Module one dry needling .pdf

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Dry Needling Module One 2013

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© Optimal Dry Needling Solutions – – United United Kingdom, USA, Europe and Middle East.- 2013

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This handout is not an ‘original manuscript’, but a collection of useful basic principles, clinical techniques techniques and theories pertaining to the field of needling.

As physiotherapists, acknowledgement acknowledgement must be made to the in-depth contribution of Drs Janet Travell and David Simons, for our working knowledge of myofascial pain syndromes.

Our personal opinion is that their books are ‘mandatory equipment’ for those of us involved in dry needling, and should be purchased and studied by all.

Recently published ‘Myofascial Trigger Points’ by Dommerholt & Dommerholt & Huijbrechts (2010) is an excellent contemporary summary of the pathophysiology relevant to this course. Further indebtedness is owed to the many years of practical clinical work and research done by Drs Chan Gunn and Andrew Fischer who have further improved the skill of therapists in this field and have, together with David Bowsher, Peter Baldry, and C-Z Hong, given us plausible Western rationale on which to base our techniques.

While this course in no way teaches acupuncture, we acknowledge the Great Tradition of Chinese Medicine.

Enjoy this wonderful approach to therapy!


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This handout is not an ‘original manuscript’, but a collection of useful basic principles, clinical techniques techniques and theories pertaining to the field of needling.

As physiotherapists, acknowledgement acknowledgement must be made to the in-depth contribution of Drs Janet Travell and David Simons, for our working knowledge of myofascial pain syndromes.

Our personal opinion is that their books are ‘mandatory equipment’ for those of us involved in dry needling, and should be purchased and studied by all.

Recently published ‘Myofascial Trigger Points’ by Dommerholt & Dommerholt & Huijbrechts (2010) is an excellent contemporary summary of the pathophysiology relevant to this course. Further indebtedness is owed to the many years of practical clinical work and research done by Drs Chan Gunn and Andrew Fischer who have further improved the skill of therapists in this field and have, together with David Bowsher, Peter Baldry, and C-Z Hong, given us plausible Western rationale on which to base our techniques.

While this course in no way teaches acupuncture, we acknowledge the Great Tradition of Chinese Medicine.

Enjoy this wonderful approach to therapy!


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Claire Waumsley BSc. Physio (Wits), Dr. Chinese Med. (AHPCSA)

Claire Waumsley has been involved in teaching Dry Needling and promoting awareness of the myofascia as a potential source of pain since the mid 1990s. She has run courses extensively within Southern Africa, the Middle East and more recently the United Kingdom and India and is a co-founder of Optimal Dry Needling Solutions. Claire spent many years working in large rural hospitals in Namibia, Malawi and South Africa Africa before moving into private practice. She now runs a practice on the Cape West Coast of South Africa. Over the years she has worked worked within Animal Animal Rehabilitation, predominantly in the equine field. st

She has presented papers and posters at the 1 International Congress on Animal Therapy in Oregon USA, the SA National Veterinary Congress, the University of Pretoria Pain Congress and the United Arab Emirates Inter national Pain Congress, 2009. Claire is qualified as a practitioner of Chinese Medicine with the AHPCSA and uses these skills within her scope of Physiotherapy. She is a grandmother of nine and a keen open water swimmer.

Bruce Barker BA, BSc. Physio (Wits)

Bruce Barker holds a Bachelor of Arts degree as well as a B.Sc. (Physio) degree and is currently registered as a M.Sc candidate at the University of the Witwatersrand in Johannesburg. He is working on a dissertation concerning the use of Dry Needling therapy in rotator cuff injuries. Bruce previously worked in the U.K. for the N.H.S, and now works in the private sector, running two practices within Gauteng’s West Rand area. He mainly sees patients with musculoskeletal problems, many of whom are in the Gold Mining Industry. Bruce has been teaching Dry Needling courses for ODNS since 2002. He is the Chairman of the Dry Needling Physiotherapy Special Interest Group in South Africa, and is passionate about using evidence-informed, clinically relevant, bio-psycho-social therapies to help people in pain. Bruce is a keen cyclist, dedicated husband and father of two young children.


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Steven Stavrou BSc. Physio (Wits), Dr. Chinese Med. (AHPCSA)

Steven operates a multi-disciplinary Integrated Health Centre in Sandton, Johannesburg, with the focus on "healing through natural treatments and rehabilitation". He is qualified both as a Doctor of Chinese Medicine and as a physiotherapist. The centre offers a unique integration of both Western Medical treatments and natural health intervention. He has been lecturing Dry Needling for nine years and has developed a comprehensive two-day course on the Temporomandibular Joint. Both Biopuncture and Prolotherapy are two specialised treatments that he offers to his patients. Steven is a keen runner, having completed several Comrades ultra-marathons. He is a devoted husband and father to his wife and son.


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Day One - Index 1.

Needling Basics Neurophysiology Choice of Needles Dangers and Special Considerations Contra-indications Pneumothorax Superficial Needling Reactor Types Clean Field Techniques Ethical Considerations Considerations for Dry Needlers

2.

Myofasciall Pain Myofascia MPS Treatment Options for MTrPs

3. 4.

Selected Abstracts: Clinically Relevant Articles Muscles Gluteus Maximus Gluteus Medius Gluteus Minimus Piriformis Short lateral rotators Gastrocnemius Soleus Selected Abstracts

5.

References and Recommended Reading Indemnity Form DN Information Consent Form Feedback Form

6 6 9 10 12 13 15 17 18 21 22 23 25 29 30 30 32 34 36 39 40 43 45 50 52 53 54 55

Drawings originally by Barbara Cummings for Travell and Simons book, ‘Myofascial Pain and Dysfunction’.

Redrawn for this manual by Karen Korte, Darling, South Africa.


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1. Needling Basics S. D. N (Neurophysiology) Referenced from the excellent work of Dr David Bowsher and Dr Peter Baldry

As Physios ... A-δ

(V. helpful)

C-Fibre (V. Troublesome)



Small myelinated 111 b fibres

Unmyelinated Polymodal fibres



Conduction time 10x faster than C

Slow conducting



Receptors just under the skin, muscle and fascia

Found in all tissues except the C.N.S.



Receptors high-threshold mechano-thermal

Polymodal receptors



“All or nothing” NB! Responds to pin prick and sudden heat

In tissue trauma, thus thresholds at different levels



First trauma pain

Second trauma pain



Warns body of impending injury

Slow to get message



Withdrawal response

Immobilisation



Clinically not real pain, rather a “get out of the way pain”

Response to avoid further injury and allow “stillness” for regeneration



Via N.S. T. tract

Via Paleothalamic tract



Parietal lobe of somatosensory cortex

Frontal cortex



Accurately localised pain

Diffuse dull, aching pain



Unaffected by morphine

Abolished by morphine

© Optimal Dry Needling Solutions – United Kingdom, USA, Europe and Middle East.- 2013

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Research Reviews Subcutaneous tissue fibroblast cytoskeletal remodeling induced by acupuncture: evidence for a mechanotransduction -based mechanism. Langevin HM, Bouffard NA, Badger GJ, Churchill DL, Howe AK. Source Department of Neurology, Vermont Cancer Center, University of Vermont College of Medicine, Burlington, Vermont 05405, USA. [email protected]

Abstract Acupuncture needle rotation has been previously shown to cause specific mechanical stimulation of subcutaneous connective tissue. This study uses acupuncture to investigate the role of mechanotransductionbased mechanisms in mechanically-induced cytoskeletal remodeling. The effect of acupuncture needle rotation was quantified by morphometric analysis of mouse tissue explants imaged with confocal microscopy. Needle rotatio n induced extensiv e f ibrobla st spreading and lamellipodia formation within 30 min, measurable as an increased in cell body cross sectional area. The effect of rotation peaked with two needle revolutions and decreased with further increas es in rotation. Sign ificant effec ts of rotation were present throughout the tissue, indicating the presence of a response extending laterally over several centimeters. The effect of rotation with two needle revolutions was pre vented b y pharmacol ogical inhibitors of actomyosin contractility (blebbistatin), Rho kinase (Y-27632 and H-1152), and Rac signaling. The active cytoskeletal response of fibroblasts demonstrated in this s tudy consti tutes an im portant step in understandin g cellular mechanotransduction responses to externally applied mechanical stimuli in whole tissue, and supports a previously proposed model for the mechanism of acupuncture involving connective tissue mechanotransduction . Copyright 2006 Wiley-Liss, Inc. Am J Physiol Cell Physiol. 2005 Mar;288(3):C747-56. Epub 2004 Oct 20.

Dynamic fibroblast cytoskeletal response to subcutaneous tissue stretch ex vivo and in vivo. Langevin HM, Bouffard NA, Badger GJ, Iatridis JC, Howe AK. Source Department of Neurology, Vermont Cancer Center, University of Vermont College of Medicine, Given C423, 89 Beaumont Ave., Burlington, VT 05405, USA. [email protected]

Abstract Cytoskeleton-dependent changes in cell shape are well-established factors regulating a wide range of cellular functions including signal transduction, gene expression, and matrix adhesion. Although the importance of mechanical forces on cell shape and function is well established in cultured cells, very little is known about these effects in whole tissues or in vivo. In this study we used ex vivo and in vivo models to investigate the effect of tissue stretch on mouse subcutaneous tissue fibroblast morphology. Tissue stretch ex vivo (average 25% tissue elongation from 10 min to 2 h) caused a significant time-dependent increase in fibroblast cell body perimeter and cross-sectional area (ANOVA, P <0.01). At 2 h, mean fibroblast cell body cross-sectional area was 201% greater in stretc hed than in unst retched ti ssue. Fi broblast s in stretched tissue had larger, "sheetlike" cell bodies with shorter processes. In contrast, fibroblasts in unstretched tissue had a "dendritic" morphology with smaller, more globular cell bodies and longer processes. Tissue stretc h in vivo for 30 min had effects that paralleled those ex vivo. Stretch-induced cell body expansion ex vivo was inhibited by colchicine and cytochalasin D. The dynamic, cytoskeleton-dependent responses of fibroblasts to changes in tissue length demonstrated in this study ha ve important implications for our understanding of normal movement and posture, as well as therapies using mechanical stimulation of connective tissue including physical therapy, massage, & acupuncture


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Choice of needles 

Needle thickness There are 2 scales which can be confusing - an Imperial one and a metric one.

Gauge (U.K.)

43

32

30

28

26

Metric (mm)

0.22

.026

0.32

0.38

0.45

For superficial 'pin-prick' stimulation we need a 13-25 mm length needle of 0.22-0.30 mm thickness. When needling the face use the thinner needles (0.22 mm). Once our needles are 50 mm or longer it is desirable to have a thickness of at least 0.35 mm, due to the depth and strength of muscle tissue penetrated.

1. Length stipulated does not include the hilt or handle of the needle. 2. Needle tips/points Two main types: Japanese and Chinese 

Japanese type: very sharp, long pointing for easy insertion, especially where scar tissue is present



Chinese type: pine shape point, or 'olive kernel' shape for less hooking of needle. Tends to push tissue out the way rather than slice through and best for use when working to depths close to periosteum or, indeed, periosteal pecking

Stainless steel needles are adequate. Gold and silver needles are used occasionally by TCM practitioner for specific energetic effects. Some needles are bronze or copper coated to give addition of ‘static' effects. Please endeavour to use needles that come pre-packed with guide tubes as this is a far more hygienic option.

© Optimal Dry Needling Solutions – United Kingdom, USA, Middle East and Europe – 2013

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Dangers and Special Considerations Associated with Dry Needling Aids and Hepatitis Please read ‘Clean Field Technique’ in this manual. Pneumothorax Please see the separate section on pneumothorax in this manual. Always work obliquely and superficially in this area, never penetrating more than 1 cm over the inter-costal areas. Danger exists especially with Emphysematous patients. Proper needling of trapezius to avoid apex of lung and also upper fibres of quadratus lumborum must be observed. When needling the thoracic spine area, needle always caudally and medially. There may be a congenital hole in mid scapula area, so take care needling infraspinatus.

Pericardium Never apply current (e-stims) across pericardium area or in patients with pace maker. Injuries Injuries should not occur if anatomical knowledge is sufficient. Be sure to complete an anatomy module. Any injuries should be reported to your malpractice insurer as soon as possible. Broken Needles Should not occur if needle quality and integrity checked before treatment -and correct gauge selected. Never re-use a needle! If a break should occur, forceps may be used to extract needle and if this fails, surgical removal. Stuck Needle This may happen during turning, or lifting of needle and needle cannot be withdrawn. It may happen in nervous patient, or due to spasm in muscles, if twist or turn of needle too wide in extent, resulting in entangling of tissue fibres. Ensure patient co-operation before the technique is attempted. Informed consent must be obtained in writing before any dry nee dl in g ma y be at te mp te d.

Fai lur e to obt ain thi s co nse nt is a crim ina l o ffe nse . To remove a stuck needle, first wait and see if the needle becomes less stuck on its own. Never ignore the therapeutic use of time. After a time, ask the patient to relax muscles and breathe deeply -withdraw needle on the out breath giving pressure to skin adjacent to needle. If no result, massage around the area (using your finger). You may also insert another small needle (0.25x25mm) close to the stuck one and twiddle vigorously while maintaining a constant withdrawal pressure. Try low frequency laser in the area for 30 seconds, and then withdraw. Moxa and other heating modalitie s are other very comfortabl e opti ons. NEVER needle to depth of needle hilt as the needle can be drawn into body by spasm, patient coughing or moving. Leave at least 5mm-10mm free needle shaft. © Optimal Dry Needling Solutions – United Kingdom, USA, Europe and Middle East.- 2013

Pregnancy There are no studies that show than DN is contra-indicated in pregnancy. However, it is wise to note that extreme caution should be shown with pregnant women, especially in the first trimester. Do not needle lumbar points as these may have referral effect to uterus. Do not needle over pregnant abdomen/ uterus as you don’t want in any way to be accused of causing a miscarriage.

Fainting This may occur in tense, nervous or tired patients. Treat patients lying down if possible. Use fewer rather than many needles at first session or until you have established the reactor type. In the event of a patient becoming pale, nauseous, or excessively sweaty/ faint, remove all needles and lay patient with legs elevated -higher than head. Ensure adequate ventilation. Fainting is rare. A rest of 10 -15 minutes should suffice with a hot drink if necessary. (Hydration after any myofascial therapy is necessary). Do not attempt needling again the same day.

Local Infections This is rare as the subcutaneous tissues have a high resistance against thin needle puncture. Concomitant use of the safety precautions in this manual will further protect the practitioner and the patient. The clean field technique applies here. Infection may be caused by inadequate sterilisation of needle, or traumatising the tissue by inexperienced needling. Patients with bacterial endocarditis may need to be on antibiotics for needling.

Bleeding Avoid needling major blood vessels. Venepuncture is not the aim of dry needling. Patients on anti-coagulants should not be needled vigorously or deeply. Hemophiliacs may be needled with permission of their physician and may need a proactive dose of clotting factor.

Bent Needle Bent needles may be caused by the patient moving his position during needling. Be sure the patient is in a comfortable position before you start. Note that a sudden increase in needle sensation may lead to severe muscle contraction (i.e. a local twitch response). If the needle strikes against bone, the patient may also move involuntarily, but this is uncommon. Avoid sudden increase in stimulation. The patient must be comfortable and told not to move body during treatment. A strong Local Twitch Response may often bend needles, and the patient must be reassured that this LTR is actually a good thing! Inspect angle of bend and withdraw in direction of obliquity - if double bend, withdraw gently step by step to prevent breaking of needle. Be gentle. Never withdraw forcefully. Small shaking movements of needle may release it. Use time therapeutically.

Muscle Memory Sometimes needling stress muscles where there has been a somatisation of an unpleasant event-may lead to an emotional release esp. in stress muscles like Upper traps, Temporalis.


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Contra-indications to Dry Needling There are relatively few absolute contra-indications associated with dry needling. Those that do exist are summarized as below.

Absolute contra-indications: Lack of signed informed consent  Existing infection at the site  Patient phobia of needles  Patient unable to remain still or follow instructions  Therapist is not qualified in the correct technique for a given area  Allergy to surgical steel  Acute cardiac arrhythmia 

Relative contra-indications: All of the following patients may be needled if the listed precautions are adhered to:   

 

Haemophiliacs – Consult the patient’s specialist prior to needling. May need plasma beforehand Warfarin/ heparin – take care to not needle vigorously; the actual risk has been shown to be minimal (Geriatrics Aging 2008:11920:93-97) Pregnancy – Needling is NOT contra-indicated but please take care especially in the f irst trimester. Needle with fewer needles and avoid the lower back and stomach areas. This is a reasonable precaution rather than a contra-indication per se. E-stims. These are only contra-indicated in the face, on the periosteum, and across the chest ( if the patient has a pacemaker) Muscle trauma: do not needle acutely injured muscles. You may however needle superficially in the area to decrease pain and swelling.


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Pneumothorax The single biggest cause of concern among physiotherapists with regard to the dangers of needling concerns pneumothoraces. There have been a number of such cases reported to the malpractice insurers, and responsible therapists must take great care to avoid this unwanted consequence. It is vital to carry malpractice insurance.

Definition A “pneumothorax” is the name given to the condition where air or gas accumulates in the pleural space, causing the characteristic dyspnoea, tight-chestedness and anxiety. Causes A Pneumothorax may develop spontaneously or be due to some form of trauma: Spontaneous pneumothoraces may be either primary, where there is no underlying lung pathology, or secondary where conditions like COPD, emphysema, asthma, Cystic Fibrosis, T.B., certain forms of interstitial lung disease or cancers are present. Primary spontaneous pneumothoraces occur predominantly in tall thin men between 20 and 40 years of age, and are due to the rupture of a bleb or a bulla in the lung. 9000 cases are reported in the USA annually. Cigarette smoking and familial history are associated with increased risk. Risk of recurrence is 50%. Secondary pneumothoraces are serious events and are fatal in 15% of cases even if treated. Traumatic pneumothoraces may be caused by either blunt trauma as in a car accident, or by penet rating trauma as in a knife wound or a needl e stick injury. For dry needlers the areas of risk are the anterior and posterior chest walls, with particular reference to the rotator cuff muscles, the pectoral girdle, the Sternocleidomastoid and the Scalenes. Please take care to follow the instructions in the areas closely to avoid causing a pneumothorax. Pathology The air accumulates in the pleural space as it cannot drain out. This causes increasing pressure on the lung tissue which may collapse under the pressure (tension pneumothorax). The pressure may increase to such an extent that the mediastinum is compromised, leading to a cardiac tamponade and death. Prompt insertion of an underwater IC drain is required. Small pneumothoraces, however, resolve without intervention in 10-14 days. Signs and symptoms          

Sudden and sharp chest pain made worse by breathing deeply. Dyspnoea (SOBAR) Tight chest Very easily fatigued Tachycardia Bluish skin tinge as oxygen concentration drops Acute anxiety and stress Nasal flaring Falling blood pressure Diminished or absent breath sounds on auscultation


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Tests Chest X-Rays and arterial blood gasses are confirmatory. What should I do if I suspect my patient has a Pneumothorax? Send them to hospital immediately and have a CXR done. Give the history of where you needled and how deeply. Note everything down accurately. If you are careful this will never be a problem for you. Advice for patients who have previously had a pneumothorax    

Avoid high altitudes Avoid SCUBA diving Avoid uncompressed aircraft Stop Smoking

Consult www.pneumoworld .org for a patient friendly site


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Superficial Needling Acute 

Suitable analgesics

Chronic 

unavailable, e.g. trauma, 

Analgesics undesirable, e.g. fractu re or soft tissue trauma in presence of possible head injury.



Acute muscle injury – muscles in protective spasm. Needle ligh tly over direct skin area, e.g. Torticollis, calf tears, back spasms, headaches.

Multiple pain areas likely to return, e.g. fibromyalgia, M.E., R.S.I., cancer pain.



Active scar referral. Needle diagonally under scar and over scar referral areas, e.g. amputation, old surgical scars. (Note - cutting injury more likely to cause neural dysfunction than crush injury).



Anatomically superficial areas, e.g. ligaments, fat pads, tendons, face, ear and anatomically delicate areas.

Key points to remember!    

Patient's consent – written, signed Patient’s comfort Wipe down area and therapist's hands with spirits / swab or Steri 601, Hibitane, Steri 601, Dermabac, etc. Sterile, single-use, needles

With physiotherapists, needling is most often used as a 'combination 'treatment'. Hot packing pre-needling will help to relax the patient (take care not to heat too large an area - especially over the dorsal spine as this may lead to drop in blood pressure and increased risk of fainting). It is preferable to needle at the end of treatment once mobilization / stretching, etc. has been done. This is for two reasons: 1. You have a better idea of patient's sensitive areas. Patient has more confidence in you as a therapist now. Do not to massage after skin puncture due to leakage of body fluids - (HIV & Hepatitis). 2. We are making use of A-δ stimulation of the body’s Opioid mediated analgesic system. This may make the patient drowsy if overstimulated.

Notwithstanding the above, it is necessary to therapeutically stretch the needled tissue after needling for maximal effectiveness of the technique.


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What do I tell the patient? The patient may be told that the pain he is feeling no longer serves a useful purpose - only of Irritant value - therefore we want to jam its transmission to consciousness by needling -and also increase the body's release of its own opioid pain relieving substances. Explain that although not as painful as an injection (where we have a wide diameter needle with a cutting edge), the dry needle has a fine gliding point and only a pin prick will be felt. This may be followed by a numbing, or on occasion, an aching sensation.

For easy insertion the patient may be asked to breathe in, and the needle withdrawn during an out breath. The needles may be left in 60 seconds to a few minutes when doing superficial needling, or stimulated to numbness.

Please note that we do need the client to feel the initial pin prick sensation which tells us that the OMAS has kicked in. On removal, compression with a cotton swab to adjacent area facilitates withdrawal and will stop any spotting if needling a vascular area. Skin and subcutaneous tissue provide efficient defense, immune and repair processes in response to any tissue damage regardless of how minor the assault. Therefore sepsis is generally not a problem - however reasonable sterility of technique should be adhered to. The patient should have an immediate effect of pain relief to a greater or lesser extent. This depends on their reactor type. Depending on the condition treated this may last from half an hour to a few days and in some instances one treatment is all that is required. The effect of treatment is generally accumulative and patients should be encouraged to move more freely once his pain has been dampened. Movement improves blood and oxygen supply to affected areas, and brings in an effect of on-going A-β pain inhibition. Superficial needling may be done daily, 2-3 times a week - or as necessary. Care being taken to preserve skin and tissue integrity and to prevent the patient from becoming needle shy. It is possible that the patient may feel somewhat drowsy or disorientated after needling and should therefore be warned not to go rushing into heavy traffic etc. directly after his treatment. Refer to the section on reactor types for more detail here.


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Reactor types The client’s neurochemical response to needling Dr Felix Mann spoke of it being as important to know who to needle as how to needle. Reactor types could be classified into: 

Hyper strong



Strong



Normal



Slow



Non-responder (10% of the population responds poorly to medical morphine)

Care should be taken when treating: 

Asthmatics



Migraine sufferers



Diabetics



Neurological conditions where membrane stabilization a problem



Fibromyalgia where serotonin mechanisms disturbed.

These patients generally respond well to needles but need to begin with only one or two needles and the therapists then gauges the patients response to the treatment before giving stronger treatment. Understanding the opioid and serotonin aspect of needling will help us to determine when dry needling is appropriate, e.g. just before an exam or sporting event could well fuzz the clarity of decision making! Anecdotally however, you can expect bright-eyed, blonde haired, allergic people to do well (strong reactor, fewer needles), and drug addicts, severely depressed and chronic pain sufferers to need a little more needling (Slow reactor).


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Clean Field Techniques Dry needling is an invasive technique. Care must be taken to e nsure the safety of both patient and therapist when using the technique.

The Basic Working Environment The premises where the technique is performed should comply with regulations as set out 1 in the relevant Government Gazette . The premises must conform to the professional guidelines for the practice of Physiotherapy as these pertain to either hospital or rooms treatments. Such premises must include a hygienic hand washing facility. Home visits: The standards here should adhere as closely as possible to the clean technique described below, with the proviso that no treatment should expose the patient to harm. All related waste should be removed from the site.

Ethical Considerations No therapist may practise any technique for which he/she has not been adequately trained. It is the responsibility of each practitioner to ensure they have this training. The therapist is required to obtain written informed consent from the patient before treatment. Such consent must include informing the patient of the exact technique to be employed, the potential risks of the technique and the likelihood of a measure of discomfort. Of particular concern is the risk of causing a pneumothorax. This must be clearly explained in a written document. See Appendix 1 – ‘Dry Needling Information’.

The treatment area should comply with the ‘Clean working environment’ principle ‘The treatment room should be free from dirt and dust, and should have a special working area, such as a table covered with a sterile towel, on which sterile equipment should be placed. This equipment (incl. containers of needles, cotton wool balls, and 70% alcohol, or similar disinfectant e.g. Dermabac) should be sealed or covered with a sterile towel until needed for use. Adequate light and ventilation should be provided throughout the treatment rooms.’ In all circumstances there must be suff icient space for a ‘clean field’ of equipment, with adequate lighting.

The Practitioner should have clean hands Practitioners should always wash their hands before treating a patient. Washing the hands again immediately before the needling procedure is particularly important in preventing infection, and should include thorough lathering with soap, scrubbing the h ands and fingernails, rinsing under running water for 15 seconds, and careful drying on a clean paper towel. Thereafter, a dermoprotective gel (Dermabac, Steritec, etc.) should be applied to the therapist’s hands and be allowed to air-dry. (The use of gloves and alcohol swabs for protection of both therapist and patient is recommended if a dermoprotective gel is not used). 1

In South Africa = No. 15907 of 12 August 1994. Of special reference here are sections 20 (Consulting rooms), 28 and Annexure 1, which pertains to this section (Performance of Professional Acts).


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Preparation of needling site The needling sites need to be clean, free from cuts, wounds or infections. The area to be treated should be covered with a dermoprotective gel (Dermabac, Steritec, etc.) and be allowed to air-dry. If such a gel is not used, then the area to be needled should be swabbed with 70% ethyl or isopropyl alcohol from the centre to the surrounding area using a rotator scrubbing motion, and the alcohol allowed to dry. The patient should be treated in a well-supported position. This is most commonly prone, supine or side lying. Where a seated position is used, the patient must be supported such that the risk of falling, as a result of fainting, is avoided.

Sterile needles and equipment Only single-use, pre-sterilised, disposable solid needles, with or without a guide tube may be used. Where a guide tube is used, this must be pre-packed with the needle. Re-usable needles are not acceptable. The needles should be opened in front of the patients. The needle should be made of stainless steel and may have a copper, plastic or rubber handle. Clean cotton wool, either sterile or unsterile, must be used upon withdrawal of the needle. The wad is to be pressed against the skin and the shaft of the needle as it is withdrawn to limit any fluid leakages. Pressure should be maintained for 5 seconds per needle. Additional pressure for up to 3 minutes should be applied if the wound leaks or if a haematoma arises. Haemophiliacs should not be treated using needles without written consent from the patient’s doctor. A disinfectant must be used on both the therapist’s hands and the treatment area immediately prior to treatment. Therapists must use either 70% isopropyl alcohol swabs or a residual disinfectant (Dermabac, Steritec etc) to achieve this. Single-use sterile gloves should be used if no residual disinfectant is used. All needles should be disposed of in a clearly marked yellow ‘sharps’ bin. The bin must clearly state ‘Danger - Contaminated needle’. This bin should be disposed of in an appropriate fashion by a medical waste company, when three quarters full. This is to avoid the risk of needles accidentally ‘bouncing’ out when attempting to force the needle into an overly full container. All swabs should be disposed of in a red biohazard bin. This must then be disposed of by a medical waste company in an appropriate fashion. Guide tubes and the plastic inserts that accompany them are to be disposed of as domestic/non-clinical waste.


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Aseptic technique A ‘no touch technique’ should be followed with respect to the shaft of the needle. Where touching is necessary, use a sterile cotton wool swab as means of contact.

In case of a needle stick injury, the therapist should do as follows:    

Encourage free bleeding from the area Wash thoroughly with disinfectant Follow the approved local needle stick protocol, or where this does not exist, consult their GP or Casualty department as soon as possible Note that the therapist is encouraged to know his/her own status independent of any exposure to risk

References: 1. 2.

British Acupuncture Council Code of Safe Practice WHO guidelines on acupuncture safety


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Ethical Considerations for Dry Needlers Ethical:



Moral Honourable



Correct



Fair



Right



All patients have a right to a healthy safe environment: 

Clinical waste disposal



Sharps bin only! Sharps bin mounted on wall/ place where it cannot be knocked over or accessed by



children 

Only sharps into sharps bin / no cotton wool!



No needles home to show family



Medical waste bins for soiled cotton wool and swabs

Informed consent Every person has the right to participate in decision making for his/her health. Information to be given to patient: 

Needle will pierce your skin Possibility of manual or electrical stimulation



Possibility of temporary fatigue, well-being, e uphoria, aggression or fainting!



Possibility of some treatment soreness or bruising Need for patient compliance, keep still during treatment and after treatment,





exercise as instructed Remember that a translator may be required 

Signed consent


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2.

Myofascial Pain

Myofascial Trigger Points (MTrPs)

Working hypothesis “MTrPs are sites of muscle injury where local biochemical changes lead to sustained muscle contraction, compression of blood vessels and a local energy crisis that causes hypoxia – this situation perpetuates the release of inflammatory cytokines and nocioceptive (pain producing) substances.” Ref. Skidar, Shah, Danhoff & Gerber.

Recognition MTrPs are tender nodules within taut bands of muscle. Normal muscle does not contain taut bands.

Once activated, MTrPs may cause: 

Motor aspects: disturbed motor function, muscle weakness due to inhibition, muscle stiffness & restricted range of motion



Sensory aspects: local pain referral, peripheral & central sensitization



Autonomic Aspects: pilomotor, vasomotor and visceral referral, where there are MTrPs in the head and neck region, dizziness, tinnitus or tearing

State of activation Active TrPs spontaneously refer both local & distant pain & often general motor dysfunction Latent Trigger points’ levels lower: commonly only motor effects from TrPs disturbing MAPs, joint biomechanics, and muscle power


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Myofascial Pain Syndrome (MPS) A regional pain disorder characterised by the presence of MTrPs The transformation of the tender nodule (MTrP) into a myofascial syndrome is poorly understood. But research has shown the presence of inflammatory mediators and muscle nocioceptor activators in the immediate region of the dysfunctional neuromuscular endplate of the TrP.

Bradykinin, 5-HT and H sensitise the muscle nocioceptors and these are then more easily activated and may respond to normal innocuous and weak stimuli such as light pressure and muscle movement. This low-grade nocioceptive input will contribute to CNS sensitization and possible development of neuropathic pain states. Niddam DM’s results with neuroimaging data suggest that hyperalgesia from MTrPs is processed in similar regions to other pain conditions. However, abnormal hippocampal hypoactivity suggest that dysfunctional stress responses may play an important role in the generation and maintenance of hyperalgesia from MTrPs in MPS.

Prevalence of MTrPs in chronic pain states Fishbain DA et al: Myofascial pain syndrome was diagnosed in 85% of persons evaluated in a pain rehabilitation referral centre. Gerwin RD: In a pain treatment referral program within a large neurological practice found that 93% of patients with musculoskeletal pain had TrPs.

Development of MTrPs 

Overload: Excessive concentric contractions, and/or eccentric overloading

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Over-use: Repetitive loading actively, or poor postural biomechanics

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Adverse metabolic factors. Certain medications may predispose MTrP development, e.g. Cholesterol drugs. Also exercise in extreme weather conditions, or when nutrition is suboptimal.

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Psychologically stressed states predispose to up-regulate MTrPs

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Secondary to abnormal CNS activity


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The Local Twitch Response An LTR is a brisk transient contraction of the palpable taut band of muscle fibres. Whereas it may be elicited by snapping palpation, working manually across the t aut band, it is most reliably and easily achieved by accurate needle insertion.

The needle is repeatedly manipulated to mechanically deactivate the MTrP . This LTR is a local phenomenon, distinct from the “Jump sign” where the entire limb or even the entire patient jerks in response to the stimulus. Clinically, the use of a needle is able to reproduce an LTR far more consistently than can be achieved by snapping palpation. This is in part due to the inaccessibility of some deeper muscles (Gluteus Medius, multifidi, etc.), but mostly due to the needle’s ability to mechanically disrupt a relatively focused area and change the local blood supply channels, thereby counteracting the local energy crisis in a way that blunt palpation rarely can. The LTR is seen as the key element in deep muscular dry needling. It is as important to intramuscular needling as a pinprick is to superficial needling. It signals that the needle has reached that part of the MTrP that will be most therapeutically effective. The LTR is completely involuntary & cannot be mimicked by the patient. As a spinally mediated reflex, it is not subject to supraspinal influences.

Meticulous accuracy by palpation is required to localise, and then fix the trigger point between the fingers of the therapist needling the patient. The LTR is the most difficult of the MTrP characteristics to reproduce reliably (Gerwin, et al 1997). A single hand insertion technique is required to elicit and monitor this effect. The LTR is felt by the patient to be deeply uncomfortable or even excruciatingly painful. It should reproduce the patient’s pain. The severity of the pain frequently associated with the LTR suggests that it can originate from stimulation of sensitised nocioceptors in the MTrP area.


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Treatment Options for MTrPs 1.

Trigger Point Injection & Dry Needling Several studies indicate that in terms of the immediate inactivation of MTrPs, Dry Needling alone is comparable to the injected use of analgesics like lidocaine, procaine and even of Botox Type A (Jaeger & Skootsky 1987, Hong 1994, Wheeler et al 1998 ). The advantage in using a local anesthetic appears to be in the decreased amount of post treatment soreness. 

Dry Needling is far and away the most successful technique for the el iciting of an LTR.

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It mechanically disrupts the integrity of the dysfunctional end plate and the affected MTrP, causing bleeding and consequen t oxidated blood supply increase.

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This effect is allied to the increase in healing stimulated by the release of platelet derived growth factor (PDGF), which attracts cells, induces DNA synthesis and stimulates collagen and protein formation



Needling also disrupts the cell membrane of the muscle fibres, discharging a brief burst of injury potential like electrical activity, called the insertional activity or “current of injury”. -2

This current has been known to generate up to 500µ amps.cm , and last for 3-4 days. This current is important in muscle repair and regeneration. 

Needling of a muscle causes a local release of potassium due to the damage of the sarcolemma fibres as the needle passes through. This causes a depolarization block of the nerve fibres in areas where potassium reaches sufficient concentration.



Needling causes the release of endogenous opioids through the stimulation of A- δ fibres which activate multiple analgesic systems in the brain and spinal cord


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2. Muscle Stretch In acutely activated MTrPs, simple focused therapeutic stretches are remarkably effective. These should always: o

Be done slowly (20-30 seconds)

o

In a pain-free range of movement while still achieving a stretch effect

o

Be accompanied by controlled breathing Therapeutic stretches may be enhanced by: 

Using hot/cold modalities (Hot pack, Spray & Stretch)



Post-isometric relaxation (Lewitt)



Reciprocal inhibition techniques



Facilitatory eye movements



Visualisaton

3. Trigger point release In previous years, the term “Ischaemic Compression” was used for this technique. This is unsatisfactory for two reasons.

i. ii.

There is no convincing experimental evidence that substantiates the suggestion that ischaemia is the primary driver of the technique’s success. The name has lead clinicians to apply unnecessary, excessive and often painful force to the patient, which is counterproductive and unethical.

The technique now recommended conforms more to the concept of barrier release more common in osteopathic circles. The therapist applies a gentle gradually increasing pressure on the MTrP until a definite increase in the resistance is encountered (the Barrier). At the same time, the patient begins to feel a degree of discomfort. By simply maintaining this degree of minimal discomfort, the palpable tension barrier releases after 30 seconds or sooner. This gentle yet effective procedure may be repeated until complete relief is felt. It has the advantage of allowing the patient to be part of the treatment as he/she gives constant feedback on the initially the discomfort, and then the relief levels. The process is vital for the patient to learn how far he/she can work in self-treatment. It works equally well with non-human patients like horses and dogs. The key is in “listening” to the patient’s tissue and adjusting the therapeutic process to the body’s pace.


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4. Deep stroking massage Sometimes called “stripping”, this consists of repetitive deep short strokes at the area of the tender spot, 10-12 repetitions, every 2-3 days for 6 weeks. There may be impressive bruising, and may elicit emotional responses. It is a painful procedure to be used sparingly with refractory, tenacious MTrPs. The effectiveness is theoretically due to the mechanical elongation of contracted sarcomeres within the contraction knots. Intracellular myoglobin, which is normally contained within the sarcomere, can be found experimentally after this procedure over a MTrP, whereas similar techniques on normal muscle do not. This strongly supports the theory that dysfunctional end plates – which are implicated in MTrP formation - are more susceptible to mechanical trauma than normal endplates are.

5. Post treatment procedures Precise protocols differ on exactly what should be done and how often. However, it is clear that movement of the needled muscle, and even the skin of the superficially needled area, is critical. Normal movement must be superimposed onto a newly released muscle and the process of proprioceptive training begun as soon as possible to combat poor movement patterns and adaptive behaviors. This aids the normalisation of sarcomere lengths which were previously unequal in their middle and end ranges. It is vital to reprogram muscle lengths for normal muscle function. Remember that the concept of central sensitization in chronic pain is crucial. 

Waumsley suggests moving the needled muscle through the full available active range of movement 3 times. This movement from a fully shortened to a fully lengthened position should be done slowly, with a gradual subjective easing of patient stiffness by the second and third cycles.

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Barker favours passive stretching of the affected muscle for 3x30 seconds, combining this with both post-isometric relaxation techniques and active inhibitory stretches taught beforehand to the patient.

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Stavrou favours a combination of active and passive stretching with low intensity isometric contractions in some patients

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A home stretching programme which progresses to a strengthening programme is vital. This should begin as soon as possible- within pain limits- as the βstimulation helps ease post-treatment soreness. Attention to causative factors, posture and diet should be part of all physio programmes.

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Strenuous activity like jogging, gym, normal sporting activity, tennis, etc. should be avoided for 24 hours to allow healing of the insertional damage.

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Ice and heat may be applied as appropriate: Ice for bruises and swelling, gentle heat for pain.

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NSAIDs are of little value in MPSs, but patients should not be advised to discontinue that which has been prescribed for them.


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6. Periosteal Pecking Technique Description of technique: Periosteal pecking is a form of needling therapy in which the periosteum is stimulated with the tip of a needle. The tip is repeatedly applied to the tender area of the periosteum (5-10mm wide), 2-4 times per second for approximately 10 seconds (Hansson et al 2008). Some therapists use as few as 2 or 3 pecks. Felix Mann suggests that only a single light peck may be sufficient. The principle mechanism of action is purported to be the stimulation of large diameter A-  fibres within the sclerotome. Brattberg (1983) showed greater efficacy for Periosteal pecking in Lateral epicondylitis patients than Steroid injections. Hansson et al (2008) showed equal efficacy for intramuscular dry needling and periosteal pecking in a mixed sample of back and neck pain patien ts when pain changes using a VAS were analysed.

Special precautions: Do not apply electrical stimulation through ‘periosteal’ needles .


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3. Selected Abstracts: Clinically Relevant Articles Treatment of Myofascial Pain Syndrome Hong, C Z; Curr Pain Headache Rep. 2006 Oct; 10(5):345-9 Myofascial pain syndrome (MPS) is caused by myofascial trigger points (MTrPs) located within taut bands o f skeletal muscle fibers. Treating the unde rlying etiologic lesion responsible for MTrP activation is the most important strategy in MPS therapy. If the underlying pathology is not given the appropriate treatment, the MTrP cannot be completely and permanently inactivated. Treatment of active MTrPs may be necessary in situations in which active MTrPs persist even after the underlying etiologic lesion has been treated appropriately. When treating the active MTrPs or their underlying pathology, conservative treatment should be given before aggressive therapy. Effective MTrP therapies include manual therapies, physical therapy modalities, dry needling, or MTrP injection. It is also important to eliminate any perpetuating factors and provide adequate education and home programs to patients so that recurrent or chronic pain can be avoided.

Myofascial Trigger Points: An Evidence-Informed Review Dommerholt J,Bron, Franssen J, 2006. The Journal of Manual & Manipulative Therapy Vol. 14 No. 4, 203 - 221 Abstract: This article provides a best evidence-informed review of the current scientific understanding of myofascial trigger points with regard to their etiology, pathophysiology, and clinical implications. Evidence-informed manual therapy integrates the best available scientific evidence with individual clinicians’ judgments, expertise, and clinical decision-making. After a brief historical review, the clinical aspects of myofascial trigger points, the interrater reliability for identifying myofascial trigger points, and several characteristic features are discussed, including the taut band, local twitch response, and referred pain patterns. The etiology of myofascial trigger points is discussed with a detailed and comprehensive review of the most common mechanisms, including low-level muscle contractions, uneven intramuscular pressure distribution, direct trauma, unaccustomed eccentric contractions, eccentric contractions in unconditioned muscle, and maximal or sub-maximal concentric contractions. Many current scientific studies are included and provide support for considering myofascial trigger points in the clinica l decision-making process. The article concludes with a summary of frequently encountered precipitating and perpetuating mechanical, nutritional, metabolic, and psychological factors relevant for physical therapy practice. Current scientific evidence strongly supports that awareness and working knowledge of muscle dysfunction and in particular myofascial trigger points should be incorporated into manual physical therapy practice consistent with the guidelines for clinical practice developed by the International Federation of Orthopaedic Manipulative Therapists. While there are still many unanswered questions in explaining the etiology of myofascial trigger points, this article provides manual therapists with an up-to-date evidence-informed review of the current scientific knowledge.


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4. Muscles Gluteus Maximus Muscle L5, S1, S2

Normal Innervation

L5, S1, S2

Function: Isometric

Assists Force closure of SIJ & tenses ITB (with TFL)

Concentric

Hip extension incl. rising from seated position

Eccentric

Limits hip flexion

Problem factors

Common MTrP causes

Prolonged sitting Prolonged uphill walking Freestyle swimming

Starting position

Contralateral Sy ly, pillow between flexed knees

Palpation landmarks

Iliac crest Sacrum Greater trochanter

Possible needle sizes

0.30x40mm-0.30x50mm

Excess adipose tissue

Grip

Flat palpation near sacrum, but pincer for free border

Keep non-dominant hand in contact with muscle being needled

Direction of insertion

Obliquely toward ASIS – at sacral level or towards your finger when pincergripping free border

Avoid pushing the needle deeper than Glut Max

Special precautions

Avoid sciatic nerve as it runs laterally from anterior to the sacrum, to turn caudally in the mid third of buttock


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Gluteal Region

Gluteus Maximus (referred pain patterns)


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Gluteus Medius Muscle L4, L5, S1

Normal Innervation

L4, L5, S1

Function: Isometric

Resists adduction i.e. prevents Trendellenburg

Concentric

Hip abduction

Eccentric

Resists adduction i.e. prevents Trendellenburg

Problem factors

Common MTrP causes


Starting position

Contralateral Sy ly, pillow between flexed knees

Palpation landmarks

Iliac crest Sacrum Greater trochanter

Possible Needle sizes

0.30x40mm-0.35x75mm


Grip

Flat palpation near sacrum, but deep palpation for more lateral TrPs



Perpendicular

Avoid periosteal peck of ilium unless intended

Special precautions

Avoid sciatic nerve, which runs vertically between the ischial tuberosity and the greater trochanter


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Gluteus Medius (referred pain patterns)

Gluteus medius muscle – needling position


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Gluteus Minimus Muscle L4, L5, S1

Normal Innervation

L4, L5, S1

Function: Isometric

Stabilization of femoral head in acetabulum

Concentric

Medial hip rotation (ant. fibres) Lateral hip rotation (post. fibres)

Eccentric

Check-reign rotation

Problem factors

Common MTrP causes


Starting position

Contralateral Sy ly, pillow between flexed knees Supine for anterior fibres

Palpation landmarks

Iliac crest Sacrum Greater trochanter TFL


0.35X75mm


Grip

Flat palpation



Toward ilium

Special precautions



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Gluteus Minimus (referred pain patterns)


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Piriformis Muscle S1, S2

Normal Innervation

S1, S2

Function: Isometric

Stabilization of femoral head in acetabulum

Concentric

Problem factors

Lateral hip rotation (in hip extension) NWB Hip abduction when hip is at 90 degrees of flexion NWB

Eccentric

Check-reign medial rotation

Common MTrP causes

Prolonged walking Prolonged sitting

Starting position

Contralateral Sy ly, hip flexed to 90 degrees and in adduction, no pillow between knees

Palpation landmarks

Draw a line from the sciatic foramen to the greater trochanter. Needle just superior to this line at the junction of the lateral and middle third of this line.


0.30x50mm-0.35x60mm (slim patient); 0.35x75mm-0.35x100mm (large patient)


Grip

Flat palpation

Keep non-dominant hand in contact muscle being needled


Perpendicular

Deep vascular bed below piriformis, avoid vigorous needling

Special precautions


© Optimal Dry Needling Solutions – United Kingdom, USA, Europe and Middle East.- 2013 36

+ FAIR test

Piriformis and Short Lateral Rotators

© Optimal Dry Needling Solutions – United Kingdom, USA, Europe and Middle East.- 2013 37

Piriformis position for Needling

Photograph showing 2 needles into the Piriformis muscle at the junction of the middle and lateral “thirds” of the muscle.

The Piriformis muscle in a needling position


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Short Lateral Rotators of the Hip 

   

Obturator Internus, Externus and Gemelli are external to the pelvis and attach to the greater trochanter Obturator internus is however also intra pelvic GOGO = Gemelli sup, Obt int, Gemelli inf, Obt ext These short rotators externally rotate the thigh in all positions Sciatic nerve lies anterior to the piriformis but posterior i.e. on top of the gemelli and obturators

Referred symptoms as for the piriformis - remember that these muscles are commonly involved with piriformis, as the coccygeus (ischiococcygeus) and levator ani muscles may be.

Needling: Obturator Internus Patient side lying: 





Approach below the inferior angle of the sacrum directly above the ischium 50mm for medial section; needle perpendicular or medially Laterally approach below insertion of piriformis at the greater trochanter; needles inserted laterally towards greater trochanter; 0.30x30mm0.35x50mm Avoid Sciatic nerve which runs posteriorly over the bellies of the short lateral rotators

Quadratus femoris attaches medially to the antero- lateral surface of the ischium and laterally to the femur. Obturator externus attaches medially to the obturator membrane and laterally to the femoral trochantor deep to Quadratus femoris.


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Gastrocnemius Muscle Group Normal Innervation

S1, S2 (Tibial n)

Function: Isometric

Assists with knee and ankle stability esp. in dysfunctional postures

Problem factors

Concentric

Plantar flexion when knee is extended

High heel shoes

Eccentric

Check-reign dorsi-flexion

Sway back posture

Common MTrP causes

Shoes, posture, sprains, fractures, night cramps, intermittent claudication

‘Plantar fasciitis’

Starting position

Supine – FABER or Crook lying (medial) Contralateral sy ly (lateral)

Palpation landmarks

Identify gastrox, soleus and lateral compartment


0.3X30mm-0.35x50mm


Grip

Lumbrical

Avoid needling into deep posterior compartment


Toward your gripping fingers

Avoid pushing the needle into your own finger

Special precautions

Vigorous needling in deep compartment may cause a compartment syndrome. This muscle is well endowed with proprioceptors and may be extremely sore post needling.


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Gastrocnemius Muscle (referred pain patterns)

Medial Gastrocnemius in FABER position © Optimal Dry Needling Solutions – United Kingdom, USA, Europe and Middle East.- 2013

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Medial Gastrocnemius superior portion


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Soleus – the “Joggers heel”

Normal Innervation

S1, S2 (Tibial n)

Function: Isometric

Assists with ankle stability

Problem factors

Plantar flexion independent of knee position especially powerful movements

High Heel shoes

Concentric

Eccentric

Check-reign dorsi-flexion

Sway back posture

Common MTrP causes

Shoes, posture, sprains, fractures, night cramps, intermittent claudication. Note that the tibial nerve ma y be entrapped by soleal MTrPs in the soleal canal

“Plantar fasciitis” “Heel spur”

Starting position

Supine – FABER or Crook lying (medial) Contralateral sy ly (lateral)

If you can ’t get a good lumbrical grip, then passively plantar flex the ankle first

Palpation landmarks

Identify gastroc, soleus and lateral compartment. Fibula in side-lying


0.3X30mm-0.35x50mm


Grip

Lumbrical – belly medial Lateral – deep palpation

Avoid needling into deep posterior compartment


Towards the TrP

Beware deep tibial vessels centrally mid-calf

Special precautions

Vigorous needling in deep compartment may cause a compartment syndrome. This muscle is well endowed with proprioceptors and a deep venous plexus, and may be extremely sore post needling.


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Soleus Muscle (referred pain patterns)

Photograph showing the correct pincer grip and needling of the medial calf. A = Gastrocnemius and B = Soleus © Optimal Dry Needling Solutions – United Kingdom, USA, Europe and Middle East.- 2013

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Selected Abstracts Cummings TM, White AR. Needling therapies in the management of myofascial trigger point pain: a systematic review. Arch Phys Med Rehabil 2001; 82:986-92. Objective: To establish whether there is evidence for or against the efficacy of needling as a treatment approach for myofascial trigger point pain. Data Sources: PubMed, Ovid MEDLINE, Ovid EMBASE, the Cochrane Library, AMED, and CIS COM databases, searched from inception to July 1999. Study Selection: Randomized, controlled trials in which some form of needling therapy was used to treat myofascial Pain Data Extraction: Two reviewers independently extracted data concerning trial methods, quality, and outcomes. Data Synthesis: Twenty-three papers were included. No trials were of sufficient quality or design to test the efficacy 9f any needling technique beyond placebo in the treatment of myofascial pain. Eight of the 10 trials comparing injection of different substances and all 7 higher quality trials found that the effect was independent of the injected substance. All three trials that compared dry needling with injection, found no difference in effect. Conclusions: Direct needling of myofascial trigger points appears to be an effective treatment, but the hypothesis that needling therapies have efficacy beyond placebo is neither supported nor refuted by the evidence from clinical trials. Any effect of these therapies is likely because of the needle or placebo rather than the injection of either saline or active drug. Controlled trials are needed to investigate whether needing has an effect beyond placebo on myofascial trigger point pain. Key Words: Acupuncture; Injections; Myofascial pain syndromes; Randomized controlled trial; Rehabilitation; Trigger points, myofascial.

Hong C-Z, Kuan T-S, Chen J-T, Chen S-M. Referred pain elicited by the palpation and by needling of myofascial trigger points: A comparison. Arch Phys Med Rehabil 1997;78:957-960. Objectives: To investigate the occurrence of referred pain (ReP) elicited by palpation (Pal-ReP) or by needle injection (Inj -ReP) of myofascial trigger points (MTrP), and to assess the correlated factors, including the pain intensity of an active MTrP and the occurrence of a local twitch response (LTR). Design: Correlational study Patients: Ninety five patients who were treated with MTrP injections. Interventions: MTrP injections Main outcome measures: Pain intensity of MTrP and occurrence of Pal-Rep, Inj-Rep, and LTR. Results: Both Pal-Rep and Inj -Rep were elicited in 53.9% of MTrPs. Inj-Rep, but not Pal-Rep, was elicited in 3 3.7% of MTrPs. Both Pal-Rep and Inj -Rep were unobtainable in 12.3% of MTrPs. The occurrence of ReP was significantly correlated to the Pain intensity of active MTrP and the occurrence of LTR. Conclusions: Rep could be elicited more frequently by needling than by palpation. The frequency of occurrence in ReP mainly depends on the pain intensity of an active MTrP.


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Novel Applications of Ultrasound Technology to Visualize and Characterize Myofascial Trigger Points and Surrounding Soft Tissue Siddhartha Sikdar, Ph.D., Jay P. Shah, M.D., Tadesse Gebreab, B.S., Ru-Huey Yen, B.S., Elizabeth Gilliams, B.S., Jerome Danoff, P.T., Ph.D., and Lynn H. Gerber, M.D. Conf Proc IEEE Eng Med Biol Soc. 2010;2010:5302-5.

2 Understanding the vascular environment of myofascial trigger points using

ultrasonic imaging and computational modeling. Sikdar S, Ortiz R, Gebreab T, Gerber LH, S hah JP.

2.1 .1 Source Department of Electrical and Computer Engineering, George Mason University, Fairfax, VA 22030, USA. [email protected]

2.1.2 Abstract Myofascial pain syndrome (MPS) is a common, yet poorly understood, acute and chronic pain condition. MPS is characterized by local and referred pain associated with hyperirritable nodules known as myofascial trigger points (MTrPs) that are stiff, localized spots of exquisite tenderness in a palpable taut band of skeletal muscle. Recently, our research group has developed new ultrasound imaging methods to visualize and characterize MTrPs and their surrounding soft tissue. The goal of this paper was to quantitatively analyze Doppler velocity waveforms in blood vessels in the neighborhood of MTrPs to characterize their vascular environment. A lumped parameter compartment model was then used to understand the physiological origin of the flow velocity waveforms. 16 patients with acute neck pain were recruited for the study and the blood vessels in the upper trapezius muscle in the neighborhood of palpable MTrPs were imaged using Doppler ultrasound. Preliminary findings show that symptomatic MTrPs have significantly higher peak systolic velocities and negative diastolic velocities compared to latent MTrPs and normal muscle sites. Using compartment modeling, we show that a constricted vascular bed and an enlarged vascular volume could explain the observed flow waveforms with retrograde diastolic flow.

Chin Med. 2011 Mar 25;6:13.

Myofascial trigger points: spontaneous electrical activity and its consequences for pain induction and propagation. Ge HY, Fernández-de-Las-Pe –as C, Yue SW. Source Center for Sensory-Motor Interaction (SM I), Department of Health Science and Technology, Aalborg University, Aalborg DK-9220, Denmark. [email protected].

Abstract Active myofascial trigger points are one of the major peripheral pain generators for regional and generalized musculoskeletal pain conditions. Myofascial trigger points are also the targets for acupuncture and/or dry needling therapies. Recent evidence in the understanding of the pathophysiology of myofascial trigger points supports The Integrated Hypothesis for the trigger point formation; however unanswered questions remain. Current evidence shows that spontaneous electrical activity at myofascial trigger point originates from the extrafusal motor endplate. The spontaneous electrical activity represents focal muscle fiber contraction and/or muscle cramp potentials depending on trigger point sensitivity. Local pain and tenderness at myofascial trigger points are largely due to nociceptor sensitization with a lesser contribution from non-nociceptor sensitization. Nociceptor and non-nociceptor sensitization at myofascial trigger points may be part of the process of muscle ischemia associated with s ustained focal muscle contraction and/or muscle cramps. Referred pain is dependent on the sensitivity of myofascial trigger points. Active myofascial trigger points may play an important role in the transition from localized pain to generalized pain conditions via the enhanced central sensitization, decreased descending inhibition and dysfunctional motor control strategy.


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Clin Biomech (Bristol, Avon). 2010 Oct;25(8):765-70. Epub 2010 Jul 27.

3. Muscle activation patterns in the scapular positioning muscles during loaded scapular plane elevation: the effects of Latent Myofascial Trigger Points. Lucas KR, Rich PA, Polus BI.

3.1 .1 Source Musculoskeletal Research Centre, Level 2, HS3, Faculty of Health Sciences, La Trobe University, Bundoora 3086, Australia. [email protected]

3.1.2 Abstract 3.1. 2.1

BACKGROUND:

Latent Myofascial Trigger Points are pain -free neuromuscular lesions that have been found to affect muscle activation patterns in the unloaded state. The aim was to extend these observations to loaded motion by investigating muscle activation patterns in upward scapular rotator muscles (upper and lower trapezius and serratus anterior) hosting Latent Myofascial Trigger Points simultaneously with l esion-free synergists for shoulder abduction (infraspinatus and middle deltoid). This approach allowed examination of the effects of these lesions on both their hosts and their lesion-free synergists in order to understand their effects on the performance of shoulder abduction.

3.1. 2.2 ME TH OD S : Surface electromyography was employed to measure the timing of onset of muscle activation of the upper and lower trapezius and serratus anterior (upward scapular rotators), infraspinatus (rotator cuff) and middle deltoid (abductor of the arm) initially without load and then with light (1-4 kg) dumbbells. Comparisons were made between control (no Latent Trigger Points; n=14) and Latent Trigger Point (n=28) groups.

3.1. 2.3

FINDINGS:

The control group displayed a relatively stable sequence of m uscle activation that was significantly different in timing and variability to that of the Latent Trigger Point group in all muscles except middle deltoid (all P<0.05). The Latent Trigger Point group muscle activation pattern under load was inconsistent, with the only common feature being the early activation of the infraspinatus.

3.1. 2.4

INTERPRETATION:

The presence of Latent Trigger Points in upward scapular rotators alters the muscle activation pattern during scapular plane elevation, potentially predisposing to overuse conditions including impingement syndrome, rotator cuff pathology and myofascial pain.


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J Headache Pain. 2011 Feb;12(1):35-43. Epub 2011 Feb 27.

Referred pain from myofascial trigger points in head and neck-shoulder muscles reproduces head pain features in children with chronic tension type headache. Fernández-de-las-Peñas C, Fernández-Mayoralas DM, Ortega-Santiago R, Ambite-Quesada S, Palacios-Ceña D,Pareja JA. Source Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Facultad de Ciencias de

la Salud, Universidad Rey Juan Carlos, Avenida de Atenas s/n, 28922 A lcorc—n, Madrid, Spain. [email protected]

Abstract Our aim was to describe the referred pain pattern and areas from trigger points (TrPs) in head, neck, and shoulder muscles in children with chronic tension type headache (CTTH). Fifty children (14 boys, 36 girls, mean age: 8 ± 2) with CTTH and 50 age- and sex- matched c hildren participated. Bilateral temporalis, masseter, superior oblique, upper trapezius, sternocleidomastoid, suboccipital, and levator scapula muscles were examined for TrPs by an assessor blinded to the children's condition. TrPs were identified with palpation and considered active when local and referred pains reproduce headache pain attacks. The referred pain areas were drawn on anatomical maps, digitalized, and also measured. The total number of TrPs was significantly greater in children with CTTH as compared to healthy children (P < 0.001). Active TrPs were only present in children with CTTH (P <0.001). Within children with CTTH, a significant positive association between the number of active TrPs and headache duration (r (s) = 0.315; P = 0.026) was observed: the greater the number of active TrPs, the longer the duration of headache attack. Significant differences in referred pain areas between groups (P <0.001) and muscles (P <0.001) were found: the referred pain areas were larger in CTTH children (P <0.001), and the referred pain area elicited by suboccipital TrPs was larger than the referred pain from the remaining TrPs (P <0.001). Significant positive correlations between some headache clinical parameters and the size of the referred pain area were found. Our results showed that the local and referred pains elicited from active TrPs in head, neck and shoulder shared similar pain pattern as spontaneous CTTH in children, supporting a relevant role of active TrPs in CTTH in children


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An in vivo microanalytical technique for measuring the local biochemical milieu of human skeletal muscle 1

2

Jay P. Shah, Terry M. Phillips, Jerome V. Danoff,

1,3

1

and Lynn H. Gerber

1

Rehabilitation Medicine Department, Clinical Research Center, National Institutes of Health; 2Ultramicro Analytical Immunochemistry Resource, Division of Bioengineering and Physical Science, Office of Research Services, National Institutes of Health, Bethesda, Maryland; and 3Department of Exercise Science, George Washington University, Washington, DC Submitted 14 April 2005 ; accepted in final form 11 July 2005 4.1

ABSTRACT

Myofascial pain associated with myofascial trigger points (MTrPs) is a common cause of nonarticular musculoskeletal pain. Although the presence of MTrPs can be determined by soft tissue palpation, little is known about the mechanisms and biochemical milieu associated with persistent muscle pain. A microanalytical system was developed to measure the in vivo biochemical milieu of muscle in near real time at the subnanogram level of concentration. The system includes a microdialysis needle capable of continuously collecting extremely small samples ( 0.5 µl) of physiological saline after exposure to the internal tissue milieu across a 105-µm-thick semi-permeable membrane. This membrane is positioned 200 µm from the tip of the needle and permits solutes of<75 kDa to diffuse across it. Three subjects were selected from each of three groups (total 9 subjects): normal (no neck pain, no MTrP); latent (no neck pain, MTrP present); active (neck pain, MTrP present). The microdialysis needle was inserted in a standardized location in the upper trapezius muscle. Due to the extremely small sample size collected by the microdialysis system, an established microanalytical laboratory, employing immunoaffinity capillary electrophoresis and capillary electrochromatography, performed analysis of selected analytes. Concentrations of protons, bradykinin, calcitonin gene-related peptide, substance P, tumor necrosis factor-α, interleukin-1 , serotonin, and norepinephrine were found to be significantly higher in the active group than either of the other two groups (P < 0.01). pH was significantly lower in the active group than the other two groups (P < 0.03). In conclusion, the described microanalytical technique enables continuous sampling of extremely small quantities of substances directly from soft tissue, with minimal system perturbation and without harmful effects on subjects. The measured levels of analytes can be used to distinguish clinically distinct groups. myofascial trigger points; musculoskeletal pain; microdialysis; soft tissue pain; p ressure pain threshold. ∼


49

5. References and Recommended Reading 1.

Baldry, P. 1992. Acupuncture, Trigger Points and Musculoskeletal Pain, Churchill and Livingstone

2.

Bowsher, D. 1998. Mechanisms of Acupuncture. Medical Acupuncture, Filsche & White, Churchill Livingstone

3.

Bruckner, P. & Kahn, D. 1993. Clinical Sports Medicine, McGraw Hill

4.

Butler, D. 1991. Mobilisation of the Nervous System, Churchill Livingstone

5.

Dommerholt.J & Huijbreghts. P. Myofascial Trigger Points. Jones & Bartlett . 2011

6.

Filshie, J & White, A. 1998. Medical Acupuncture, Churchill Livingstone

7.

Gerwin, R.D., Shannon, S., Hong, C-Z., Hubbard, D., Gevirtz, R. 1997. Interrater reliability in myofascial trigger point examination. Pain 69:65 -73

8.

Gunn, C. 1989. Treating Myofascial Pain: Intramuscular Stimulation, University of Washington

9.

Hong C-Z, Hsueh T –C. 1996. Difference in pain relief after trigger point injections in myofascial pain patients with and without fibromyalgia. Arch Phys Med Rehabil 77(11 ):1 161-1166.

10.

Hong CZ. 1994. Lidocaine injection versus dry needling to myofascial trigger point. The importance of the local twitch response. Arch Phys Med Rehabil 73:256-263

11.

Hong, C-Z., Kuan, T-S., Chen, J-T., Chen, S-M. 1997. Referred Pain Elicited by Palpation and by needling of Myofascial Trigger Points: A Comparison. Arch Phys Med Rehabil 78:957-960

12.

Hooshmand, H. 1993. Chronic Pain: Reflex Sympathetic Dystrophy, C.R.C. Press, Tokyo

13.

Melzack & Wall. The Challenge of Pain, Penguin

14.

Jimbo S, Atsuta Y, Kobayashi T, Matsuno T. 2008. Effects of dry needling at tender points for neck pain (katakori): near-infrared spectroscopy for monitoring oxygenation of trapezius. Journal of Orthopaedic science, 13:101-106

15.

National Commission for Certification of Acupuncturists (1989) Clean Needle Technique for Acupuncturists

16.

Oschman, J. 2002. Energy Medicine, The Scientific Basis. Churchill Livingstone.

17.

Rachlin, Edward. 1994. Myofascial Pain and Fibromyalgia. Mosby Shah JP, Phillips TM, Danoff JV, Gerber LH. An in vivo micro analytical technique for measuring the local biochemical milieu of human skeletal muscle. J Appl Physiol 2005;99(5): 1977 –1984 [Epub 2005 Jul 21].

18. Jay

P. Shah. 2008. Integrating Dry Needling with New Concepts of Myofascial Pain,

Muscle Physiology, and Sensitization. Chapter 5 of Contemporary Pain Medicine: Integrative Pain Medicine: The Science and Practiceof Complementary and Alternative Medicine in Pain Management Edited by: J. F. Audette and A. Bailey © Humana Press,

Totowa, NJShipton, E.A.. Pain: Acute and Chronic, Witwatersrand University Press 19.

Simons, D. 1990. Muscular Pain Syndromes, Advances in Pain Research, Volume 1, Raven Press.

20.

Simons, David. 2001. Muscle Pain. Understanding its Nature, Diagnosis and


50

Treatment. Lippincott, Williams & Wilkins. 21. Travell, S. & Simons, D. 1983. Myofascial Pain and Dysfunction, Williams & Wilkins. 22. Whyte Ferguson L. & Gerwin R. Clinical Mastery in treatment of Myofascial pain.

Lippincott Williams & Wilkins. 2005 23.

Webb, J. 1986. Pain Control via Dorso-lumbar Sympathetic flow, Australian Journal of Physiotherapy 32(2).

24.

Wells, J.C.D. & Woolf, C.J. 1991. Pain Mechanisms and Management, Volume 47(3). Churchill Livingstone.

25.

Wheeler, A.H., Goolkasian, P., Gretz, S.S. 1997. A randomised double blind prospective pilot study of Botulinum Toxin Injection for Refractory, Unilateral, Cervicothoracic, Paraspinal Myofascial Pain Syndrome. Spine 23(15):1662-1664.

25. Wheeler, A.H., Goolkasian, P., Gretz, S.S. 1997. A randomised double blind prospective pilot study of Botulinum Toxin Injection for Refractory, Unilateral, Cervicothoracic, Paraspinal Myofascial Pain Syndrome. Spine 23(15):1662-1664.


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Indemnity Form For Use on the Dry Needling Courses Only 1. I, ................................................................................................................. (the undersigned) hereby give my consent to be dry needled by any of my co-participants and the demonstrator in ways consistent with the content of the Optimal Dry Needling Solutions course, in association with Club-Physio and The Dry Needling Institute. 2. I have read and understood the document called “Dry Needling Information” and have had sufficient opportunity to ask any questions that I want to. 3. I agree to expose the appropriate area of my body being needled, and to loosen or remove such clothing as may be necessary for the technique to be performed properly. 4. I indemnify Optimal Dry Needling Solutions and all of its lecturers and course organisers against any claim which may arise from this course. 5. I acknowledge that I personally carry appropriate Malpractice insurance. 6. I freely participate in this course and am under no pressure to sign this document.

(Course Participant)

(Date)


52

Dry Needling information Your physiotherapist has offered to treat you using a technique called ‘Dry Needling’ . This information leaflet explains more about this technique. Dry Needling is a very successful medical treatment which uses very thin needles without any medication (a dry needle) to achieve its aim. Dry Needling is used to treat pain and dysfunction caused by muscle problems, sinus trouble, headaches, and some nerve problems. It is not at all the same as acupuncture. Acupuncture is part of Traditional Chinese Medicine, whereas dry needling is a western medicine technique. Dry Needling works by changing the way your body senses pain (neurological effects), and by helping the body heal stubborn muscle spasm associated with tr igger points (myofascial effects). There are additional electrical and chemical changes associated with dry needling therapy which assist in the healing process. It is important to see the needles as just one part of your overall rehabilitative treatment. Dry needling is not a miracle cure – it is a normal part of physiotherapy. It is vital that you do the exercises and follow the advice your therapist gives you in conjunction with the needling for optimal recovery. Your therapist has been specifically trained in the various needling techniques. The therapist will choose a length and thickness of needle appropriate for your condition and your body size, and then insert it through the skin at the appropriate place. You will feel a small pinprick. Depending on the type of needle technique chosen by your therapist, you may also feel a muscle ache and a muscle twitch. These are all normal and good sensations, and mean that you will experience good relief from your symptoms. In general, there is very little risk associated with this technique if performed properly by a trained physiotherapist. You may have a little bruising around the needle site, much the same as you would with any injection. On rare occasions, people may feel very happy, tearful, sweaty or cold. These symptoms all fade quickly. Fainting may occur in a very small minority of people. There are no lasting ill effects of these side effects. If you are being treated in the shoulder, neck or chest area, there is an additional risk that involves your lung. If the lung itself is punctured, you may develop a condition called a pneumothorax (air in the space around the lung). This is a rare but serious problem, and you should go directly to a hospital casualty department without panicking if it occurs. The symptoms of this event include shortness of breath which gets worse, sudden sharp pain each time you breathe in, a bluish tinge to your lips, and an inability to “catch your breath”. The trea tment is very successful for this rare but possible complication. If you are happy to continue with the therapy as suggested by your therapist, and have asked any questions that you may want to, then please sign the consent form attached to this page, and hand it to your physiotherapist. Please keep this information page for your own records.

©Optimal Dry Needling Solutions


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Consent for Dry Needling Treatment This document is to be read in conjunction with the information sheet titled ‘ Dry Needling information’

1. I (full name), …………………………………………………………………………………. capacity as:

in my

Please circle which of the following two applies in your case: The patient (if aged 18 or over), Or The parent or legal guardian, of ……………………………………………………………………………………………. (patient’s full name) Who is my: Spouse / Child / Grandchild / Parent / Sibling / Foster Child / Ward (please circle the appropriate term) do hereby give my consent for the performance of dry needling therapy by the physiotherapist named ............................................................................................. at the physiotherapy practice. I understand that the therapist is appropriately qualified and trained to perform the required therapy. 2. The areas of the body that I consent to have dry needled are:

3. I am satisfied that the technique has been fully explained to me, and that my concerns have been addressed and that my questions have been answered to my satisfaction. I have read the attached information sheet ca lled “Dry Needling information”, and am in a satisfactory position to weigh up the risks and limitations of the technique as regards known side effects. 4. I understand that the technique is performed within a rehabilitative framework and that I must follow instructions as given by the physiotherapist. 5. I understand that in the event of any litigation arising consequent to this therapy, it can only be done within the jurisdiction of the Magistrate’s Court. The applicant will be responsible for his own and the d efendant’s legal costs. 7. I hereby indemnify the therapist and the practice against any liability arising from unforeseen or unknown consequences. Date: ..................

Patient

Time: ................

Place: ...........................

Guardian/Mandated person


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Module one dry needling .pdf

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