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