Needling therapy for myofascial pain: recommended technique with multiple rapid needle insertion

Li-Wei Chou, Yueh-Ling Hsieh, Ta-Shen Kuan, Chang-Zern Hong, Li-Wei Chou, Yueh-Ling Hsieh, Ta-Shen Kuan, Chang-Zern Hong

Abstract

Myofascial trigger point (MTrP) is a major cause of muscle pain, characterized with a hyperirritable spot due to accumulation of sensitized nociceptors in skeletal muscle fibers. Many needling therapy techniques for MTrP inactivation exist. Based on prior human and animal studies, multiple insertions can almost completely eliminate the MTrP pain forthwith. It is an attempt to stimulate many sensitive loci (nociceptors) in the MTrP region to induce sharp pain, referred pain or local twitch response. Suggested mechanisms of needling analgesia include effects related to immune, hormonal or nervous system. Compared to slow-acting biochemical effects involving immune or hormonal system, neurological effects can act faster to provide immediate and complete pain relief. Most likely mechanism of multiple needle insertion therapy for MTrP inactivation is to encounter sensitive nociceptors with the high-pressure stimulation of a sharp needle tip to activate a descending pain inhibitory system. This technique is strongly recommended for myofasical pain therapy in order to resume patient's normal life rapidly, thus saving medical and social resources.

Keywords: Acupuncture; Analgesia; Mechanism; Myofascial trigger point; Needling.

Figures

Fig. 1
Fig. 1
Multiple MTrP loci in a myofascial trigger point region.
Fig. 2
Fig. 2
Connection of “myofascail trigger point circuit” (“MTrP circuit”) in the spinal cord.
Fig. 3
Fig. 3
Stimulation of a sensitive locus with needle tip during MTrP injection to elicit pain, referred pain or local twitch response.
Fig. 4
Fig. 4
Spontaneous electrical activity (SEA) including endplate noise (EPN) and endplate spike (EPS) can be frequently recorded in a MTrP region.
Fig. 5
Fig. 5
Contraction knot in the endplate zone of a taut band with shortening of sarcomeres, but relatively elongated sarcomeres outside the endplate zone, to increase tension of the taut band.
Fig. 6
Fig. 6
Simons’ integrated hypothesis of myofascial trigger point.
Fig. 7
Fig. 7
Hong’ rapid multiple needle insertion technique, including careful palpation of MTrP to direct the injection needle (A), and a special way of holding and controlling syringe with the palm firmly contact with patient’s body (B).

References

    1. Travell JG, Simons DG. Myofascial pain and dysfunction: The trigger point manual. Baltimore: Williams & Wilkins; 1983.
    1. Simons DG, Travell JG, Simons LS. Myofascial pain and dysfunction: the trigger point manual. 2. Baltimore: Williams & Wilkins; 1999.
    1. Kao MJ, Han TI, Kuan TS, Hsieh YL, Su BH, Hong CZ. Myofascial trigger points in early life. Arch Phys Med Rehabil. 2007;88:251–4. doi: 10.1016/j.apmr.2006.11.004.
    1. Han TI, Hong CZ, Kuo FC, Hsieh YL, Chou LW, Kao MJ. Mechanical pain sensitivity of deep tissues in children–possible development of myofascial trigger points in children. BMC Musculoskelet Disord. 2012;13:13. doi: 10.1186/1471-2474-13-13.
    1. Gerwin RD, Shannon S, Hong CZ, Hubbard D, Gevirtz R. Interrater reliability in myofascial trigger point examination. Pain. 1997;69:65–73. doi: 10.1016/S0304-3959(96)03248-4.
    1. Hong CZ. Myofascial pain therapy. Journal of Musculoskeletal Pain. 2004;12:37–43. doi: 10.1300/J094v12n03_06.
    1. Hong CZ, Simons DG. Pathophysiologic and electrophysiologic mechanisms of myofascial trigger points. Archives of Physical Medicine and Rehabilitation. 1998;79:863–72. doi: 10.1016/S0003-9993(98)90371-9.
    1. Hong CZ. Muscle pain syndrome. In Braddom: Physical Medicine and Rehabilitation, 4th ed Chapter 43 2011;971-1001, Elsevier, New York.
    1. Hong CZ. Myofascial trigger point injection. Critical Review of Physical and Rehabilitation Medicine 1993;5:203–17.
    1. Hong CZ. Considerations and recommendations regarding myofascial trigger point injection. Journal of Musculoskeletal Pain. 1994;2:29–59. doi: 10.1300/J094v02n01_03.
    1. Hong CZ. Research on myofascial pain syndrome. Critical Reviews in Physical and Rehabilitation Medicine 2008;20:343–66.
    1. Hong CZ. Persistence of local twitch response with loss of conduction to and from the spinal cord. Archives of Physical Medicine and Rehabilitation. 1994;75:12–16.
    1. Hong CZ. Treatment of myofascial pain syndrome. Current Pain and Headache Reports. 2006;10:345–49. doi: 10.1007/s11916-006-0058-3.
    1. Mense S, Simons DG. Muscle pain. Understanding its nature, diagnosis, and treatment. Philadelphia: Lippincott Williams and Wilkins; 2001.
    1. Simons DG, Hong CZ, Simons LS. Endplate potentials are common to midfiber myofacial trigger points. American Journal of Physical Medicine and Rehabilitation. 2002;81:212–22. doi: 10.1097/00002060-200203000-00010.
    1. Simons DG, Hong CZ, Simons LS. Prevalence of spontaneous electrical activity at trigger spots and at control sites in rabbit skeletal muscle. Journal of Musculoskeletal Pain. 1995;3:35–48. doi: 10.1300/J094v03n01_04.
    1. Simons DG. Diagnostic criteria of myofascial pain caused by trigger points. Journal of Musculoskeletal Pain. 1999;7:111–20. doi: 10.1300/J094v07n01_11.
    1. Simons DG. Do endplate noise and spikes arise from normal motor endplates? American Journal of Physical Medicine and Rehabilitation. 2001;80:134–40. doi: 10.1097/00002060-200102000-00012.
    1. Simons DG. Review of enigmatic MTrPs as a common cause of enigmatic musculoskeletal pain and dysfunction. J Electromyogr Kinesiol. 2004;14:95–107. doi: 10.1016/j.jelekin.2003.09.018.
    1. Simons DG. New aspects of myofascial trigger points: etiological and clinical. Journal of Musculoskeletal Pain. 2004;12:15–21. doi: 10.1300/J094v12n03_03.
    1. Simons DG., New Views of Myofascial Trigger Points Etiology and Diagnosis. Arch Phys Med Rehabil. 2008;89:157–59. doi: 10.1016/j.apmr.2007.11.016.
    1. Simons DG. Clinical and etiological update of myofascial pain from trigger points. Journal of Musculoskeletal Pain. 1996;4:93–121. doi: 10.1300/J094v04n01_07.
    1. Simons DG, Stolov WC. Microscopic features and transient contraction of palpable bands in canine muscle. American journal of physical medicine. 1976;55:65–88.
    1. Simons DG, Travell J. Myofascial trigger points, a possible explanation. Pain. 1981;10:106–9. doi: 10.1016/0304-3959(81)90053-1.
    1. Simons D, Travell J, Simons L. Myofascial pain and dysfunction: the trigger point manual. 2. Baltimore: Williams & Wilkins; 1999.
    1. Borg-Stein J, Simons DG. Myofascial pain. Archives of Physical Medicine and Rehabilitation 2002;83.
    1. Kostopoulos D, Rizopoulos K. The manual of trigger point and myofascial therapy. SLACK Incorporated, Thorofare, New Jersey 2001.
    1. Acquadro MA, Borodic GE. Treatment of myofascial pain with botulinum A toxin. Anesthesiology. 1994;80:705–6. doi: 10.1097/00000542-199403000-00041.
    1. Cheshire WP, Abashian SW, Mann JD. Botulinum toxin in the treatment of myofascial pain syndrome. Pain. 1994;59:65–9. doi: 10.1016/0304-3959(94)90048-5.
    1. Gobel H, Heinze A, Reichel G, Hefter H, Benecke R. Efficacy and safety of a single botulinum type A toxin complex treatment (Dysport) for the relief of upper back myofascial pain syndrome: results from a randomized double-blind placebo-controlled multicentre study. Pain. 2006;125:82–8. doi: 10.1016/j.pain.2006.05.001.
    1. Hong CZ. Lidocaine injection versus dry needling to myofascial trigger point: The importance of the local twitch response. American Journal of Physical Medicine and Rehabilitation. 1994;73:256–63. doi: 10.1097/00002060-199407000-00006.
    1. Fischer AA. New approaches in treatment of myofascial pain. Physical Medicine and Rehabilitation Clinics of North America. 1997;8:153–69.
    1. Melzack R, Stillwell DM, Fox EJ. Trigger points and acupuncture points for pain: Correlations and implications. Pain. 1977;3:3–23. doi: 10.1016/0304-3959(77)90032-X.
    1. Melzack R. Myofascial trigger points: Relation to acupuncture and mechanisms of pain. Archives of Physical Medicine and Rehabilitation. 1981;62:114–17.
    1. Dorsher PT, Fleckenstein J. Trigger Points and Classical Acupuncture Points: Part 1: Qualitative and Quantitative Anatomic Correspondences. Deutsche Zeitschrift f¸r Akupunktur 2008;51:15–24.
    1. Lin JG, Chen WL. Acupuncture analgesia: a review of its mechanisms of actions. Am J Chin Med. 2008;36:635–45. doi: 10.1142/S0192415X08006107.
    1. Lin JG, Chen WL. Review: Acupuncture analgesia in clinical trials. Am J Chin Med. 2009;37:1–18. doi: 10.1142/S0192415X09006679.
    1. Cheng X. Chinese Acupuncture and Moxibustion, Beijing: Foreign languages press. 1987356.
    1. Ellis A, Wiseman N, Boss K. Fundamentals of Chinese Acupuncture, Revised Edition. Paradigm Publications,. Brookline Massachusetts 1991.
    1. Chou LW, Hong JY, Hong CZ. A new technique for acupuncture therapy and its effectiveness in treating fibromyalgia syndrome: a case report. Journal of Musculoskeletal Pain. 2008;16:193–98. doi: 10.1080/10582450802161978.
    1. Chou LW, Hsieh YL, Kao MJ, Hong CZ. Remote influences of acupuncture on the pain intensity and the amplitude changes of endplate noise in the myofascial trigger point of the upper trapezius muscle. Arch Phys Med Rehabil. 2009;90:905–12. doi: 10.1016/j.apmr.2008.12.020.
    1. Chu J. Dry needling (intramuscular stimulation) in myofascial pain related to lumbosacral radiculopathy. European Journal of Physical Medicine and Rehabilitation. 1995;5:106–21.
    1. Chu J. Does EMG (dry needling) reduce myofascial pain symptoms due to cervical nerve root irritation? Electromyogr Clin Neurophysiol. 1997;37:259–72.
    1. Chu J., Twitch-obtaining intramuscular stimulation Observations in the management of radiculopathic chronic low back pain. Journal. 1999;7:131–46.
    1. Gunn CC, Milbrandt WE, Little AS, Mason KE. Dry needling of muscle motor points for chronic low-back pain: a randomized clinical trial with long-term follow-up. Spine (Phila Pa 1976) 1980;5:279–91.
    1. Lewit K. The needle effect in the relief of myofascial pain. Pain. 1979;6:83–90. doi: 10.1016/0304-3959(79)90142-8.
    1. Chou LW, Hsieh YL, Chen HS, Hong CZ, Kao MJ, Han TI. Remote therapeutic effectiveness of acupuncture in treating myofascial trigger point of the upper trapezius muscle. Am J Phys Med Rehabil. 2011;90:1036–49. doi: 10.1097/PHM.0b013e3182328875.
    1. Chu J, Neuhauser DV, Schwartz I, Aye HH. The efficacy of automated/electrical twitch obtaining intramuscular stimulation (atoims/etoims) for chronic pain control: evaluation with statistical process control methods. Electromyogr Clin Neurophysiol. 2002;42:393–401.
    1. Chu J, Yuen K, Wang B, Chan R, Schwartz I, Neuhauser D. Electrical twitch-obtaining intramuscular stimulation in lower back pain: a pilot study. American Journal of Physical Medicine and Rehabilitation. 2004;83:104–11. doi: 10.1097/01.PHM.0000107485.86594.8B.
    1. Aranha MF, Alves MC, Berzin F, Gaviao MB. Efficacy of electroacupuncture for myofascial pain in the upper trapezius muscle: a case series. Rev Bras Fisioter. 2011;15:371–9. doi: 10.1590/S1413-35552011005000022.
    1. Baldry P. Superficial dry needling at myofascial trigger point sites. Journal of Musculoskeletal Pain. 1995;3:117–26. doi: 10.1300/J094v03n03_10.
    1. Baldry P. Superficial dry needling. In: Fibromyalgia syndrome: a practitioner’s guide to treatment CL Chaitow (Ed) Churchill Livingston, Edinburgh 2000.
    1. Goddard G, Karibe H, McNeill C, Villafuerte E. Acupuncture and sham acupuncture reduce muscle pain in myofascial pain patients. J Orofac Pain. 2002;16:71–6.
    1. Fu ZH, Xu JG. A brief introduction to Fu’s subcutaneous needling. The Pain Clinic. 2005;17:343–48. doi: 10.1163/1568569054729599.
    1. Fu ZH, Chen XY, Lu LJ, Lin J, Xu JG. Immediate effect of Fu’s subcutaneous needling for low back pain. Chin Med J (Engl) 2006;119:953–6.
    1. Fu ZH, Wang JH, Sun JH, Chen XY, Xu JG. Fu's subcutaneous needling: possible clinical evidence of the subcutaneous connective tissue in acupuncture. J Altern Complement Med. 2007;13:47–51. doi: 10.1089/acm.2006.6125.
    1. Fu ZH, Hsieh YL, Hong CZ, Kao MJ, Lin JG, Chou LW. Remote subcutaneous needling to suppress the irritability of myofascial trigger spots: an experimental study in rabbits. Evidence-Based Complementary and Alternative Medicine 2012;Article ID 353916:8 pages.
    1. Kalichman L, Vulfsons S. Dry needling in the management of musculoskeletal pain. J Am Board Fam Med. 2010;23:640–6. doi: 10.3122/jabfm.2010.05.090296.
    1. Travell J, Bobb AL. Mechanism of relief of pain in sprains by local injection technics. Fed Proc. 1947;6:37–8.
    1. Hsieh YL, Chou LW, Joe YS, Hong CZ. Spinal cord mechanism involving the remote effects of dry needling on the irritability of myofascial trigger spots in rabbit skeletal muscle. Arch Phys Med Rehabil. 2011;92:1098–105. doi: 10.1016/j.apmr.2010.11.018.
    1. Hsieh YL, Yang SA, Yang CC, Chou LW. Dry needling at myofascial trigger spots of rabbit skeletal muscles modulates the biochemicals associated with pain, inflammation, and hypoxia. Evidence-Based Complementary and Alternative Medicine 2012;Article ID 342165:12 pages.
    1. Chou LW, Kao MJ, Lin JG. Probable mechanisms of needling therapies for myofascial pain control. Evidence-Based Complementary and Alternative Medicine 2012;Article ID 705327:11 pages.
    1. Unschuld PU. Huang Di nei jing su wen : Nature, knowledge, imagery in an ancient Chinese Medical Text. University of California Press, Ltd London, England 2003.
    1. Unschuld PU, Tessenow H, Jinsheng Z. Huang Di nei jing su wen : An annotated translation of Huang Di’s Inner Classic - Basic questions. 1. England: University of California Press; 2011.
    1. Pomeranz B, Chiu D. Naloxone blockade of acupuncture analgesia: endorphin implicated. Life Sci. 1976;19:1757–62. doi: 10.1016/0024-3205(76)90084-9.
    1. Pomeranz B, Cheng R, Law P. Acupuncture reduces electrophysiological and behavioral responses to noxious stimuli: pituitary is implicated. Exp Neurol. 1977;54:172–8. doi: 10.1016/0014-4886(77)90243-6.
    1. Clement-Jones V, McLoughlin L, Tomlin S, Besser GM, Rees LH, Wen HL. Increased beta-endorphin but not met-enkephalin levels in human cerebrospinal fluid after acupuncture for recurrent pain. Lancet. 1980;2:946–9. doi: 10.1016/S0140-6736(80)92106-6.
    1. Han JS, Xie GX, Zhou ZF, Folkesson R, Terenius L. Enkephalin and beta-endorphin as mediators of electro-acupuncture analgesia in rabbits: an antiserum microinjection study. Adv Biochem Psychopharmacol. 1982;33:369–77.
    1. Mendelson G. The possible role of enkephalin in the mechanism of acupuncture analgesia in man. Med Hypotheses. 1977;3:144–5. doi: 10.1016/0306-9877(77)90062-7.
    1. Han Z, Jiang YH, Wan Y, Wang Y, Chang JK, Han JS. Endomorphin-1 mediates 2 Hz but not 100 Hz electroacupuncture analgesia in the rat. Neurosci Lett. 1999;274:75–8. doi: 10.1016/S0304-3940(99)00670-9.
    1. Acupuncture Han JS. neuropeptide release produced by electrical stimulation of different frequencies. Trends Neurosci. 2003;26:17–22. doi: 10.1016/S0166-2236(02)00006-1.
    1. Cheng RS, Pomeranz B. Electroacupuncture analgesia could be mediated by at least two pain-relieving mechanisms; endorphin and non-endorphin systems. Life Sci. 1979;25:1957–62. doi: 10.1016/0024-3205(79)90598-8.
    1. Chen XH, Han JS. Analgesia induced by electroacupuncture of different frequencies is mediated by different types of opioid receptors: another cross-tolerance study. Behav Brain Res. 1992;47:143–9. doi: 10.1016/S0166-4328(05)80120-2.
    1. Lao L, Zhang RX, Zhang G, Wang X, Berman BM, Ren K. A parametric study of electroacupuncture on persistent hyperalgesia and Fos protein expression in rats. Brain Res. 2004;1020:18–29. doi: 10.1016/j.brainres.2004.01.092.
    1. Stein C. The control of pain in peripheral tissue by opioids. N Engl J Med. 1995;332:1685–90. doi: 10.1056/NEJM199506223322506.
    1. Sekido R, Ishimaru K, Sakita M. Differences of electroacupuncture-induced analgesic effect in normal and inflammatory conditions in rats. Am J Chin Med. 2003;31:955–65. doi: 10.1142/S0192415X03001491.
    1. Huang C, Hu ZP, Long H, Shi YS, Han JS, Wan Y. Attenuation of mechanical but not thermal hyperalgesia by electroacupuncture with the involvement of opioids in rat model of chronic inflammatory pain. Brain Research Bulletin. 2004;63:99–103. doi: 10.1016/j.brainresbull.2004.01.006.
    1. Tsai HY, Lin JG, Inoki R. Further evidence for possible analgesic mechanism of electroacupuncture: effects on neuropeptides and serotonergic neurons in rat spinal cord. Japanese journal of pharmacology. 1989;49:181–85. doi: 10.1254/jjp.49.181.
    1. Takagi J, Yonehara N. Serotonin receptor subtypes involved in modulation of electrical acupuncture. Jpn J Pharmacol. 1998;78:511–4. doi: 10.1254/jjp.78.511.
    1. Chang FC, Tsai HY, Yu MC, Yi PL, Lin JG. The central serotonergic system mediates the analgesic effect of electroacupuncture on ZUSANLI (ST36) acupoints. J Biomed Sci. 2004;11:179–85.
    1. Liu X, Zhu B, Zhang SX. Relationship between electroacupuncture analgesia and descending pain inhibitory mechanism of nucleus raphe magnus. Pain. 1986;24:383–96. doi: 10.1016/0304-3959(86)90124-7.
    1. Jones SL. Descending noradrenergic influences on pain. Prog Brain Res. 1991;88:381–94.
    1. Takeshige C, Sato T, Mera T, Hisamitsu T, Fang J. Descending pain inhibitory system involved in acupuncture analgesia. Brain Res Bull. 1992;29:617–34. doi: 10.1016/0361-9230(92)90131-G.
    1. Yoshimura M, Furue H. Mechanisms for the anti-nociceptive actions of the descending noradrenergic and serotonergic systems in the spinal cord. J Pharmacol Sci. 2006;101:107–17. doi: 10.1254/jphs.CRJ06008X.
    1. Hong CZ. Needling therapy for myofascial pain control. Evidence-Based Complementary and Alternative Medicine 2013;Article ID 946597:2 pages.

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