Trigger Point Needling - An integrated Mechanisms Based Approach

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:

  1. A local needling approach using electrostimulation
  2. A segmental approach in addition to or as an alternative to a local approach
  3. Enhanced central regulatory effects
trig points

1) Local needling effects

Sensory

  • Axon reflex - CGRP, ATP - trophic, analgesic and vasodilatory effects
  • Anti-inflammatory effects

Motor

  • Fascial signalling - influencing the shape and size of fibroblasts promoting improved function and mobility
  • Deactivation of the dysfunctional motor endplates and reduction in local EMG activity at TrP sites

Mechanical

  • Normalise local muscle tone and restoration of muscle contractile function due to TrP deactivation
  • Improved neural tissue mobility and function

2) Segmental needling effects

Sensory

  • Enkephalinergic pain modulation at dorsal horn - effect suppresses nociceptive input arising from the TrP as well as other structures within the segment including muscle, articular and neural (nervi nervorum) tissue

Motor

  • Suppress spinal segmental motor reflex activity at ventral horn normalising general muscle tone through the dorsal and ventral segments
  • Needling muscle tissue will result in an initial increase then time dependant decrease in segmental SNS activity due to modulatory effects at intermediolateral horn relating to the myotomal segment being needled
    • Upper limb: T2-T9 paraspinal and/or medial forearm region
    • Lower limb: T10-L2 paraspinal and/or medial leg region
    • Dorsal spinal at the corresponding segmental levels

Mechanical

  • Improved spinal and peripheral articular mobility due to segmental pain modulatory effects and normalisation of muscle tone through the segment/s
  • As a result may improve neural tissue mobility and function

3) Extra-segmental needling effects

Sensory (specific and nonspecific effects)

  • Extra/multi segmental descending pain inhibition due to activation of the PAG
  • Activation of the endogenous opioid analgesic system - a learned, possibly target directed effect

4) Central Regulatory needling effects

Sensory (specific and nonspecific effects)

  • ‘Deactivation’ of the limbic system
  • Central regulation of autonomic tone at the level of the hypothalamus
  • Other neuroendocrine regulatory effects

Additional Notes

1. Local Approach with Electro - Stimulation

  • Enhance local sensory and motor effects of needling with electro-stimulation using the Pointer Excel II 5-10’’ x 3 bursts at the TrP site
  • Follow with with inline electro-stimulation at 2 Hz x 4 -8 points along the local taut band for 10-20 mins to enhance the segmental and extrasegmental effects

2. Segmental Approach - use with or as alternative to local approach

  • Needling will have segmental effects regardless of where in the myotomal segment the needle is located
  • Use additional paraspinal or peripheral somatic segmental points to enhance segmental pain modulation OR if unable to treat TrP locally due to pain sensitivity
  • Also useful for treating articular pain within corresponding segments
  • Use paraspinal (T1-T12) or peripheral (medial forearm or tibial region) to modulate SNS tone through upper and/or lower limb segments in cases of chronicity where higher levels of catecholamines and vaso reflexive change maybe contributing to TrP sensitisation and the energy crisis
  • EA at 2 Hz may be used to enhance the segmental effects

3. Use of Central Regulatory Points

  • Needling will have central regulatory effects regardless of location
  • Use additional central regulatory points to further modulate central autonomic tone and de-activate the limbic system in with higher levels of cognitive affective dysfunction
  • Typically classical Acupuncture points may be used and ‘access points’ to the central nervous system for example LR3, ST36, LI11, LI4

By Simon. 

References:

  • Dommerholt J, Fernandez de las Penas C. Trigger Point Dry Needling. An evidence and clinical based approach. 1st ed. Churchill Livingstone; 2013.
  • White A, Cummings M, Barlas P, et al. Defining an adequate dose of acupuncture using a
  • neurophysiological approach—a narrative review of the literature. Acupunct Med 2008;26:111–20.
  • White A. Western medical acupuncture: a definition. Acupunct Med 2009;27(1):33.
  • Watkin, H. Segmental dysfunction. Acupunct Med 1999;17(2):118-123.
  • White A, Cummings M. Does acupuncture relieve pain? BMJ 2009;338:a2760.
  • White A, Cummings M. Filshie J. An introduction to western medical acupuncture. Churchill Livingstone; 2008.
  • Simons DG, Travell JG, Simons PT. Travell & Simons’ Myofascial pain & dysfunction. The trigger point manual. Volume 1. Upper half of body. 2nd ed. Baltimore: Williams & Wilkins;1999.
  • Simons DG. Review of enigmatic MTrPs as a common cause of enigmatic musculoskeletal pain and dysfunction. J Electromyogr Kinesiol 2004;14:95-107.
  • Cummings TM, White AR. Needling therapies in the treatment of myofascial trigger point pain: a systematic review. Arch Phys Med Rehabil 2001;82(7):986-992.
  • Simons DG. Review of enigmatic MTrPs as a common cause of enigmatic musculoskeletal pain and dysfunction. J Electromyogr Kinesiol 2004;14:95-107.
  • Gerwin RD, Shanon S, Hong CZ, Hubbard D, Gervitz R. Interrater reliability in myofascial trigger point examination. Pain 1997;69:65-73.
  • Bowsher D. Mechanisms of acupuncture. In: Filshie J, White A, editors. Medical acupuncture- a western scientific approach. 1st ed. Edinburgh: Churchill Livingstone; 1998.p.69-82.
  • Travell JG, Simons DG, Simon LS. Myofascial pain and dysfunction. The trigger point manual. Vol 2. 1st ed. The lower extremities. Baltimore: Williams and Wilkins; 1999.
  • Han JS. Acupuncture: neuropeptide release produced by electrical stimulation of different frequencies. Trends Neurosci 2003:26:17-22,
  • Lund I, Lundeberg T. Are minimal, superficial or sham acupuncture procedures acceptable as inert or placebo controls? Acupunct Med. 2006;24(1):13-15.
  • Langevin, Helene M., et al. Evidence of connective tissue involvement in acupuncture. The FASEB journal; 2002;16(8):72-874.
  • Langevin, Helene M., and Jason A. Yandow. Relationship of acupuncture points and meridians to connective tissue planes.The Anatomical Record 2002;269(6): 257-265.
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