiti huo, wagonjwa 39 waliohusika walipimwa wakati wa kuanza (siku nne baada ya upasuaji) na wiki nane, wiki kumi na mbili na miezi sita baada ya upasuaji. Wagonjwa 19 katika kundi la DN walipokea matibabu ya kawaida ya ukarabati na matibabu ya DN ya kila wiki kati ya wiki 4 na 8 baada ya upasuaji, wakati kikundi cha kudhibiti kilipokea ROM ya pasifu ya <unk> sub-therapeutic <unk> wakati wa matibabu ya DN. Mbali na mabadiliko ya kihistoria katika ROM ya mviringo wa bega katika kundi la kudhibiti, hakuna tofauti kubwa katika matokeo kati ya makundi mawili, na makundi yote mawili yalionyesha uboreshaji kwa muda. Kietries et al. walifanya ukaguzi wa utaratibu na uchambuzi wa meta ili kuchunguza ushahidi kuhusu athari za DN juu ya kupunguza maumivu ya wagonjwa wenye maumivu ya myofascial ya juu. Katika masomo kumi na mawili yaliyokusanywa na kujumuishwa katika uchambuzi wao, masomo matatu yalionyesha athari kubwa inayopendelea DN juu ya udhibiti wa udanganyifu na athari za papo hapo kwenye kukandamiza maumivu, na utafiti mmoja ulikuwa na maana ya kliniki. Utafiti wa kwanza ulionyesha athari kubwa ya DN juu ya udhibiti wa udanganyifu katika kudhibiti maumivu katika wiki 4, ingawa tahadhari inapaswa kutumika kwa sababu ya 95% ya muda wa uaminifu (CI) kuvuka mstari wa hakuna tofauti. Uchunguzi wa kwanza ulilinganisha matibabu ya DN na matibabu mengine na kutathmini athari zao za papo hapo juu ya maumivu, ikidokeza athari ya wastani inayopendelea matibabu mengine juu ya DN. Hata hivyo, masomo haya yalikuwa ya maana ya kliniki ya mashaka kutokana na ukubwa wao wa athari ya kati ya makundi. Uchunguzi wa jumla wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti wa utafiti. Gattie et al. waligundua kuwa kuna ushahidi wa ubora wa chini wa kupendekeza athari ndogo inayopendelea DN juu ya udanganyifu au udhibiti katika kuboresha matokeo ya kazi mara moja na kwa muda mrefu. Kwa mfano, katika utafiti wa kwanza, ushahidi wa ubora wa chini ulionyesha kwamba DN haikuwa na athari, ingawa utafiti mmoja uliripoti kwamba DN ilisababisha uboreshaji wa matokeo ya kazi. Dembowski na wenzake walimaliza ripoti ya kesi juu ya mkurugenzi wa miaka 18 wa chuo kikuu cha pole vaulter ambaye aliendelea na mkazo mkali wa hamstring na alikuwa na historia ya mkazo mwingi kwenye sehemu yake ya mwisho isiyohusika. Katika uchunguzi wake wa kwanza, mwanariadha alionyesha ROM ndogo ya goti, udhaifu, unyenyekevu kwa palpation, na dysfunction kulingana na Tathmini ya Selective Functional Movement (SFMA), kulingana na utambuzi wa mkazo wa hamstring wa daraja la 2. Alifanya mazoezi ya mazoezi ya mwili mara tatu kwa wiki kwa wiki tatu, akizingatia kuimarisha msukumo wa kawaida, na aliagizwa kufanya mazoezi ya nyumbani pia. Kwa sababu ya uwepo wa MTRP, alipokea kikao cha DN mara moja kwa wiki baada ya kumaliza mazoezi yake kwa siku hiyo bila athari yoyote mbaya. Mgonjwa alionyesha maboresho katika kila ziara ya mfululizo, kukamilisha sawa kazi moja kwa moja mguu kuinua, kuwa na hakuna upungufu wa AROM, na kuboresha SFMA yake. Siku ya 20, wakati wa kurudi kwake kwa tathmini ya michezo, uchunguzi wa kimwili haukuwa na maana, na aliweza kukidhi vigezo maalum vya kazi, haswa nguvu ya eccentric ndani ya 10% ya mguu usiohusika, na pia kukamilisha vipimo kadhaa vya kazi maalum za michezo. Katika uchunguzi wake wa kufuatilia, hakukuwa na majeraha mapya yaliyoripotiwa, upungufu uliopo, na alikuwa akishiriki kikamilifu katika pole vaulting (5). Katika ripoti nyingine ya kesi iliyochapishwa na Patrick et al, walijaribu mbinu ya multimodal ya kusimamia kwa uangalifu jeraha la mhimili wa ulnar collateral (UCL) katika pitcher wa baseball ya chuo kikuu. Mshambuliaji huyo alipewa matibabu ya matibabu ya nje wiki 6 baada ya jeraha na sindano ya plasma yenye platelet (PRP). Katika uchunguzi wake wa kwanza, aligunduliwa na daraja la I na daraja la II la UCL, pamoja na ripoti za maumivu yaliyoongezeka, upungufu wa nguvu ya viungo vya juu na vya chini, upungufu wa kuajiri motor wa misuli ya scapula-thoracic, na ulemavu mkubwa uliopimwa na Ulemavu wa Mkono, Mabega na Mkono (DASH). Katika wiki nne za kwanza, mwanariadha alimaliza mazoezi ya utulivu wa bega na bega ili kuimarisha sehemu ya juu ya mguu (UE). Ingawa kufikia nguvu kamili katika UE yake katika hatua hii, yeye bado hakuweza kukamilisha programu ya kutupa maumivu bure. Kwa wiki tano na sita baada ya tathmini ya awali, alipokea kikao cha DN kila wiki pamoja na mazoezi yake ya ukarabati ili kuanzisha majibu mengine ya uchochezi mkali, kuzuia maumivu, na kukuza uponyaji wa ligament ya sprained. Mtrp iligunduliwa katika misuli ya flexor ya mkono wake, ambayo ilipokea DNA iliyounganishwa na IES ili kuchochea LTR. Kwa mfano, kwa ajili ya avascular UCL, DNA inatumika kwa njia ya pistoning, ambayo inasaidia kuimarisha mfumo wa uponyaji wa extracellular. MRI ya ufuatiliaji baada ya kikao cha pili cha DN ilithibitisha kupungua kwa machozi na kutoteleza pamoja na hakuna edema. Katika wiki 7-12, rehabilitation ilibadilisha lengo lake kwa kuimarisha mlolongo wa kinetic kutumika katika biomechanics kutupa, pamoja na neuromuscular reeducation kurekebisha mifumo iliyobadilishwa katika mechanics yake kutupa. Baada ya matibabu, aliripoti viwango vya chini vya maumivu, alionyesha maboresho katika nguvu, fomu sahihi ya kutupa, na alama za ulemavu zilizopungua kwenye tathmini ya DASH. Katika msimu wa kwanza wa msimu wa pili, mwanariadha huyo alirudi kwenye mchezo baada ya miezi sita baada ya kuumia bila maumivu kwa kasi kamili. Katika ripoti ya kesi, mchezaji wa NBA mwenye umri wa miaka 29 alipata jeraha la kuwasiliana wakati wa mchezo wa kitaaluma, na kusababisha avulsion kali ya rectus abdominis na adductor longus kutoka symphysis ya pubic, pamoja na machozi ya sehemu ya adductor brevis na pectineus. Baada ya upasuaji wa majeraha, mwanariadha huyo aliongozwa kupitia hatua tatu za ukarabati - kukarabati kwa kasi, kukarabati kwa kasi, na kurudi kwenye michezo - hadi alipokutana na vigezo vya kurudi kwenye mchezo ambavyo vilijumuisha kupunguzwa kwa maumivu, normalization ya ROM na nguvu, maboresho ya maswali ya matokeo, kupunguzwa kwa asymmetries ya harakati, na kukimbia bila maumivu na kushiriki katika michezo. Katika hatua ya kukata, hatua mbalimbali zilitumiwa kama vile cryotherapy, compression ya hewa, mazoezi ya mnyororo wa kinetic wazi, ROM, na shughuli za kupanda uzito ili kukuza uponyaji sahihi wa matengenezo ya upasuaji. Kipindi cha subacute (mwaka wa 1 hadi 3 baada ya upasuaji) kilijumuisha mbinu za ziada za matibabu ya mkono, kuimarisha hatua kwa hatua, na udhibiti wa gari katika ndege nyingi za harakati. Katika kipindi hiki, siku za maumivu ya kuongezeka, mwanariadha alipokea DN katika maeneo ya kuongezeka kwa sauti na uchungu uliopatikana ndani ya adductor longus, rectus abdominis, na misuli ya mkoa inayohusiana. Baada ya mtihani, aliripoti kupungua kwa maumivu, kupungua kwa maumivu baada ya shughuli za ROM, na uboreshaji katika ROM kulingana na uchunguzi wa kuona. Katika hatua ya tatu, mazoezi ya uhamisho wa kazi, mazoezi ya nguvu ya maendeleo, na shughuli za juu za plyometric na agility. Matibabu ya mikono na DN ilipunguzwa wakati wa awamu hii, ikitumiwa tu ikiwa ulemavu ulionyeshwa uwezekano wa kuhusiana na vizuizi vya mwendo na au kuongezeka kwa maumivu. Alirudia mashindano ya msimu wa wiki tano baada ya upasuaji, na aliona uboreshaji katika kipimo cha maumivu, Copenhagen Hip na Groin Outcome Score, mwendo, nguvu, Functional Movement Screen, Y Balance Test, na vipimo vya utendaji wa michezo. Katika miaka miwili ya kufuatilia, aliendelea kuwa mchezaji wa mpira wa kikapu wa kitaalamu na hakuwa na matatizo yoyote au majeraha ya mara kwa mara. Kama ilivyoelezwa hapo awali, ni vigumu kwa utafiti kufanya majaribio ya kliniki ya ubora wa juu ili kuamua ufanisi wa DN kutokana na uvamizi wake. Kwa kuongezea, utafiti uliochapishwa ni kinyume, bila makubaliano ya kweli juu ya athari ya ukubwa wa DN kwenye kupunguza maumivu na athari yake juu ya kuboresha utendaji. Hata hivyo, kesi kadhaa kufanya ushahidi zaidi bado inapaswa kufanyika kueleza juu ya faida ya DN. Lakini wakati wa kushirikiana na mazoezi ya kurekebisha na uchambuzi wa mifumo ya harakati, DN inaweza kucheza jukumu muhimu katika kupona kwa mwanariadha na kurudi kwa utendaji wa kilele.