DISCUSSION
The results of this case report suggest the addition of DN targeting MTrPs of the distal levator scapulae muscle and distal enthesis over the medial aspect of the superior angle of the scapula, along with joint mobilization (C1-C4 in supine and T1-T6 in prone grade III/IV), strength training and ergonomic education may be useful when treating individuals with CTTH associated with LSS.
Manual therapy, therapeutic exercise and ergonomics are common types of physical therapy interventions for CTTH and were addressed with this patient.70,75 Notably, resistance training has been found to stimulate collagen turnover and increase levels of growth factor that further insulate tissue from pathology and be beneficial for CTTH patients.76,77
Although multiple interventions were utilized and no cause-and-effect relationship can be established in a single case report, DN targeting MTrPs in the distal belly and enthesis of the levator scapulae reproduced and appeared to improve the patient’s headache symptoms, reflecting a change in pain intensity scores (NPRS, 0-10) from 5/10 on the second visit to 1/10 on the third visit after the first inclusion of the DN intervention. Notably, the amount of reported change in pain intensity was considerably smaller (i.e., from 6/10 at the initial visit to 5/10 on the second visit) when cervical and thoracic mobilization along with a home exercise program was only administered. In addition, the observed changes in pain intensity following the addition of the DN treatment to MTrPs suggests the etiology for this specific patient was likely not from underlying facet joint dysfunction.78
Inactivation of MTrPs can improve local circulation, increase range of motion, decrease muscle tightness and improve the overall functional status of a muscle.78 Two meta-analyses concluded that trigger point DN may be effective in decreasing pain in the short and medium term compared to control or sham needling.79,80Reductions in headache intensity, frequency and duration have been demonstrated following 3 sessions of DN to active MTrPs in muscles of the head and neck.31Additionally, a recent meta-analysis reported that DN produces similar effects to other interventions for short term headache relief.79Results demonstrate that potential benefits of DN included an increase in cervical ROM and a decrease in MTrP tenderness and headache frequency. Notably, DN was shown to provide significant improvement in short-term disability in patients with tension type headache.79
Notably, this case study performed targeted DN to the levator scapulae enthesis or teno-osseous junction, i.e., the interface between the periosteum and the tendon of the levator scapulae. Poor tendon vascularization and vessel anastomosis may justify DN to this region;81 in addition, previous clinical trials have reported successful outcomes in pain and disability when DN to the enthesis at the periosteal region was included.34,82-85