Myofascial Pain: Treatment with Dry Needling Trigger Point Acupuncture
Definition and History of Trigger Points and Trigger Point Acupuncture
The method of relief from pain, now called “Dry Needling” by physical therapists, and “trigger point acupuncture” or “myo-fasical acupuncture” by licensed Acupuncturists, has its origin in classical Chinese acupuncture which always looked at the human body and mind as a continuous whole. But modern western anatomists have had to reverse engineer their understanding of the way that pain and inflammation can cross barriers that used to be thought of as fixed. Because once science understood the role of the nervous system as a carrier of sensation, it was understood that all pain in the musculature had to have direct neural involvement associated with dermatomes and nerve root distributions, such as you see in sciatic pain. This was wrong.
Relief from pain that originates from a focus of neural hyperactivity in the different structures of the musculoskeletal system , now called trigger points, originated in England in the late 1930’s at University College Medical School. It was there that researchers discovered that referred pain from a focus of irritation in muscle and or other connective tissues or fascia may be felt in both broad and specific areas, such as muscles, joints and even teeth.
This was significant, as pain from these foci of irritation do not follow the dermatomal (skin) or nerve root distribution of neurological pain common to actual nerve injury. In fact, it was demonstrated by Drs. Good, Kelly, and Travel, in England, Australia, and the U.S., that each individual muscle in the body, when affected by these “irritant foci”, has its own unique and specific pattern of pain referral that is predictable and map-able. These foci of irritation came to be called, over time, “myofascial trigger points.”
It was discovered that the common characteristic of the various trigger points, regardless of the tissue, was electrical hyperactivity. It was also discovered that it is possible to “de-activate” these acutely tender points through the insertion of a needle, and in the process relieve the pain and inflammation that is common to sports injuries, degenerative pain like arthritis, or painful conditions such as headache or TMJ.
Dry Needling and Trigger Point Acupuncture
In England a study was done with 3 cohorts of patients with chronic back pain. The purpose of the study was to discover whether the traditional biomedicine technique of injecting lidocaine into trigger points was effective because of the lidocaine, or because of the needle itself. This study was done because it was recognized that there was a potential reaction between the fibers in the trigger points and the needle itself because of the characteristic “muscle twitch” response that occurred immediately upon inserting the hypodermic needle.
One cohorts trigger points were injected with lidocaine, one with saline, a kind of sham injection as no medical value was theorized for the saline, and one cohort received just the needle. In this report this third technique was called “dry needling” simply because there was no liquid being injected.
Recently, in some states in the USA, physical therapists, who are not licensed acupuncturists, and have not generally studied acupuncture theory or point locations, have gained permission to perform what they call “dry needling.” These physical therapists know their anatomy very well, and have studied trigger point locations well, so I for one, not only have no objection to what they are doing, but am all for it. Whatever helps people.
But where the confusion lies is thinking that PTs are doing something that is not acupuncture. They are doing acupuncture, they even use acupuncture needles for their Dry Needling, and not hypodermic needles, since they are not allowed to perform injections. The reason why what PTs end up doing is called Dry Needling and not Trigger Point Acupuncture is legal and political. First, to differentiate themselves, and, second, because they are not licensed to do acupuncture. There are many different styles of acupuncture within China, let alone Japan, Korea, Vietnam, and the rest of the world where acupuncture has spread in the last 50 years or more. There are lots of acupuncturists who do not do Trigger Point dry needling, even remotely. The Balance method of Richard Tan, for example, relies on needling of distal points that are nowhere near the source of the pain, and without going anywhere near trigger points. Most acupuncturists do not study trigger points either, and practice all kinds of techniques that involve very very light needling in which the needle makes it just barely past the skin.
When I treat chronic and acute pain with or without trigger points (although its really rare to find any chronic or acute pain condition without trigger points, unless its purely neurological) in my San Diego acupuncture practice, unless there is a specific request to do very light acupuncture, or Japanese style acupuncture, which I also do, I myself do Dry Needling based on the Trigger Points and Motor Points, but I also often combine Dry Needling, or Trigger Point Acupuncture with Myofascial Acupuncture in which I may needle the origin and insertions of the muscles and tendons, or the facscial layer, or into the tendons. I also pay attention to the Acupuncture Channels as described in Chinese Acupuncture theory, for example that supply the Qi and Blood to the painful area. For example if needling trigger points in the back for a herniated disc, I will usually needle the “opening and closing points” of the “Governing vessel” which has the effect of relaxing all the ligaments and small muscles that act on the spine. This gives an even faster and deeper result than just needling the trigger points, and its one of the reasons why Dry Needling plus Acupuncture is better than Dry Needling alone. Which is not to say that a P.T. might offer other things I dont, such as ultrasound….There are many different ways to treat. I like to add electrical stimulation, deep heat, and cupping to difficult cases to help the Dry Needles do their job.
Lets talk a little more about pain relief with Dry Needling and “Trigger Point” or “Myo-fascial” acupuncture. I prefer the latter nomenclature, as the technique I have developed over the past twenty years in my San Diego acupuncture practice is not limited to the deactivation of trigger points, but includes stimulation of motor points, needling into fascia, tendons, ligaments, and even just below the skin or the skin itself. It also involves the use of Chinese style “cupping”, that I have modified with the use of a warm sliding technique using Ayuredic herbal oils like Mahanarayan oil, electrical stimulation, and application of counter-irritants (like Tiger Balm or Ben Gay, but what I use is Dr. Shih”s linement ), all of which combine to provide powerful relief from pain.
However, the practice of trigger point acupuncture requires a knowledge of western anatomy, as well as the precise location and referral pattern of the trigger points found in the various muscles, tendons, ligaments, joint capsules, periosteum, and even skin of the body. Trigger points occur often in the thick portion of muscle bellies, particularly in the region of the motor point, but are also found in their origin and insertion. Its the careful palpation of the skin, muscles, tendons and ligaments that enables the acupuncturist to identify their location and do very precise acupuncture needling.
Cause of Myofascial Trigger Points
Trigger points can form in weak, overused muscles, such as occurs in repetitive stress injuries in keyboard use. But they can also occur in very strong, but overused muscles, such as occurs in runners who rest inadequately, or other athletes. I recently deactivated the forearm and wrist trigger points in a patient that routinely does 1000 pushups at a stretch.
Trigger points may also occur in trauma from direct injury, such as a blow or sprain, as in the patient with sudden onset shoulder pain after being pulled suddenly and unexpectedly by her 110 pound dog Many of us are familiar with the “tension” lumps found in both the shoulders and low back, properly called “fibrositic nodules.” These nodules also contain trigger points.
Effect of Trigger Points
The problem of trigger points is not just that they are at the source of much myofascial pain; but that a muscle containing active trigger points undergoes shortening, and becomes weaker and less capable of the task at hand. This can then lead to a cascade of compensatory biomechanics, that further increase pain within the affected and allied muscles.
Diseases/Pain Conditions that Benefit from Trigger Point Acupuncture
Over the past 24 years doing Dry Needling and Trigger Point Acupuncture here in my San Diego acupuncture clinic, and even before, starting with my internship at Pacific College of Oriental Medicine, and continuing with my further advanced studies with Matt Callison, Greg Berkoff, D.C., and others, I have been amazed at the wide variety of conditions that benefit from Dry Needling and Trigger Point or Myofasical style acupuncture. Here is a brief list
Back Pain due to Herniated Disc, Sprain of Strain
Should Pain from Throwing
Golfer’s Elbow, Tennis Elbo
Tension Headache, Migraine
Tight Shoulder from Stress and Overuse
Role of Stress
I have observed a link between the presence of pervasive, active trigger points and the presence of shortened tight muscles, a bowstring pulse, and high levels of stress responses. We know, scientifically, that constant and poorly managed stress places us in the “fight or flight” response that elevates our stress hormones like cortisol. My informal theory is that this mechanism imitates an overuse syndrome in that our muscles are held as if ready to run or fight. This is work, and places our muscles into anaerobic sources of respiration and concomitant lactic acid burn. This creates various chemical cascades that may contribute to both inflammation and the formation of active trigger points.
Treatment of Trigger Points and Stress with Acupuncture
One of the great things about acupuncture of any kind is that is places you into the relaxation response, similar to what is achieved by meditation. Acupuncture reduces our body’s biochemical responses to stress, lowers blood pressure and reduces inflammation and pain.In terms of hormones and neurotransmitters it does this by increasing the secretion of our body’s natural opiates, endorphins; and by increasing secretion of natural cortisone-like anti-inflammation drugs in the adrenal glands.
Myofascial trigger point acupuncture goes one step further. In addition to being profoundly relaxing, as above, when you relieve trigger points, especially the ones in the muscle belly associated with motor points, the muscle responds by actually lengthening; this has a decompressing effect on joints, tendons, and tendon sheaths. It is not unusual after a myofascial acupuncture treatment for the affected joints to “release” as after a chiropractic adjustment, gently, naturally, and safely. This is generally followed by an immediate relief in pain. Nothing releases a tight muscle and trigger points like a carefully placed acupuncture needle. Generally the patient feels an immediate effect while still on the table.
It is also typical that after acupuncture treatment to feel extremely refreshed, as if after a deep sleep. One will often sleep profoundly well the night of a treatment, which has enormous restorative value.I have found myo-fascial acupuncture, along with herbal medicine, stretching, therapeutic exercises such as Function First or Egoscue, massage, exercise, and progressive relaxation practices such as body scanning and mindfulness extremely effective in the treatment of even the most difficult cases of myofascial pain, frozen shoulder, and migraine.
Copyright Eyton J. Shalom, M.S., L.Ac. San Diego, CA October 2013
All Rights Reserved, Use With Permission
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