Constantly injured? Get a needle in you!

By Kylie Takarangi APA Titled Sports Physiotherapist, Masters Sports Physiotherapy

PG Sports Physio, BPHTY, BSC, APAM

As a middle aged bloke who rediscovered his love for all things sports, I did forget that with exercise, can come injuries. And when you hit a certain age, not only can injuries be more common they can also linger and without proper treatment, cause a genuine halt to any progress you're trying to make.

In my case, a persistent neck and shoulder injury, followed by some lower back pain was leading me to restricted movement, a fair amount of pain and inconsistent training.

Thanks to Kylie Takarangi I was introduced to the wonders of dry needling. His what Kylie had to say.

What is it?

Trigger point dry needing (DN) involves a fine needle or acupuncture needle insertion into the skin and muscle where a specific myofascial trigger point (MTrP) is identified. Myofascial trigger point is a sensitive and possibly irritable taut band palpable in the skeletal muscle. DN can be used as an adjunct to manual therapy techniques.

Is it the same as acupuncture? What are the differences?

DN focused on identifying abnormal or sensitised muscle tissue through palpation, pain and range of motion deficits. Acupuncture in the tradition sense is reliant on meridians and status of chi rather than pain provocation or changes to mobility.

How does dry needling work?

Dry-needling, via insertion to these myofascial trigger points via mechanical stimulation or local twitch response, causes an analgesic effect through changing the messages at the spinal cord reflex level. Therefore, changing the pain message and response to the brain. [1] [2]

A Possible theory of DN’s role in influencing the nervous system is the ‘Gate control theory of pain’ [3]. DN alters the autonomic nervous system function to change the pain response through central nervous system (CNS). Pain is a centrally (CNS) modulated response due to trauma of tissue, overload of tissue or changes in the body’s periphery.

This process will lead to movement restriction. It is thought that needling instigates an alteration in the peripheral segments nervous system function [6]. Sensory input (e.g. low back pain) is inhibited in the CNS by another type of input (needling). Points are chosen close to the injured body part with the intention of inducing a strong segmental pain inhibitory effect [6]. Needles stimulate a change in the skeletal muscle tissue and effect the range of motion (ROM), aiming to restore normal movements. Changes to a person’s ROM indicate improved tissue physiology and are likely to result in central pain response [6].

Therefore, if we can change movement patterns, we can change pain.

Why is it said to be so good for you? And when is it best used in therapy?

Presentation of acute spontaneous pain/tenderness in the upper shoulder/trapezius area is a common presentation in clinic. Patients often describe a tight feeling in the shoulders unilateral or bilateral, often with referral to the neck or referral to the shoulder.

It can be related to postural dysfunctions e.g. office work resulting in increased muscle tone, or an acute injury such as ‘wrye neck’ where patients experience sudden onset of pain in the upper trapezius.

A palpable taut band of muscle is often felt with associated pain, reduced ROM in the cervical spine, pain on functional activities such as rotation of the neck and prolonged sitting.Dry needling may be an appropriate management technique in a number of clinical situations such as these to reduce pain, restore ROM and improve function.

How do I know if it's working for me? What are the signs it is beneficial to me?

The effectiveness of this treatment depends greatly on the skill of the therapist to accurately palpate myofascial trigger points as well as kinaesthetic awareness of the anatomical structures.

Indication to use dry needling by a practitioner

• Clinical presentation examined by the clinician

• Identification of myofascial trigger points in the muscle through palpation

• Deep dry needling reproduces the patient's pattern of pain

• Identification of the tight muscle band in the form of palpation

• Client recognition of pain with palpation

• Loss of ROM

It is suggested that dry-needling reduces/removes nociceptive (painful) input from trigger points, normalising synaptic efficacy and reduce peripheral and central sensitization.

Dry-needling can restore muscle activation and strength as well as ROM.

Are there any risks or side effects to dry needling?

DN therapy should be avoided in patients under the following circumstances [4] [5]

• In a patient with needle phobia.

• Patient is unwilling, fear, patient belief.

• Unable to give consent - communication, cognitive, age-related factors.

• Medical emergency or acute medical condition.

• Over an area or limb with lymphedema as this may increase the risk of infection/cellulitis and the difficulty of fighting the infection if one should occur.

• Inappropriate for any other reason.

What's the research behind it?

Dry needling is a useful tool and adjunct to other treatment modalities for acute myofascial pain syndrome and Lower back pain (LBP). Evidence has shown treatment to be more effective than sham needling in reducing pain intensity and improving quality of life. There is no evidence to suggest it does harm or has no effect at all. Higher quality RCTs are required with increased sample size and longer term follow-up.

A Cochrane review (2005) of Randomised controlled trials (RCTs) concluded that trigger point dry needling may be beneficial for low back pain when used in combination with other treatments. However further higher quality studies are needed to confirm this [3].

A systematic review and meta-analysis with level 1a evidence suggests that: [3]

• Very low–quality to moderate quality evidence suggests that dry needling performed by physiotherapists is more effective than no treatment, sham dry needling, and other treatment modalities for reducing pain and improving pain threshold in patients presenting with musculoskeletal pain in the immediate to 12-week follow-up period.

• Low-quality evidence suggests superior outcomes with dry needling for functional outcomes when compared to no treatment or sham needling.

• No difference in functional outcomes exists when compared to other physiotherapy treatments.

• Evidence of long-term benefit of dry needling is currently lacking.

Evidence supporting the use of DN for patients with MFS was shown in a recent double-blinded RCT [7]. This RCT randomly assigned 39 patients with MFS to either DN (treatment group) or Sham needling (control group). Patients were treated in six sessions over four weeks, and did not perform any other exercises or receive other forms of treatment within this time period. Pain and quality of life was assessed using the VAS (pain) analogue scale and the Short Form-36 (SF-36) respectively. Patients treated with DN reported significantly (p<0.001) lower VAS scores and significant increase in the quality of life scores (SF-36) both from treatment to treatment, and compared to patients who received sham needling.

Should you combine dry-needling with any other type of therapy?

Clinically DN is effective for patients who present with MFS, loss of ROM and function. When there is an obvious palpable painful taut band of skeletal muscle. This combine with other treatment modalities including soft tissue massage, mobility exercises, postural correction and strength rehabilitation exercises will offer a good long term outcome.

Who do you turn to for dry needling?

DN could be considered when there is an active palpable pain producing muscle trigger point that is identified by the clinician and matched through the patient’s pain response and symptoms. Those that have a reduction in ROM, function and experiencing pain could discuss with their clinician if DN is the right form of treatment for them.

Get back to healthy living.

1 Chen JT, Chung KC, Hou CR, Kuan TS, Chen SM, Hong CZ. Inhibitory effect of dry needling on the spontaneous electrical activity recorded from myofascial trigger spots of rabbit skeletal muscle. Am J Phys Med Rehabil 2001; 80: 729–35.

2 Ga H, Choi JH, Park CH, Yoon HJ. Dry needling of trigger points with and without paraspinal needling in myofascial pain syndromes in elderly patients. J Altern Complement Med. 2007; 13: 617– 624.

3 Furlan A D., Van Tulder M W., Tsukayama H., Lao L., Koes B W., Berman B M. (2005). Acupuncture and dry needling for low back pain (Review). Cochrane Database of Systematic Reviews (1) 1-19.

DOI: 10.1002/14651858.CD001351.pub2

4 Australian Society of Acupuncture Physioterapists Inc. Guidelines for safe acupuncture and dry needling practice, 2007.

5 White, A., Cummings M., Filshie, J. Evidence of safety of acupuncture. An introduction to Western medical acupuncture. Edinburgh: Churchill Livingstone, 2008.

6 Bradnam L. (2003). A proposed clinical reasoning model for western acupuncture. NZ Journal of Physiotherapy 31(1):40-45.

7 Tekin L., Akarsu S., Durmus O., Cakar E., Dincer U & Kiralp M Z. (2013). The effect of dry needling in the treatment of myofascial pain syndrome: a randomized double-blinded placebo-controlled trial. Clinical Rheumatology. 32(3):309-315;. UI: 23138883