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.  

Chronic Musculoskeletal pain, N°2, Myofascial pain syndrome.

Chronic Musculoskeletal pain, N°2, Myofascial pain syndrome.

Dry-Wet NEEDLING and BMN

DIAGNOSTIC CRITERIA

1.-The pain

*-* The active TP, is a sensitive, irritable, and painful nodule. It can be painful during movements or even at rest. 

The pain increases when a contraction is performed against fixed resistance.

Local spontaneous pain of the TP is reproduced by palpation, which also reproduces, regional pain, at distance from the TP, so-called referred pain.

 *-* For a latent TP, activation, by palpation, pressure, physical activity, arouses the local pain of the TP and reproduces the regional or referred pain, sometimes the only pain spontaneously felt by the Patient.                           

2 - Painful tendons

Contracture of the muscle fibers also affected the tendon which can become inflamed and painful.

3. - Muscular cord or Taut-band

It is a bundle of muscular fibers contracted, more or less deep, over the length of the muscle, the width of a thread or wider, 3-4mm.

4.- In the middle of the taut band, one finds, the TP:

A sensitive area of 2.5 mm in diameter. Powering up the muscle or its palpation causes an exquisite pain at the level of the TP corresponding to the pain described by the Patient. The active TP is sometimes surrounded by adipose tissue. 

5. - Local Twitch Response_ LTR.

It is a specific reaction of the myofascial pain syndrome. It is a spinal reflex, a transient contraction of the muscle fibers of the cord in response to induced or spontaneous.

When palpation is negative, the 'taut band' contraction, referred and locale pain can be caused by inserting a needle into the TP.

OOo There is a positive correlation between the localized contractile response and the therapeutic outcome.

6 - Referred pain.  

Perfectly described in the princeps work of Travell and Simons. It is located at a more or less distance from the TP. It is constant for a given individual and variable from one individual to another. It can range from a postural deviation to severe and disabling pain that affects the patient’s quality of life and forced him to rest. In the area of referred pain, are noted paresthesia / a hyperesthesia, hyper-excitability of the motor units.
7. - In response to the digital pressure of the TPs or the Dry / Wet Needling, there is a muscular response either in the form of fasciculation or a more extensive muscle flexion or jump sign.

• There is a partial muscular impotence: Partly attributable to the taut band whose muscular strength is diminished.

The muscle is weakened by muscular atrophy, reaction to the avoidance of the activation of the painful muscle and appeal to the agonist or antagonist muscles in which can also be created secondary TPs either without atrophy or (without) painful origin.

Muscular weakness contributes to postural deviation secondary to pain.
The range of stretching is limited: Passive or active stretching increases the pain. This results in a restriction of active and passive mobility due either to motion avoidance or to adherence to chronic TP. 

The TP compromises muscle coordination.

8 - Neuro-Vegetative Symptoms

Pallor, coldness, sweating symptoms or abnormal sweating, lacrimation, pilo-motor activity (goose bumps), flushing, edema, ptosis, nausea depending on the painful intensity...

The muscle where the primary TP locates is more sensitive to cold or weather changes.

Other neurological symptoms may be associated with: Paresthesia, blurred vision, shaking and tremors.

MICROSCOPIC examination,

It is unusual.

Part of the muscle fiber is contracted in a small thickened area and the rest of the thinner fiber is stretched.

Several of these contracted muscle fibers in the same area are probably what is felt as a "node" in the muscle. These muscle fibers are not available for use because they are already contracted, which explains that one cannot contract a stiff muscle housing TPs.

The sustained contraction probably leads to the release of chemicals, sensitizers, producing the pain felt by TP pressure.  Some structural changes can be irreversible if TPs are not treated promptly. The contractile portions, at the center of the TP can be separated and retracted at each end, leaving, in the center of the TP an empty part.