DRY NEEDLING? WHAT’S OUT THERE?
- “Myofascial pain syndrome is characterized by the presence of one or more symptomatic myofascial trigger points (MTrPs) located in skeletal muscle. Myofascial trigger points are palpable, localized areas of hyperalgesic muscle tissue typically located in a taught band of fibers”
Myofascial pain syndrome is pain believed to be originating from the myofascia. I feel like Webster’s dictionary at this point. You know what I mean? For instance when you look up a word such as ambulation and the first definition is: The act of ambulating. Thanks wise guy!
Let’s start with myofascial. There are two types of fascia spoken of in the research. The first is superficial (superficialis) fascia and the second is deep (profundus) fascia. There is this awesomely boring book to read about fascia if you are ever having trouble falling asleep (Fascia: The Tensional Network of the Human Body: The science and clinical applications in manual and movement therapy). I only recommend it if you are really interested because it is very long and very boring. I guess that we also have to start with “What is fascia?” In school we didn’t learn much about this tissue. For those that graduated before 2012, we were only taught that it is the white stuff that we have to cut through in order to see the muscles. It was more of a nuisance than an actual tissue to pay attention to. Boy, have things changed! If you have watched any of Kelly Starrett’s videos or read the book: Supple Leopard (which I highly recommend to most of my athletic patients), then you will see many ways in which the fascia can be moved and “loosened”. Fascia is a very tough tissue that helps to give us shape and encompasses the entire body. It covers our muscles and even covers the small structures that make up an entire muscle. Big picture: it’s everywhere. The research on it is still young and we don’t know its full purpose yet, but are starting to understand that when it is angry…it let’s us know.
These MTrPs are palpable, meaning that we can feel them if we attempt to feel you up. They are the “knots” that most people complain about. Some of these “knots” are like small marbles and others are like small sausage links. Either way, they are hyperalgesic, which means…for a lack of a better term…angry.
- “In addition, research indicates active MTrPs have greater concentrations of inflammatory and nociceptive agents, as well as a lower pH, compared to non-pathologic muscle fibers”
There are some details hidden this sentence. The first is the description of “active” trigger points. If some are active, then others are inactive. These are historically called latent trigger points. This type of trigger point has the same palpable nature of a trigger point, but doesn’t cause pain. I don’t know of any research that looks at the pH of latent trigger points. Think about it though. The only way that we can really know if a trigger point is active or inactive is to play with it and see if it hurts.
- “It has been suggested that TDN (trigger point dry needling) hyperstimulates the pain-generating area and thereby normalizes the local sensory inputs. Another hypothesis suggests that TDN causes natural opioid-mediated pain suppression by stimulating local alpha-delta nerve fibers.”
The take home point from this is that we have no idea how this may work! There are theories as to the why it works, but there are articles showing that it works. Put this in perspective…I consistently say that our profession is in its infancy regarding research, but I really should say that we are in our toddler stage. I have a young daughter and am just waiting for her “Why” stage. As a curious father myself, I always want to answer the question when I can, but at the same time I know that I will (through no fault of my own, as it appears to be a genetic trait of parents) answer her question with “because I said so”.
- “Trigger point dry needling is administered by inserting a thin, solid filiform needle directly into the palpable trigger point…then incrementally manipulated within the tissue in order to elicit a localized twitch response (LTR) and removed once the MTrP has been released”
Picture a pincushion…enough said! I like why’s, but there aren’t many with this regards. I can remember during a clinical, the clinical instructor was teaching me acupressure techniques in which you hold a force downward onto the knot and wait for the patient’s pain response to change or hold for 90 seconds, whichever comes first. This just seemed so arbitrary to me. What I saw was that I was going to dig my thumb into a patient and wait for them to tell me that it doesn’t hurt as much. People aren’t dumb. In the words of Dr. House… all people lie. If I tell you that I will push into your skull with enough force to cause you pain and that I will stop when your symptoms are better…what will you do? I think I’d be fixed.
There are too many vague descriptions for me with regards to this technique. “Incrementally manipulated”? What does this even mean? I can see a session lasting for hours and coming into the room every 10 minutes to “release the muscle”. This technique may work, but we still don’t have enough information to make this type of treatment standard yet.
- “Moderate to severe adverse events causing significant distress or further medical treatment (e.g., fainting, headache, nausea) occurred at a rate of <0.04%”
This means that 4 in 10,000 will have an adverse reaction. Hypersensitivy to aspirin is between 1-2 in 100. Overall, this appears to be a safe intervention, but we still have yet to see if it is effective.
- “TDN is more effective than stretching and percutaneus electric nerve stimulation, and at least equally as clinically effective as manual MTrP release and other needling treatments”
This means that dry needling has more promise than basic stretching, but is no better than many other techniques to reduce pain.
- “It appears that TDN, as performed and measured in each study, does not influence strength, variably improves ROM and function and frequently decreases pain”
We know that it helps pain. We don’t know how it helps pain. There are two major theories for affecting pain: the bottom-up theory and the top-down theory. The bottom-up theory is using an external stimulus to reduce your painful complaint. Again, if I put an ice pack on your painful area or hit a separate area with a hammer, your initial pain will reduce. The top down theory is not spoken of in the research very often. This is using your brain to reduce your pain, such as with meditation. It is also called the endogenous (internal) opioid (cocaine) theory. Aside from pain relief, there appears to be little evidence that it helps any other complaints. Since a majority of patients are coming to therapy for pain complaints, this could be used as an adjunct to mechanical (movement based) therapy in order to reduce pain complaints. (As of today’s date, I have absolutely no training in this treatment).
- “TDN treatment may allow for improved tolerance to other interventions, such as manual therapy and therapeutic exercise, with potential for overall accelerated progression and more lasting positive results”
This statement sums up my thoughts on this type of treatment approach. It can be used as an adjunct to get the patient back to where the research is strong…exercise. I will have to look into the legalities of performing this type of intervention in our state, as each state has it’s own rules regarding invasive procedures for PT’s.
MORAL: Using dry needling techniques can be useful for pain reduction, but has no other effects. This could be an intervention in order to return the patient back to functional activities assuming the patient has demonstrated that he/she will be a non-responder to a mechanical (movement based) intervention program.
Functional Therapy and Rehabilitation
(Now part of Goodlife PT)
903 N 129th Infantry Dr
EXCERPTS TAKEN FROM:
Boyles R, Fowler R, Ramsey D, Burrows E. Effectiveness of trigger point dry needling for multiple body regions: a systematic review. JMMT.2015;23(5):276-293.