Dry Needling for Myofascial Pain - a Mechanisms Review Part 2

This is part 2 in a series of blog posts where I am sharing key highlights I took away from presentations, by Professor Cesar Fernandez de Las Penas, at the recent annual Spring Conference of the BMAS.

Part 1 can be viewed here...

With regards dry needling ‘mechanisms of action’ two main hypotheses were discussed:

Firstly a mechanical mechanism whereby the needle tip ‘destroys’ the dysfunctional motor end plate resulting in deactivation of the MTrP. This hypothesis is supported by evidence which shows a 60-70% decrease in local electrical activity within the end plate zone after dry needling. A certain amount of muscle damage has also be shown to occur, however 28 hours after dry needling the muscle morphology is restored to normal based on histological analysis. The normalisation of motor end plate activity after dry needling may partly explain a reduction in local muscle tone, amelioration of the local twitch response and improved muscle function.

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Part 1. Dry Needling for Myofascial Pain - a Mechanisms Review

I recently attended the annual Spring Conference of the BMAS where we had the good fortune of listening to two presentations by Professor Cesar Fernandez de Las Penas. Almost every slide referenced a journal paper and in order to fully appreciate the wealth of evidence presented I recommend viewing the post conference webcast.

During the following weeks I will share a few posts here that will offer key highlights I took away from the presentations. I am sure you will find them interesting and informative.

Part 1

Myofascial pain syndrome is a consequence of either active or latent myofascial trigger points (MTrP) within muscles. From an aetiological point of view, a dysfunctional motor end plate is considered to be central in explaining the exquisite tender spot found within a muscular taut band and the subsequent referred pain phenomenon all of which are MTrP diagnostic criteria.

When using Acupuncture to treat trigger points, the descriptive term Dry Needling may be used and can be applied in one of two ways. Firstly using two fingers along a taut band the needle is inserted perpendicularly into the MTrP located between fingers.

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How Do Our Patients Really Feel About Acupuncture?

The objective of this very interesting qualitative study by Stomski et al (2013) was to explore the experience of Acupuncture care from the perspective of people with chronic low back pain. For a change we are given some very interesting information about how our patients perceive, feel about and interpret Acupuncture treatment as opposed to simply focussing on objective outcome measures such as pain scores etc.

As a quick aside, for those of you who have not already read Peter O’Sullivan’s paper discussing the need to reevaluate how we manage chronic low back pain, I’d thoroughly recommend doing so given its relevance to this article

As a clinician who uses Acupuncture partly as a facilitatory technique, one which allows us to more easily influence unhelpful thoughts and behaviours relating to pain, such a study can provide useful information to help guide us based on the patients subjective experience.

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Shoulder Girdle Course Reflection

On Saturday the 26th of April 2014, Lorraine Carroll and myself delivered the first in a series of 1 day practical Medical Acupuncture and Dry Needling courses.

The course was fully booked with the maximum of 12 attendees. Our attendees got to grips with the shoulder girdle and its attending musculature and learned a number of advanced needling techniques. They also received an evidence based contemporary clinical overview, a rapid functional assessment approach for the medical acupuncturist as well as how to manage a course of treatment.

The pre-course online theory modules were well received, helping lay a theoretical and safety platform to allow a strong hands-on practical emphasis on the day.

Participants were split into small practical groups which meant that close attention was given to help attendees refine their needling techniques allowing them to confidently and immediately put them to good use for their patients.

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Further Evidence For Dry Needling In The Treatment Of Myofascial Pain

A recent systematic review by Kietrys et al (2013), provides us with level 1A evidence in support of what we as clinicians using Dry Needling for Myofascial Pain Syndrome (MPS) have known for a long time....it works!

In the meta-analysis, twelve quality RCT’s were selected which met the following inclusion criteria: human subjects, dry needling intervention group, and MPS involving the upper quarter. The methodological quality scores ranged from 23 to 40 points, with a mean of 34 points (scale range 0-48, best possible score-48) using the the MacDermid Quality Checklist.

The authors concluded:

Based on the best current available evidence, we recommend (Grade A) Dry Needling, compared to sham or placebo, for decreasing pain (immediately after treatment and at 4 weeks) in patients with upper quarter MPS. Due to the small number of high quality RCTs published to date, additional well-designed studies are needed to inform future evolution of this recommendation.
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