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Dry needling of trigger points
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Dry needling of trigger points Jan Dommerholt
CHAPTER CONTENTS Introduction Scientific evidence of dry needling General guidelines for dry needling Dry needling of select neck, shoulder, and arm muscles Scalene muscles Pectoralis minor muscle Pectoralis major muscle Supraspinatus muscle Infraspinatus/teres major/teres minor muscles Rhomboid major and minor muscles Subscapularis muscle Latissimus dorsi muscle Deltoid muscle Biceps brachii muscle Triceps brachii muscle Brachialis muscle Brachioradialis muscle Supinator muscle Pronator teres muscle Wrist and finger extensor muscles
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INTRODUCTION Treating clinically relevant trigger points (TrP) with invasive procedures requires a thorough knowledge of the functional anatomy of muscles and their direct
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environment. TrPs are identified with manual palpation using either a flat or pincher palpation technique (see Chapter 32). Once a TrP is identified, the clinician must visualize its location in a three-dimensional perspective and appreciate the depth and presence of neighbouring structures, including arteries, veins, nerves, and internal organs. For most muscles, the needle should not be used to locate the TrP, as this would make inactivating TrPs a rather random process (Dommerholt et al 2006). In the neck, shoulder, and arm region, most muscles can be palpated, except parts of the subscapularis and serratus anterior muscles, which are partially in between the scapula and the rib cage. In that case, the clinician can only use the needle to locate and treat TrPs approaching the muscles from the medial border of the scapula. Inactivating TrPs with a needle requires an excellent kinaesthetic sense and awareness, based on training, experience, and anatomical knowledge (Noe¨ 2004). At any time, the clinician must know where in the body the tip of the needle is and which structures will be encountered. Well-developed kinaesthetic perception makes needling procedures safe and accurate as the clinician will be able to appreciate changes in structures and accurately identify when the needle penetrates the skin, the subcutaneous connective tissue and fascial layers, the muscle, and ultimately the taut band and TrP (Mayoral del Moral 2005). When in doubt, stay out! Invasive TrP therapies can be divided into injection and dry needling. TrP injections are administered with a hypodermic syringe; TrP dry needling is administered with a solid filament needle. Dry needling can be divided into superficial and deep dry needling techniques (Dommerholt et al 2006). Some older studies suggested that dry needling would cause more post-needling soreness (Hong 1994, Kamanli et al 2005), but in these © 2011 Elsevier Ltd. DOI: 10.1016/B978-0-7020-3528-9.00034-0
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studies, injections were compared to dry needling using a syringe. In a more recent study comparing injections with dry needling using a solid filament needle, there was no significant difference between the two approaches (Ga et al 2007). Dry needling provided longer lasting relief (Ga et al 2007). This chapter covers deep dry needling techniques and does not include specific information about superficial dry needling or TrP injections, but much of the information does apply with minor changes. Dry needling is within the scope of practice of medicine, acupuncture, and in many jurisdictions of physical therapy and chiropractic. Each practitioner will use discipline-specific philosophy and management approaches to determine when and how dry needling techniques will be applied. Acupuncture practitioners may refer to dry needling as ‘TrP acupuncture’, but this does not imply that dry needling would be in the exclusive domain of any discipline (Association of Social Work Boards, Federation of State Boards of Physical Therapy et al 2006). Although dry needling is performed with the same needle acupuncturists use, dry needling does not require any knowledge of traditional acupuncture theory or Chinese medicine (Baldry 2005, Amaro 2007, White 2009). Early in the 19th century, physicians used needles, including ladies’ hat pins, to treat tender points in the low back region (Churchill 1821, 1828, Elliotson 1827, Osler 1912). Dry needling is an expansion of the TrP injection techniques promoted by Travell, Simons, and others and is based on the observation that the actual mechanical stimulation of a TrP by the needle may be responsible for the therapeutic benefits (Steinbrocker 1944, Travell & Simons 1992, Simons et al 1999).
SCIENTIFIC EVIDENCE OF DRY NEEDLING One of the first prospective scientific studies of dry needling was published in 1980 and showed its effectiveness in the treatment of injured workers with low back pain (Gunn et al 1980). An authoritative Cochrane review found that dry needling was a potentially useful adjunct in the treatment of individuals with chronic low back pain, but agreed that more high-quality studies are needed (Furlan et al 2005). A study of the effects of latent TrPs on muscle activation patterns in the shoulder region demonstrated that a combination of TrP dry needling and passive stretching restored normal muscle activation patterns (Lucas et al 2004). A prospective, open-label, randomized study on the effect of deep dry needling on shoulder pain in 101 patients following a cerebrovascular accident, showed that after only four dry needling treatments, patients who were treated with dry needling reported significantly less pain during sleep and during physical therapy treatments, had more restful sleep, and
experienced significantly less frequent and less intense pain. They reduced their use of analgesic medications and demonstrated increased compliance with the rehabilitation programme compared to patients who received the regular rehabilitation programme (Dilorenzo et al 2004). TrP dry needling of the infraspinatus muscle decreased the pain intensity of the shoulder, increased active and passive shoulder internal rotation, and increased the pressure pain threshold of TrPs in the ipsilateral anterior deltoid and extensor carpi radialis longus muscles (Hsieh et al 2007). Dry needling of TrPs in the extensor carpi radialis longus reduced the irritability of TrPs in the ipsilateral trapezius muscle and the overall pain intensity, and improved cervical range of motion (Tsai et al 2010). A similar study of the effect of needling two acupuncture points in the extensor carpi radialis longus and extensor indices muscles reduced the pain intensity and endplate noise associated with a TrP in the trapezius muscle (Chou et al 2009). The authors compared the results to a sham needling procedure, whereby a needle was inserted into a rubber connector with direct contact on the skin. Subjects could feel the sharp needle tip, which makes it questionable whether this was a true sham procedure. Any needling is likely to have a physiological effect, such as a release of endorphins, a change in pain thresholds, or an expectancy of a positive outcome (Pariente et al 2005, Birch 2006, Lund & Lundeberg 2006, Wang et al 2008). Both actual needling and so-called sham procedures can activate areas involved in sensorimotor processing, and deactivate brain regions more active during rest than during other tasks. Interestingly, in one study areas associated with cognitive functioning were activated by both real and sham needling, but actual needling evoked a stronger response. The authors noted that some of the differences could be due to atypical stimuli from deeper, sub-dermal receptors stimulated by needling, compared to cutaneous receptors stimulated by sham procedures (Napadow et al 2009). Light touch of the skin has been shown to be able to stimulate mechanoreceptors coupled to slow conducting unmyelinated C fibre afferents, which in turn can activate insular regions, but not necessarily the somatosensory cortex (Olausson et al 2002). Kong et al (2006) confirmed that low and moderate pain stimuli were more effective in activating particular areas of the brain than strong pain stimuli. Dry needling may reduce endplate noise at TrPs (Chen et al 2001) and the chemical concentrations of several nociceptive substances found in the immediate environment of active TrPs (Shah et al 2003, 2005, 2008). Subjects with active TrPs demonstrated abnormal central processing and hyperalgesia in response to electrical stimulation and compression of the TrP (Niddam et al 2007, 2008). Enhanced brain activity was observed in somatosensory and limbic regions, and suppressed activity was noted in the hippocampus (Niddam et al 2008). There is increasing evidence that TrPs contribute to the
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development of central sensitization (Ferna´ndez-de-lasPen˜as et al 2007, 2009a,b, Giamberardino et al 2007, Ferna´ndez-Carnero et al 2008). There is some evidence from animal studies that needling therapies involve the descending pain inhibitory system (Takeshige et al 1992a,b).
GENERAL GUIDELINES FOR DRY NEEDLING The following sections provide basic guidance to needling TrPs in the neck, shoulder, and arm muscles. It should be noted that the skills needed to safely and accurately use these techniques can only be learned through attending hands-on courses offered by qualified and experienced tutors. Reading this chapter does not constitute any qualification to use dry needling in clinical practice. There are general guidelines, which should be adhered to. It is recommended that patients are lying down during any needling procedures, because of the risk of vasodepressive syncope. For every muscle, anatomical landmarks should be identified, including the margins of the muscle and any relevant bony structures, i.e. the medial and lateral borders of the scapula and the scapular spine when needling the supraspinatus muscle. Once a TrP is identified, the landmarks are once again verified to assure safe needling. There is ongoing debate whether disinfection of the skin is necessary and guidelines vary in different countries and regions. For TrP dry needling, using needles in tubes is recommended (White et al 2008). The tube is placed on the skin overlying the TrP and the needle is quickly tapped into the skin. The tube is removed, and the needle is moved in and out into the region of the TrP by drawing the needle back to the subcutaneous tissue and redirecting it. If the needle is not withdrawn sufficiently, the needle will follow the same pathway and the clinician will not be able to alter its direction. The objective of needling is to elicit so-called local twitch responses, which are an indication that the TrP is indeed inactivated (Hong 1994). Following needling procedures, haemostasis must be accomplished to prevent or minimize local bleeding, help restore and maintain range of motion, and facilitate a return to normal function. Only very experienced clinicians should use needling procedures with patients who routinely take warfarin or similar anticoagulants. The use of platelet inhibitors is generally not an absolute contraindication to needling, but requires care to achieve haemostasis.
DRY NEEDLING OF SELECT NECK, SHOULDER, AND ARM MUSCLES Muscles included in the following sections either cause or contribute to local pain or referred pain in the shoulder or arm. The wrist and finger flexors are not included as the
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Fig 34.1 Dry needling of the scalene muscles.
treatment is very similar to the treatment of the wrist extensors. The hand muscles are not included as they generally do not cause arm pain.
Scalene muscles (Fig 34.1) The anterior and middle scalene muscles originate from the first rib, and the posterior scalene muscle comes from the second rib. The muscles insert at the transverse processes of cervical vertebrae C3–C7. For TrP dry needling, the patient is lying either supine or in the lateral position. The medial scalene muscle lies anterior to the transverse processes of the cervical spine. The needle is inserted into the belly of the muscle where the TrP is found. The anterior scalene muscle is identified by asking the patient to sniff sharply (Katagiri et al 2003). The muscle is approached lateral to the clavicular head of the sternocleidomastoid muscle. The posterior scalene muscle is not needled due to its close proximity to the apex of the lungs. Precautions: The jugular vein should be identified and avoided. The scalene muscles cannot be needled towards the lungs, due to the risk of causing a pneumothorax.
Pectoralis minor muscle (Fig 34.2) The pectoralis minor muscle originates from the third, fourth and fifth ribs near their costal cartilages and inserts at the coracoid process of the scapula. For TrP dry needling, the patient lies supine. The coracoid process should be identified first. The needle is inserted through the pectoralis muscle and directed either upwards towards the coracoid process, or in a lateral direction tangential to the rib cage. Precautions: Care must be taken to avoid pneumothorax. Also, the neurovascular bundle of the arm lies under the pectoralis minor muscle close to the coracoid process.
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Fig 34.2 Dry needling of the pectoralis minor muscle.
Fig 34.4 Dry needling of the supraspinatus muscle.
humeral head. For dry needling, the patient is in sidelying. The needle is directed slightly posteriorly towards the upper border of the scapula and scapular spine. Precautions: If the needle is directed towards the anterior wall of the supraspinatus fossa, there is a considerable risk of causing a pneumothorax.
Infraspinatus/teres major/teres minor muscles (Fig 34.5)
Fig 34.3 Dry needling of the pectoralis major muscle.
Pectoralis major muscle (Fig 34.3) The pectoralis major muscle has four separate origins; the first arising from the clavicle, the second from the sternum, the third from the ribs, and an abdominal attachment via the aponeuroses of the external abdominal oblique and rectus abdominis muscles. The muscle inserts over the greater tubercle of the humerus along the lateral lip of the bicipital groove. For dry needling, the patient lies supine. When needling over the chest wall, needling is always directed towards a rib with the index and middle fingers placed in the intercostal space to avoid causing pneumothorax. Other portions of the muscle can be needled via a pincer palpation with the needle directed towards the fingers. Precautions: The ribs must be palpated and used as a guideline to avoid pneumothorax.
The three muscles originate from different aspects of the posterior surface of the scapula below the scapular spine. The infraspinatus muscle arises from the infraspinatus fossa and attaches to the middle part of the greater tubercle of the humeral head. The teres major originates at the inferior angle of the scapula and inserts in front of the humerus to its lesser tubercle. The teres minor originates from a higher and more lateral point than the teres major near the axillary border of the scapula. The teres minor inserts behind the humerus to the greater tubercle. For dry needling, the patient lies in the prone position or in
Supraspinatus muscle (Fig 34.4) The muscle arises from the supraspinatus fossa and attaches to the upper part of the greater tubercle of the
Fig 34.5 Dry needling of the infraspinatus/teres major/teres minor muscles.
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side-lying with the arm supported with a pillow. Body landmarks must be palpated before each needle insertion. The medial and lateral border of the scapula should be palpated prior to the needle insertion. For the infraspinatus, the needle is inserted directly into the TrP. When possible, the teres major and minor are grasped between the thumb and the index finger and the needle is inserted towards the finger or the scapula. If the muscles cannot be held in a pincer palpation, careful needling in a lateral direction tangential to the curvature of the rib cage is indicated. Precautions: Individuals with osteoporosis may present with thin and fenestrated scapulae. By developing a good kinaesthetic awareness of needling, clinicians should notice when the needle leaves the muscle. Fig 34.7 Dry needling of the subscapularis muscle.
Rhomboid major and minor muscles (Fig 34.6) The rhomboid minor attaches from the spinous processes of C7–T1 and reaches inferior laterally to the medial scapular border at the level of its spine. The rhomboid major muscle originates from the spinous processes of T2–T5 and inserts over the medial border of the scapula to its inferior angle. The muscle is needled in side-lying or prone position. When needling over the chest wall, needling is always directed towards a rib with the index and middle fingers placed in the intercostal space to avoid causing pneumothorax. The needle is inserted in a shallow angle towards the rib in order to avoid penetrating the lung. Precautions: The rhomboid muscle poses a relatively high risk for pneumothorax. The ribs must be palpated and the needle should always be directed to towards the ribs.
Subscapularis muscle (Fig 34.7) The subscapularis muscle lies over the anterior surface of the scapula. It originates from the inner surface of the scapula and attaches to the lesser tuberosity of the
humerus. For dry needling, the patient lies supine with the arm held in approximately 90 degrees of abduction with the elbow bent. The clinician manually brings the scapula in a protracted and laterally displaced position, which will provide greater access to the lateral aspect of the muscle. The palpating hand is placed against the rib cage and rests on the muscle. The needle is inserted between the palpating fingers towards the undersurface of the scapula. An alternative dry needling may be the following. To treat the more medial TrPs, the patient is placed in the side-lying position on the side that needs to be treated or in prone. The patient’s trunk is positioned in such a way that there is winging of the scapula, which makes it possible to needle TrPs in the subscapularis muscle. The needle is directed toward the undersurface of the scapula tangential over the rib cage. Precautions: With needling the lateral aspect of the muscle, the lungs are protected by keeping the palpating fingers against the chest wall to accurately locate the rib cage. Needling towards the ribs must be avoided for both needle techniques.
Latissimus dorsi muscle (Fig 34.8)
Fig 34.6 Dry needling of the rhomboid major and minor muscles.
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The latissimus dorsi originates from the spinous process of the lower T6 vertebra, the thoracolumbar fascia, iliac crest and inferior three or four ribs. The insertion of the muscle is at the intertubercular groove of the humerus. The muscle can be needled with the patient in supine, prone or side-lying. To needle the latissimus dorsi in the axilla, the patient lies supine with the arm abducted at shoulder level. The muscle is palpated with a pincer palpation and the needle is inserted perpendicularly to the skin. Needling the latissimus dorsi over the trunk requires a similar approach described in the section on the rhomboid muscles. Precautions: All needle insertions are made in consideration of the chest wall and lungs.
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Fig 34.8 Dry needling of the latissimus dorsi muscle.
Fig 34.10 Dry needling of the biceps brachii muscle.
pincer palpation. The needle is inserted perpendicular to the skin and directed towards the practitioner’s finger. Precautions: The neurovascular bundle, which includes the median nerve, the musculocutaneous nerve, the ulnar nerve, and the brachial artery, is located medially to the biceps brachii muscle and must be avoided.
Triceps brachii muscle
Fig 34.9 Dry needling of the deltoid muscle.
Deltoid muscle (Fig 34.9) The muscle originates from the anterior border of the lateral third of the clavicle, the lateral border of the acromion bone, lower lip of scapular spine and the fascia over the infraspinatus muscle, and the insertion is over the deltoid tuberosity at the humerus. For dry needling, the patient is either in supine or side-lying position. The needle is inserted perpendicularly through the skin directly into the taut band. Precautions: None.
Biceps brachii muscle (Fig 34.10) The long head of the biceps brachii muscle originates from the glenoid fossa with its tendon passing through the glenohumeral joint. The short head originates from the coracoid process without passing through the glenohumeral joint. Both heads attach distally to the lesser tuberosity of the radius. For dry needling, the patient lies in supine. The muscle is palpated and picked up via a
The triceps muscle consists of three heads: the long head originates from the scapula inferior to the glenoid fossa, the medial head originates from the medial portion of the humerus and the lateral head originates from the lateral side of the humerus. All three heads insert to the olecranon process on the ulna via a common tendon. For dry needling, the patient can be in supine, prone or side-lying. The muscle is needled via a pincer palpation. Precautions: The radial nerve passes posteriorly against the humerus and underneath the triceps muscle.
Brachialis muscle (Fig 34.11) The brachialis muscle originates from the distal two-thirds of the humerus and inserts at the coronoid process of the ulnar tuberosity. The muscle extends into the joint capsule of the elbow. For dry needling, the patient lies supine with the elbow supported and relaxed in a slight flexion. The muscle is palpated with a flat palpation technique. The muscle is needled only from the lateral aspect of the arm to avoid hitting the neurovascular bundle. The needle is directed medially. Precautions: The neurovascular bundle should be avoided over the medial head of the muscle.
Brachioradialis muscle (Fig 34.12) The muscle starts from the upper two-thirds of the supracondylar ridge of the humerus and attaches over the distal radius at the styloid process. For dry needling, the patient
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Fig 34.11 Dry needling of the brachialis muscle.
Fig 34.13 Dry needling of the supinator muscle.
Precaution: With the posterior approach, there is a risk of hitting the sensory and motor branches of the radial nerve.
Pronator teres muscle Fig 34.12 Dry needling of the brachioradialis muscle.
lies in supine position. TrPs are identified via pincer palpation. The needle is inserted and directed towards the practitioner’s finger. Precautions: This muscle is the most superficial muscle over the lateral elbow. The radial nerve passes close to it and should be avoided.
Supinator muscle (Fig 34.13) The supinator muscle originates from the lateral humeral epicondyle, radial collateral ligament, and the annular ligament and the supinator crest of the ulna. The muscle inserts over the radial tuberosity and upper third of the radial shaft. For dry needling, the patient is in supine with the arm supinated. Flat palpation against the radial bone on the volar side of the arm is used to identify the muscle. The needle is inserted pointing proximally towards the humerus. It is possible to needle the supinator muscle at the dorsal aspect of the forearm but there is a risk of hitting the superficial radial nerve, which lies over the muscle, or the posterior interosseus nerve, which lies in between the two heads of the muscle.
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The pronator teres muscle has a humeral and an ulnar head. They originate from the medial epicondyle and the medial side of the coronoid process of the ulnar respectively. Both heads insert over the radius distally from the insertion of the supinator muscle. For dry needling, the patient lies supine with the forearm supinated. The median nerve runs in between the two heads of the pronator teres muscle. The muscle can be needled at the proximal, medial portion approximately 1–2 cm below the elbow joint to avoid the median nerve or at the distal portion close to the insertion over the radius. The muscle is palpated with a flat palpation technique. The needle is inserted perpendicular to the skin and directed towards the ulna or radius respectively. Precautions: The median nerve runs between the two heads of the muscle and should be avoided.
Wrist and finger extensor muscles (Fig 34.14) The wrist extensors (extensor carpi radialis longus and brevis muscles) originate from the lateral supracondylar ridge of the humerus, the lateral epicondyle, the radial ligament of the elbow, and the intermuscular septa through a common tendon, which is shared with the extensor carpi ulnaris muscle, and the extensor digitorum muscle.
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Dry needling of trigger points The attachments are at the base of the second and third metacarpal bone, the ulnar side of the base of the fifth metacarpal bone, and the distal phalanx of the fingers respectively. For dry needling, the extensor carpi radialis longus and brevis can be needled with the muscles held in a pincer palpation. The extensor carpi ulnaris and extensor digitorum muscles are treated with a flat palpation. Precautions: The radial nerve crosses over the extensor digitorum muscle.
Fig 34.14 Dry needling of the wrist and finger extensor muscles.
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Dry needling of trigger points Jan Dommerholt
CHAPTER CONTENTS Introduction Scientific evidence of dry needling General guidelines for dry needling Dry needling of select neck, shoulder, and arm muscles Scalene muscles Pectoralis minor muscle Pectoralis major muscle Supraspinatus muscle Infraspinatus/teres major/teres minor muscles Rhomboid major and minor muscles Subscapularis muscle Latissimus dorsi muscle Deltoid muscle Biceps brachii muscle Triceps brachii muscle Brachialis muscle Brachioradialis muscle Supinator muscle Pronator teres muscle Wrist and finger extensor muscles
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INTRODUCTION Treating clinically relevant trigger points (TrP) with invasive procedures requires a thorough knowledge of the functional anatomy of muscles and their direct
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environment. TrPs are identified with manual palpation using either a flat or pincher palpation technique (see Chapter 32). Once a TrP is identified, the clinician must visualize its location in a three-dimensional perspective and appreciate the depth and presence of neighbouring structures, including arteries, veins, nerves, and internal organs. For most muscles, the needle should not be used to locate the TrP, as this would make inactivating TrPs a rather random process (Dommerholt et al 2006). In the neck, shoulder, and arm region, most muscles can be palpated, except parts of the subscapularis and serratus anterior muscles, which are partially in between the scapula and the rib cage. In that case, the clinician can only use the needle to locate and treat TrPs approaching the muscles from the medial border of the scapula. Inactivating TrPs with a needle requires an excellent kinaesthetic sense and awareness, based on training, experience, and anatomical knowledge (Noe¨ 2004). At any time, the clinician must know where in the body the tip of the needle is and which structures will be encountered. Well-developed kinaesthetic perception makes needling procedures safe and accurate as the clinician will be able to appreciate changes in structures and accurately identify when the needle penetrates the skin, the subcutaneous connective tissue and fascial layers, the muscle, and ultimately the taut band and TrP (Mayoral del Moral 2005). When in doubt, stay out! Invasive TrP therapies can be divided into injection and dry needling. TrP injections are administered with a hypodermic syringe; TrP dry needling is administered with a solid filament needle. Dry needling can be divided into superficial and deep dry needling techniques (Dommerholt et al 2006). Some older studies suggested that dry needling would cause more post-needling soreness (Hong 1994, Kamanli et al 2005), but in these © 2011 Elsevier Ltd. DOI: 10.1016/B978-0-7020-3528-9.00034-0
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studies, injections were compared to dry needling using a syringe. In a more recent study comparing injections with dry needling using a solid filament needle, there was no significant difference between the two approaches (Ga et al 2007). Dry needling provided longer lasting relief (Ga et al 2007). This chapter covers deep dry needling techniques and does not include specific information about superficial dry needling or TrP injections, but much of the information does apply with minor changes. Dry needling is within the scope of practice of medicine, acupuncture, and in many jurisdictions of physical therapy and chiropractic. Each practitioner will use discipline-specific philosophy and management approaches to determine when and how dry needling techniques will be applied. Acupuncture practitioners may refer to dry needling as ‘TrP acupuncture’, but this does not imply that dry needling would be in the exclusive domain of any discipline (Association of Social Work Boards, Federation of State Boards of Physical Therapy et al 2006). Although dry needling is performed with the same needle acupuncturists use, dry needling does not require any knowledge of traditional acupuncture theory or Chinese medicine (Baldry 2005, Amaro 2007, White 2009). Early in the 19th century, physicians used needles, including ladies’ hat pins, to treat tender points in the low back region (Churchill 1821, 1828, Elliotson 1827, Osler 1912). Dry needling is an expansion of the TrP injection techniques promoted by Travell, Simons, and others and is based on the observation that the actual mechanical stimulation of a TrP by the needle may be responsible for the therapeutic benefits (Steinbrocker 1944, Travell & Simons 1992, Simons et al 1999).
SCIENTIFIC EVIDENCE OF DRY NEEDLING One of the first prospective scientific studies of dry needling was published in 1980 and showed its effectiveness in the treatment of injured workers with low back pain (Gunn et al 1980). An authoritative Cochrane review found that dry needling was a potentially useful adjunct in the treatment of individuals with chronic low back pain, but agreed that more high-quality studies are needed (Furlan et al 2005). A study of the effects of latent TrPs on muscle activation patterns in the shoulder region demonstrated that a combination of TrP dry needling and passive stretching restored normal muscle activation patterns (Lucas et al 2004). A prospective, open-label, randomized study on the effect of deep dry needling on shoulder pain in 101 patients following a cerebrovascular accident, showed that after only four dry needling treatments, patients who were treated with dry needling reported significantly less pain during sleep and during physical therapy treatments, had more restful sleep, and
experienced significantly less frequent and less intense pain. They reduced their use of analgesic medications and demonstrated increased compliance with the rehabilitation programme compared to patients who received the regular rehabilitation programme (Dilorenzo et al 2004). TrP dry needling of the infraspinatus muscle decreased the pain intensity of the shoulder, increased active and passive shoulder internal rotation, and increased the pressure pain threshold of TrPs in the ipsilateral anterior deltoid and extensor carpi radialis longus muscles (Hsieh et al 2007). Dry needling of TrPs in the extensor carpi radialis longus reduced the irritability of TrPs in the ipsilateral trapezius muscle and the overall pain intensity, and improved cervical range of motion (Tsai et al 2010). A similar study of the effect of needling two acupuncture points in the extensor carpi radialis longus and extensor indices muscles reduced the pain intensity and endplate noise associated with a TrP in the trapezius muscle (Chou et al 2009). The authors compared the results to a sham needling procedure, whereby a needle was inserted into a rubber connector with direct contact on the skin. Subjects could feel the sharp needle tip, which makes it questionable whether this was a true sham procedure. Any needling is likely to have a physiological effect, such as a release of endorphins, a change in pain thresholds, or an expectancy of a positive outcome (Pariente et al 2005, Birch 2006, Lund & Lundeberg 2006, Wang et al 2008). Both actual needling and so-called sham procedures can activate areas involved in sensorimotor processing, and deactivate brain regions more active during rest than during other tasks. Interestingly, in one study areas associated with cognitive functioning were activated by both real and sham needling, but actual needling evoked a stronger response. The authors noted that some of the differences could be due to atypical stimuli from deeper, sub-dermal receptors stimulated by needling, compared to cutaneous receptors stimulated by sham procedures (Napadow et al 2009). Light touch of the skin has been shown to be able to stimulate mechanoreceptors coupled to slow conducting unmyelinated C fibre afferents, which in turn can activate insular regions, but not necessarily the somatosensory cortex (Olausson et al 2002). Kong et al (2006) confirmed that low and moderate pain stimuli were more effective in activating particular areas of the brain than strong pain stimuli. Dry needling may reduce endplate noise at TrPs (Chen et al 2001) and the chemical concentrations of several nociceptive substances found in the immediate environment of active TrPs (Shah et al 2003, 2005, 2008). Subjects with active TrPs demonstrated abnormal central processing and hyperalgesia in response to electrical stimulation and compression of the TrP (Niddam et al 2007, 2008). Enhanced brain activity was observed in somatosensory and limbic regions, and suppressed activity was noted in the hippocampus (Niddam et al 2008). There is increasing evidence that TrPs contribute to the
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development of central sensitization (Ferna´ndez-de-lasPen˜as et al 2007, 2009a,b, Giamberardino et al 2007, Ferna´ndez-Carnero et al 2008). There is some evidence from animal studies that needling therapies involve the descending pain inhibitory system (Takeshige et al 1992a,b).
GENERAL GUIDELINES FOR DRY NEEDLING The following sections provide basic guidance to needling TrPs in the neck, shoulder, and arm muscles. It should be noted that the skills needed to safely and accurately use these techniques can only be learned through attending hands-on courses offered by qualified and experienced tutors. Reading this chapter does not constitute any qualification to use dry needling in clinical practice. There are general guidelines, which should be adhered to. It is recommended that patients are lying down during any needling procedures, because of the risk of vasodepressive syncope. For every muscle, anatomical landmarks should be identified, including the margins of the muscle and any relevant bony structures, i.e. the medial and lateral borders of the scapula and the scapular spine when needling the supraspinatus muscle. Once a TrP is identified, the landmarks are once again verified to assure safe needling. There is ongoing debate whether disinfection of the skin is necessary and guidelines vary in different countries and regions. For TrP dry needling, using needles in tubes is recommended (White et al 2008). The tube is placed on the skin overlying the TrP and the needle is quickly tapped into the skin. The tube is removed, and the needle is moved in and out into the region of the TrP by drawing the needle back to the subcutaneous tissue and redirecting it. If the needle is not withdrawn sufficiently, the needle will follow the same pathway and the clinician will not be able to alter its direction. The objective of needling is to elicit so-called local twitch responses, which are an indication that the TrP is indeed inactivated (Hong 1994). Following needling procedures, haemostasis must be accomplished to prevent or minimize local bleeding, help restore and maintain range of motion, and facilitate a return to normal function. Only very experienced clinicians should use needling procedures with patients who routinely take warfarin or similar anticoagulants. The use of platelet inhibitors is generally not an absolute contraindication to needling, but requires care to achieve haemostasis.
DRY NEEDLING OF SELECT NECK, SHOULDER, AND ARM MUSCLES Muscles included in the following sections either cause or contribute to local pain or referred pain in the shoulder or arm. The wrist and finger flexors are not included as the
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Fig 34.1 Dry needling of the scalene muscles.
treatment is very similar to the treatment of the wrist extensors. The hand muscles are not included as they generally do not cause arm pain.
Scalene muscles (Fig 34.1) The anterior and middle scalene muscles originate from the first rib, and the posterior scalene muscle comes from the second rib. The muscles insert at the transverse processes of cervical vertebrae C3–C7. For TrP dry needling, the patient is lying either supine or in the lateral position. The medial scalene muscle lies anterior to the transverse processes of the cervical spine. The needle is inserted into the belly of the muscle where the TrP is found. The anterior scalene muscle is identified by asking the patient to sniff sharply (Katagiri et al 2003). The muscle is approached lateral to the clavicular head of the sternocleidomastoid muscle. The posterior scalene muscle is not needled due to its close proximity to the apex of the lungs. Precautions: The jugular vein should be identified and avoided. The scalene muscles cannot be needled towards the lungs, due to the risk of causing a pneumothorax.
Pectoralis minor muscle (Fig 34.2) The pectoralis minor muscle originates from the third, fourth and fifth ribs near their costal cartilages and inserts at the coracoid process of the scapula. For TrP dry needling, the patient lies supine. The coracoid process should be identified first. The needle is inserted through the pectoralis muscle and directed either upwards towards the coracoid process, or in a lateral direction tangential to the rib cage. Precautions: Care must be taken to avoid pneumothorax. Also, the neurovascular bundle of the arm lies under the pectoralis minor muscle close to the coracoid process.
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Fig 34.2 Dry needling of the pectoralis minor muscle.
Fig 34.4 Dry needling of the supraspinatus muscle.
humeral head. For dry needling, the patient is in sidelying. The needle is directed slightly posteriorly towards the upper border of the scapula and scapular spine. Precautions: If the needle is directed towards the anterior wall of the supraspinatus fossa, there is a considerable risk of causing a pneumothorax.
Infraspinatus/teres major/teres minor muscles (Fig 34.5)
Fig 34.3 Dry needling of the pectoralis major muscle.
Pectoralis major muscle (Fig 34.3) The pectoralis major muscle has four separate origins; the first arising from the clavicle, the second from the sternum, the third from the ribs, and an abdominal attachment via the aponeuroses of the external abdominal oblique and rectus abdominis muscles. The muscle inserts over the greater tubercle of the humerus along the lateral lip of the bicipital groove. For dry needling, the patient lies supine. When needling over the chest wall, needling is always directed towards a rib with the index and middle fingers placed in the intercostal space to avoid causing pneumothorax. Other portions of the muscle can be needled via a pincer palpation with the needle directed towards the fingers. Precautions: The ribs must be palpated and used as a guideline to avoid pneumothorax.
The three muscles originate from different aspects of the posterior surface of the scapula below the scapular spine. The infraspinatus muscle arises from the infraspinatus fossa and attaches to the middle part of the greater tubercle of the humeral head. The teres major originates at the inferior angle of the scapula and inserts in front of the humerus to its lesser tubercle. The teres minor originates from a higher and more lateral point than the teres major near the axillary border of the scapula. The teres minor inserts behind the humerus to the greater tubercle. For dry needling, the patient lies in the prone position or in
Supraspinatus muscle (Fig 34.4) The muscle arises from the supraspinatus fossa and attaches to the upper part of the greater tubercle of the
Fig 34.5 Dry needling of the infraspinatus/teres major/teres minor muscles.
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side-lying with the arm supported with a pillow. Body landmarks must be palpated before each needle insertion. The medial and lateral border of the scapula should be palpated prior to the needle insertion. For the infraspinatus, the needle is inserted directly into the TrP. When possible, the teres major and minor are grasped between the thumb and the index finger and the needle is inserted towards the finger or the scapula. If the muscles cannot be held in a pincer palpation, careful needling in a lateral direction tangential to the curvature of the rib cage is indicated. Precautions: Individuals with osteoporosis may present with thin and fenestrated scapulae. By developing a good kinaesthetic awareness of needling, clinicians should notice when the needle leaves the muscle. Fig 34.7 Dry needling of the subscapularis muscle.
Rhomboid major and minor muscles (Fig 34.6) The rhomboid minor attaches from the spinous processes of C7–T1 and reaches inferior laterally to the medial scapular border at the level of its spine. The rhomboid major muscle originates from the spinous processes of T2–T5 and inserts over the medial border of the scapula to its inferior angle. The muscle is needled in side-lying or prone position. When needling over the chest wall, needling is always directed towards a rib with the index and middle fingers placed in the intercostal space to avoid causing pneumothorax. The needle is inserted in a shallow angle towards the rib in order to avoid penetrating the lung. Precautions: The rhomboid muscle poses a relatively high risk for pneumothorax. The ribs must be palpated and the needle should always be directed to towards the ribs.
Subscapularis muscle (Fig 34.7) The subscapularis muscle lies over the anterior surface of the scapula. It originates from the inner surface of the scapula and attaches to the lesser tuberosity of the
humerus. For dry needling, the patient lies supine with the arm held in approximately 90 degrees of abduction with the elbow bent. The clinician manually brings the scapula in a protracted and laterally displaced position, which will provide greater access to the lateral aspect of the muscle. The palpating hand is placed against the rib cage and rests on the muscle. The needle is inserted between the palpating fingers towards the undersurface of the scapula. An alternative dry needling may be the following. To treat the more medial TrPs, the patient is placed in the side-lying position on the side that needs to be treated or in prone. The patient’s trunk is positioned in such a way that there is winging of the scapula, which makes it possible to needle TrPs in the subscapularis muscle. The needle is directed toward the undersurface of the scapula tangential over the rib cage. Precautions: With needling the lateral aspect of the muscle, the lungs are protected by keeping the palpating fingers against the chest wall to accurately locate the rib cage. Needling towards the ribs must be avoided for both needle techniques.
Latissimus dorsi muscle (Fig 34.8)
Fig 34.6 Dry needling of the rhomboid major and minor muscles.
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The latissimus dorsi originates from the spinous process of the lower T6 vertebra, the thoracolumbar fascia, iliac crest and inferior three or four ribs. The insertion of the muscle is at the intertubercular groove of the humerus. The muscle can be needled with the patient in supine, prone or side-lying. To needle the latissimus dorsi in the axilla, the patient lies supine with the arm abducted at shoulder level. The muscle is palpated with a pincer palpation and the needle is inserted perpendicularly to the skin. Needling the latissimus dorsi over the trunk requires a similar approach described in the section on the rhomboid muscles. Precautions: All needle insertions are made in consideration of the chest wall and lungs.
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Fig 34.8 Dry needling of the latissimus dorsi muscle.
Fig 34.10 Dry needling of the biceps brachii muscle.
pincer palpation. The needle is inserted perpendicular to the skin and directed towards the practitioner’s finger. Precautions: The neurovascular bundle, which includes the median nerve, the musculocutaneous nerve, the ulnar nerve, and the brachial artery, is located medially to the biceps brachii muscle and must be avoided.
Triceps brachii muscle
Fig 34.9 Dry needling of the deltoid muscle.
Deltoid muscle (Fig 34.9) The muscle originates from the anterior border of the lateral third of the clavicle, the lateral border of the acromion bone, lower lip of scapular spine and the fascia over the infraspinatus muscle, and the insertion is over the deltoid tuberosity at the humerus. For dry needling, the patient is either in supine or side-lying position. The needle is inserted perpendicularly through the skin directly into the taut band. Precautions: None.
Biceps brachii muscle (Fig 34.10) The long head of the biceps brachii muscle originates from the glenoid fossa with its tendon passing through the glenohumeral joint. The short head originates from the coracoid process without passing through the glenohumeral joint. Both heads attach distally to the lesser tuberosity of the radius. For dry needling, the patient lies in supine. The muscle is palpated and picked up via a
The triceps muscle consists of three heads: the long head originates from the scapula inferior to the glenoid fossa, the medial head originates from the medial portion of the humerus and the lateral head originates from the lateral side of the humerus. All three heads insert to the olecranon process on the ulna via a common tendon. For dry needling, the patient can be in supine, prone or side-lying. The muscle is needled via a pincer palpation. Precautions: The radial nerve passes posteriorly against the humerus and underneath the triceps muscle.
Brachialis muscle (Fig 34.11) The brachialis muscle originates from the distal two-thirds of the humerus and inserts at the coronoid process of the ulnar tuberosity. The muscle extends into the joint capsule of the elbow. For dry needling, the patient lies supine with the elbow supported and relaxed in a slight flexion. The muscle is palpated with a flat palpation technique. The muscle is needled only from the lateral aspect of the arm to avoid hitting the neurovascular bundle. The needle is directed medially. Precautions: The neurovascular bundle should be avoided over the medial head of the muscle.
Brachioradialis muscle (Fig 34.12) The muscle starts from the upper two-thirds of the supracondylar ridge of the humerus and attaches over the distal radius at the styloid process. For dry needling, the patient
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Fig 34.11 Dry needling of the brachialis muscle.
Fig 34.13 Dry needling of the supinator muscle.
Precaution: With the posterior approach, there is a risk of hitting the sensory and motor branches of the radial nerve.
Pronator teres muscle Fig 34.12 Dry needling of the brachioradialis muscle.
lies in supine position. TrPs are identified via pincer palpation. The needle is inserted and directed towards the practitioner’s finger. Precautions: This muscle is the most superficial muscle over the lateral elbow. The radial nerve passes close to it and should be avoided.
Supinator muscle (Fig 34.13) The supinator muscle originates from the lateral humeral epicondyle, radial collateral ligament, and the annular ligament and the supinator crest of the ulna. The muscle inserts over the radial tuberosity and upper third of the radial shaft. For dry needling, the patient is in supine with the arm supinated. Flat palpation against the radial bone on the volar side of the arm is used to identify the muscle. The needle is inserted pointing proximally towards the humerus. It is possible to needle the supinator muscle at the dorsal aspect of the forearm but there is a risk of hitting the superficial radial nerve, which lies over the muscle, or the posterior interosseus nerve, which lies in between the two heads of the muscle.
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The pronator teres muscle has a humeral and an ulnar head. They originate from the medial epicondyle and the medial side of the coronoid process of the ulnar respectively. Both heads insert over the radius distally from the insertion of the supinator muscle. For dry needling, the patient lies supine with the forearm supinated. The median nerve runs in between the two heads of the pronator teres muscle. The muscle can be needled at the proximal, medial portion approximately 1–2 cm below the elbow joint to avoid the median nerve or at the distal portion close to the insertion over the radius. The muscle is palpated with a flat palpation technique. The needle is inserted perpendicular to the skin and directed towards the ulna or radius respectively. Precautions: The median nerve runs between the two heads of the muscle and should be avoided.
Wrist and finger extensor muscles (Fig 34.14) The wrist extensors (extensor carpi radialis longus and brevis muscles) originate from the lateral supracondylar ridge of the humerus, the lateral epicondyle, the radial ligament of the elbow, and the intermuscular septa through a common tendon, which is shared with the extensor carpi ulnaris muscle, and the extensor digitorum muscle.
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Dry needling of trigger points The attachments are at the base of the second and third metacarpal bone, the ulnar side of the base of the fifth metacarpal bone, and the distal phalanx of the fingers respectively. For dry needling, the extensor carpi radialis longus and brevis can be needled with the muscles held in a pincer palpation. The extensor carpi ulnaris and extensor digitorum muscles are treated with a flat palpation. Precautions: The radial nerve crosses over the extensor digitorum muscle.
Fig 34.14 Dry needling of the wrist and finger extensor muscles.
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