fbpx

Dry Needling and Ehlers Danlos Syndrome

PrevDry Needling for Nerve Entrapment09 February 2025NextGeorgia Bill Could Limit Patient Access to Dry Needling24 February 2025
February 16, 2025

While the impact of dry needling (DN) has been established for various indications and body regions [1-21], it is not necessarily clear when or even whether dry needling of patients with systemic hypermobility is indicated. Hypermobile individuals may “create” muscle contractures, commonly known as “taut bands’ in the myofascial pain literature, to provide stability in otherwise unstable joints. It is conceivable that lowering the muscle tone of such contractures would increase joint instability, leading to an immediate decrease in function. Before deciding to use dry needling on a patient with hypermobile joints, have a look at one of our previous blogs, summarizing some of the main characteristics of hypermobility, Ehlers-Danlos Syndrome (EDS), and Hypermobility Spectrum Disorders (HSD).

Systemic hypermobility usually does not pose any major problems until puberty. In clinical practice, many teenage girls with EDS experience their pain and major dysfunction within weeks or months after their first menses. Most children are hypermobile, with girls having greater joint mobility than boys. Range of motion increases until adolescence and tapers into adulthood and old age. Since joint mobility in children is far greater than in adults, diagnosing hypermobility in children is challenging as there are no age-related norms for range of motion [22]. An Australian study of 1,584 subjects showed that 61% of girls and 37% of boys were hypermobile [23]. This does not necessarily indicate that these children had abnormal range of motion or experienced disproportionate pain or dysfunction. Javadi Parvaneh and Shiari (2016) modified the Beighton criteria to improve the identification of hypermobility in children [24], but this test is not commonly used as most children with hypermobility are not symptomatic.

It is important to realize that not all hypermobile people are symptomatic [22]. However, those with systemic hypermobility tend to have higher reports of pain.  A study of 466 subjects with EDS demonstrated that 99% suffered from joint pain, 91% suffered from extremity pain, and many common comorbidities, such as chronic fatigue (82%), anxiety (73%), and depression (69%) [25]. Joint hypermobility was a common precursor to pain hypersensitivity and central sensitization in 40 hypermobile adolescents [22].

Dry Needling

Since pain is very common in patients with EDS and HSD, DN may seem like an excellent treatment option, but some caution is warranted. Managing pain in hypermobile patients can be quite challenging and often requires a multimodal, interdisciplinary approach [26, 27] that may include manual therapy, such as trigger point therapy and soft tissue mobilizations [52], pain science education [28], cognitive, emotional, and behavioral therapy [29], and external-focus exercise therapy [30, 31]. The role of DN for hypermobile patients has not been scientifically confirmed. Still, based on our extensive clinical experience with hypermobile patients, DN can be an important aspect of physiotherapy for patients with HSD and EDS, especially for reducing pain [32]. Our physical therapy center, Bethesda Physiocare (Bethesda, Maryland, USA), is one of only 22 centers globally recognized as EDS Centers & Networks of Excellence (Figure 2). We have treated thousands of patients with EDS/HSD.

Trigger point injections were recommended in a case report from India [33].  Studies comparing TrP injections with DN show many similarities in outcomes, but these studies are usually non-pragmatic with limited clinical applicability and methodological flaws [34-39].  There is a risk that DN may reduce the patient’s joint stability, especially when that patient uses contractures for stabilization. Because it is sometimes difficult to predict how a patient with EDS will respond to DN, we recommend treating only a few muscles or maybe just a few TrP points during the first treatment sessions combined with pain science education [40-42]. Once a patient’s pain level has reduced, therapy must include progressive or graded loading, improving loading tolerance, and reducing kinesiophobia [43-45]. Another question is whether physiotherapists should needle stiffer areas, for example, sections of the spine, in hypermobile individuals. The stiffer areas may be more “normal” or functional, yet the relatively stiffer areas are also common causes of myofascial pain [32].

Another aspect to consider with needling patients with EDS is that connective tissues, especially fascia, are organized differently than in patients without hypermobility [46]. In hypermobile EDS patients, the extracellular matrix changes exhibit reduced inter-fascial plane gliding [47], which is a bit surprising as, previously, decreased fascial gliding was primarily associated with a loss of flexibility [48]. Type I collagen and hyaluronan are important for fascial force transmission and gliding, promoting sliding of adjacent fascial tissue layers [49], but excessive hyaluronan can lead to stiffness of the ECM [50]. Hyaluronan or hyaluronic acid is a key component of the ECM found in vertebrate tissues [51], including in articular joint synovial fluid, providing lubrication and viscoelasticity to protect cartilage surfaces. The reduced gliding ability found in EDS patients may explain at least partially the widespread pain, but it may also impact proprioception and the ability to generate force and contract muscles efficiently [52, 53].

Up to 40% of muscle force is transmitted via fascia, especially the epimysium, and not through tendons [53, 54]. When connective tissues have significant laxity, forces may not get transmitted to adjacent fascial layers [32]. The changes in fascial gliding may be due to an increase in type I collagen and pathologic changes in matrix metalloproteinases in the ECM [55], which likely results in increased viscosity, reduced lubrication, and sliding movement of fascia [41]. It is conceivable that fascial needling approaches, including winding fascial needles in fascial tissues [56, 57], or Fu Subcutaneous Needling [58-60], may benefit patients with EDS. The theoretical basis for using needles in the treatment of fascial adhesions and scar tissue has developed sufficiently to consider its use in the clinic [61-66], and conceivably, these techniques may also be useful for patients with EDS, but there is no research to support this notion.

As hypermobile patients get older, they will likely become less hypermobile, mostly because the percentage area of collagen 1 increases significantly with aging [67]. There is some evidence that part of aging is associated with a decrease in the percentage of elastic fibers in the perimysium and a decrease in hyaluronan [67]. Older skin has less hyaluronan than younger skin [68]. Another contributing factor is the Yes-associated protein (YAP), expressed particularly in the deep fascia, where it is involved with fascial mechanotransduction, remodeling, regeneration, and fibrogenesis [69].

Jan Dommerholt, PT, DPT

The Obvious Choice for Dry Needling Education

Dry Needling Course Series

Image module

Dry Needling 1: Foundations I

The Dry Needling 1 course is an excellent starting point for learning the fundamentals of dry needling therapy. With a focus on the safe and effective application of dry needling techniques, you will gain a solid understanding of myofascial trigger points, needling techniques, precautions, and how to apply these techniques in clinical practice.

Image module

Dry Needling 2: Foundations II

The Dry Needling 2 course is an intermediate-level course that provides in-depth knowledge and hands-on training for dry needling techniques of the extremities, including the upper and lower body. By completing this course, you will expand upon the skills you acquired in the DN-1 course and better understand the application of dry needling for managing musculoskeletal pain and dysfunction.

Image module

Dry Needling 3: Advanced

The Dry Needling 3 course is the final course in the series and the last step before becoming a Certified Myofascial Trigger Point Therapist – Dry Needling (CMTPT/DN). This course offers an in-depth study of advanced dry needling techniques for hand muscles, several lower extremity and foot muscles, the craniofacial and craniomandibular muscles, and more.

Register Today

References

  1. Hernández-Secorún, M., et al., Effectiveness of Dry Needling in Improving Pain and Function in Comparison with Other Techniques in Patients with Chronic Neck Pain: A Systematic Review and Meta-Analysis. Pain Res Manag, 2023. 2023: p. 1523834.
  2. Hernández-Secorún, M., et al., Effectiveness of Dry Needling in Improving Pain and Function in Comparison with Other Techniques in Patients with Chronic Neck Pain: A Systematic Review and Meta-Analysis. Pain Research and Management, 2023. 2023: p. 1523834.
  3. Forogh, B., et al., Efficacy of trigger point dry needling on pain and function of the hip joint: a systematic review of randomized clinical trials. Acupunct Med, 2023: p. 9645284231207870.
  4. Vázquez-Justes, D., et al., Effectiveness of dry needling for headache: A systematic review. Neurología (English Edition), 2022. 37(9): p. 806-815.
  5. Valera-Calero, J.A., et al., Efficacy of Dry Needling and Acupuncture in Patients with Fibromyalgia: A Systematic Review and Meta-Analysis. Int J Environ Res Public Health, 2022. 19(16).
  6. Rodríguez-Huguet, M., M.J. Vinolo-Gil, and J. Góngora-Rodríguez, Dry Needling in Physical Therapy Treatment of Chronic Neck Pain: Systematic Review. J Clin Med, 2022. 11(9).
  7. Nuhmani, S., et al., Dry needling in the management of tendinopathy: A systematic review of randomized control trials. Journal of Bodywork and Movement Therapies, 2022.
  8. Jiménez-Del-Barrio, S., et al., The Effectiveness of Dry Needling in Patients with Hip or Knee Osteoarthritis: A Systematic Review and Meta-Analysis. Life (Basel), 2022. 12(10).
  9. Javier-Ormazábal, A., et al., Invasive Physiotherapy as a Treatment of Spasticity: A Systematic Review. Degener Neurol Neuromuscul Dis, 2022. 12: p. 23-29.
  10. Griswold, D., et al., Dry Needling for Subacromial Pain Syndrome. A Systematic Review with Meta-analysis. Pain Med, 2022.
  11. Giorgi, E., et al., The Effectiveness of Dry Needling Combined With Therapeutic Exercises in Treating Tendinopathy Conditions: A Systematic Review. J Sport Rehabil, 2022. 31(7): p. 918-924.
  12. Blanco-Díaz, M., et al., A Systematic Review of the Effectiveness of Dry Needling in Subacromial Syndrome. Biology, 2022. 11(2): p. 243.
  13. Ughreja, R.A. and V. Prem, Effectiveness of dry needling techniques in patients with knee osteoarthritis: A systematic review and meta-analysis. J Bodyw Mov Ther, 2021. 27: p. 328-338.
  14. Pourahmadi, M., et al., Dry needling for the treatment of tension-type, cervicogenic, or migraine headaches: a systematic review and meta-analysis. Phys Ther, 2021. 101(5).
  15. Hadizadeh, M., et al., The efficacy of intramuscular electrical stimulation in the management of patients with myofascial pain syndrome: a systematic review. Chiropractic and Manual Therapies, 2021. 29(1).
  16. Navarro-Santana, M.J., et al., Effects of Trigger Point Dry Needling for Nontraumatic Shoulder Pain of Musculoskeletal Origin: A Systematic Review and Meta-Analysis. Physical Therapy, 2021. 101(2): p. pzaa216.
  17. Navarro-Santana, M.J., et al., Effectiveness of Dry Needling for Myofascial Trigger Points Associated with Neck Pain Symptoms: An Updated Systematic Review and Meta-Analysis. Journal of Clinical Medicine, 2020. 9(10).
  18. Navarro-Santana, M.J., et al., Effects of trigger point dry needling on lateral epicondylalgia of musculoskeletal origin: a systematic review and meta-analysis. Clin Rehabil, 2020. 34(11): p. 1327-1340.
  19. Sarmiento-Hernández, I., et al., Effectiveness of Invasive Techniques in Patients with Fibromyalgia: Systematic Review and Meta-Analysis. Pain Medicine, 2020. 21(12): p. 3499-3511.
  20. Fernandez-de-Las-Penas, C., et al., Is Dry Needling Effective for the Management of Spasticity, Pain, and Motor Function in Post-Stroke Patients? A Systematic Review and Meta-Analysis. Pain Med, 2021. 22(1): p. 131-141.
  21. Fernandez-De-Las-Penas, C., et al., Is Dry Needling Effective When Combined with Other Therapies for Myofascial Trigger Points Associated with Neck Pain Symptoms? A Systematic Review and Meta-Analysis. Pain Res Manag, 2021. 2021: p. 8836427.
  22. Dommerholt, J. and N. Mayberry, Hypo- and Hypermobility, in Fascia in Sport and Movement, R. Schleip, J. Wilke, and A. Baker, Editors. 2021, Handspring Publishing: Pencaitland. p. 77-95.
  23. Morris, S.L., et al., Hypermobility and Musculoskeletal Pain in Adolescents. J Pediatr, 2017. 181: p. 213-221 e1.
  24. Javadi Parvaneh, V. and R. Shiari, Proposed modifications to Beighton criteria for the diagnosis of joint hypermobility in children. Indian J Rheumatol, 2016. 11: p. 97-100.
  25. Murray, B., et al., Ehlers-Danlos syndrome, hypermobility type: A characterization of the patients’ lived experience. Am J Med Genet A, 2013. 161A(12): p. 2981-8.
  26. Revivo, G., et al., Interdisciplinary Pain Management Improves Pain and Function in Pediatric Patients with Chronic Pain Associated with Joint Hypermobility Syndrome. PM R, 2018.
  27. Zhou, Z., A. Rewari, and H. Shanthanna, Management of chronic pain in Ehlers-Danlos syndrome: Two case reports and a review of literature. Medicine (Baltimore), 2018. 97(45): p. e13115.
  28. Tewari, S., et al., Chronic pain in a patient with Ehlers-Danlos syndrome (hypermobility type): The role of myofascial trigger point injections. J Bodyw Mov Ther, 2017. 21(1): p. 194-196.
  29. Louw, A., Treating the brain in chronic pain, in Manual therapy for musculoskeletal pain syndromes – an evidenced and clinical-informed approach, C. Fernández de las Peñas, J. Cleland, and J. Dommerholt, Editors. 2016, Churchill Livingstone (Elsevier): Edinburgh.
  30. Baeza-Velasco, C., et al., Cognitive, emotional, and behavioral considerations for chronic pain management in the Ehlers-Danlos syndrome hypermobility-type: a narrative review. Disabil Rehabil, 2018: p. 1-9.
  31. Wulf, G. and R. Lewthwaite, Optimizing performance through intrinsic motivation and attention for learning: The OPTIMAL theory of motor learning. Psychon Bull Rev, 2016. 23(5): p. 1382-1414.
  32. Wulf, G., et al., Triple play: Additive contributions of enhanced expectancies, autonomy support, and external attentional focus to motor learning. Q J Exp Psychol (Hove), 2018. 71(4): p. 824-831.
  33. Langevin, H.M., C.A. Francomano, and C. DaPrato, Chapter 5 – Myofascial pain: Myofascial knee pain in a young woman with hypermobile Ehlers-Danlos syndrome, in The Symptom-Based Handbook for Ehlers-Danlos Syndromes and Hypermobility Spectrum Disorders, C.A. Francomano, et al., Editors. 2024, Elsevier. p. 45-49.
  34. Tewari, S., et al., Chronic pain in a patient with Ehlers-Danlos syndrome (hypermobility type): The role of myofascial trigger point injections. Journal of Bodywork and Movement Therapies, 2017. 21(1): p. 194-196.
  35. Cummings, T.M. and A.R. White, Needling therapies in the management of myofascial trigger point pain: a systematic review. Arch Phys Med Rehabil, 2001. 82(7): p. 986-92.
  36. Kara, S., et al., Comparison of kinesio taping, dry needling and lidocaine injection methods in myofascial pain syndrome. Journal of Bodywork and Movement Therapies, 2024. 38: p. 128-132.
  37. Griswold, D., et al., Comparing dry needling or local acupuncture to various wet needling injection types for musculoskeletal pain and disability. A systematic review of randomized clinical trials. Disability and Rehabilitation, 2023: p. 1-15.
  38. Navarro-Santana, M.J., et al., Dry Needling Versus Trigger Point Injection for Neck Pain Symptoms Associated with Myofascial Trigger Points: A Systematic Review and Meta-Analysis. Pain Med, 2022. 23(3): p. 515-525.
  39. Nagarajan, V., et al., Local Corticosteroid Injection Versus Dry Needling in the Treatment of Lateral Epicondylitis. Cureus, 2022. 14(11): p. e31286.
  40. Nowak, Z., et al., Intramuscular injections and dry needling within masticatory muscles in management of myofascial Pain. Systematic review of clinical trials. Int J Environ Res Public Health, 2021. 18(18).
  41. Diener, I., M. Kargela, and A. Louw, Listening is therapy: Patient interviewing from a pain science perspective. Physiother Theory Pract, 2016. 32(5): p. 356-67.
  42. Bonatesta, L., et al., Pain Science Education Plus Exercise Therapy in Chronic Nonspecific Spinal Pain: A Systematic Review and Meta-analyses of Randomized Clinical Trials. J Pain, 2022. 23(4): p. 535-546.
  43. Chimenti, R.L., et al., The effects of pain science education plus exercise on pain and function in chronic Achilles tendinopathy: a blinded, placebo-controlled, explanatory, randomized trial. Pain, 2023. 164(1): p. e47-e65.
  44. Vaegter, H.B., et al., Kinesiophobia is associated with pain intensity but not pain sensitivity before and after exercise: an explorative analysis. Physiotherapy, 2018. 104(2): p. 187-193.
  45. Priore, L.B., et al., Influence of kinesiophobia and pain catastrophism on objective function in women with patellofemoral pain. Phys Ther Sport, 2019. 35: p. 116-121.
  46. Dommerholt, J., N. Mayberry, and M. Sickel, Physiotherapie mit externem Fokus. Der Schmerzpatient, 2019. 2(4): p. 178-187.
  47. Wang, T.J. and A. Stecco, Fascial thickness and stiffness in hypermobile Ehlers-Danlos syndrome. American Journal of Medical Genetics Part C: Seminars in Medical Genetics, 2021. 187(4): p. 446-452.
  48. Wang, T.J., et al., Change in gliding properties of the iliotibial tract in hypermobile Ehlers–Danlos Syndrome. Journal of Ultrasound, 2023. 26(4): p. 809-813.
  49. Cruz-Montecinos, C., et al., In vivo relationship between pelvis motion and deep fascia displacement of the medial gastrocnemius: anatomical and functional implications. Journal of Anatomy, 2015. 227(5): p. 665-672.
  50. Fede, C., et al., A Closer Look at the Cellular and Molecular Components of the Deep/Muscular Fasciae. Int J Mol Sci, 2021. 22(3).
  51. Mambetsariev, N., et al., Hyaluronic Acid Binding Protein 2 Is a Novel Regulator of Vascular Integrity. Arteriosclerosis, Thrombosis, and Vascular Biology, 2010. 30(3): p. 483-490.
  52. Cowman, M.K., et al., The Content and Size of Hyaluronan in Biological Fluids and Tissues. Frontiers in Immunology, 2015. 6.
  53. Stecco, C., et al., The Ankle Retinacula: Morphological Evidence of the Proprioceptive Role of the Fascial System. Cells Tissues Organs, 2010. 192(3): p. 200-210.
  54. Yucesoy, C.A., et al., Extramuscular Myofascial Force Transmission: Experiments and Finite Element Modeling. Archives of Physiology and Biochemistry, 2003. 111(4): p. 377-388.
  55. Huijing, P.A., Epimuscular myofascial force transmission: a historical review and implications for new research. International Society of Biomechanics Muybridge Award Lecture, Taipei, 2007. J Biomech, 2009. 42(1): p. 9-21.
  56. Chiarelli, N., et al., Matrix Metalloproteinases Inhibition by Doxycycline Rescues Extracellular Matrix Organization and Partly Reverts Myofibroblast Differentiation in Hypermobile Ehlers-Danlos Syndrome Dermal Fibroblasts: A Potential Therapeutic Target? Cells, 2021. 10(11): p. 3236.
  57. Langevin, H.M., et al., Connective tissue fibroblast response to acupuncture: dose-dependent effect of bidirectional needle rotation. J Altern Complement Med, 2007. 13(3): p. 355-60.
  58. Langevin, H.M., et al., Subcutaneous tissue fibroblast cytoskeletal remodeling induced by acupuncture: Evidence for a mechanotransduction-based mechanism. J Cell Physiol, 2006. 207(3): p. 767-74.
  59. Xiao, A.J., et al., [Review on the role of Fu’s subcutaneous needling (FSN) in pain relieving]. Zhongguo Zhen Jiu, 2013. 33(12): p. 1143-6.
  60. Xu, W., Further discussion on the effect of FSN to immune system. j Chin Med Acupunct, 2020. 27(1): p. 1-5.
  61. Huang, C.H., et al., Efficacy of Fu’s Subcutaneous Needling on Myofascial Trigger Points for Lateral Epicondylalgia: A Randomized Control Trial. Evid Based Complement Alternat Med, 2022. 2022: p. 5951327.
  62. Rozenfeld, E., et al., Dry needling for scar treatment. Acupunct Med, 2020. 38(6): p. 435-439.
  63. Chiquet, M., et al., How do fibroblasts translate mechanical signals into changes in extracellular matrix production? Matrix Biol, 2003. 22(1): p. 73-80.
  64. Finando, S. and D. Finando, Fascia and the mechanism of acupuncture. J Bodyw Mov Ther, 2011. 15(2): p. 168-76.
  65. Grinnell, F., Fibroblast biology in three-dimensional collagen matrices. Trends Cell Biol, 2003. 13(5): p. 264-9.
  66. Langevin, H.M., et al., Fibroblast cytoskeletal remodeling contributes to connective tissue tension. J Cell Physiol, 2011. 226(5): p. 1166-75.
  67. Pirri, C., et al., Elastic Fibres in the subcutaneous tissue: Is there a difference between superficial and muscular fascia? A cadaver study. Skin Res Technol, 2022. 28(1): p. 21-27.
  68. Fede, C., et al., The Effects of Aging on the Intramuscular Connective Tissue. International Journal of Molecular Sciences, 2022. 23(19): p. 11061.
  69. Laurent, U.B.G. and A. Tengblad, Determination of hyaluronate in biological samples by a specific radioassay technique. Analytical Biochemistry, 1980. 109(2): p. 386-394.
  70. Pirri, C., et al., A New Player in the Mechanobiology of Deep Fascia: Yes-Associated Protein (YAP). International Journal of Molecular Sciences, 2023. 24(20): p. 15389.
div#stuning-header .dfd-stuning-header-bg-container {background-color: #111133;background-size: cover;background-position: center center;background-attachment: scroll;background-repeat: no-repeat;}#stuning-header div.page-title-inner {min-height: 120px;}