sixth Clinical Practical Training
assigment(2)
Prepared by : Salsabeel Salamah
supervisor: DR . Rula Hilal
March 31, 2023
Dry needling
Trigger-point dry needling is an invasive procedure where a fine
needle or acupuncture needle is inserted into the skin and muscle. It is aimed
at myofascial trigger points (MTrP) which are hyperirritable spots in skeletal
muscle that are associated with a hypersensitive palpable nodule in a taut
band. Trigger point dry needling can be carried out at superficial or deep
tissue level.
Pathophysiology of MTrPs
Trigger points are thought to be due to an excessive release of
acetylcholine from selected motor endplates. They can be divided into
Active and Latent myofascial trigger points.
Active trigger points can spontaneously trigger local or referred pain.
They cause muscle weakness, restricted ROM and autonomic phenomena.
Latent trigger points do not cause pain unless they are stimulated.
They may alter muscle activation patterns and contribute to restricted ROM.
Therefore both active and latent trigger points cause allodynia at the
trigger point site and hyperalgesia away from the trigger point following
applied pressure.
The formation of trigger points is caused by the creation of a taut band
within the muscle. This band is caused by excessive acetylcholine release
from the motor endplate combined with inhibition of acetylcholine esterase
and upregulation of nicotinic acetylcholine receptors.
Initially taut bands are produced as a normal protective, physiological
measure in the presence of actual or potential muscle damage. They are
thought to occur in response to unaccustomed eccentric or concentric
loading, sustained postures and repetitive low load stress. However when
sustained they contribute to sustained pain.
Pain caused by trigger points is due to hypoxia and decreased
bloodflow within the trigger point. This leads to a decreased pH which
activates the muscle nociceptors to restore homeostasis. This causes
peripheral sensitization.
Trigger points are also involved in central sensitization. The
mechanism remains unclear but trigger points maintain nocioceptive input
into the dorsal horn and therefore contribute to central sensitization.
Deep VS Superficical Dry Needling
Superficial dry needling: involves inserting the needle up to
10 mm into the subcutaneous tissue, its benefits include ease of
administration, decreased risk of significant tissue trauma,
reduced risk of nerve and visceral injury and patient comfort.
Deep dry needling : involves the insertion of the needle
beyond the subcutaneous tissue into the muscle with the
intention of reaching myofascial trigger points.
Mechanisms of Action
Dry needling has been shown to immediately increase pressure pain
threshold and range of motion, decrease muscle tone, and decrease pain in
patients with musculoskeletal conditions. Its suggested mechanisms of
action include:
o Local Twitch Response: Dry needling can elicit ‘local twitch
response’ which is an involunatary spinal reflex resulting in a
localized contraction of the affected muscles that are being dry
needled. Local twitch response can lead to alteration in the
length and tension of muscles fibers and stimulate
mechanoreceptors like A Beta fibers.
o Effects on Blood Flow: Sustained contraction of taut muscle
bands in trigger points might cause local ischemia and hypoxia.
Dry needling causes vasodialation in the small blood vessels
leading to increased muscle blood flow and oxygenation.
o Neurophysiological effects: Dry needling may produces local
and centeral nervous responses to restore hemostasis at the site
of the trigger point which results in reduction in both centeral
and peripheral sensitization to pain.
o Remote Effects: Dry needling of distal MTrP has been found
to have analgesic effect on proximal MTrP. The literature has
conflicting evidence regarding the contralateral effect.
o Placebo Effect.
Indication
Dry needling may be indicated for myofascial pain with the presence
of trigger points. Dry needling has also been shown to be beneficial for the
management of strains, osteoarthritis and tendinopathies.
Contradindications:
Absolute contraindications
DN therapy should be avoided in patients under the following
circumstances :
o In a patient with needle fobia.
o Patient unwillng - fear, patient belief.
o Unable to give consent - communication, cognitive, age-related
factors.
o Medical emergency or acute medical condition.
o 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.
o Inappropriate for any other reason.
Relative Contraindications
o Abnormal bleeding tendency
o Compromised immune system
o Vascular disease
o Diabetes
o Pregnancy
o Children
o Frail patients
o Patients with epilepsy
o Phychological status
o Patient allergies
o Patient medication
o Unsuitable patient for any reason
