THIEME

Original Research

Effectiveness of Dry Needling in Bothersome

Chronic Tinnitus in Patients with Myofascial
Trigger Points
Carla Alexandra Campagna1 Juliana Anauate1 Laura Garcia E. Vasconœlos1 Jeanne Oiticica1

1 Otolaryngology Department, Faculdade de Medicina da Address for correspondence Jeanne Oiticica, PhD, University of Sao
Universidade de São Paulo, São Paulo, SP, Brazil Paulo–Otorhinolaryngology, Alameda Dos Jurupis 657 CJ 72
Indianopolis, Sao Paulo, Sao Paulo 04088002, Brazil
Int Arch Otorhinolaryngol (e-mail: [email protected]).

Abstract Introduction Therapeutic dry needling (DN) is effective in reducing the discomfort of
chronic somatosensory tinnitus in patients with myofascial trigger points (MTP)s.
Objective To evaluate the efficacy of DN in chronic somatosensory tinnitus discom-
fort in patients with MTP.
Methods Placebo-controlled paired trial that included 16 patients with a diagnosis of
somatosensory chronic tinnitus and with the presence of at least one active or latent
MTP. Treatment was performed in two phases: (1) four sessions (one session per week
for four consecutive weeks) of placebo DN and (2) four sessions of therapeutic DN with
a gap (washout) of 15 days between these phases.
Keywords Results The Tinnitus Handicap Inventory (THI) variable and its emotional domain had
► tinnitus a statistically significant reduction in therapeutic DN when compared with placebo DN
► physiotherapy (p ¼ 0.024 and p ¼ 0.011, respectively).
► somatosensorial The tinnitus visual analogic scale (VAS) signaled a reduction in tinnitus discomfort
tinnitus when compared with moments before and after therapeutic DN (p < 0.05).
► dry needling Conclusion The therapeutic DN technique for MTP in patients with chronic tinnitus of
► trigger points somatosensory origin proved effective in reducing symptom discomfort, as measured
► placebo-controlled by the THI (total score) and its emotional domain when compared with placebo DN.

Introduction
tinnitus awareness (intensity, frequency, location) from
Tinnitus can be defined as sound perception in the head or in forced contraction maneuvers of the head and/or neck
the ear in the absence of an external environmental sound muscles.3 According to this Levine3, this subtype of subjec-
source.1 Epidemiological data show that the prevalence of tive tinnitus can be present in about 68% of patients.
tinnitus in the city of São Paulo is of 22%.2 A possible explanation for this phenomenon might lie in
Tinnitus is a symptom that can be triggered by several the existing connections between auditory and somatosen-
causes and, in general, two or three etiological factors can be sory pathways. This has previously been shown in the
identified in the same patient. Among these factors, auditory literature through a study in which an auditory stimulus
and somatosensory system disorders stand out. The somato- (the sound of rubbing hands) managed to trigger a tactile
sensory subtype has as its main characteristic modulation in sensation (dryness sensation of the palms).4

received DOI https://doi.org/ © 2021. Fundação Otorrinolaringologia. All rights reserved.

October 13, 2020 10.1055/s-0041-1730429. This is an open access article published by Thieme under the terms of the
accepted ISSN 1809-9777. Creative Commons Attribution-NonDerivative-NonCommercial-License,
March 3, 2021 permitting copying and reproduction so long as the original work is given
appropriate credit. Contents may not be used for commercial purposes, or
adapted, remixed, transformed or built upon. (https://creativecommons.org/
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Effectiveness of Dry Needling in Bothersome Chronic Tinnitus Campagna et al.

Experimental studies have shown that in the face of an sory origin. Our hypothesis is that treating MTPs through DN
installed hearing loss, changes in (pre-existing) neural con- is effective in reducing tinnitus discomfort.
nections between the trigeminal and dorsal spine pathways
occur (gracile and cuneiform nuclei) over the dorsal cochlear
Methods
nucleus in the brainstem.5 These changes involve the amount
and expression of glutamate receptors and of auditory and The present clinical trial was placebo-controlled and cross-
proprioceptive pathways on this nucleus. This rearrange- over (ClinicalTrials.gov Identifier: NCT03295890). It was
ment of neural connections culminates in the increase of previously submitted to the Research Ethics Committee of
somatosensory influence on the dorsal cochlear nucleus. our institution and was approved under the Process Opinion
This evidence supports, once again, the relevance of cross Number 1.784.310, CAAE: 60675516.4.0000.0068 of
modal neural plasticity (reorganization ability between two October 20th, 2016). All subjects of the present trial have
or more sensory modalities) for the generation of tinnitus.5 authorized and signed the free and informed consent form
Somatosensory tinnitus may be related to the existence of (FICF).
myofascial trigger points (MTPs) in the head musculature
and/or7 in the neck and/or shoulder girdle, to temporoman- Placebo and Therapeutic Groups
dibular joint (TMJ) disorders, and/or to craniocervical pro- After a previous pilot project, 16 patients were selected.
prioceptive disorders.6,7 The selection criteria included: (1) age > 18 years old, (2)
The association between tinnitus and MTPs has already both genders, (3) constant tinnitus, (4) unilateral or bilateral,
been widely discussed in the literature.8–13 (5) for at least 6 months, (6) presence of at least 1 MTP (active
Myofascial trigger points are hyper-irritable areas located or latent) in the head, neck and/or shoulder girdle.
in a tense band of the skeletal muscle. They can be active or The criterion for the diagnosis of somatosensory tinnitus
latent, depending on their clinical characteristics. An active included the presence of tinnitus (intensity, frequency, loca-
MTP causes spontaneous resting pain, and its palpation tion) modulation (exacerbation, onset, attenuation) during
generates a reported pain pattern, similar to the pain com- passive palpation of the head and neck muscles by one of the
plaint of the patient. Latent MTPs may not cause spontaneous researchers, as shown in ►Table 1. Usually those patients
pain, and may only appear in the face of the local stimulus; may have a previous pathological history of: (1) pain epi-
however, they can have repercussions, which may include sodes in the head, neck or shoulder girdle, (2) head or neck
decrease of range of motion (ROM) as well as muscle trauma, (3) inappropriate posture or postural habits, (4)
weakness.8 bruxism for long periods, (5) manipulation of the teeth,
Clinical complaints related to MTPs (pain, limitation of jaw, or cervical spine, (6) cervical spine dysfunction and/or
ROM, paresthesia, and weakness) occur by the shortening of listhesis associated with the symptom.13,24
muscle fibers and pressure on adjacent nerves and body The following exclusion criteria were used: (1) previous
tissues.14 experience with needles for therapeutic purposes, (2) formal
Treatment modalities already described for MTPs include: contraindication to DN, such as chronic use of anticoagulants
(1) antidepressants, neuroleptics, non-hormonal anti-in- or the presence of hematologic diseases, (3) needle phobia or
flammatory drugs,15–17 (2) acupuncture, (3) ultrasonogra- refusal of the proposed therapy, (4) use of medication for
phy therapeutic application (longitudinal and compressional pain or tinnitus that could interfere in the study outcome,
sound waves that travel through biological tissue and indu- such as anti-inflammatory drugs and/or muscle relaxants, up
ces mechanical vibration as well as displacement of mole-
cules), (4) diathermy, (5) transcutaneous electrical neural Table 1 Muscles suitable for placebo and therapeutic dry
stimulation (TENS), (6) cold spray (cryotherapy resource needling
used as a local anesthetic in physical therapy), (7) several
stretching techniques, (8) dry needling (DN), and (9) local Muscles suitable for placebo and therapeutic dry
injections with anesthetics and/or steroids.18,19 The clinical needling
efficacy of these therapies is yet to be defined, since studies Masseter
comparing pre-and post-treatment outcomes with control Temporalis (medium fibers)
and placebo groups are scarce.
Sternocleidomastoid
Dry needling works as a mechanical stimulus and physical
agent that treats MTPs in the affected muscle tissue by Posterior Scalene
inserting a long thin needle. This results in a decrease of Trapezius (descending fibers)
muscle pain and stiffness, in an improvement in the ROM, Infraspinatus
and in a balance in muscle strength and function.20–22 The
Splenius muscle of the head
technique does not require injection of any drug and may
Medial and Lateral Pterygoids
result in local muscle spasm. Triggering, etiological and
perpetuating factors should be corrected to prevent relapse. Rhomboid major
Although DN has been described for some time as a Scapula Lift
therapeutic strategy in the treatment of MTPs,23 it has never Digastric (posterior belly)
been tested in patients with chronic tinnitus of somatosen-

International Archives of Otorhinolaryngology © 2021. Fundação Otorrinolaringologia. All rights reserved.

 Effectiveness of Dry Needling in Bothersome Chronic Tinnitus Campagna et al.

to 30 days prior to the initial assessment, (5) manual therapy

for pain management up to 30 days before the initial assess-
ment, and (6) patients with fibromyalgia.
All patients were evaluated by an otolaryngologist and
underwent tonal, vocal and immittance audiometry, high-
frequency audiometry, tinnitus psychoacoustic measure-
ments, blood tests, and magnetic resonance imaging (MRI)
in case of suspected retrocochlear lesion.
On the 1st day of placebo DN, the selected subjects were
submitted to: (1) physical reassessment for MTP, (2) measure-
ment of degree of tinnitus discomfort and (3) cervical and/or
shoulder girdle pain, both using VAS, (4) answering of the
Tinnitus Handicap Inventory (THI) and of the Neck Disability
Index – Brazil (NDI-BR) questionnaires, and (5) measurement
of muscle tension using the Neutone (Try-All, Chiba City,
Kanto, Japan) device. This device is capable of measuring
muscle tension/muscle tone if the measurement condition
does not change during follow-up and the position and posture
of the patient are consistently replicated at every therapeutic
session.19 Measurements placed perpendicular to the muscle
to be tested by the Neutone device were established, per-
Fig. 2 Placebo needle: moments 1 and 2.
formed in triplicate for each patient, always by the same
researcher, in order to keep a uniform and constant pressure
pattern as well as to prevent measurement misreading. local pressure was then performed, followed by a nonthera-
After collecting the measurement variables, the patient peutic stretching of the “treated” muscle with free hands.
was instructed to lie down in ventral (prone) or dorsal We are aware that, in physical therapy, one of the techni-
(supine) decubitus, depending on the muscle suitable for ques used in rehabilitation is passive and therapeutic
treatment (see ►Table 1). stretching of the muscle in question. In order to not interfere
with the response to MTP treatment, in DN placebo, the
Placebo Dry Needling muscular stretching was not fully performed, according to
After proper positioning of the patient, the therapist made the technique protocol.
hand and local skin asepsis of the location to be needled with At the end of the procedure, the patient was instructed to
70% alcohol and wore disposable latex gloves during the sit again to have muscle tension measured using the Neutone
procedure. The marketed placebo kit (Asia-Med, Asia-Med device. At the end of this stage, the degree of tinnitus distress
Acupuncture Needle, Suhl, Turingia, Germany), had a guide and pain was measured again using the VAS.
and a needle (►Fig. 1). It was positioned over the selected Dry needling placebo sessions were performed once a
MTP with the fixed guide for inserting the placebo needle week by the same therapist for four consecutive weeks, and
into the skin. As soon as the needle guide was forced against the THI and NDI-BR questionnaires were used again at the
the skin, it was retracted into the guide, which caused the end of the 4th placebo session. The measurements of the
patient to feel a tactile and/or visual illusion of true pene- variables were done immediately after (at the end) the last
tration (►Fig. 2). This procedure lasted for  1 minute and session.
the needle was then removed along with the guide. A very light After an interval of 15 days (washout), all patients began
the second phase of treatment, which was called therapeutic
DN, with Asia-Med Acupuncture Needle CE 98527 O123 Suhl
(►Fig. 3).

Therapeutic Dry Needling

After the washout period, the patient returned to the outpa-
tient clinic, answered the THI and NDI-BR questionnaires,
scored the tinnitus and pain discomfort through the VAS
(before and after therapeutic DN), and had the measure-
ments of muscle tension retraced by the Neutone device
(before and after therapeutic DN). The needle, along with the
guide, was held with the fingers. Subcutaneous skin pene-
tration into the MTP was performed. The needle progressed
 between 1 and 2 cm away from the target MTP and was
then angled at 30°. The DN protocol used in our study
Fig. 1 Placebo needle. followed recommendations according to Dommerholt et al.25

International Archives of Otorhinolaryngology © 2021. Fundação Otorrinolaringologia. All rights reserved.

Effectiveness of Dry Needling in Bothersome Chronic Tinnitus Campagna et al.

58 years old, with unilateral tinnitus in the majority of cases

(82.2%).
Comparing the two groups, we observed that the THI
variable and its emotional domain reduced, in average, more
in the therapeutic DN group than in placebo DN group, with a
statistically significant difference (p ¼ 0.024 and p ¼ 0.011,
respectively) and proven by the analysis of confidence inter-
vals (CIs) for the means of change.
The tinnitus VAS for therapeutic DN showed improvement
of the tinnitus discomfort, with a statistically significant
mean difference, comparing the moments before and after
therapy (p < 0.05). Conversely, the placebo DN showed no
additional benefit in the treatment of tinnitus according to
the study variables (p > 0.05).
Fig. 3 Examples of therapeutic dry needling in the trapezius muscle
There was a tendency to observe a statistically significant
(descending fibers).
difference (p ¼ 0.073) in the tinnitus VAS, since its reduction
was greater after therapeutic DN than after placebo DN.
The primary objective of the technique was to achieve a
rapid contractile muscle response.25 This is an involuntary
Discussion
spinal reflex that contracts muscle fibers in the tense range,
an effect that can be achieved both through digital pressure General Characteristics of the Sample
and through DN of the MTP.26 Long and thin needles with a One of the nonauditory comorbidities most commonly as-
diameter of 0.25  30 mm were used for superficial body sociated with tinnitus includes head and neck dysfunction
tissues, and needles with a diameter of 0.25  40 mm were (chronic spasms, muscle tension, neck pain, restriction of
used for deeper body tissues. ROM), which usually precedes the onset of tinnitus. In a
Faced with a local twitch response (LTR), the needle sample of 2,400 patients with tinnitus, 297 (12%) reported
remained in place for  30 seconds to deplete the reflex and that tinnitus started within 2 weeks after the trauma and, in
then, it was removed. The site was pressed again to check for most cases,  24 hours after it.29
reactions. In case of signal of nonabolished LTR, the needle was The average age observed in our patients was 58 years old,
replaced, reinserted into the target MTP, and at this time held and the ratio of tinnitus between females and males was 2:1.
for up to 3 minutes. In some patients, intermittent needle These findings are similar to those of the epidemiological
twisting was required.27 The sessions took place once a week field study conducted for the city of São Paulo.2 In this study,
for a period of 4 consecutive weeks, and the THI and NDI-BR the symptom prevalence peak was at 65 years old. Out of 430
questionnaires were used again at the end of the 4th therapeu- inhabitants with tinnitus (among 1,960 respondents), 273
tic DN session (see Flowchart 1 for the timeline of the clinical (63.5%) were female and 157 (36.5%) were male.2 However,
trial). The measurements of the variables were done immedi- the aspect of gender may be controversial in the interna-
ately after (at the end) the last session. We did not collect any tional literature, depending on the country and population
more patient’s data after that. Patients underwent to tinnitus studied.
treatment with other protocols. A previous clinical experience with 150 patients exam-
ined between 1994 and 1996 at the Otorhinolaryngology
Statistical Analysis Department of the Universidade de São Paulo reinforces that
The statistical methodology included the Student t-test. The our local sample probably differs from that described as
patient qualitative characteristics were described by means usual around the world, whose male individuals are the ones
of their absolute and relative frequencies. Ages were de- most frequently affected by the symptom. In this local study,
scribed using their means and standard deviation (SD), the authors observed that 60% of the tinnitus patients were
median, minimum and maximum.28 female and 40% were male.30 In addition, according to this
The study variables are plotted in ►Table 2, categorized same study, tinnitus was bilateral in 50% of the cases,
according to the moment of the timeline in which they unilateral in 39%, and the others perceived it in the head.30
occurred, through their means and SDs, and their corre- In our sample, unilateral tinnitus was found in 80% of the
sponding levels of statistical significance. patients. This variation can be explained by the tinnitus
subtype selected for the referred therapeutic intervention
in our study.
Results
A well-established concept in the literature is that one of
Our sample comprised 16 patients with somatosensory the main characteristics of somatosensory tinnitus is that it
chronic tinnitus who met the selection criteria and under- occurs predominantly in one of the ears,24 mainly because
went placebo DN and therapeutic DN. None of the patients such subtype of chronic tinnitus is generally associated with
gave up treatment during the trial period. Among them, a somatic disorder of the head and neck, which affects
more than two thirds were female, with a mean age of primarily one side of the body.

International Archives of Otorhinolaryngology © 2021. Fundação Otorrinolaringologia. All rights reserved.

 Effectiveness of Dry Needling in Bothersome Chronic Tinnitus Campagna et al.

Flowchart 1 (clinical trial timeline).

could be considered clinically relevant, the absolute change in

Measurement Variables
the questionnaire was compared with the Clinical Global
Tinnitus Handicap Inventory Score Reduction when Impression Improvement (CGI-I), which was the scale used
Comparing Placebo Dry Needling with Therapeutic to measure symptom severity, response, and treatment effi-
Dry Needling ciency in 210 patients with tinnitus.33 A reduction of at least
The THI is the only questionnaire validated and adapted to the seven points could be considered to indicate a clinically
Portuguese language up to the present time.31 It was created to relevant improvement in therapeutic clinical trials and to
quantify subjectively the impact of tinnitus on the quality of calculate the sample size.33
life of the patient and to classify reactions and discomfort into Our study revealed an improvement of  7 points in the
three main domains: (1) functional, (2) emotional, and (3) total THI score in 31.2% of the patients after placebo DN, and in
catastrophic.32 The THI score of the same patient was tested at 68.7% of the patients after therapeutic DN, considering a
2 different points in time to determine its replicability and minimum change variation of 7 points, as mentioned above.33
reliability with a 95% CI in the retest. In a previous study, to The percentage of clinical improvement in patients submitted
determine the minimum difference in the total THI score that to placebo DN, although high, matches with the previous

International Archives of Otorhinolaryngology © 2021. Fundação Otorrinolaringologia. All rights reserved.

 Table 2 Description of scales before and after each treatment phase, with the corresponding confidence intervals, and comparative tests between treatment groups

Placebo pPlacebo (pre VS post) Terapeutic p Terapeutic(pre VS post) pD Placebo VS terapeutic 

Variable Pre Post Change Pre Post Change pre-post

International Archives of Otorhinolaryngology

pre-post
VAS Tinnitus 0.206 <0.001 0.073
average  SD 7.5  1.7 6.6  2.2 0.94  1.73 6.5  2.3 4.2  2.8 2.31  2.3
VAS Pain 0.383 0.310 0.958
average  SD 4.6  3.3 3.4  2.9 1.25  2.35 3.2  3.2 1.9  2.3 1.31  3.68
THI 0.999 0.003 0.024
average  SD 51.1  21.7 51.4  18.8 0.25  14.91 45.8  18.2 35  15.1 10.75  8
Functional >0.999 0.105 0.116
average  SD 19.8  10.3 20.1  9.3 0.37  6.25 17.5  9.5 13.5  8.6 4  6.81
Emotional 0.032 0.011
Effectiveness of Dry Needling in Bothersome Chronic Tinnitus

>0.999
average  SD 19.1  9.8 19.9  8.1 0.75  7.66 17.4  7.8 12.3  7.2 5.13  5.21
Catastrophic >0.999 >0.999 0.926

© 2021. Fundação Otorrinolaringologia. All rights reserved.

average  SD 11.4  3.6 11.3  3.5 0.13  3.38 10.3  4 10  5 0.25  4.49
NDI-BR >0.999 >0.999 0.920
average  SD 10  5.8 9.3  5.2 0.69  2.63 8.9  4.9 8  10.4 0.94  10.47
Campagna et al.

Neutone (Performed side) 0.064 0.076 0.967

average  SD 21.8  5.5 19  6.6 2.75  6.41 21  6.5 18.3  6.9 2.69  3.19
Neutone Ratio (Performed/contralateral side) 0.243 >0.999 0.175
average  SD 2.1  2.4 1.1  0.1 0.63  2.13 1.2  0.4 1.3  0.5 0.1  0.2

Abbreviations: NDI-BR, neck disability index-Brasil; p, probability; SD (standart deviation); THI, tinnitus handicap inventory; VAS, visual analogue scale.
Bonferroni multiple comparisions; Student paired t-test
 Effectiveness of Dry Needling in Bothersome Chronic Tinnitus Campagna et al.

report in the literature, which indicates 40% improvement in with the limbic system, through the hippocampus with the
chronic tinnitus patients due to a placebo effect.34 gateway to centers that mediate emotional control and
memory.37
Reduction of Emotional Domain Tinnitus Handicap It is also known that the acoustic environment can affect
Inventory Scores when Comparing Placebo Dry Needling nonauditory brain regions as well. The amygdala and the
with Therapeutic Dry Needling hippocampus are the two largest areas of the limbic system
Our results also showed that DN interfered not only with the that receive neural inputs directly or indirectly from the
total THI score, but especially with its emotional domain, central auditory system, as well as the auditory thalamus
which is understandable, since our input sample included (medial geniculate body). Therefore, acoustic stimuli can
patients with average THI scores > 37 points. Tinnitus severity promote functional changes in the limbic system. In the
is known to be directly correlated with stress, anxiety, depres- same way, direct and indirect projections of the limbic
sion, and emotional exhaustion levels.35 It is also known that, system can also modulate neural activity in areas of the
the higher the total score of the questionnaire, the higher the central auditory system.38
chances for this to happen, especially if the THI score is  38 The response of the amygdala to sounds depends directly
points.36 on their relevance in the sensory environment. Functional
Evidence suggests that structures involved in controlling MRI in blind individuals, whose acoustic environment is
the emotional neurophysiological and biological state and more relevant than in individuals with normal visual acuity,
mood contribute directly to tinnitus modulation.35 In the shows a more intense amygdala response in the face of a
brainstem, two structures have global influence on these sound stimulus with emotional connotation. Brain amygdala
functions, the cerulean locus (CL) and the dorsal raphe feedback to sensory stimuli occur even during sleep. How-
nucleus (DRN).35 The projections of these networks diffuse ever, the hippocampal-auditory system is essential for long-
into the cerebral cortex and to tinnitus-generating sites term hearing memory formation. The presence or absence of
through direct inputs to the cochlear nucleus and to the sound affects directly the structural and functional plasticity
inferior colliculus.35 These CL inputs use norepinephrine and of the hippocampus.39
serotonin as neuromodulators.35 The high prevalence of Experimental studies have shown that rats subjected to
tinnitus whose psychoacoustic characteristics modulate reversible conductive hearing loss developed depression,
through forceful contractions of head and neck muscles memory deficit, and reduction of dopamine, homovanilic
can, therefore, in some way reflect, in part, the synergy of acid and acetylcholinesterase activity. These behavioral and
brainstem connections between tinnitus-generating sites, molecular changes disappeared after hearing rehabilitation.40
somatosensory nuclei, trigeminal, cervical, mood and emo- Neurocognitive tests have been used to compare skills
tion modulating centers, including the CL and the DRN.35 between patients with moderate/severe/catastrophic tinni-
One of the first brain functional imaging studies to tus (THI  38) with the normal population, matched by age,
provide evidence of the link between the limbic system gender, and educational level.36 Results showed significantly
and the central auditory cortex was performed by measuring higher deficits in the learning curve of tinnitus patients
cerebral blood flow in order to map regions responsive to regarding evoked and associative memory and also when
tinnitus modulation.37 Patients whose voluntary orofacial following commands and paying attention.36
movements modulated tinnitus intensity were compared In a systematic review article, clinical trials evaluating the
with a control group and submitted to two different para- impact of tinnitus on cognitive function were surveyed.
digms. The first paradigm was unilateral cochlear stimula- Evidence suggests that the cortical cognitive impairment
tion through pure tones, whose effect was the activation of in patients with disabling chronic tinnitus possibly arises
the bilateral central auditory cortex in both groups (tinnitus from a deficit in the processing and targeting of attention
and control). The fact that unilateral sound stimulation resources and in the conflict solving and executive control of
triggers a cortical effect in both cerebral hemispheres is fully responses.41
understood, given the network and cross-neural connections Therefore, the reduction in the THI total scores and in its
decussation in the brainstem. In the second paradigm, there emotional domain seems to be supported by previous find-
was modulation of tinnitus awareness through orofacial ings in literature showing a direct relationship among tinni-
movements. Unexpectedly, in the latter, the change in cere- tus, emotional state, cognition, and memory.
bral blood flow was unilateral, which directly involves the It seems that, in the moment we correct factors associated
central auditory pathways as being responsible for sponta- to tinnitus, such as MTP, and reduce the referred discomfort,
neous neural activity that results in symptom modulation. we directly or indirectly help improve emotional and mood
Another relevant finding was that the sound stimulus acti- reactions related to the very awareness of tinnitus. Another
vated a larger number of brain regions in the tinnitus group possible explanation for the reduction in the emotional THI
when compared with the control group. These findings, once score would be the action of MTP deactivation in the seroto-
again, support the neurophysiological model of Jastreboff1, ninergic system, which modulates various physiological and
which emphasizes the dramatic reorganization of the central behavioral functions such as sleep, hunger, pain, mood, and
auditory cortex and related and associated brain areas in emotions.
tinnitus patients. Such wide range of brain areas is activated Most serotoninergic neurons are found in the DRN and in
through neural connections of the central auditory cortex the medial raphe nucleus (MRN), with numerous projections

International Archives of Otorhinolaryngology © 2021. Fundação Otorrinolaringologia. All rights reserved.

Effectiveness of Dry Needling in Bothersome Chronic Tinnitus Campagna et al.

on the auditory system, including the cochlear nucleus (CN), transcutaneous electrical stimulation (TENS), manual thera-
which centralizes most of them. Although the serotoninergic py, occlusive treatments, laser, home cervical exercises, and
action in the auditory system is not well clarified, it is muscle relaxation techniques for MTP.
believed that it takes part in modulatory responses to simple The effect of TENS was tested in 65 patients with chronic
and complex sounds, such as vocalization, for example. The tinnitus.44 The authors did not specify whether the patients
dorsal cochlear nucleus (DCN) is a site of particular interest had somatosensory tinnitus as a diagnosis or not. Cases with
when studying the serotoninergic action in the auditory mild hearing loss and severe tinnitus were selected. The
system, since it is the main terminal where thousands of patients were treated twice a week for 4 consecutive weeks;
multisensory inputs converge, which manages the location 45 were treated with TENS and 20 with placebo stimulation.
and orientation of the sound source and is an important About 62% of the TENS-treated patients had tinnitus im-
center for tinnitus generation and modulation.42 provement, versus 10% of those in the placebo group. Al-
It is well-known that an atypical serotonergic transmis- though the improvement reported by patients was greater in
sion underlies the pathogenesis of tinnitus, at one or more the study group than in the placebo group, it was observed
levels of the auditory pathways, previously documented by that the VAS for tinnitus discomfort decreased from 6.7 to 5.4
spontaneous hyperactivity found all over its network.43 This after TENS, and from 6.5 to 5.7 in the placebo group. In other
fact should contribute not only to the generation but also to words, there was no statistically significant difference be-
the persistent tinnitus awareness in some patients, as well as tween the two groups. The same occurred for the THI score,
to the emotional and mood reactions related to it.43 which decreased from 49.4 on average to 42.8 after TENS and
We can infer that the treatment of MTPs and their conse- rose from 44.5 on average to 45.2 in the placebo group.
quent improvement in our sample may have contributed to In a recent clinical trial, interocclusal treatment was
the regularization of this neural signaling pathway. The evaluated for a period of 3 years in 89 patients with tinnitus
reduction in spontaneous hyperactivity of these multisenso- and mandibular muscle pain.45 The 64 patients who reached
ry connections could explain the reduction in the THI the end of the study had a mean reduction from 68.3
emotional domain score in these patients. (100 mm scale) to 37.4 for tinnitus disability assessed by
the VAS, after 1 year of trial. No significant reduction was
Visual Analogue Scale of Tinnitus Discomfort before observed in subsequent years. The number of affected pain-
and after Therapeutic Dry Needling ful muscles decreased from 7 to 2 in 1 year of therapy, and
Clinical trials that study patients with subjective symptoms remained so for 2 consecutive years. The authors considered
such as chronic pain depend on the adequate measurement a change  20 mm in the VAS as clinically significant; 58% of
of their disability as a requirement to verify the response to the patients had this improvement within 1 year of therapy,
treatment. Although there is no gold standard method for and this was sustained in 43% of the cases for 2 consecutive
measuring subjective symptoms, scales are adopted routine- years. About 46% of the patients reported a 50% reduction in
ly in the clinical practice. the frequency and severity of tinnitus.
The VAS is a metric scale for intensity or frequency of In a clinical trial, 20 patients with subjective tinnitus
symptoms that require direct objective measurement. The underwent 2 weekly sessions, up to a total of 12 complete
scale ranges from “0 cm” which corresponds to “absence of sessions with continuous, low-intensity, red-wave (630 nm)
the symptom” to “10 cm” (unbearable symptom). The symp- and infrared (808 nm) diode laser, full dose of 120 Joules per
tom score can be decoded as follows: mild (up to 3 cm), ear and per session with the purpose of suppressing tinnitus
moderate (4 to 7 cm), and severe (8 to 10 cm). The scale needs temporarily.46 A paired t-test showed improvement in the
to be visually presented to the patient so that they can see it. VAS for tinnitus intensity from 5.7 before to 3.2 after
In our research, there was no statistically significant differ- completing therapy (p <0.0001); the THI score reduced
ence regarding the perception of tinnitus for treatments with from 68.6 to 54.6 (14 points reduction on average).
placebo and therapeutic DN, as measured by the VAS, despite Michiels et al.47 evaluated prognostic indicators for tinni-
the tendency towards statistical deviation observed. We be- tus disability reduction after cervical physiotherapy in
lieve that this is because the sample size was smaller than patients with somatic cervicogenic tinnitus. Patients with
initially designed. The screening for the inclusion and exclu- moderate to severe tinnitus were assessed using the Tinnitus
sion criteria made it very difficult for us to reach the desired Functional Index (TFI) questionnaire and the cervical com-
sample size in a timely manner (a number of patients who plaints questionnaire (Bournemouth Cervical Questionnaire
could have been included in the research had had previous [QCB] > 14 points). They received physical therapy treatment
experiences with acupuncture). However, when analyzing for the cervical spine, multimodal care, which included
exclusively the tinnitus before and after therapeutic DN, the manual mobilization and home exercises of cervical self-
variation in the VAS was statistically significant. mobilization for the flexor muscles. Twelve physical therapy
Currently, studies evaluating physical therapy treatments sessions were held for 6 weeks. Measurement variables were
of somatosensory tinnitus are not comparable in terms of documented before, immediately after treatment, and
techniques used and of variables measured during the clini- 6 weeks after the end of treatment. The patients whose
cal follow-up of the patients. For this reason, we searched in tinnitus modulated (increased or decreased) simultaneously
the literature for clinical trials that used study variables such with cervical complaints had the lowest TFI scores, immedi-
as the THI and the VAS. Among them, we have found ately after therapy (p ¼ 0.001), and after late follow-up

International Archives of Otorhinolaryngology © 2021. Fundação Otorrinolaringologia. All rights reserved.

 Effectiveness of Dry Needling in Bothersome Chronic Tinnitus Campagna et al.

(p ¼ 0.03). In addition, patients with low-frequency tinnitus 5 Dehmel S, Cui YL, Shore SE. Cross-modal interactions of auditory
and worsening after inadequate spinal postures were also and somatic inputs in the brainstem and midbrain and their
responsible for lower TFI scores after treatment (R ¼ 0.357), imbalance in tinnitus and deafness. Am J Audiol 2008;17(02):
S193–S209
that is, they responded better to therapy.
6 Manfredini D, Olivo M, Ferronato G, Marchese R, Martini A,
We know that pain is a subjective symptom affected by Guarda-Nardini L. Prevalence of tinnitus in patients with different
several factors. In physical therapy, ways of treating discom- temporomandibular disorders symptoms. Int Tinnitus J 2015;19
fort are studied tirelessly in different groups and levels of (02):47–51
severity. This would not be different for patients with 7 Bressi F, Casale M, Papalia R, et al. Cervical spine disorders and its
association with tinnitus: The “triple” hypothesis. Med Hypothe-
somatosensory tinnitus. In our research, even though MTPs
ses 2017;98:2–4
were present in the treated patients (as mentioned before),
8 Travell JG, Simons DG, Simons LS. Travell & Simons’ myofascial
pain was not unbearable or incapacitating. For this reason, pain and dysfunction: the trigger point manual. Second edition
the VAS measurements for pain did not produce values Philadelphia: Lippincott Williams & Wilkins, 1 vol.
statistically significant at the end of the trial. In the same 9 Yeng LT, Kaziyama HHS, Teixeira MJ. Myofascial painful syn-
way, the Neutone device, which assessed muscular tension drome. Rev Med 2001;80(n.spe1):94–110
10 Alvarez DJ, Rockwell PG. Trigger points: diagnosis and manage-
and could be related to pain generated by MTPs, did not
ment. Am Fam Physician 2002;65(04):653–660
reveal statistically relevant changes. 11 Travell JG, Simons LS, Simons DG. Dor e disfunção miofascial
Although these values were not significant, patients with manual dos pontos-gatilho. 2 ed. Porto Alegre: Artmed; 2005
somatosensory tinnitus searched for treatment for their 12 Ralli M, Salvi RJ, Greco A, et al. Characteristics of somatic tinnitus
main discomfort and were commonly not aware of the patients with and without hyperacusis. PLoS One 2017a12(11):
relationship between the somatic and auditory systems 1–15
13 Sanchez TG, Rocha CB. Diagnosis and management of somatosen-
and that they may affect each other. When the patient is
sory tinnitus: review article. Clinics (São Paulo) 2011;66(06):
correctly diagnosed, we know there are greater chances for 1089–1094
improvement of symptoms and, consequently, of their quali- 14 Akamatsu FE, Yendo TM, Rhode C, et al. Anatomical Basis of the
ty of life.13 Pain, which in many instances is not a simple Myofascial Trigger Points of the Gluteus Maximus Muscle. Biomed
clinical finding, becomes a great ally to stop tinnitus discom- Res Int 2017;2017:4821968. Doi: 10.1155/2017/4821968
15 Simpson LL. Molecular pharmacology of botulinum toxin and
fort and fully improve it.
tetanus toxin. Annu Rev Pharmacol Toxicol 1986;26:427–453
What could be observed when conducting the present
16 Imamura ST, Fischer AA, Imamura M, et al. Pain management
research was the dedication of the patients, for they were using myofascial approach when other treatment failed. Phys
never absent in the treatment sessions and believed in the Med Rehabil Clin N Am 1997;8(01):179–196
improvement of their symptoms. And it really came true, for 17 Björne A. Assessment of temporomandibular and cervical spine
the efficacy of DN in the MTP of patients with chronic disorders in tinnitus patients. Prog Brain Res 2007;166:215–219.
Doi: 10.1016/S0079-6123(07)66019-1
tinnitus was confirmed.
18 Herraiz C, Aparicio JM. [Diagnostic clues in pulsatile tinnitus
(somatosounds)]. Acta Otorrinolaringol Esp 2007;58(09):426–433
19 Tachibana K, Ueki N, Uchida T, Koga H. Randomized Comparison
Conclusion
of the Therapeutic Effect of Acupuncture, Massage, and Tachi-
The therapeutic DN technique for MTPs in patients with bana-Style-Method on Stiff Shoulders by Measuring Muscle
chronic somatosensory tinnitus was effective in reducing the Firmness, VAS, Pulse, and Blood Pressure. Evid Based Complement
Alternat Med 2012;2012:989705. Doi: 10.1155/2012/989705
discomfort of the symptom measured by the THI (total score)
20 Wyant GM. Chronic pain syndromes and their treatment. II.
and its emotional domain. Trigger points. Can Anaesth Soc J 1979;26(03):216–219. Doi:
10.1007/BF03006985
Funding 21 Amanda B, Manuela M, Antonia M, Claudio M, Gregorio B.
Coordenação de Aperfeiçoamento de Pessoal de Nível Posturography measures and efficacy of different physical treat-
Superior Faculdade de Medicina da Universidade de São ments in somatic tinnitus. Int Tinnitus J 2010;16(01):44–50
Paulo 22 Michiels S, Naessens S, Van de Heining P, et al. The effect of
physical therapy treatment in patients with subjective tinnitus: a
systematic review. Front Neurosci 2016;10:545
Conflict of Interests 23 Ong J, Claydon LS. The effect of dry needling for myofascial trigger
The authors have no conflict of interests to declare. points in the neck and shoulders: a systematic review and meta-
analysis. J Bodyw Mov Ther 2014;18(03):390–398
24 Michiels S, Ganz Sanchez T, Oron Y, et al. Diagnostic Criteria for
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