How to treat myofascial trigger points with dry needling

What is a myofascial trigger point

Myofascial trigger points (MTrPs) can affect all of us – whether you sit at your desk for too long, or workout religiously. They are those painful tight bands in your muscle that feel like violin strings – nodules of muscle / “knots”. MTrPs are painful on compression (pushing on them), but can also lead to referred pain or tenderness in other areas. For example, a MTrP in your shoulder can refer pain into your neck and/or prompt headaches.

There are a number of theories why MTrPs come about, including:
-Trauma: sprains, strains, chronic repetitive overloading
-Mechanical: poor posture, scoliosis, poor ergonomics
-Degenerative: arthritic conditions altering mobility/flexibility
-Nerve root compression: sensitisation of spinal segment and associated muscles

It is believed that the nerves which talk to muscles (motor neurone endplates) excessively release a chemical which activates the muscle (acetylcholine). This results in the small muscle fibres shortening and forming contracted bands. In conjunction with decreased blood circulation, this starves the muscle fibres of vital nutrients and waste drainage. As a result, a host of inflammatory chemicals are released (which hurt!) making the area very sensitive and can cause swelling and heat. This can also lead to “central sensitisation”, a state in which our central nervous system becomes hypersensitive, leading to normal inputs (like pushing or contracting the muscle) hurt, when it would usually feel fine.

What dry needling is NOT

Dry needling (DN) is NOT acupuncture, which is part of Traditional Chinese Medicine (TCM). Very briefly, TCM is based on the theory that the body is controlled by a force of energy called “Qi”, which circulates around the body via 12 primary meridians. A TCM acupuncturist aims to detect abnormal flow or quality of Qi, and would needle the respective acupoint to help restore balance. TCM uses this philosophy to treat a wide range of issues including, but not limited to; musculoskeletal dysfunction, smoking, fertility, digestion and and other non-musculoskeletal and neuromuscular conditions.

What dry needling IS

DN derives from modern western medicine. It involves placing a solid filament needle through the skin, into MTrPs in muscles. The diameter of the needle used is very small, just thick enough to allow the tissue to be pierced while maintaining needle integrity (about 5x the size of a single muscle fibre, often 0.25mm).

The aim of myofascial DN is to reverse the effects and reduce MTrPs. The mechanisms through which DN brings about pain relief include:

-Circulation: Research has demonstrated increases in blood flow and oxygen saturation levels following DN (essentially helping the muscle to breathe again), and improvements in the removal of harmful waste products such as lactic acid.
-Neurologically: The implementation of DN disrupts the effects of peripheral and central pain modulation. DN has been observed to suppress motor end plate activity (peripheral) and reduces hypersensitivity (central) which is created by MTrPs. Therefore returning the muscles to its original state and reduces the perceived pain (neurological).
-Cellular: Evidence suggests there is increased fibroblast activity following DN. Fibroblasts are the most common cell in connective tissue responsible for maintaining its structural integrity. They also play a critical role in immune response to tissue injury and healing.
-Muscle tone: The inhibition of the muscle (via the nervous system) can help reduce the tone of the MTrPs, thus increasing the mobility of the muscle affected.

What to expect

The practitioner is guided to the MTrP via palpation of the typical taut bands and hypersensitive nodules within the affected muscle. They may also look for characteristic “jump” sign and local twitch response (LTR), which may reproduce associated referred pain. The needle is inserted into the muscle, aiming for the MTrP. Successful placement requires sound anatomical knowledge, the ability to visualise the MTrP within the muscle in 3 dimensions and will often result in a LTR. The practitioner may choose to simulate the muscle further by moving the needle up and down – this is to trigger a LTR which is believed to bring about a greater outcome from treatment. Research has shown that eliciting a LTR improves the neurological benefits discussed above, which results in greater pain relief and muscle tone reduction.
The number of needles used is dependant on the individual patient presentation and patient experience with DN. One or more needle may be used on one or more muscle, with patient consent and comfort being of paramount importance.

The insertion of the needle is usually painless, and the stimulation of the muscle may feel like a small to moderate ache. Significant adverse events secondary to DN are rare and have been calculated to be as low as 0.04%. However, the repeated stimulation used to elicit LTRs often leads to added micro trauma and post needling soreness, which can temporarily increase pain levels and sometimes minor bruising, similar to a strong massage. This is normal and will reduce within 24-72 hours.

Despite the benefits of DN, it’s important to note that treating MTrPs should be part of a wider treatment plan to fulfil patient care. When applied alongside other treatment methods (such as joint mobilisation, soft tissue, strengthening, rehabilitation and patient education), DN can be a very effective tool in the treatment and management of pain.

Written by Jake Alsop

 

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