.. DRY NEEDLING N°1 Trigger Point-BMN

.. DRY NEEDLING N°1 Trigger Point-BMN                  

Dolor osteomuscular crónico -N°1- síndrome de dolor miofascial. PUNCIÓN SECA y la BMN.

Trigger point Dry Needling (or Intramuscular Manual Therapy. Trigger point needling Functional dry needling. Intramuscular stimulation). 

Abbreviations
TP, TPs: Trigger Point, Trigger Points.
DN: Dry Needling
WN: Wet Needling
AP, APs: Acupuncture Point, Acupuncture Points.
Ac: Acupuncture.

The Trigger point_ TP, TRAVELL and SIMONS, is defined as a tender nodule, a knot inserted in a palpable taut band of a skeletal muscle. 

DN involves palpating the taut band within the affected muscle, isolating the tender nodule, and inserting an acupuncture needle directly into the TP to cause a muscle twitch, a reflexive relaxation and lengthening of the muscle.

This set of manipulations, deactivates the TP responsible for the musculoskeletal pain and impaired movement caused by trauma or disease but ignores the root cause as it is not a holistic treatment but this approach is evolving …

TPs, Acupuncture Points and Ashi Points 
Many TPs are confused with APs.
Dorsher & al., determined that of the 255 TPs, listed by Travell and Simons, 234 (92 percent) had anatomic correspondence with classical, miscellaneous, or new APs listed in Deadman & al.

·                     For Acupuncture
Outside the listed APs there are APs commonly termed ‘Ashi point’ that do not necessarily correspond with traditional point locations. 
Ashi points are specific tender spots, palpated in a pain area and painful when pressed, without name, randomly located and only selected in accordance with the syndromes or diseases.

Ashi points are often not technically APs or on specific meridians but have a clinical effect nonetheless.

They are treated and needled in Acupuncture according to a classically and globally approach.

·                     For Dry Needling 
In front of the same components, for the Therapist using TPs, this falls within his jurisdiction with exquisitely tender and hyperirritable spots, included in a taut band of a skeletal muscle, painful on deep palpation and originated of a referred pain and motor dysfunction in deep palpation. Inserting an acupuncture needle into the area, in concordance with the TPs treatment or DN, pain or sufferings are relieved after having reproduced the pain spontaneously felt.

‘ Either Acupuncture or DN, deepen palpation allows finding musculoskeletal tender points interpreted for millennia as Ashi points by the Acupuncturist and since 50 years as TPs by Professionals in DN’. 
Both are treated by insertion of acupuncture needles either compact or hollow with the possibility for the latter (the BMN) to associate Acupuncture and DN respectively with Mesopuncture and Wet Needling _WN.

The Distal Trigger Points 
Evolution of the DN treatment, as including distal TPs in DN, brings DN nearer to Acupuncture

Some authors recommend to research and treat the distal TPs, away from the primary TPs.  This recommendation involving, in the TPs treatment, the distal TPs is similar to the conventional diagnostic and therapeutic approach, performed in Acupuncture, since a lot of years, for research and treatment of local and remote APs.

·                     The facts 
About 75% of pain is caused by TPs. Over 74% of common TPs are located remote to the area where the patient feels pain.

·                     Therefore, in a Patient too sensitive to be needled in the area of the primary pain source, the treatment can be initiated with distal needling. A recent study demonstrated that distal points needling reduce proximal pain by means of the diffuse noxious inhibitory control.

·                     Distal TPs are listed in Pain guides available on the internet. Then they will be adapted to the particularism of each patient.

In summary
Insertion of a needle into a TP, confused with an AP, could be likened to Acupuncture. 
Injection of a liquid drug into a TP could be equated with Mesopuncture.
Research and involvement of remote TPs in the DN treatment is a classical approach in Acupuncture.   

. Dry Needling N°2- Trigger Point - BMN

. Dry Needling N°2- Trigger Point - BMN

Extension of the Dry and Wet Needling activity field

Dry needling can be appropriate and very helpful for Patients with chronic pain, of undetermined origin but clearly identified not to be of internal organ origin especially when other interventions have failed, although DN initiated being limited to the local area of pain only: Extending its field of activity in the treatment of any non-visceral chronic pain by TPs is also a classical approach to Acupuncture… …

DN and needles

·                 Hypodermic needle, 1981.

In 1981, having found that, the effectiveness of the alone needle insertion, was identical to the liquid drug injection, TRAVELL & SIMONS recommended the use of a single hypodermic needle, without injection.

“In comparative studies, DN was found to be as effective as injecting an anesthetic solution such as procaine or lidocaine in terms of immediate inactivation of the TP”. 

DN focuses only, on treating the locally musculoskeletal pain and dysfunction by inserting hypodermic needles into the locally painful area.

TECHNIQUE OF THE DN

Dry Needling DN is a treatment technique used in conjunction with other treatments to inactivate the TPs and treat pain and dysfunction they cause.

The interventionist therapist will not have to stimulate, in principle, any distal or auricular AP during the treatment with DN but he can find more than one TP in a muscle and more than one muscle with numerous TPs.

It was used originally in DN, a sterile hollow hypodermic needle, inserted in an empty or 'dry' syringe body (empty as opposed to a syringe filled with injectable solution used, in the Wet Needling) inserted through the skin and muscle, to reach directly the TP, without drug injection: Proper placement of the needle into the TP causes a localized muscle contraction.

Currently, is used an acupuncture needle, controversial use by Acupuncturists because Acupuncture Needle involves Care or Acupuncture session.

Whatever it is the needle is inserted into the TP, located in an area, the Taut Band, where the muscle is stretched, contracted and sensitive: The perceptible or visible flexion of this band of muscle fibers confirms the correct insertion of the needle into the TP.

It is an involuntary spinal cord reflex, in which the muscular fibers of the stretched muscle band contract, due to a reflexive relaxation and elongation of the muscle fibers, improving the overall muscular flexion and relieving altered motions.

Repeated movements of the needle, for about one minute in situ, in its insertion point, without completely removing it, help to inactivate the TP allowing, in the absence of pain and by an involuntary spinal cord reflex, the overall muscle contraction, its lengthening and improving flexibility. 

These manipulations can be painful, a fortiori if, more than one TP in a muscle requires needling and more than one muscle with multiple TPs, is involved: Perhaps a few drops of anesthesia would be appreciated, interesting possibility when using the BMN.

Mechanism of Action

The exact mechanisms of the therapeutic effects of the needle insertion into the TP are not fully understood, although the principle behind DN is known as being the reflex arc.

Studies, Dr. Jay Shah and colleagues and other Authors, have shown that Dry Needling,

·                 Disrupts mechanically the integrity of the dysfunctional endplates within the trigger area.

·                 Causes, locally, favorable biochemical changes which aid in reducing the pain, partially.

·                 Involves supra-spinal pain control via midbrain periaqueductal gray matter.

DN also affects the central nervous system about the perception and modulation of pain.

**- No mention is made of the role of connective tissue, its fundamental substance particularly, like the role described thereto, in Acupuncture, in the management of the therapeutic effect due to the implantation of the acupuncture needle in the soft tissue, into the APs location in the connective tissue.

Another hypothesis about the healing mechanism

  Dry Needling injures and causes minor bleeding within the tissues. The minor trauma elicits a local inflammation, recognized by the body as an acute problem area, requiring an increased blood flow while usually this area has a poor blood circulation. By increasing bleeding and blood flow into the tampered area the body tries allowing the area to heal.

·                 Acupuncture Needle, 1999.

In 1999, on the second edition of their book, Travell and Simons advocated, for disabling the TPs, to use an acupuncture needle, thin, compact and less painful than a hypodermic needle, wider in diameter.

This recommendation allowed the Professionals to mitigate the insertion and manipulation pain of the hypodermic needle into the TP, already spontaneously painful.
Moreover, hypodermic needle was described in unflattering terms, by the Therapists, as causing a searing pain and discomfort. 

The use of an acupuncture needle and confusion of many TPs with APs has aroused among Acupuncturists, a deep and sustainable controversy, yet noticeable today but also including some signs of lull.  

DRY NEEDLING, N°3, Trigger Point-BMN

DRY NEEDLING, N°3, Trigger Point-BMN

                  

·                 Acupuncture needle for DN

It was necessary for optimizing the needle insertion pain, to select a finer needle even compact.

·                 Karl LEWIT, 1979, published in the medical journal ‘Pain’ an article emphasizing the role in DN, of a solid filament needle as is used in the Acupuncture practice. Acupuncture needle for DN.

**- How are described acupuncture needles

By the Therapists:  Acupuncture needles are thin as a filament, sterile and effective and do not cause the searing pain of a large hypodermic needle. (This is no longer true currently).
By the Regulations. FOOD AND DRUG ADMINISTRATION
An acupuncture needle is a device intended to pierce the skin in the practice of Acupuncture. The device consists of a solid, stainless steel needle. The device may have a handle attached to the needle to facilitate the delivery of Acupuncture treatment.

Indeed, acupuncture needles are effective for inactivating TPs.

Acupuncture Needle and the controversy

The choice of acupuncture needle as a cause of controversy is artificial now.

This choice is only the triggering event of a dispute initiated by the Acupuncturists regarding several encroachments on their Profession by the Needling therapy: Common points, field of activity extended to remote points, treatment of all pain causes except of visceral origin, insertion or injection in a skin point and more.

·                 In various countries, Acupuncturists, referring to the first texts of Travell and Simons describing the procedure of DN with hypodermic needle instead of Acupuncture needle now, argue that anytime a Therapist uses an acupuncture needle while performing a 'dry needling' session, he will be outside of his scope of practice and into the Acupuncture practice.

·                 Other authors are more intransigent

Dry Needling, intramuscular stimulation or any other method by which a needle is inserted to effect therapeutic change, is, by definition, the practice of Acupuncture.

Controversy and protocol, Acupuncture and Acupuncture needles.  

The controversy has diminished because on one hand the classical approach of DN treatment has evolved, including it in a protocol treatment encouraging coupling DN and Acupuncture, especially if it is noted a probability of confusion between TPs and APs, of location either defined or randomized as Ashi points, on the other hand the use of a disposable device classified both as acupuncture and hypodermic needle, the BMN.

**-* DN Protocol

It is interesting to note some evolution in the DN treatment favoring the lull of the controversy while DN becomes a protocol treatment including Acupuncture.
DN cannot be regarded as a full-fledged medicine that is why, partially, some Authors recommend considering DN as a protocol with a prominent place for Acupuncture in its two versions: Acupuncture and Mesopuncture (and various other treatments), for maintaining homeostasis and preventing pain to become chronic. 
DN works best when it is combined with other physical therapy interventions such as soft tissue massage, stretching, strengthening, posture training and home exercises.
DN works best, when it is combined, in front of recurrent TPs for example, with a diagnostic and therapeutic set, identical to that achieved in General Practice;

In many ways, the protocol recommended corresponds to the conduct and conclusions of the acupuncture session: Questioning and looking for personal and family history, inspection, palpation, differential diagnosis, additional tests, biological or radiological etc.

Indeed, the DN cannot be considered  as a medicine in its own right, which is, why some authors recommend integrating the DN in a treatment protocol with a place of choice for Acupuncture and its two versions: Acupuncture and Mesopuncture (and various other treatments), for maintaining homeostasis and prevention to the chronicity of pain. 

**-* Acupuncture in DN Protocol

Acupuncture is an Eastern version of Medicine, trying to determine and treat the root cause of the diseases and their symptoms, in particular:

·                 All diseases encountered in the daily medical practice.

·                 Musculoskeletal pain as well as pain due to any cause.

·                 Other medical conditions.

Acupuncture, in its two versions, Acupuncture and Mesopuncture, is an integral part of Chinese Medicine treating both the symptoms and the identified root cause of the health problem, according to a holistic approach. 
Acupuncture is thus the treatment of choice to treat all pathology involving the TPs.  
It is a fully qualified medicine, which allows eliciting a long-term relief by searching, finding and treating the underlying factors, which perpetuate, in this case, the TPs in an activity state contributing to chronic pain. 
Both Acupuncture as an eastern medicine and Dry Needling as a western medicine, use very fine, compact or hollow, needles inserted into the skin and muscle, into numerous common sites, APs/TPs.

Acupuncture needles are inserted into Acupuncture Points_ APs, located in local and distal areas connected by meridians described as cleavage planes of the connective tissue.
Acupuncture needles are inserted in Trigger points of often confused location with the APs.

DRY NEEDLING, N°4, Trigger Point-BMN

DRY NEEDLING, N°4, Trigger Point-BMN

Inserting acupuncture needles in carefully selected points, of recognized and logical efficacy, enables on one hand to easily deal with the TPs involved in the painful condition and secondly to act on the various factors initiating and perpetuating the state of active TPs.

·                 Various Acupuncture Points_ APs could be selected: Tender points or “Ah-Shi” points, proximal or remote APs on the meridians and extra-meridians, affecting the area of pain or disharmony.

·                 Various factors could be treated: Mechanical stresses, injuries, nutritional or sleep problems, emotional factors, acute or chronic infections, organ dysfunction and disease…

*-* Acupuncture needles in the Protocol of Dry Needling

Both Acupuncture, oriental medicine and Dry Needling, Western medicine, use very thin and compact or hollow needles, inserted into the skin and the muscle, in many common points seen as Trigger Points or Acupuncture points. 

n    Acupuncture needles are inserted into Acupuncture Points _ APs located in proximal as well as distal areas, connected by meridians described as cleavage planes of connective tissue.

n    Acupuncture needles are inserted into APs often confused with Trigger Points.    

n    The insertion of acupuncture needles into carefully selected points, of recognized and logical efficiency, on the one hand, allows managing easily those Trigger Points involved in the painful condition and on the other hand acts on the various factors initiating and perpetuating the active state of the Trigger Point...

BMN in DN and Wet needling

It is possible to use the BMN both for Dry & Wet Needling as recommended.

 BMN being a hypodermic and Acupuncture needle, its use avoids the controversy on using an acupuncture needle and performing an acupuncture act without being an official Acupuncturist and not using a hypodermic needle as advocated by Travell and Simons in their first book. 

BMN is a disposable device used by Acupuncturists for Acupuncture and Mesopuncture and all Therapists practicing Dry or Wet needling as well as professionals in Mesotherapy. 
It is a hollow acupuncture needle with a diameter identical to current acupuncture needle (0.30 mm) topped with an empty resilient polymer reservoir.

The resilient polymer reservoir located in the handle of the needle, (or rather, topping the hollow needle, the reservoir is used for gripping the needle) is filled by the Therapist with the liquid drug he has previously selected, based on the disease to be treated.

The BMN is of dual identity: It is a hypodermic needle because it is hollow, but it is also an acupuncture needle, as described by the FDA.

Its use is plural if we consider, 

·         First, the multiplicity of TPs confused with APs with, for the latter the need to leave in situ the acupuncture needle while allowing the supine position, the treatment continuing.   

·         The second feature is the ability to initiate or complete the effectiveness

of the DN or Acupuncture treatment resulting from insertion of a metal needle, by injecting a liquid drug chosen for its own therapeutic virtues or its complementary biochemical or mechanical effect, thus performing a Wet Needling or a Mesopuncture session.  

It is thus possible, for the Therapist, to perform with the same BMN inserted in the TP, both Dry needling coupled or not, with Wet needling, facilitating the TPs deactivation and optimizing the therapeutic result of this deactivation.

If from moreover the TP is of common localization with the Acupuncture Point, it would be possible:

·                 To keep the BMN inserted in the Point for about 20 minutes as recommended for an acupuncture treatment.

·                 To Achieve with the same BMN insertion, both versions of Acupuncture: Metal needle therapy (Acupuncture) and treatment with the liquid drug reservoir, injected into the TP (Mesopuncture).

·                 To continue the treatment while the patient is lying on his back, with various BMN inserted in the TPs or APS, located in the back.

·                 To perform, possibly, with the same needle insertion some Mesotherapy points, in the dermis around the AP.

In fact, the BMN leaves, to the Therapist, the complete freedom to choose:

For TPs, the Wet and Dry needling, 
For APs, Acupuncture and Mesopuncture,  
For Allopathic /Homeopathic medicine, the creation of Mesotherapy points by injecting micro doses of liquid drug into the dermis surrounding the APs.

Chronic Musculoskeletal pain.N°1. Myofascial pain syndrome

Chronic Musculoskeletal pain, Myofascial pain syndrome. N°1.

Dry-Wet NEEDLING and BMN. Definitions # Etiology.        

Definitions Etiology.                                                                     

The Myofascial Pain Syndrome_ MPS is one cause, in 85% of cases, of chronic musculoskeletal pain.

The MPS is the set of symptoms caused by painful functional disruption of the locomotor system involving Active (myofascial) #Trigger Points (TPs): Musculoskeletal pain, muscular weakness, mobility restriction, neurovegetative signs.

We distinguish primary and secondary form.   

• Primary MPS (in French, SDM or Syndrome Douloureux Myofascial). Consequence of muscle overuse: epicondylitis, frozen shoulder, tension. Headache…

• Secondary MPS. During various disorders: Dysfunction of the temporomandibular joint, sprain, whiplash, osteoarthritis and fibromyalgia

 Cause

*The Trigger Points at the starting of myofascial pain, are the most common cause of chronic musculoskeletal pain: In 85% of cases, the cause of chronic musculoskeletal pain involves Active Trigger Points_ ATP.

Around 75% of musculoskeletal pain is caused by Trigger Points.

About 92% of TPs are Acupuncture Points _ APs: Only 20% of TPs correspond to APs listed and commonly used in acupuncture treatments but all Trigger Points correspond to ASHI points.

Trigger Points, Ashi Points

*-*Trigger Points

The terms, trigger Points, Myofascial Pain Syndrome, muscle strand, local contractile response, were defined by Dr. Janet TRAVELL (1950) and described, in the book she published, with Dr. David G. Simons ""Myofascial pain and dysfunction. The trigger point manual. Baltimore: Williams & Wilkins, 1981”,

The TPs is defined as a sensitive, painful, hyper-irritable, circumscribed nodule located in a tight, firm, palpable muscle fiber strand in contracture of a skeletal muscle: Taut Band or tight bandage. 

·         It is an irritable spot either spontaneously (active) or on digital compression (latent) able to generate either local or referred pain to other musculature, motor dysfunction, vegetative signs can accompany these two types of pain such as sweating, swelling and "goose bumps." 

Location

The TPs are located in general, in one of the 400 skeletal muscles (for example, the TPs selected in this article are of musculoskeletal origin).

They are also located in the fascia, ligaments, tendons, joint capsules, skin and the periosteum.

Activation

These TPs may become activated by a variety of factors such as, poor posture, overuse, or muscle imbalance.

·         TPs exhibit a local twitch response (muscle fasciculation) or jump sign (flexion response) in response to digital pressure or Dry & Wet Needling.

·         Only clinical criteria currently define TPs; Two new modalities, sleep-elastography and magnetic resonance- elastography, may help to obtain objective confirmation.

*-* The ASHI points: They are not systematized APs, located in or off meridians, or APs not located d or not into meridians or meridians or   meridians. They are of random location, of varying duration, sensitive to the pressure, and depend on the causal disease.

Nota

Only clinical criteria currently define PGs;

Two new modalities, sleep-elastography and magnetic resonance elastography, may help to obtain objective confirmation.

PATHOPHYSIOLOGY
The existence and understanding of genesis of the TPs, was the subject of many debates involving EMG, elastography, Magnetic Resonance, ultrasound etc. to both confirm their existence and obtain a more extensive knowledge of the pathophysiology of these TPs, commonly overlooked cause of chronic musculoskeletal pain and dysfunction.

The etiology and genesis of TPs have yet to be satisfactorily explained.

It is generally thought that abnormal muscle strain, in combination with emotional stress, in genetically predisposed individuals, can cause a LTP to develop in a taut muscle band and subsequent nerve sensitization.

Taut muscle bands commonly occur in pain-free individuals.

Several diverse yet complementary models have been proposed to explain the development of TPs at the cellular level, but it is still not known what the role of each is in the pathogenesis of chronic musculoskeletal pain. Nonetheless, it is clear that the pathogenesis of TPs is a complex process that involves both the central and peripheral nervous systems.

Recent basic studies have confirmed that,  at the site of an active TP, there are elevated levels of inflammatory mediators, known to be associated with persistent pain states and myofascial tenderness and that this local milieu changes with the occurrence of local twitch response.

ETIOLOGY

Contributing factors

Among the various direct causes or contributing factors, generating TPs in Patients, mention may be made, with many authors of:  

·                              Occupational or athletic activities with postural deficiencies, muscle imbalances, static postures, monotonous and repetitive gestures overuse injuries, intervertebral discs diseases, trauma…

·                              Psychosocial and emotional factors, fatigue…

·                              Inflammatory diseases, fever, arthritis, viral infections…

·                              Internal disease, scar formation after surgical incision etc.

Perpetuating or aggravating factors

·                      Further aggravating factors may lead to the creation of further TPs 

·                     Chronic psychological problems. 

·                     Chronic infections. 

·                     Chronic muscle tension due to poor posture…

EXAMINATION of the Trigger Points.

• Stretch the muscle for palpation of the tight band tense meeting and TP between the relaxed muscle fibers.

• Palpation of the tight band is performed applying it against the underlying structures or by pinching it.

It often produces a localized contractile response. It may cause referred pain.

APPROPRIATE TREATMENT

Appropriate treatment to the locally musculoskeletal pain and dysfunction could be performed by needling therapies applied into the TP, a locally painful area, to produce a “twitch” response and deactivate the TP.

Needling therapies can be divided in two groups with or without liquid drug injected:

·                    Two versions of Acupuncture: Acupuncture & Mesopuncture.

·                    Two versions of DN: Wet & Dry needling, in association with other treatments, optionally.