Last weekend on Saturday the 7th of November 2015 I had the pleasure of delivering the third in a regional series focussing on the integration of medical acupuncture in the treatment of low back pain. I suppose I should not have been surprised how quickly the course filled given how challenging low back pain can be to treat. We are all looking for those added skills which might make the difference between a successful or unsuccessful course of treatment.
Myofascial pain syndrome (MPS) is clinically defined as a regional pain syndrome characterised by muscle pain caused by myofascial trigger points (MTrPs). Often overlooked or misdiagnosed, pain due to MPS is common and may range from an annoying dull ache to debilitating pain capable of mimicking nerve root irritation, osteoarthritic type pain and even visceral pain.
Peripheral intramuscular nociceptors can become sensitised by mechanical ischaemic and/or peripheral inflammatory factors resulting in a physiological cascade involving the the release of excess acetylcholine by the motor end plate. This in turn leads to the development of a contraction ‘knot’ within the muscle, commonly referred to as a MTrP. This localised contracture has been proposed to further impair local circulation resulting in an energy crisis which in turn results in further nociceptive sensitisation and so the cycle continues.
A hand held point stimulator device is a very useful tool which may be used when needling in the treatment of musculoskeletal pain syndromes - mainly for the deactivation of trigger points (TrP). It may be tolerated better with less treatment soreness as opposed to a more conventional dry needling technique, this is certainly the case from my own clinical experience with the device. The lack of evidence for efficacy is due to the fact that to my knowledge no trials have been performed to date, however we may be guided by the current evidence we have supporting the use of needling for myofascial pain syndrome for example. Clinically we have very good evidence to suggest a handheld point stimulator is an extremely effective way of comfortably augmenting the needle effect.
Is a versatile hand held electro-stimulatory device and can also be used to locate areas of decreased skin resistance thought to correspond with traditional acupuncture points.
What follows is an attempt to further rationalise the use of an integrated mechanisms based needling approach in the treatment of myofascial pain related to the presence of trigger points.
I have provided a list of references which have influenced my understanding of the proposed neurophysiological mechanisms which may occur at the various levels. However some of the effects listed are based on clinical observation and discussion with colleagues.
The following mechanisms may apply when a myofascial trigger point is accurately located using the diagnostic criteria and then needled using:
- A local needling approach using electrostimulation
- A segmental approach in addition to or as an alternative to a local approach
- Enhanced central regulatory effects
How does Acupuncture work?
Needling activates specific nerve endings within the muscles - this triggers the release of substances which improve blood flow to the area, reduces pain and inflammation and promotes healing.
Needling also has effects within the CNS which further reduces pain, eases muscle tension and can promote a sense of wellbeing.
2 Hz EA - Adding gentle low frequency electrical stimulation enhances the segmental and central analgesic effects of needling by activating the central nervous system in a way similar to exercise...