Jan Dommerholt

Trigger point dry needling

Abstract Trigger point dry needling is a treatment technique used by physical therapists around the world. In the United States, trigger point dry needling has been approved as within the scope of physical therapy practice in a growing number of states. There are several dry needling techniques, based on different models, including the radiculopathy model and the trigger point model, which are discussed here in detail. Special attention is paid to the clinical evidence for trigger point dry needling and the underlying mechanisms. Comparisons with injection therapy and acupuncture are reviewed. Trigger point dry needling is a relatively new technique used in combination with other physical therapy interventions.

Myofascial Trigger Points: An Evidence-Informed Review

Abstract This article provides a best evidence-informed review of the current scientific understanding of myofascial trigger points with regard to their etiology, pathophysiology, and clinical implications. Evidence-informed manual therapy integrates the best available scientific evidence with individual clinicians judgments, expertise, and clinical decision-making. After abrief historical review, the clinical aspects of myofascial trigger points, the interrater reliability for identifying myofascial trigger points, and several characteristic features are discussed, including the taut band, local twitch response, and referred pain patterns. The etiology of myofascial trigger points is discussed with a detailed and comprehensive review of the most common mechanisms, including low-level muscle contractions, uneven intramuscular pressure distribution, direct trauma, unaccustomed eccentric contractions, eccentric contractions in unconditioned muscle, and maximal or sub-maximal concentric contractions. Many current scientific studies are included and provide support for considering myofascial trigger points in the clinical decision-making process. The article concludes with a summary of frequently encountered precipitating and perpetuating mechanical, nutritional, metabolic, and psychological factors relevant for physical therapy practice. Current scientific evidence strongly supports that awareness and working knowledge of muscle dysfunction and in particular myofascial trigger points should be incorporated into manual physical therapy practice consistent with the guidelines for clinical practice developed by the International Federation of Orthopaedic Manipulative Therapists. While there are still many unanswered questions in explaining the etiology of myofascial trigger points, this article provides manual therapists with an up-to-date evidence-informed review of the current scientific knowledge.

Dry needling — peripheral and central considerations

Abstract Dry needling is a common treatment technique in orthopedic manual physical therapy. Although various dry needling approaches exist, the more common and best supported approach targets myofascial trigger points. This article aims to place trigger point dry needling within the context of pain sciences. From a pain science perspective, trigger points are constant sources of peripheral nociceptive input leading to peripheral and central sensitization. Dry needling cannot only reverse some aspects of central sensitization, it reduces local and referred pain, improves range of motion and muscle activation pattern, and alters the chemical environment of trigger points. Trigger point dry needling should be based on a thorough understanding of the scientific background of trigger points, the differences and similarities between active and latent trigger points, motor adaptation, and central sensitize application. Several outcome studies are included, as well as comments on dry needling and acupuncture.

Performing arts medicine – Instrumentalist musicians Part I – General considerations

Performing arts medicine is a relatively new specialty addressing the medical needs of dancers, musicians, ice skaters, and gymnasts. This paper focuses on the role of healthcare providers in the diagnosis and therapeutic management of instrumentalist musicians. Musicians are at high risk for developing painful musculoskeletal problems, including pain and overuse injuries, entrapment and peripheral neuropathies, and focal dystonias. Musicians careers are threatened, when they are no longer able to play their instrument because of pain and dysfunction. To appreciate music-related injuries, it is important that clinicians are familiar with the context of musicians injuries and disorders. This is the first paper in a series of three. This paper discusses the importance of taking an extended history. The typical history procedures need to be broadened when interviewing musicians, and should include instrument-specific questions, and questions regarding practice habits, education, repertoire, and employment. The second article addresses the physical examination, while the third article provides three case reports of musicians with hand problems, which serve to illustrate the points made in the first two articles. The articles are illustrated with several tables and photographs of musicians to assist the reader in assessing instrumentalist musicians and determining the most appropriate course of action.

Myofascial Pain Syndromes-Trigger Points

Four articles this quarter present major progress in new experimental data. Hou et al. demonstrated in rabbits that motor endplate potentials [spontaneous electrical activity] of trigger spots are partially dependent on increased calcium channel permeability. Delaney et al. report an elegant way to measure the effect of myofascial trigger point [TrP] massage on autonomic nervous system activity. This opens a new research window through which to explore the close relation between TrP activity and autonomic nervous system activity. Esenyel et al. present a randomized, controlled, unblinded comparison of the results of ultrasound application and injection of TrPs and found that both were equally and significantly effective. This is one of the very few scientific papers that address the effectiveness of treating TrPs with ultrasound. Pongratz reported a noteworthy histological study specifically of TrPs. In addition, the efficacy of needling TrPs is becoming firmly established, and one review article presents in detail the importance of considering TrPs in patients with symptoms of radiculopathy.

Complex regional pain syndrome—1: history, diagnostic criteria and etiology

Abstract Physical therapists and other health care providers frequently evaluate and treat patients with complex regional pain syndrome (CRPS). The term CRPS replaces the previous terms reflex sympathetic dystrophy (now referred to as CRPS Type I) and causalgia (CRPS Type II). Part 1 of this paper describes the diagnostic criteria for CRPS and the clinical features and etiology of both CRPS Types I and II. CRPS is a multifactorial syndrome with overlapping symptoms. Although much progress has been made in the understanding of CRPS, many questions remain unanswered. CRPS is probably a disease of the central nervous system. Yet, peripheral inflammatory processes, abnormal sympathetic-afferent coupling, and adrenoreceptor pathology may also be part of the picture. It is likely that in the near future the current concepts of CRPS will be replaced by a new mechanism-based term or group of terms leading to improved clinical guidelines. Part 2 in this series reviews the physical therapy management of patients with CRPS.

Performing arts medicine--instrumentalist musicians, Part II--examination.

Part I of this articles series included background information on performing arts medicine with a special focus on musicians. It covered in detail what questions need to be included in the history, when healthcare providers first examine musicians. In part II of the series, the emphasis is on the physical examination, including posture, range of motion and hypermobility, ergonomics, and instrument-specific examination procedures. The final article in the series will describe three case histories of musicians with hand pain.

An evidence-informed review of the current myofascial pain literature--January 2015.

This article provides an up-to-date review of the most recent publications about myofascial pain, trigger points (TrPs) and other related topics. We have added some commentaries where indicated with supporting references. In the Basic Research section, we reviewed the work by Danish researchers about the influence of latent TrPs and a second study of the presence and distribution of both active and latent TrPs in whiplash-associated disorders. The section on Soft Tissue Approaches considered multiple studies and case reports of the efficacy of myofascial release (MFR), classic and deep muscle massage, fascial techniques, and connective tissue massage. Dry needling (DN) is becoming a common approach and we included multiple studies, reviews, and case reports, while the section on Injection Techniques features an article on TrP injections following mastectomy and several articles about the utilization of botulinum toxin. Lastly, we review several articles on modalities and other clinical approaches.

Performing arts medicine – Instrumentalist musicians: Part III – Case histories

In parts I and II of this article series, the basic principles of examining musicians in a healthcare setting were reviewed [Dommerholt, J. Performing arts medicine - instrumentalist musicians: part I: general considerations. J. Bodyw. Mov. Ther., in press-a; Dommerholt, J. Performing arts medicine - instrumentalist musicians: part II: the examination. J. Bodyw. Mov. Ther., in press-b]. Part III describes three case reports of musicians with hand pain, interfering with their ability to play their instruments. The musicians consulted with a performing arts physiotherapist. Neither musician had a correct medical diagnosis if at all, when they first contacted the physiotherapist. Each musician required an individualized approach not only to establish the correct diagnosis, but also to develop a specific treatment program. The treatment programs included ergonomic interventions, manual therapy, trigger point therapy, and patient education. All musicians returned to playing their instruments without any residual pain or dysfunction.

Complex regional pain syndrome—2: physical therapy management

Abstract Part I of this article reviewed the history, etiology and underlying mechanisms of CRPS I and II. The current article reviews the available research of physical therapy treatment interventions for patients with CRPS. As outlined in Part 1 of this article, there continues to be much uncertainty about the underlying mechanisms of CRPS. It remains challenging to develop evidence-based guidelines for physical therapy or for any other discipline. There is a paucity of prospective randomized clinical trials. The majority of published reports are case reports or consensus-based. Although the article is written primarily from a physical therapy perspective, the clinical guidelines are also of interest to other health care providers. Given the complexity and scope of CRPS, an interdisciplinary management approach is recommended.