5.3.1 Pressure Algometer
A) Intra-group analysis: Pressure Algometer
With regards to the intra-group analysis of the pressure algometer, the Wilcoxon signed rank test was used to assess for changes in mean values over time between the 1st to 3rd, 3rd to 5th and 1st to 5th treatments. As indicated in Table 4.2, both groups had statistically significant differences (p ≤ 0.05). Group A and group B had a P-value of 0.00.
76 As shown in figure 4.1, both groups showed improvement in mean values over all three pressure algometer readings. However, group A showed the greatest improvement with an increase of 1.15 kg/cm² from 2.8 kg/cm² to 3.95 kg/cm², in comparison to group B which had an increase of 0.27 kg/cm² from 2.9 kg/cm² to 3.17 kg/cm². Therefore it can be concluded that both groups showed improvements through the entire trial period however the dry needling and kinesio tape® group (group A), showed greater improvement with regards to the pressure algometer readings as the participants were able to withstand more pressure before pain was perceived.
B) Inter-group analysis: Pressure Algometer
The Independent T Test, that tests for normality was inconclusive, therefore the Mann- Whitney U tests were used for the inter-group analysis to determine if there is a statistical significance between group A and B at their first, third and fifth treatments. It is shown in table 4.3, that there were no statistically significant differences (p ≥ 0.05) between the two groups at the 1st and 3rd treatments but there was a significant difference at the 5th treatment with a p-value of 0.03. This suggests that both groups improved on a relatively similar level over the first two readings however group A had a greater overall improvement at the last reading.
C) Results Discussion
The improvement or increase in pain pressure threshold in both groups allowing the upper fibers of the trapezius muscle to withstand an increase in pressure before pain was experienced could be attributed to the stimulation of the A –delta fibers which close the pain gate and therefore inhibit the nociceptor fibers during and after dry needling (Travell and Simons, 1983).
Travell and Simons (1999), further stated that the therapeutic effect of dry needling is the mechanical disruption of a myofascial trigger point which damages or even destroys the motor endplates and causes distal axon denervations when the needle pierces the
77 trigger point. This could trigger changes in the cholinesterase and acetylcholine receptors as part of the normal muscle regeneration (Dommerholt et al., 2006).
Dry needling has been found to be effective in increasing the pain threshold as it can activate the stimulation of A-delta nerve fibers for up to 72 hours post needling. Prolonged stimulation of A-delta fibers will activate the encephalomeric inhibitory dorsal horn interneuron resulting in opioids mediated pain suppression (Dommerholt, 2004).
The results are also supported by a study done by Srbely, Dickey, Lee and Lowerison (2010), that investigated how dry needling stimulation of myofascial trigger points evoked segmental anti-nociceptive effects. Significant increase in pressure pain threshold were observed in the dry needling group post dry needling, compared to the sham dry needling group. Their result suggested that trigger point stimulation to a single trigger point evokes short term segmental anti-nociceptive effects (Srbely, Dickey, Lee and Lowerison, 2010)
Therefore due to the mechanical effect and the pain suppression caused by dry needling, the myofascial trigger point was able to withstand an increase in pressure, however dry needling may cause post dry needling soreness and the effects of dry needling may only last up to 72 hours. The application of kinesio tape® may minimise the post dry needling soreness and prolong the effects of the dry needling.
Therefore the kinesio tape® post dry needling group might of shown a greater improvement due to the added effects proposed by Kase et al. (2003), that kinesio tape® lifts the fascia and soft tissue, creating more space and thereby decreasing pressure directly above an area of pain, inflammation, swelling, or oedema. Kase et al. (2003), continues to propose that kinesio tape ® could decrease pain by Increasing the level of circulation in the area, allowing for increased removal of exudates, stimulation of the mechanoreceptors and increasing sensory stimulation to close the pain gate.
78 5.3.2 Cervical Range of Motion Device (CROM)
5.3.2.1 Flexion
A) Intra-group analysis: Flexion
The intra-group analysis for flexion in the cervical range of motion readings was assessed using the wilcoxon signed rank test for changes in mean values over time for the two groups. As indicated in Table 4.4, both groups had statistically significant differences (p ≤ 0.05) between the 1st and 3rd
, the 3rd and 5th visit as well as between the 1st and 5th visit.
As seen in figure 4.2, both groups showed improvement in mean flexion values over all three cervical ranges of motion readings. However, group A showed the greatest improvement with an increase of 9.2 degrees from 62.8 degrees to 72 degrees, in comparison to group B which had an increase of 2.6. This indicated that applying kinesio tape® after dry needling, showed the best result within the group with regards to the mean flexion values of cervical range of motion.
B) Inter-group analysis: Flexion
The Independent T Test, that tests for normality was inconclusive, therefore the Mann- Whitney U tests were used for the inter-group analysis to determine if there is a statistical significance between group A and B at their first, third and fifth treatments. It is shown in table 4.5, that there were no statistically significant differences (p ≥ 0.05) between the two groups at the 1st and 3rd treatments but there was a significant difference at the 5th treatment with a p-value of 0.04. This suggests that both groups improved on a relatively similar level over the first two readings however group A had a greater overall improvement at the last reading.
79 5.3.2.2 Extension
A) Intra-group analysis: Extension
The intra-group analysis for extension in the cervical range of motion readings was assessed using the wilcoxon signed rank test for changes in mean values over time for the two groups. As indicated in Table 4.6, both groups had statistically significant differences (p ≤ 0.05) between the 1st and 3rd
, the 3rd and 5th visit as well as between the 1st and 5th visit.
As seen in figure 4.3, both groups showed improvement in mean extension values over all three cervical ranges of motion readings. However, group A showed the greatest improvement with an increase of 8.8 degrees from 62.4 degrees to 71.2 degrees, in comparison to group B which had an increase of 3.6. This indicated that applying kinesio tape® after dry needling, showed the best result within the group with regards to the mean extension values of cervical range of motion.
B) Inter-group analysis: Extension
The Independent T Test, that tests for normality was inconclusive, therefore the Mann- Whitney U tests were used for the inter-group analysis to determine if there is a statistical significance between group A and B at their first, third and fifth treatments. It is shown in table 4.7, that there were no statistically significant differences between the three groups (p ≥ 0.05). This suggests that both groups improved on a similar level over the three readings.
5.3.2.3 Left Lateral Flexion
A) Intra-group analysis: Left Lateral Flexion
The intra-group analysis for left lateral flexion in the cervical range of motion readings was assessed using the wilcoxon signed rank test for changes in mean values over time
80 for the two groups. As indicated in Table 4.8, both groups had statistically significant differences (p ≤ 0.05) between the 1st and 3rd
, the 3rd and 5th visit as well as between the 1st and 5th visit.
As seen in figure 4.4, both groups showed improvement in mean left lateral flexion values over all three cervical ranges of motion readings. However, group A showed the greatest improvement with an increase of 9.8 degrees from 45.7 degrees to 55.5 degrees, in comparison to group B which had an increase of 3.9. This indicated that applying kinesio tape® after dry needling, showed the best result within the group with regards to the mean left lateral flexion values of cervical range of motion.
B) Inter-group analysis: Left Lateral Flexion
The Independent T Test, that tests for normality was inconclusive, therefore the Mann- Whitney U tests were used for the inter-group analysis to determine if there is a statistical significance between group A and B at their first, third and fifth treatments. It is shown in table 4.9, that there were no statistically significant differences between the two groups (p ≥ 0.05). This suggests that both groups improved on a similar level over the three readings.
5.3.2.4 Right Lateral Flexion
A) Intra-group analysis: Right Lateral Flexion
The intra-group analysis for right lateral flexion in the cervical range of motion readings was assessed using the wilcoxon signed rank test for changes in mean values over time for the two groups. As indicated in Table 4.10, both groups had statistically significant differences (p ≤ 0.05) between the 1st and 3rd
, the 3rd and 5th visit as well as between the 1st and 5th visit.
As seen in figure 4.5, both groups showed improvement in mean right lateral flexion values over all three cervical ranges of motion readings. However, group A showed the
81 greatest improvement with an increase of 10 degrees from 46.47 degrees to 56.47 degrees, in comparison to group B which had an increase of 3.6. This indicated that applying kinesio tape® after dry needling showed the best result within the group with regards to the mean right lateral flexion values of cervical range of motion.
B) Inter-group analysis: Right Lateral Flexion
The Independent T Test, that tests for normality was inconclusive, therefore the Mann- Whitney U tests were used for the inter-group analysis to determine if there is a statistical significance between group A and B at their first, third and fifth treatments. It is shown in table 4.11, that there was a statistically significant difference between the two groups (p ≥ 0.05) at first reading however there was no significant difference at the 3rd and 5th treatments. This suggests that both groups improved on a similar level over the 3rd and 5th readings however group A started with an better right lateral flexion range of motion than group B.
5.3.2.5 Left Rotation
A) Intra-group analysis: Left Rotation
The intra-group analysis for left rotation in the cervical range of motion readings was assessed using the wilcoxon signed rank test for changes in mean values over time for the two groups. As indicated in Table 4.12, both groups had statistically significant differences (p ≤ 0.05) between the 1st and 3rd
, the 3rd and 5th visit as well as between the 1st and 5th visit.
As seen in figure 4.6, both groups showed improvement in mean left rotation values over all three cervical ranges of motion readings. However, group A showed the greatest improvement with an increase of 10.14 degrees from 60.86 degrees to 71 degrees, in comparison to group B which had an increase of 2.2. This indicated that
82 applying kinesio tape® after dry needling, showed the best result within the group with regards to the mean left rotation values of cervical range of motion.
B) Inter-group analysis: Left Rotation
The Independent T Test, that tests for normality was inconclusive, therefore the Mann- Whitney U tests were used for the inter-group analysis to determine if there is a statistical significance between group A and B at their first, third and fifth treatments. It is shown in table 4.13, that there was a statistically significant difference between the two groups (p ≥ 0.05) at first reading however there was no significant difference at the 3rd and 5th treatments. This suggests that both groups improved on a similar level over the 3rd and 5th readings however group A started with an better left rotation range of motion than group B.
5.3.2.6 Right Rotation
A) Intra-group analysis: Right Rotation
The intra-group analysis for right rotation in the cervical range of motion readings was assessed using the wilcoxon signed rank test for changes in mean values over time for the two groups. As indicated in Table 4.14, both groups had statistically significant differences (p ≤ 0.05) between the 1st and 3rd
, the 3rd and 5th visit as well as between the 1st and 5th visit.
As seen in figure 4.7, both groups showed improvement in mean right rotation values over all three cervical ranges of motion readings. However, group A showed the greatest improvement with an increase of 10.67 degrees from 61.6 degrees to 72.27 degrees, in comparison to group B which had an increase of 2.27. This indicated that applying kinesio tape® after dry needling, showed the best result within the group with regards to the mean right rotation values of cervical range of motion.
83 B) Inter-group analysis: Right Rotation
The Independent T Test, that tests for normality was inconclusive, therefore the Mann- Whitney U tests were used for the inter-group analysis to determine if there is a statistical significance between group A and B at their first, third and fifth treatments. It is shown in table 4.15, that there was a statistically significant difference between the two groups (p ≥ 0.05) at first reading however there was no significant difference at the 3rd and 5th treatments. This suggests that both groups improved on a similar level over the 3rd and 5th readings however group A started with an better right rotation range of motion than group B.
C) Results Discussion
A myofascial trigger point contains a hypersensitive taut palpable band. A restricted range of motion in the cervical spine is primarily due to a restriction of muscular stretching which is a result of muscle tension and functional shortening. Restricted movement due to pain occurs from sensitised nociceptors found within the central myofascial trigger point. Attempting to passively stretch a functionally shortened muscle will result in pain. Increased tension within a functionally shortened muscle, stretching or contracting, has the ability to cause pain (Travell and Simons, 1983). Therefore inactivating the active trapezius trigger point will eliminate the taut palpable band and allow for non-painful stretching (Travell and Simons, 1983). This is confirmed by Baldry (2002), who states that the range of motion can be reduced in a muscle due to pain and the inability to fully stretch a muscle containing an active myofascial trigger point.
Cummings and White (2001), stated that dry needling may disrupt the integrity of the dysfunctional endplates within the trigger area resulting in mechanical and physiological resolution of the trigger points, which can lead to an increased range of motion. This could explain the improvement seen in both treatment groups.
84 Dry needling has been proven to increase cervical range of motion by inactivating trigger points in the cervical muscles. This provides the necessary energy to unlock the actin and myosin cross bridge formations and the energy needed to re-uptake Ca2+ (Travell and Simons, 1983). The histamine concentration obtained by the dry needling also accounts for the increase in range of motion (Lavelle et al., 2007).
An accurately placed needle may also provide a localised stretch to the contractured cytoskeletal structures, which would allow the involved sarcomeres to resume their resting length by reducing the degree of overlap between actin and myosin filaments (Dommerholt, 2004). This can be supported by research conducted by Kalichman and Vulfsons (2010), as well as Cummings and White (2001), whose findings showed an improvement of the cervical range of motion after dry needling the trapezius muscle.
The improvement could also be due to the theory that dry needling promotes blood flow to the affected part of the muscle and removes metabolites, while the blood also provides nutrients to the area. This will cause relaxation of the previously contracted muscle fibers and will in turn increase the muscle length and result in increased range of motion (Gatterman, 1990).
These results are supported by a study done by Irnich, Behrens, Gleditsch, Stor, Schreiber, Schops, Vickers and Beyers (2002), who investigated the immediate effects of dry needling and acupuncture at distant points in chronic neck pain. The study revealed that dry needling was effective in increasing cervical range of motion.
Kase et al. (2003), proposed that kinesio taping® can activate neurological and circulatory systems and promote proper venous and lymphatic flow. It effectively reduces inflammation and provides stability to injured joints allowing the body's own natural healing process. A study done by Yoshida and Kahanov (2007) found that applying kinesio tape® to the lumbar para-spinals was successful in increasing the lumbar range of motion. This result is also supported by Thelen, Dauber and Stoneman (2008), whose findings showed that kinesio tape® can have a positive effect on range of
85 motion of the shoulder when thought to be limited by musculoskeletal pain, they stated that kinesio tape® may assist clinicians to obtain immediate improvement in painless shoulder range of motion.
When the application procedure is followed correctly, the taped area can be used to facilitate a weakened muscle or to relax an overused muscle as well as improve active range of motion, relieve pain, adjust misalignment, or improve lymphatic circulation (Kase et al., 2003).
Due to kinesio tape® covering a greater surface area over the trapezius muscle, it will therefore have a greater effect over more of the muscle than the focus point at the trigger point in which the dry needling will effect and will therefore allow the muscle to function at a unit and possible increase the range of motion and thus the combination of the kinesio tape® and dry needing will have a greater effect in the treatment of myofascial trigger points.