My previous post generated some discussion, and a lot of questions.
What is dry needling?
Am I a candidate? How can it help me?
How many needles? How often? How long does it last?
Can I work out afterwards?
Does it hurt?
If you're short on time watch this quick 2-3 minute video...
If you're on the cerebral side and like to know the science behind everything. The how, and why, then keep reading...
What is dry needling?
Dry needling is a technique physical therapists use is in select states whose practice acts permits for the treatment of trigger points that result in pain and movement impairments caused by trigger points. Trigger points are "needled" with a solid, filament, dry needle with the goal of releasing or inactivating trigger points to relieve pain, improve range of motion, and normalize dysfunctions of the motor end plates, which helps speed up the patient's return to active rehabilitation.
What is a trigger point?
A trigger point is a rope-like bands within a muscle muscle within a muscle. They're the sensitive knots you feel in your shoulders, or that spot the massage therapist finds in your quad that makes you want to cry. We all have trigger points. Some are latent, and sleeping, others are active and cause pain, and movement dysfunction. Think about tying a knot in a shoe lace. The overall length of the shoe lace shortens. Muscles all work on a length-tension relationship. You're muscle needs to be able to stretch so far in order for the joint to work properly. You're body is smart, however, if you're lacking mobility then its going to compensate and find that mobility elsewhere. You'll get away with compensation patterns for a while, until an injury creeps up on you. But I stretch and foam roll. Im good. But are you? Think about tying a knot in a shoe lace. The overall length of the shoe lace shortens. Stretching it only makes the knot tighter, and foam roller, and massage only gets you so far.Stretching it only makes the knot tighter, and foam roller, and massage only gets you so far.
Latent vs Active Trigger points
Latent trigger points might limit mobility, but are not actively painful or sensitive to touch. Latent trigger points can turn active if there's an injury, or overuse of the muscle group. For example, an accident where an individual sustained whiplash may trigger intense shoulder + neck pain, and headaches. Running hills on vacation in Colorado when you're usually training in flatlands of Ohio can traumatize the quads, and glutes. Active trigger points can be tender to the touch, and touching a trigger point may cause pain to other parts of the body. This is called referred pain. If you've ever sprained a hamstring, or had a made case of hamstring tendonitis/osis then you know a muscle is fully capable of referring pain all the way down the leg mimicking good ol' sciatica, a bulging disc, or a pinched nerve in the back. If the active trigger point causes problems for long enough the issue can turn into a chronic problem called myofascial pain syndrome. This term has replaced the term fibromyalgia and chronic pain. When a patient hears these words its a death sentence and they lose all hope, and I'll be honest as a clinician hearing the patient recall a diagnosis of fibromyalgia its likely going to be an uphill battle. Theres hope to rewrite the script, teach people how to manage, and regain control over chronic pain with the new terminology.
Here’s a good 1-minute primer on fibromyalgia from One-Minute Medical School:
Moral of the story, A) don't ignore aches and pains. Its usually much more difficult and takes months if not years longer for a therapist to help, and B) if you've been diagnosed with myofascial pain syndrome, fibromyalgia, or chronic pain ask me, or the therapist you are consulting with, how dry needling can help!
Why and How does a trigger point form?
Good question. This is something we're still trying to figure out.
Trigger points are thought to develop especially following unaccustomed eccentric and concentric loading, but also occur after low-load repetitive tasks and sustained postures, with respiratory stress, such as over-breathing. Once active trigger points exist, there will be a constant nociceptive input into the brain and spinal cord which can result in dysfunctional, altered motor control strategies, lead to further muscle overload or even disuse, and result in the development of peripheral and central sensitization aka chronic pain and referred pain.
Before I continue the explanation, lets revisit a human anatomy and physiology 101:
Muscles are made up of fibers called sarcomeres. Sarcomeres are the smallest structure of a muscle. Sarcomeres are small ribbon like pieces of tissue that when strung together make up a muscle. Think of what it looks like when you cut into a steak, or chicken breast, that is a muscle you are eating. Millions of sarcomeres make up a myofibril. Hundreds of thousands of myofibrils make up a myofiber. Thousands of myofibers make up a fasicle, and hundreds of fasicles make up a muscle.
Muscle fibers, or myofibers, have receptors that correspond to nerves called motor units. A nerve release chemicals at the motor unit based on electric charge running through the body that triggers the muscle to contract. The force of a muscle contraction is controlled by the number of activated motor units. The number of muscle fibers within each unit can vary within a muscle and between muscle to muscle. Larger muscles have a greater number of motor units and contain more muscle fibers, whereas smaller muscles contain fewer muscle fibers in each motor unit. For example, thigh muscles can have a thousand fibers in each unit, while eye muscles (yes, your eyes have muscles) might have ten. Muscles that have more motor units are able to generate more force, and control force output more finely by activating on a percentage of its motor units. Its how the body figures out how to jump up to a 6inch step or a 24inch box, pick up a 5lb or a 25lb dumbbell. A trigger point usually forms within the fasicles of the muscle. A well trained therapist can easily palpate the taut bands.
Simons, Gerwin et al. and by McPartland suggest trigger points are a result of excessive release of acetylcholine at the motor endplate, combined with an inhibition of acetylcholine esterase which is responsible for absorbing acetylcholine when we want the muscle to stop contracting. Sustained contraction of taut bands cause ischemia and hypoxia in the core of trigger points. Basically cutting off blood supply to the muscle tissue and resulting in tissue trauma or death. Muscle contraction results in muscle shortening and causes stretch within the muscle. Stretch happens to be a reflex trigger for muscle to release of acetylcholine at the motor endplate, the chemical that initiates a muscle contraction which results in prolonged, and more vigorous contraction. Its a self-sustaining vicious cycle.
Why does a trigger point cause pain?
The low oxygen levels due to decreased blood supply lead to a significant drop in pH and acidic environment. In active trigger points, the pH may be well below 5, which is more than sufficient to excite muscle nociceptors. Nociceptors are nerves that sense pain.
The release of several nociceptive substances, such as calcitonin gene-related peptide (CGRP), adenosine triphosphate (ATP), bradykinin (BK), serotonin (5-HT), prostaglandins (PGs), potassium, and protons. A low pH activates acid sensing ion channels (ASICs) and transient receptor potential vanilloid (TRPV) receptors, which in turn contribute to pain with palpation of the trigger point, and eventually referred pain and central sensitization.
How does pain become chronic or referred?
A muscle is fed from nerves that stem from the brain and spinal cord. Nerves are the information highway between the brain and muscles. The nociceptors sense pain and send a message back up through the nerves that feed the muscle, to the spinal cord, and up to the brain saying something is wrong. The brain responds to the signal and sends out the emergency squad.
Did you know that each vertebrae in your back has two nerves that exit from on each side of each bone. These nerve form a big rope through the neck and armpit that divide through the arm and feed very select muscle groups, likewise in the hip and down the leg. Each muscle can be traced back through a single nerve. Sometimes muscle groups can share nerves as their roots and trunks branch into divisions much like a tree. This is how and why a physical therapist therapist can accurately pinpoint the exact disc and nerve that is aggravated given your pain pattern and muscle presentation without the expensive tests of MRI and Xrays. This is also how pain become widespread, "referred." After the brain receives the information of pain. It sends the EMS back through the nerve, as well as the nerve associated with the segments above and below. This is because of the crosstalk between nerves and muscles. Muscle and nerve cross talk can occur 3-5 segments above and below the actual source of pain! To give you perspective the neck only has 7 vertebrae, and the back 5, so thats pretty significant.
If the body is high alert for a prolonged period, then it starts losing its ability to tell whats a minor vs a major problem. Its much better to mistake a minor problem for a major, then mistake a major problem for a minor. As a result the body responds to everything likes its a major problem. Did I lose you? Think about your email inbox. It automatically sorts spam from everything thats important, and more recently it's learned to sort into primary, social, promotions, updates etc. Imagine if your email thought everything was important and had to go to your primary inbox! We'd quickly get overwhelmed, have a huge headache, and not even know where to begin or how to start replying. Pain threshholds are lowered. Everything becomes painful, even perceives stimuli that should not be painful as pain. These terms are called "hypersensitivity" and "allodynia" and indications that the problem is know mapped in the brain, and a chronic issue, aka central sensitization.
Central sensitization has been described in association with many chronic pain syndromes, such as endometriosis, low back pain, irritable bowel syndrome, surgical pain, whiplash, shoulder impingement, and fibromyalgia. Sensitization is not specific for myofascial trigger points. Trigger points are, however, involved in nearly every pain syndrome and it is likely that central sensitization involves trigger points, as has been shown for whiplash, tension-type headaches, chronic primary headaches, lateral epicondylalgia, breast cancer surgery, fibromyalgia, and temporomandibular disorders among others.
How does needling release trigger points and relieve pain?
Dry Needling acts locally and globally. For Example, when a needle is introduced into a trigger point eliciting a local twitch response and a cascade of reactions due to release of cytokines, substance P and CGRP (Calcitonin Gene Related Peptide) resulting in vasodilation, increased blood vessel formation, and increased tissue repair. In addition, a Beta Endorphin release from the brain creating an analgesic pain relieving affect and segmentally, at the spinal level, enkephalin release enhances the systemic pain relief. Enkephalin are known as endogenous ligands, as they are internally derived and bind to the body's opioid receptors which is why dry needling is being trialed in the fight on opioid medications. More on that in a later blog post...
Does the trigger point go away? How often does it need to be performed?
The knot may not "go away," but the sensitivity should be reduced, and the movement impairments resolved. The individual should be able to participate in exercises with greater ease, less pain and improved range of motion. The frequency of needling depends on the body part, how long the dysfunction and pain have been problematic, and how compliant the individual is with performing prescribed corrective exercises. Generally, 10-15 minutes per muscle group/region is sufficient, every 7-10days for 4-6 weeks. On average, my patients have 3-5, sessions with dry needling.
Whats the difference between acupuncture?
My knowledge of acupuncture is limited. My education did not include Eastern Traditional Chinese Medicine. What I do know, is that both dry needling and acupuncture involve the insertion of thin needles, solid, monofilament needles into certain parts of the body, but the similarities stop there. During an acupuncture session needles are inserted into points along meridian lines, or ashi points. These lines and points represent the body’s organs, and flow of energy based on ancient Chinese medicine. Acupuncture is based on the idea of balance and restoring proper flow of energy throughout the body. For exampled, a needle might be inserted in the lower leg to affect headaches. Dry needling is rooted in Western Medicine and supported by sound, scientific evidence. Only muscles around the dynfunctional joint or region are treated. For example to address headaches, the muscles in the head, neck, and shoulders are treated with dry needling. Additionally, dry Needling is rarely a stand-alone procedure. Manual soft tissue mobilization, therapeutic exercise, neuromuscular reeducation, and functional retraining is performed in combination with the interventions.
Does Dry Needling Hurt?
Yes. It hurts. Im not going to lie to you, but its not as bad as you think. Its a bizarre sensation. Its more unnerving than painful because you dont know when or where you're going to feel the "muscle jump."
You usually don't feel the insertion of the needle, only when the trigger point is penetrated resulting in a local twitch response that patients describe as a "msucle jump." If you've ever had PT after a knee surgery its very similar to the sensation produced during Russian stimulation using neuromuscular electrical stimulation modality. After dry needling you feel as if you've completed an intense workout and experiencing delayed onset muscle soreness. You might have a small bruise if you bruise easily, but usually you just feel bruised. Some body regions are more painful than others. For example, the larger the muscle the greater the twitch. The deeper the muscle the more it feels like a cramping, dull aching, vs a muscle jump. Soreness is more annoying than painful, and effects daily life depending on the body part of daily tasks. The calf, for example, is a difficult area to rest after treatment because we use the calf to walk! Its usually the most sensitive, but the most effective! I cant say enough about dry needling efficacy for achilles tendonitis and plantar fasciitis!
What else does dry needling help with?
Pinched nerves and bulging discs in the neck and back
Hip and Gluteal Pain
Knee Pain: runners knee, jumpers knee, knee osteoarthritis
Muscular Strains/Ligament Sprains
Muscle is an orphan organ. Muscle tissue is the largest organ in the body, complex and vulnerable to dysfunction, and the primary target of the wear and tear of daily activities, nevertheless it is the bones, joints, bursa and nerves on which physicians usually concentrate their attention. I cant tell you how many athletes have been sidelined second to injury, or undergone invasive injections and/or surgeries before trying conservative interventions like dry needling. Additionally, a handful of these individuals return to activity, and realize the same pain is still present because the joint, nerve, or bursa was treated and not the muscle! No medical speciality claims it muscle, and not many people know that a physical therapist is the musculoskeletal provider of choice with direct access, meaning you can see a PT (in select states) without a prescription from a medical doctor.
If you think that dry needling can help you, or have additional questions or concerns, then please reach out to Dr. Erika Patterson ,call 614.887.7755, to learn more or schedule and appointment.
Dr. Erika Patterson, PT, DPT, OCS
Dr. Patterson is a Doctor of Physical Therapy, APTA board certified Orthopedic Clinical Specialist,
with advanced certifications in manual therapy, dry needling, RPR, and specializes in Endurance & Multi-Sport Athletes.