Category Archives: Dry Needling

‘Poking Long Pointy Needles’ – Needling Including Ultrasound-Guided Needling of Myofascial Trigger Points for Pain Relief

Feature Image Credit: Studio Musculoskeletal

https://studioms.com.au/pages/dry-needling

Dear Pain Matters blog readers,

Recently, I had the honour and pleasure of meeting one of Vancouver’s most respected pain clinicians, Dr Gillian Lauder, pediatric anesthesiologist, complex pediatric pain physician and director of the Acute Pain Service in the Department of Pediatric Anesthesia at BC Children’s Hospital.

I first heard about Dr Lauder’s work after reading an inspirational story about a young girl named Anaïs Poirier whom Dr Lauder had successfully treated for CRPS.  After a full recovery from CRPS, and in response to a question about who her hero was, Anaïs replied:

‘That’s an easy one! Dr. Lauder, because she saved my life. I know pain doesn’t kill you, but it takes everything away from you.’

Giving a Voice to Children who Suffer from Chronic Pain

https://www.theglobeandmail.com/life/giving/giving-a-voice-to-children-who-suffer-from-chronic-pain/article4400974/

Dr Lauder has also published a book called Complex Regional Pain Syndrome (CRPS) Explained – For Teenagers, By Teenagers (available in Amazon).

Over coffee, Dr Lauder and I discussed various topics including needling of myofascial trigger points for pain relief.

Inspired by Gillian’s comments, today’s blog post is dedicated to needling of myofascial trigger points – with or without medication or saline only injections – for pain relief.

INTRODUCTION

Overview

The objective of needling of myofascial trigger points is pain relief as well as enhanced movement and mobility.

Needling techniques vary and may include:

  • Dry needling (aka non-injection needling);
  • Pharmaceutical injection needling including lidocaine and corticosteroid injection needling; and
  • Saline only-injection needling (see future blog post on myoActivation, developed by Dr Greg Siren).

Trigger points are identifiable via:

(1) Clinical examination including manual palpation – to feel densified tissue regions;

(2) Ultrasound imaging – to locate hypoechogenic areas in muscle (more later); and

(3) Thermal analysis (more later) (Cojocaru et al, 2015).

A study by Stecco et al (2013) suggested that excess hyaluronic acid may be a contributing factor for trigger points.

Presumably, needling of trigger points (that also leads to the ‘local twitch response’) results in release of excess hyaluronic acid as well as reduced pressure and inflammation in the immediate surrounding area.

Some definitions:

Dry needling (aka non-injection needling or nonacupoint needling) means that needles without saline or medical injections (e.g. without lidocaine and other anaesthetics, corticosteroids or botox) are used to target myofascial trigger points.

Myofascial active trigger points are sore, hypersensitive/hyperirritable, palpable hard nodules (‘tender points’, or ‘knots’) located within the myofascia that surrounds a taut band of skeletal muscle.  Compression of these trigger points may result in pain as well as motor and autonomic dysfunction.  Local pressure or stretch of tissue may also activate trigger points.

Referred pain is pain that may radiate from trigger points into larger areas that may even be remote to trigger points.

What exactly is dry needling of myofascial trigger points?:

Insertion of needles into palpable nodules (ie rapid, brief mechanical stimulation of active trigger points) in the myofascia results in an involuntary spinal reflex.  Specifically, trigger point needling elicits a sudden involuntary muscle contraction (local twitch response) in the taut band.

Local twitch responses in superficial trigger points can easily be seen while twitch responses occurring more deeply may only be visible via real-time ultrasonography.

Once a local twitch response is elicited, deactivation of the trigger point occurs and myofascial tension relief, reduced pain and improved musculoskeletal function result.  

Twitch responses may also be achieved during non invasive treatments including transcutaneous electrical stimulation, manual compression of trigger points and massage.

NB Twitch responses are not the same as muscle spasms.  Whilst the entire muscle is involved in both cases, the twitch response refers to a small spontaneous twitch only, and not an entire muscle contraction (as in muscle spasms).    

CASE STUDIES

(1) Ultrasound-Guided Trigger Point Needling for Myofascial Pain  

A Ukrainian study involving 133 myofascial pain patients compared ultrasound-guided versus non-ultrasound-guided trigger point needling.  Average pain levels were 7.2 and 7.4, respectively, prior to dry needling treatment.

Ultrasound scanning was done to precisely identify myofascial trigger points.

Dry needling was performed over 2 – 4 session to inactivate all trigger points.  Steel acupuncture needles (28 gauge) were used during dry needling treatments.

This study found that ultrasound-guided trigger point needling led to enhanced pain relief by evoking a greater number of local twitch responses.  Specifically, pain levels dropped from an average of 7.2 to 1.1 within 24 hours following ultrasound-guided trigger point needling.  This compares to average pain level decreases from 7.4 to 2.7 in the non-ultrasound-guided dry needling group (Bubnov and Wang, 2013).

(2) Ultrasound-Guided Trigger Point Needling (Including Medication Injection) in Patients with Chronic Chest Wall Pain Following Surgery    

Eight patients (7 women and 1 man; mean age = 56; 47 to 74) suffered severe chest wall pain (serratus anterior muscle pain syndrome) for 1 to 3 years, with pain levels ranging from 7 to 10.  The chest wall pain had started after surgery for lung cancer (n=2), cardiac surgery (n=2) and total mastectomy (n=4).

Once the trigger points in the serratus anterior muscle were identified, all 8 patients were offered 1 – 3 injections over 3 months.

Ultrasound-guided injection of medicine into the infiltration sites was performed to deactivate the trigger points.  Medication comprised lidocaine, bupivacaine and triamcinolone.

Ultrasound-guided trigger point injection treatment resulted in reduced pain levels (down to 3 or 4) in all 8 patients shortly after the first injection as well as 55% less pain (on average) after 3 months.   

(3) A 29 Year Old Female with Myofascial Pain Syndrome

A 29 year old female patient (let’s call her ‘Annie’) suffered myofascial pain syndrome in her left orofacial region for 3 months (pain rating up to 9).  Annie’s pain was dull, diffuse and ongoing.  Her pain affected her left ear and pre-auricular region, extended to her left temporal area and was accompanied by a headache.  Annie’s pain increased while chewing food and she was unable to open her mouth widely.  Her quality of sleep was also affected.

Following palpation, myofascial trigger points over her masticatory and suboccipital muscles were identified as well as referred pain to her left ear and a taut muscle band.  

Annie was offered 3 deep dry needling sessions over a week to deactivate the myofascial trigger points in the orofacial muscles.  

During Annie’s 1st appointment, the exact locations of her myofascial trigger points were identified via palpation of the affected muscles.  Thereafter, dry needling of her sternocleidomastoid and masseter using a 25 mm stainless steel needle was done.  The needle was positioned perpendicular to the trigger points before performing the ‘lift and thrust’ maneuver to evoke the local twitch response.  

During her 2nd appointment, Annie stated that half of her pain was gone and that her headache was now significantly reduced!  She was also able to open her mouth wider.  Dry needling of her lateral pterygoid (via a 40 mm needle), temporalis (via a 13 mm needle) and deep masseter muscles was performed resulting in a local twitch response in the masseter.

On her 3rd visit (on the 7th day), Annie finally had NIL pain!  There was no pain following palpation of the sternocleidomastoid, masseter, digastric and suboccipital muscles and her myofascial trigger points were no longer tender.  Her headache had disappeared shortly after her 2nd session and she was now able to open her mouth widely. 

Complete resolution of Annie’s myofascial pain syndrome via needling demonstrates the benefits of dry needling in patients with non-dental orofacial pain (Asha et al, 2015).

(4) A 40 Year Old Male with Myofascial Pain Syndrome

A 40 year old man suffered posterior thigh pain despite massage therapy, chiropractic adjustments and physical therapy.  Myofascial pain syndrome in the quadratus femoris was diagnosed following palpation.  Dry needling (based on a grading system) was offered.

The patient enjoyed immediate benefits following dry needling treatment.  Furthermore, he was completely pain free at the 4-month follow-up consultation (Anandkumar, 2017).

(5) An Iranian Clinical Trial Involving Dry Needling of Myofascial Trigger Points for Heel Pain  

A single-blinded clinical trial involving 20 patients with chronic heel pain due to plantar fasciitis revealed that a weekly session of dry needling of myofascial trigger points for 4 consecutive weeks can reduce the severity of heel pain (Eftekharsadat et al, 2016).

(6) A 53 Year Old Male with Painful Plantar Fasciitis

A 53 year old Iranian man suffered bilateral plantar heel pain that involved sharp, stabbing pain and accumulation of fluid beneath the metatarsal heads.  Pain levels were 8 in the right foot and 6 in the left foot and he was unable to stand for more than 20 minutes at a time.  

Dry needling of myofascial trigger points was offered twice a week for 2 weeks.

The man enjoyed a 60-70% decrease in pain levels (ie his pain levels dropped from 8 to 3 in his right foot and from 6 to 2 in his left foot), and he was able to return to his normal daily activities.   

THE SCIENCE BEHIND NEEDLING OF MYOFASCIAL TRIGGER POINTS FOR PAIN RELIEF 

What do trigger points look like?

Ultrasound images of trigger points from 3 studies are shown below:

(1) An Indian ultrasound study found that trigger points appear as echogenic structures under the surface of the trapezius muscle (and not inside the muscle mass).  These echogenic structures do not appear in or around unaffected, healthy skeletal muscle.

Here is an example of an echogenic structure (i.e. trigger point):

Credit for above ultrasound image of a trigger point: Parthasarathy et al, 2017.

 

(2) An American paper called Dry Needling for Myofascial Trigger Point Pain included 2 ultrasound images (A and B, below).  In A, a trigger point appears as a focal hypoechoic nodule in the upper trapezius.  In B, four (4) hypoechoic myofascia trigger points are visible.

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Credit for above ultrasound images: Unverzagt et al, 2015.

 

(3) A Romanian ultrasound- and thermal-based study identified trigger points via:

  • Clinical examination;
  • Ultrasound imaging; and
  • Thermal analysis.  

Thermal analysis via infrared thermography revealed that trigger points have higher temperatures than the areas immediately surrounding them.  It is possible that reduced blood flows lead to decreased temperatures around trigger points.

Thus, trigger points have unique thermal patterns.  Specifically, a cooler region surrounds a hotter area, the latter representing the trigger points themselves.  NB The thermal images are available in the paper by Cojocaru et al, 2015.

The trigger points could no longer be detected during follow-up clinical and ultrasound examination done 5 days after the successful injection procedure.

A trigger point, described as (quoting from paper) ‘an ellipsoidal hypoechogenic area in the muscle’, is seen here:

 

JMedLife-08-315-g001.jpg

Credit for above ultrasound image of a trigger point: Cojocaru et al, 2015.

 

(4) Many ultrasound images of trigger points are available in literature (Wong, 2017; Mayoral et al, 2013; other papers).

Benefits of Ultrasound Imaging of Trigger Points

Ultrasound-guided needling of trigger points can enhance the accuracy of needle placement in deeper musculature and intraarticular regions hence reducing the risk of pneumothorax, needling damage to organs and tissue (eg kidneys, lungs, salivary glands, adipose) as well as other complications (Botwin et al, 2008).    

Is dry needling of trigger points similar to acupuncture?

Researchers have suggested that the entire fascia network may be the physical substrate of all acupuncture-related meridians (the latter having been part of Traditional Chinese Medicine for 1,000’s of years).  Peter Dorsher noted an 89% overlap in myofascial meridians and the acupuncture principal meridian (Behnam et al, 2015).  Dorsher also found that 92% of all 255 trigger points correlated with acupuncture points.  The local twitch response can be compared to acupuncture’s ‘de qi’ sensation (Bai et al, 2011; Dorsher, 2006; Dorsher, 2009).

These observations suggest a positive correlation between the anatomy-based dry needling of trigger points and acupuncture.  

SUMMARY

The science behind dry needling (aka non-injection) vs injection needling of trigger points is incomplete.  Many medical professionals are still sceptical about this procedure.  Quoting from a paper offering a critical view (see Abstract):

‘…the theory of MPS [myofascial pain syndrome] caused by TrPs [trigger points] has been refuted…’ (Quintner et al, 2015).

Ongoing research that includes imaging (e.g. real-time ultrasonography) to specifically locate and identify the trigger points during dry needling (puncture) will enhance the underlying science and credibility for this technique.

Real-time ultrasound imaging can also enhance the accuracy of trigger point needling, particularly when targeting hyperactive trigger points located within the deeper fascia and musculature layers, intraarticular regions and other areas that cannot be palpated.  This reduces the risk of pneumothorax and other complications that may otherwise result from ‘blind methods’ (Mayoral et al, 2013).  

Dry needling of myofascial trigger points may offer effective and long-lasting pain relief, reduced focal inflammation, regeneration, increased mobility and enhanced autonomic function for patients suffering from musculoskeletal pain and/or myofascial pain syndromes.

Note: For patients who have a fear of needles (i.e. needle phobia), hypnotherapy may be beneficial.  For further information, please refer to my blog post called ‘Chronic Pain and Hypnotherapy’.

Sabina Walker

Blogger, Pain Matters (in WordPress)

PS A follow-up blog post on The myoActivation System of Pain Care (developed by Dr Greg Siren, BC, Canada) will be added shortly.  Stay tuned…

REFERENCES

Case Studies

(1) Ultrasound-Guided Trigger Point Needling for Myofascial Pain  

Bubnov and Wang. Clinical Comparative Study for Ultrasound-Guided Trigger-Point Needling for Myofascial Pain. Medical Acupuncture (17 Dec 2013); 25(6): 437-443.

https://www.researchgate.net/publication/259189884_Clinical_Comparative_Study_for_Ultrasound-Guided_Trigger-Point_Needling_for_Myofascial_Pain

(2) Ultrasound-Guided Trigger Point Needling (Including Medication Injection) in Patients with Chronic Chest Wall Pain Following Surgery  

Vargas-Schaffer et al. Ultrasound-Guided Trigger Point Injection for Serratus Anterior Muscle Pain Syndrome: Description of Technique and Case Series. A&A Case Reports (15 Sept 2015): 5(6); 99-102.

https://journals.lww.com/aacr/Fulltext/2015/09150/Ultrasound_Guided_Trigger_Point_Injection_for.4.aspx

(3) A 29 Year Old Female with Myofascial Pain Syndrome

Asha et al. A Novel Case of Orofacial Pain Treated by Dry Needling Technique – A Case Report. Dentistry (2015); 5: 319.

http://www.academia.edu/25006600/Open_Access_Case_Report_A_Novel_Case_of_Orofacial_Pain_Treated_by_Dry_Needling_Technique_-A_Case_Report

(4) A 40 Year Old Male with Myofascial Pain Syndrome

Anandkumar, S. Effect of Dry Needling on Myofascial Pain Syndrome of the Quadratus Femoris: A Case Report. Physiotherapy Theory and Practice (Feb 2018); 34(2): 157-164. 

https://www.ncbi.nlm.nih.gov/pubmed/28922048

(5) An Iranian Clinical Trial Involving Dry Needling of Myofascial Trigger Points for Heel Pain  

Eftekharsadat et al. Dry Needling in Patients with Chronic Heel Pain Due to Plantar Fasciitis: A Single-Blinded Randomized Clinical Trial. Medical Journal of the Islamic Republic of Iran (2016); 30: 401.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5038993/

(6) A 53 Year Old Male with Painful Plantar Fasciitis

Behnam et al. The Use of Dry Needling and Myofascial Meridians in a Case of Plantar Fasciitis. J Chiropr Med. (March 2014); 13(1): 43–48.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3976498/?report=reader#__ffn_sectitle

Other Academic References

(1) Mayoral et al. Myofascial Trigger Points: New Insights in Ultrasound Imaging. Techniques in Regional Anesthesia and Pain Management (July 2013); 17(3): 150–154.  

http://www.asociacionandaluzadeldolor.es/wp-content/uploads/2017/02/US-miofascial.pdf

(2) Mayo Clinic. Acupuncture And Myofascial Trigger Therapy Treat Same Pain Areas. ScienceDaily (14 May 2008).

http://www.sciencedaily.com/releases/2008/05/080513101614.htm>

(3) Dorsher PT. Trigger Points and Acupuncture Points: Anatomic and Clinical Correlations. Medical Acupuncture (May 2006); 17.

(4) Dorsher PT. Myofascial Referred-Pain Data Provide Physiologic Evidence of Acupuncture Meridians. J Pain (July 2009); 10 (7): 723–31.

doi:10.1016/j.jpain.2008.12.010

(5) Liu et al. Traditional Chinese Medicine Acupuncture and Myofascial Trigger Needling: The Same Stimulation Points? Complementary Therapies in Medicine (2016); 26: 28-32.

doi:10.1016/j.ctim.2016.02.013.

(6) Bai et al. Review of Evidence Suggesting That the Fascia Network Could Be the Anatomical Basis for Acupoints and Meridians in the Human Body (2011). Evidence-Based Complementary and Alternative Medicine (2011); Article ID 260510, 6 pages.

http://dx.doi.org/10.1155/2011/260510

https://www.hindawi.com/journals/ecam/2011/260510/

(7) Unverzagt et al. Dry Needling for Myofascial Trigger Point Pain: A Clinical Commentary. International Journal of Sports Physical Therapy. 2015;10(3):402-418.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4458928/pdf/ijspt-06-402.pdf

(8) Wong YM. Developments of Nonacupoint Needling in Japan. Medical Acupuncture (2017); 29(6): 349-351.

doi:10.1089/acu.2017.1247.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5733641/

(9) Botwin et al. Ultrasound-Guided Trigger Point Injections in the Cervicothoracic Musculature: A New and Unreported Technique. Pain Physician (Nov/Dec 2008); 11(6): 885-9.

https://www.ncbi.nlm.nih.gov/pubmed/19057634

(10) Parthasarathy S, John Charles S A. Analgesic Efficacy of Ultrasound Identified Trigger Point Injection in Myofascial Pain Syndrome: A Pilot Study in Indian Patients. Indian J Pain (2016); 30: 162-5.

http://www.indianjpain.org/article.asp?issn=0970-5333;year=2016;volume=30;issue=3;spage=162;epage=165;aulast=Parthasarathy

(11) Wong YM. Developments of Nonacupoint Needling in Japan. Medical Acupuncture (2017) ;29(6): 349-351.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5733641/

(12) Myofascial Trigger Point

https://en.wikipedia.org/wiki/Myofascial_trigger_point

(13) Zhou K, Ma Y & Brogan MS. Dry needling versus acupuncture: the ongoing debate. 

https://aim.bmj.com/content/33/6/485

(14) Cojocaru MC, Cojocaru IM, Voiculescu VM, Cojan-Carlea NA, Dumitru VL, Berteanu Met al. Trigger points–ultrasound and thermal findings. J Med Life (2015); 8(3): 315-8.

https://www.ncbi.nlm.nih.gov/pubmed/26351532

(15) Stecco et al. Fascial components of the myofascial pain syndrome. Curr Pain Headache Rep (2013); 17: 352.

https://spinalmanipulation.org/wp-content/uploads/2017/04/fascial-components-of-myofascial-pain-syndrome-2013.pdf

(16) Quintner, Bove and Cohen. A Critical Evaluation of the Trigger Point Phenomenon, Rheumatology (1 March 2015); 54(3): 392–399.

https://academic.oup.com/rheumatology/article/54/3/392/1796114

 

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