1  

An evidence-based introduction to dry needling as a safe and effective treatment for patients

Michelle Finnegan, PT, DPT, OCS, MTC, CMTPT, CCTT, FAAOMPT Jennifer Nelson, PT, DPT, COMT, CMTPT, FAAOMPT

November 5-6, 2016 College Park, MD

Disclosures

Michelle Finnegan is a senior instructor for the dry needling courses taught by Myopain Seminars

Jennifer Nelson is a lab instructor for the dry needling courses taught by Myopain Seminars

Session Learning Objectives

1.  Describe and discuss the characteristics of myofascial pain.

2.  Recognize and explain precipitating and perpetuating factors of myofascial TrPs.

3.  Discuss the different conditions that myofascial TrPs can be apart of and how they can contribute to pain.

At the end of the practical component of the

workshop the therapist will be able to:

1.  Correctly palpate and identify myofascial TrPs within the specific muscles that were included.

2.  Demonstrate safe needle handling and technique for the muscles learned.

3.  Discuss OSHA precautions relative to the performance of dry needling of myofascial TrPs.

The History of Trigger Points and Dry Needling

Trigger Points in History

•  French physician Guillaume de Baillou (1538-1616): published “Liber de Rheumatismo:” “muscular rheumatism”

•  British physician Balfour (1816): “patients as having a large number of nodular tumours and thickenings which were painful to the touch, and from which pains shot to neighbouring parts

2  

Trigger Points in History

•  German physician Müller (1912):

“Nodules and bands require more than a cursory

examination. They are likely to be

overlooked because physicians

tend not to search for them in

a systematic and skillful

manner.”

Trigger Points in History

•  1931: First trigger point manual published in Germany –  Lange M, Die Muskelhärten (Myogelosen). München: J.F.

Lehmann's Verlag, 1931

Trigger Points in History

•  Late 1930’s: Janet Travell became interested in trigger points after being introduced to the work of John H. Kellgren published in 1938

John H. Kellgren (1936) •  Studied pain phenomena by injecting various

substances into muscles, tendons, and periosteum.

•  The area of pain is not identical to the site of injection

•  The pain symptoms following injections are similar to pain symptoms following muscle contractions under ischemic conditions (compression)

Referred Pain Referred Pain

3  

J.H. Kellgren: Deep Pain Sensibility The Lancet, June 4,1949 Trigger Points in History

•  1938-1963: 3 clinicians, starting at similar times, published papers emphasizing cardinal features of myofascial trigger points

–  Michael Gustein (Great Britain) –  Michael Kelly (Austrailia) –  Janet Travell (United States)

**none of them know of the others work**

Janet Travell & David Simons

•  Publication of the trigger point manuals

•  Worldwide interest of

researchers and clinicians in a wide range of specialties

„Re-Discovery“ of Trigger Points

1984

1997 – first formal dry needling course in the United States

Janet G. Travell, MD Seminar Series™

(now Myopain Seminars)

4  

h'p://myopainseminars.com/resourcesnews-­‐rulings/  

States that have approved dry needling by PTs

1989 – 2012

What is a myofascial trigger point (MTrP)?

Trigger Point

±  taut band

a hyperirritable spot in the skeletal muscle that is associated with a hypersensitive palpable nodule in a taut band (Simons, 1999).

Recommended Criteria

ü Taut band palpable (if muscle is accessible)

ü Exquisite spot tenderness of a nodule in a taut band

ü Patient’s recognition of current pain complaint by pressure on the tender nodule (identifies an active trigger point)

What about the reliability of locating TrPs?

5  

0

20

40

60

80

100

STCM TRAP INFRASP LATS EDC

%

Taut Band

Interrater Reliability

0

20

40

60

80

100

STCM TRAP INFRASP LATS EDC

Trigger Point

0

20

40

60

80

100

STCM TRAP INFRASP LATS EDC

Tenderness

0

20

40

60

80

100

STCM TRAP INFRASP LATS EDC

%

Pain Rec.

0

20

40

60

80

100

STCM

TRAP

INFRASP

LATS

EDC

Referred Pain

Gerwin, R.D., et al., Interrater reliability in myofascial trigger point examination. Pain, 1997. 69(1-2): p. 65-73.

0

20

40

60

80

100

STCM

TRAP

INFRASP

LATS ED

C

%

Local twitch

Experienced clinicians can reach acceptable agreement in the diagnosis of TrPs in three

shoulder muscles

Test-retest reliability of myofascial trigger point detection in patients with rotator cuff tendonitis

± Fifty-eight patients with rotator cuff tendonitis

± HIGHLY RELIABLE for: presence or absence of the taut band, spot tenderness, jump sign and pain recognition between sessions.

± RELIABILITY VARIED for: referred pain and local twitch response depending on the muscle being studied.

Al-Shenqiti AM, Oldham JA: Clin Rehabil. 2005;19(5):482-487

§  Identification of clinically relevant TrP(s) in the region of the upper trapezius musculature is a reproducible procedure.

§  When performed by two experienced clinicians, agreement is substantial.

§  A pairing of one experienced and one inexperienced observer, both of who have undergone a standardization protocol, can yield moderate agreement.

An  experienced  physiotherapist  can  reliably  idenAfy  TrP  locaAons  in  the  upper  trapezius  muscle  using  a  palpaAon  protocol  

Barbero  et  al  J  Manual  Manipula0ve  Ther.  Vol  20  (4):171-­‐177,  2012    

6  

§  Evidence for the diagnostic reliability of TrPs is available from only a limited number of studies

§  Data on the reliability of physical examination

for trigger points are conflicting §  Examiners are not representative of those who

would normally use the test in practice

Clinical  Journal  of  Pain.  25(1),  2009  

What contributes to the development of trigger

points?

EAology  of  MTrPs  

•  low  level  muscle  contracAons  

Dommerholt J, Bron C, and Franssen J: Myofascial trigger points; an evidence-informed review. J Manual & Manipulative Ther, 2006:14(4):203-221. Gerwin RD, Dommerholt J, and Shah J: An expansion of Simons' integrated hypothesis of trigger point formation. Curr Pain Headache Rep, 2004. 8:468-475.

direct trauma

• Direct  trauma  

•  unaccustomed eccentric contractions

•  maximal or submaximal concentric contractions

± Associated MTrP

± Afferent Input from Joints

± Afferent Input from Internal Organs

± Stress / Tension Inte

grat

ed T

rigge

r Poi

nt H

ypot

hesi

s

Dommerholt, J. and McEvoy, J., Myofascial Trigger Point Release Approach, in Orthopaedic Manual Therapy; from Art to Evidence, C. Wise, Editor., F.A. Davis: Philadelphia, in press.

7  

What about the pathophysiology of trigger

points?

Microdialysis  System  

Shah, J.P., et al., An in-vivo microanalytical technique for measuring the local biochemical milieu of human skeletal muscle. J Appl Physiol, 2005. 99: p. 1980-1987

The image cannot be displayed. Your computer may not have

Microdialysis  of  TrPs  with  0.3  mm  needle  

Fluid in

Fluid out

Solute exchange surface – dialyzer membrane set 0.2 mm from the needle tip

Delivery tubes

Shah, J.P., et al., An in-vivo microanalytical technique for measuring the local biochemical milieu of human skeletal muscle. J Appl Physiol. 2005.

99: p. 1980-1987

0

50

100

150

200

250

300

350

400

0:00 2:24 4:48 7:12 9:36 12:00 14:24 16:48

pg/m

l

Time

Substance P

Shah, J.P., et al., An in-vivo microanalytical technique for measuring the local biochemical milieu of human skeletal muscle. J Appl Physiol, 2005. 99: p. 1980-1987 Shah JP, Danoff JV, Desai MJ, Parikh S, Nakamura LY, Phillips TM, and Gerber LH, Biochemicals associated with pain and inflammation are elevated in sites near to and remote from active myofascial trigger points. Arch Phys Med Rehabil. 89(1): 16-23, 2008"

Elevated  levels:  •  CGRP  •  Norepinephrine  •  TNF  –  α  •  Interleukin  1,  6  and  8  •  Serotonin  Reduced  levels:  •  Interleukin  12     Ø  Shah, J.P., et al., An in-vivo microanalytical technique for measuring the local

biochemical milieu of human skeletal muscle. J Appl Physiol, 2005. 99: p. 1980-1987

Ø  Shah JP, Danoff JV, Desai MJ, Parikh S, Nakamura LY, Phillips TM, and Gerber LH, Biochemicals associated with pain and inflammation are elevated in sites near to and remote from active myofascial trigger points. Arch Phys Med Rehabil. 89(1): 16-23, 2008"

pH

0

1

2

3

4

5

6

7

8

0:00 2:24 4:48 7:12 9:36 12:00 14:24 16:48

Time

pH

un

its Gr.1

Gr.2Gr.3

Shah, J.P., et al., An in-vivo microanalytical technique for measuring the local biochemical milieu of human skeletal muscle. J Appl Physiol, 2005. 99: p. 1980-1987 Shah JP, Danoff JV, Desai MJ, Parikh S, Nakamura LY, Phillips TM, and Gerber LH, Biochemicals associated with pain and inflammation are elevated in sites near to and remote from active myofascial trigger points. Arch Phys Med Rehabil. 89(1): 16-23, 2008"

8  

Pain 129 (2007) 102–112

•  Acidic pH has a profound effect on the initiation and perpetuation of muscle pain

•  A more acidic milieu may activate ASIC1 or ASIC3 muscle nociceptors, which in turn could produce mechanical hyperalgesia

O2- tissue saturation in TrPs  

Brückle, W., et al., Gewebe-pO2-Messung in der verspannten Rückenmuskulatur (m. erector spinae). Z. Rheumatol., 1990. 49: p. 208-216.

MTrP  -­‐  Retrograde  Blood  Flow  

Ballyns JJ, Shah JP, Hammond J, Gebreab T, Gerber LH, Sikdar S. Objective Sonographic Measures for Characterizing Myofascial Trigger Points

Associated with Cervical Pain. J Ultrasound Med 2011; 30:1331-1340.

Sikdar  S,  OrAz  R,  Gebreab  T,  Gerber  LH,  Shah  JP,  Understanding  the  vascular  environment  of  myofascial  trigger  points  using  ultrasonic  imaging  and  computaAonal  modeling.  Conf  Proc  IEEE  Eng  Med  Biol  Soc    1:  5302-­‐5,  2010.  

Sikdar S, et al. Novel Applications of Ultrasound Technology to Visualize and Characterize Myofascial Trigger Points and Surrounding Soft Tissue Arch Phys

Med Rehabil. 2009;90:1829-38  

9  

What about the effect of trigger points on the

neuromuscular system?

disturbed  motor  funcAon  

Latent  TrPs  influence  muscle  acAvaAon  pa'erns  (MAPs)  

• Results:  

– Control  group  had  a  stable  sequenAal  MAP  

– LTrP  group  had  a  variable  MAP  that  was  staAsAcally  significant  

Lucas  et  al.    Latent  myofascial  trigger  points:  their  effects  on  muscle  acAvaAon  and  movement  efficiency.    Journal  of  Bodywork  and  Movement  Therapies  (2004)  8,  160-­‐166.    

Postural  control  in  women  with  myofascial  neck  pain  

•  PaAents  with  MPS-­‐related  neck  pain  showed  an  increased  surface  area  and  a  faster  sway  velocity  than  control  subjects  

         Talebian  S,  et  al.    Journal  of  Musculoskeletal  Pain,  Vol  20  (1),  2012  

10  

restricted range of motion

Gonzalez-­‐Perez  LM,  Infante-­‐Cossio  P,  Granados-­‐Nuñez  M,  UrresA-­‐Lopez  FJ:  Treatment  of  temporomandibular  myofascial  pain  with  deep  dry  needling.  Med  Oral  Patol  Oral  Cir  Bucal    17(5):e781-­‐785,  2012.  

Myofascial  pain  in  the  lateral  pterygoid  muscle  (n=36)                                                                                                              (VAS)        Average  SD  

IniAal  pain  (before  treatment)  8.45      1.46  Pain  2  weeks  ajer  DDN      2.25      0.81  Pain  1  month  ajer  DDN      2.15      0.87  Pain  2  months  ajer  DDN      2.05      0.75  Pain  6  months  ajer  DDN      1.95      0.61  

A significant improvement in pain and an improvement of functional limitation which persisted up to 6 months after finishing the treatment. Note: there was no control group.

muscle  weakness/inhibiAon  

A  latent  MTP  is  associated  with  an  accelerated  development  of  muscle  fa0gue  and  simultaneously  overloading  ac0ve  motor  units  close  to  a    MTP.  

•  Group  1:  2+  TrPs  on  dominant  side  •  Group  2:  no  TrPs    •  Isometric  shoulder  flexion  and  scapAon  w/hand  

held  dynamometer    •  RESULTS:    those  with  latent  TrPs  were  significantly  

weaker  than  those  in  control  group  

This  study  shows  that  MTPs  are  associated  with  reduced  efficiency  of  reciprocal  inhibiAon,  which  may  contribute  to  the  delayed  and  incomplete  muscle  relaxaAon  following  exercise,  disordered  fine  movement  control,  and  unbalanced  muscle  acAvaAon.  

The  presence  of  latent  MTrPs  may  not  affect  the  strength  of  the  upper  trapezius.  

11  

muscle  s0ffness  �  Chen  Q,  Bensamoun  SF,  Basford  JR,  Thompson  JM,  An  KN.  IdenAficaAon  and  

QuanAficaAon  of  Myofascial  Taut  Bands  with  MagneAc  Resonance  Elastography.  Arch  Phys  Med  Rehab  2007,  88:1658-­‐61.    

�  Chen  Q,  Basford  JR,  An  KN.  IdenAficaAon  of  Myofascial  Taut  Band  Using  MagneAc  Resonance  Elastography.  Clin  Biomech  2008,  23  :623-­‐9.    

 

23 y.o. - Non MPS 28 y.o. - MPS

•  VibraAon  elastography  over  normal  muscle  and  acAve  MTrPs  in  UT  

•  AcAve  MTrPs  have    – significantly  lower  entropy  (p  <  0.05)    – significantly  larger  nonvibraAng  regions  (p  <  0.05)  

•  AcAve  MTrPs  have  more  heterogeneous  sAffness  when  compared  with  normal,  unaffected  muscle  

Turo  D  et  al.    Ultrasonic  characterizaAon  of  the  upper  trapezius  muscle  in  paAents  with  chronic  neck  pain.  Ultrason  Imaging.  2013  Apr;35(2):173-­‐87.    

local  tenderness  

•  Multiple TrPs were identified in the infraspinatus muscle on the painful side

•  Multiple latent TrPs were identified bilaterally

European Journal of Pain 12 (2008) 859–865

Clin  J  Pain  2009;25:506–512  

12  

Clin  J  Pain  2009;25:506–512  

Lower  PPT  =  Myofascial  Trigger  Points  

pain  

Muscle  trigger  points,  pressure  pain  threshold,  and  cervical  range  of  mo0on  in  pa0ents  with  high  level  of  

disability  related  to  acute  whiplash  injury  

•  Local  and  referred  pain  elicited  from  acAve  TrPs  reproduced  neck  and  shoulder  pain  pa'erns  in  individuals  with  acute  WADs  

•  The  number  of  acAve  TrPs  was  related  to  higher  neck  pain  intensity  

Fernandez-­‐Perez  AM  et  al.  J  Orthop  Sports  Phys  Ther.  2012  Jul;42(7):634-­‐41  

Referred  Pain  

AcAve  trigger  points  induce  larger  referred  pain  areas  and  higher  pain  intensiAes  than  

latent  TrPs                                                                                                                                                              (Hong  et  al.  Arch  Phys  Med  Rehabil  78:957-­‐960,  1997)  

Radiculopathy? MTrP referred pain? Both?

Facet  joint?  Trigger  point?  Both?  

AcAve  MTrPs  

•  Spontaneously  acAve  •  Reproduce  familiar  symptoms  •  Influence  the  musculoskeletal  system  the  same  way  latent  trigger  points  do  – Decreased  ROM  – Decreased  strength  – Altered  muscle  firing  pa'erns  

13  

Latent  MTrPs  

•  Are  not  spontaneously  acAve  •  Require  digital  sAmulaAon  to  cause  pain  •  Do  not  reproduce  familiar  symptoms  •  Influence  the  musculoskeletal  system  

– Decreased  ROM  – Decreased  strength  – Altered  muscle  firing  pa'erns  

What  is  dry  needling?  

What are we talking about when it comes to dry needling?

Dry  Needling:  Another  Manual  Physical  Therapy  PerspecAve  

14  

Dry  Needling  Approaches  

Not  all  techniques  are  created  equal  

The application of OMT is based on a comprehensive assessment of the patient’s NMS system and of the patient’s functional abilities. This examination serves to define the presenting dysfunction(s) in the articular, muscular, nervous and other relevant systems.

www.ifompt.com

Clinical  reasoning    

a  process  in  which  the  therapist,  interacAng  with  the  paAents  and  significant  others,  structures  meaning,  goals  and  health  

management  strategies  based  on  clinical  data,  client  choices  and  professional  judgment  and  

knowledge              

Jones  MA,  Rive'  DA.  (2004)  Clinical  reasoning  for  manual  therapists.  Edinburgh:  Bu'erworth  Heinemann    

•    increased  skill  in  iden0fying  and  elimina0ng  relevant  trigger  points:      

àbeWer  outcome  

Muscle Fiber Direction

•  You  must  know  your  anatomy  in  order  to  know  your  fiber  direcAon  

Palpation of a MTrP

15  

Manual  Therapy  

•  Focus on the Spine

•  Extremities

Structural Lesion Model of musculoskeletal pain

Muscle Pain? Muscle Pain:

A Major Medical Problem?

Since no specialty claims skeletal muscle as its organ, it is often overlooked

David G. Simons, MD

Unique Characteristics of Muscle Pain

•  Aching, cramping pain, difficult to localize and referred to deep somatic tissues

•  Muscle pain activates unique cortical structures

•  Inhibited more strongly by descending pain-modulating pathways

•  Activation of muscle nociceptors is much more effective at inducing neuroplastic changes in dorsal horn neurons

Jan  Dommerholt  and  Jay  P.  Shah:  “Myofascial  Pain  Syndrome”  In:  J.C.  Ballantyne,  J.P  Rathmell.,  and   S.M.   Fishman,   Editors:   Bonica’s   Pain   Management,   4th   EdiAon,   BalAmore,   Lippinco',  Williams  &  Wilkins,  2010;  Chapter  35,  450-­‐471.    

16  

Strong activation of the anterior cingulate cortex and periaquaductal gray (PAG)

Svensson P, Minoshima S, Beydoun A, Morrow TJ, and Casey KL, Cerebral processing of acute skin and muscle pain in humans. J Neurophysiol. 78(1): 450-60, 1997

Niddam DM, Chan RC, Lee SH, Yeh TC, and Hsieh JC, Central modulation of pain evoked from myofascial trigger point. Clin J Pain. 23(5): 440-8, 2007

Myofascial Pain: Activates anterior cingulate cortex/ periaquaductal gray (PAG) → associated w/ affective-emotional pain component and w/ hightened attention to painful stimulus

Cutaneous Pain: No involvement of the anterior cingular cortex

MTrPs have been identified with

ü  radiculopathies ü  joint dysfunction ü  disk pathology ü  tendonitis ü  craniomandibular dysfunction ü  migraines ü  tension-type headaches ü  carpal tunnel syndrome ü  computer-related disorders ü  whiplash associated disorders ü  spinal dysfunction

ü  pelvic pain and other urologic syndromes

ü  most pain syndromes ü  post-herpetic neuralgia ü  complex regional pain

syndrome ü  nocturnal cramps ü  phantom pain ü  Barré Liéou syndrome ü  neurogenic pruritus ü  etc. etc.

Dommerholt J, Bron C, and Franssen J: Myofascial trigger points; an evidence-informed review. J Manual & Manipulative Ther, 2006:14(4):203-221

Muscle  

Joint  

Joints  Teeth  

Muscles  

Suboccipitals  

SCM  &Traps  

Masseter  Temporalis  

Cervical  Spine  

TMJ  Occlusion  

QuesAons…..