Introduction

Several researchers have examined the efficacy of deep dry needling (DN) on TrPs of the muscles of the lumbar spine. Deep DN may be more effective in reducing pain compared with standard acupuncture therapy or superficial needling in elderly patients presenting with chronic low back pain (Itoh et al., 2004). More recently, Itoh and colleagues (2006) found similar findings with DN being superior to sham needling in the short term for elderly patients with low back pain. It should be noted that both studies had small sample sizes, and therefore definitive conclusions cannot be drawn. When evaluating the effects of DN compared with the effects of anaesthetic injections and percutaneous electrical nerve stimulation, DN was equally successful in inactivating TrPs in low back muscles and reducing pain (Perez-Palomares et al., 2010). Comparing DN with DN combined with neuroscience education showed that, although both groups exhibited similar decreases in pain and in scores on the Roland-Morris Disability Questionnaire and Oswestry Low Back Pain Disability Index, the group that received DN and neuroscience education demonstrated greater improvement of pressure sensitivity at the L3 transverse process and a greater reduction of kinesiophobia. The researchers found similar increases in pressure sensitivity at all assessed areas (Téllez-García et al., 2015). A Cochrane review by Furlan and colleagues (2005) of 35 randomised controlled trials of acupuncture and DN for chronic low back pain concluded that DN may be a useful adjunct to conventional therapies. Most studies were of lower methodological quality than recommended by the Cochrane Back Review Group (Furlan et al., 2005). In a recent systematic review, Boyles and colleagues (2015) reported limited benefit of DN to the lumbar paraspinal muscles; however, only one study met the inclusion and exclusion criteria of the paper. For other areas of the body DN has been shown to be effective (Liu et al., 2015; Morihisa et al., 2016; Gattie et al., 2017), especially for short-term pain relief, increased range of motion, and improved quality of life compared with no intervention, sham, and placebo (Espejo-Antûnez et al., 2017). A recent study confirmed that the benefits of three sessions of DN TrPs in cervical muscles persisted for at least 6 weeks (Gerber et al., 2015, 2017) with objective tissue improvements assessed by ultrasound vibration elastography lasting as long as 8 weeks (Turo et al., 2015). Overall, there is a promising trend toward better myofascial pain and DN studies with improved methodological quality (Gattie et al., 2017; Stoop et al., 2017).

Two recent studies examined the physiological changes in lumbar muscle function after DN. Both studies demonstrated improvements in muscle activation after DN with changes in the thickness of the lumbar multifidus muscle (Koppenhaver et al., 2015a; Dar & Hicks, 2016). However, Koppenhaver and colleagues (2015a) also reported a decrease in nociceptive sensitivity. A limitation of both studies is that subjects received only one DN treatment, which is not common in clinical practice. Further work has been done to examine whether there are particular clinical predictors that would determine which patients would most likely benefit from DN of the lumbar multifidus muscle. Among multiple variables, pain with the multifidus lift test was the strongest predictor of improved disability after DN. The multifidus lift test is used to examine the activation of the lumbar multifidus muscle at the L4-L5 and L5-S1 levels based on palpation by the therapist. In this study, the multifidus lift test was performed by asking prone patients to lift their abducted arm of the table as the clinician palpated the contralateral lumbar multifidi muscles. Subjects who had pain that worsened with standing had a 23% smaller improvement in disability than those who had pain that was not aggravated by standing (Koppenhaver et al., 2015b).

Although thoracic spine pain has a lifetime prevalence of almost 20% in the general population (Briggs et al., 2009), there is limited evidence of the efficacy of DN for thoracic spine pain (Fernández-de-las-Peñas et al., 2015). Currently, there is only one report of two patients with thoracic spine pain, motor control dysfunction, and tightness and pain in the thoracic paraspinal muscles who showed improvements in pain and range of motion after two sessions of DN (Rock & Rainey, 2014). Another paper, although not exclusively pertaining to the thoracic spine region, compared the effectiveness of DN in the thoracic, lumbar spine, and sacral regions versus cross tape in patients with fibromyalgia (Castro-Sanchez et al., 2017). DN was directed to TrPs in the thoracic, lumbar, and sacral multifidus and iliocostalis muscles, the quadratus lumborum muscle, and the latissimus dorsi muscle both in the axilla and on the rib cage. The DN group showed a significant decrease in the number of TrPs compared with the cross tape group along with a major improvement in pain intensity. Both groups demonstrated changes in spinal mobility, but the effect sizes were negligible to small. Mahmoudzadeh and colleagues established that DN was a valuable addition to a more traditional treatment approach for patients with discogenic low back pain (Mahmoudzadeh et al., 2016). Anandkumar and Manivasagam presented a case of a 42-year-old female with complaints of diffuse pain in her thoracic paraspinal region from T2 to T7. The patient was treated with DN targeting the fascia twice weekly for 2 weeks with reported improvements in pain, range of motion, and functional activities (Anandkumar & Manivasagam, 2017).

Currently there is no direct evidence to support DN of thoracic muscles for pain in the lumbar region other than the established referred pain patterns of the lower thoracic multifidus and longissimus thoracis muscles into the lumbar region (Simons et al., 1999). There is, however, one DN study of the lower trapezius muscle to treat mechanical neck pain (Pecos-Martin et al., 2015). DN of a TrP was compared with DN of a non-TrP region of the same muscle with improvements of pain, pressure pain threshold testing, and disability in the needling group compared with the control group and baseline measurements. Although no other studies have looked at needling of thoracic spine muscles for neck pain, empirically, needling of the upper thoracic multifidi can improve cervical, thoracic and lumbar pain and dysfunction.

A recent study showed that DN might be useful in patients with cancer-related trunk pain. Hasuo and colleagues (2016) described five patients with terminal cancer and intractable pain, who initially responded to opioid pain medications. When pain control became less effective, the opioid dosages were increased, but patients became delirious. Based on diagnostic imaging, the increase in pain was thought to be due to either the primary cancer lesion or metastases; however, when specific muscles were examined, the patients’ familiar pain was reproduced. DN of TrPs reduced the patients’ pain, delirium, and pain medication intake (Hasuo et al., 2016). Vas and colleagues (2016) reported a significant decrease of pain in subjects with intractable pain due to pancreatic cancer after DN of the abdominal and paravertebral muscles. Subjects received DN if they still experienced pain greater than a 5 of 10 on a Visual Analog Scale after having either a neurolytic coeliac plexus block or a splanchnic nerve radiofrequency ablation.

Although the literature to date supports the inclusion of deep DN for mitigation of pain related to TrPs of the trunk, studies are limited in scope, quality, and quantity. Ongoing research, including high quality randomised controlled trials, is warranted for improved clinical decision making.

Clinical relevance of trigger points in syndromes related to the trunk

The most prevalent syndrome associated with the trunk is low back pain. Throughout the world low back pain continues to be a major concern with the highest prevalence among women and those aged 40 to 80 years (Manchikanti et al., 2014). The prevalence of low back pain is also on the rise. The overall prevalence has increased by 162%, with increases in non-Hispanic blacks as high as 226%. Furthermore, the number of individuals who sought healthcare for back pain increased from 73.1% to 84% (Manchikanti et al., 2014). Although pain with a myofascial origin was the primary cause of pain in 85% of patients going to a tertiary pain clinic (Chu et al., 2016), the role of muscles, specifically TrPs, in the aetiology of low back pain appears to be overlooked in favour of structural disorders that can be seen on imaging (Hendler & Kozikowski, 1993). Attempting to identify a single source of pain may cause practitioners to ignore the potential contribution of other tissues to the overall pain presentation. Low back pain should be considered a summation of dysfunctions with ligamentous instability and facet joint degeneration occurring in conjunction with development of motor control dysfunction and muscle TrPs formation (Kirkaldy-Willis, 1990; Chaitow, 1997; Paris, 1997; Waddell, 1998; Bajaj et al., 2001a, 2001b; Fernández-de-las-Peñas, 2009). Fernández-de-las-Peñas (2009) examined the relationship between TrPs and facet joint hypomobility. He postulated that increased tension from taut bands may maintain abnormal facet joint compression and displacement and, conversely, abnormal sensory input from dysfunctional facet joints may reflexively activate TrPs. Persistent nociceptive input from any number of tissues of the spine leads to an increase in responsiveness of the corresponding dorsal horn neurons (Mense, 2008; Taguchi et al., 2008) and, through antidromic mechanisms, sensitisation of the tissues at the same segmental levels. Hoheisel and colleagues (2011) established that, in anaesthetised rats, the nociceptive input from the thoracolumbar fascia increased significantly from 4% to 15% in animals with an experimentally induced inflammation of the lumbar multifidus muscle.

Several studies have examined the role of TrPs in the aetiology and maintenance of low back pain. Teixera and colleagues (2011) identified the presence of TrPs in 85.7% of patients diagnosed with failed back surgery pain syndrome primarily in the quadratus lumborum and gluteus medius muscles. Similarly, Njoo and van der Does (1994) reported a greater number of TrPs in the quadratus lumborum and gluteus medius muscles in patients with nonspecific low back pain versus control patients. Iglesias-González and colleagues (2013) examined the quadratus lumborum, iliocostalis lumborum, psoas major, piriformis, gluteus minimus, and gluteus medius muscles in patients with nonspecific low back pain. They confirmed the prevalence of active TrPs in the quadratus lumborum, gluteus medius, and iliocostalis lumborum muscles. There is a strong correlation between the prevalence of TrPs and persistent back pain (Chen & Nizar, 2011). The trapezius, piriformis, and quadratus lumborum muscles were most commonly involved with a favourable outcome after DN interventions. These findings suggest that the persistence of pain may in fact be due to unresolved TrPs. Cornwall and colleagues (2006) injected the lumbar multifidus muscles with hypertonic saline at the L4 level to examine their referral patterns. All subjects reported local pain with 87% reporting referred pain into the anterior or posterior thigh. Samuel and colleagues (2007) established the connection between muscle-induced pain and lumbar disc disease in a study of 60 subjects with lumbar disc prolapse. There was a significant association between disc disease and the presence of TrPs in muscles innervated by the corresponding segmental level, i.e., L4-L5 lesions with anterior tibialis TrPs. In a similar type of study, Hsueh and colleagues (1998) found an association between the level of disc lesion and cervical and trunk muscles with TrPs. The latissimus dorsi muscle was involved with lesions at the C3-C4, C5-C6, and C6-C7 levels, and the rhomboid minor muscle was involved with lesions of C4-C5, C5-C6, and C6-C7 levels.

A less recognised contributing factor to low back pain and, indeed, to pain throughout the body is dysfunctional breathing. Dysfunctional breathing includes breathing pattern disorders such as hyperventilation, periodic deep sighing, thoracic-dominant breathing, forced abdominal breathing, and thoracoabdominal asynchrony, which is better known as paradoxical breathing (Boulding et al., 2016). Breathing pattern disorders can adversely affect posture and can induce muscle pain (Chaitow, 1997, 2004; Hodges & Richardson, 1999; Hodges et al., 2001; Courtney, 2009; Neiva et al., 2017), which can subsequently lead to the development of TrPs due to overuse of certain muscles. Beeckmans and colleagues (2016) reported a significant correlation between low back pain and the presence of respiratory disorders such as asthma, dyspnea, respiratory infections, and different forms of allergy. To date, no articles have been published on the correlation between hyperventilation syndrome and low back pain (Beeckmans et al., 2016); however, hyperventilation is the most commonly researched and described type of dysfunctional breathing (Boulding et al., 2016).

Hyperventilation is associated with a variety of conditions, including asthma (Ogata et al., 2006; D’alba et al., 2015), anxiety (Howell, 1997), panic disorder (Hasler et al., 2005; Meuret & Ritz, 2010), endocrine diseases (Lencu et al., 2016), and mouth breathing (Han et al., 1997). A primary symptom of hyperventilation is dyspnea or difficulty in breathing (Boulding et al., 2016), which can cause an increase in the respiratory rate leading to hyperventilation. Several medical conditions are associated with dyspnea, including mental disorders and asthma (Berliner et al., 2016), and these conditions have an established relationship with hyperventilation. Others conditions such as liver disease (Kaltsakas et al., 2013), lung disease, and cardiovascular system disorders (Berliner et al., 2016) are also associated with dyspnea but have not been specifically considered with hyperventilation, although the physiological changes that occur support a correlation.

Hyperventilation leads to respiratory alkalosis (primary hypocapnia), an increase in the body’s pH, decreases in partial pressure of carbon dioxide (PaCO₂), and compensatory decreases in blood bicarbonate (HCO₃) levels (Porth, 2011; Greger & Windhorst, 2013; Johnson, 2017). This, in turn, results in a host of neurophysiological changes, including an increased affinity of haemoglobin for oxygen, sympathetic nervous system dominance, anxiety and panic, vasoconstriction, and smooth and skeletal muscle spasm and constriction (Porth, 2011; Greger & Windhorst, 2013). With reduced blood flow and diminished availability of oxygen, muscles become prone to fatigue and the formation of TrPs. The hypoxic environment stimulates the release of nociceptive substances, for example, bradykinin, calcitonin gene-related peptide, and prostaglandins, among others; these substances in turn perpetuate TrP sensitisation and pain (Dommerholt & Shah, 2010). Deleterious effects on spinal stability and skeletal alignment may occur. Studies in which strenuous exercise was simulated revealed reduced postural functions of both the transverse abdominus and diaphragm as respiratory demands increased. Spinal stabilisers become overloaded, making them more vulnerable to injury. Hyperactivity of accessory muscles of respiration such as the pectoralis major and minor, upper trapezius, levator scapula, and sternocleidomastoid may occur with resulting rib cage stiffness, forward head posture, suboccipital compression, headaches, and temporomandibular joint disease (Hruska, 1997, 2002; Courtney, 2009; Bartley, 2010). Inactivation of TrPs of the neck, thorax, abdominal wall, and low back may assist in restoring normal breathing mechanics. Conversely, breathing retraining may help prevent the development of TrPs in the first place. All 29 subjects with neck or back pain, who had plateaued with manual therapy and exercise, had a low end tidal CO₂, which is an indication of arterial CO₂ in people with normal cardiopulmonary function (Mclaughlin et al., 2011). All patients experienced improved pain, function, and end tidal CO₂ with breathing retraining.

Muscle pain related to visceral disease occurs in more predictable, specific patterns than that of breathing dysfunction. Muscle hyperalgesia is triggered by a reflex arc known as the visceral-somatic reflex. Noxious signals from a distended organ are thought to trigger neuroplastic changes in the dorsal horn of both sensory neurons and of neighbouring efferent neurons. The resultant efferent signals create neurogenic inflammation, hyperalgesia, and TrPs in somatic structures sharing the same segmental level (Gerwin, 2002; Giamberadino et al., 2002; Montenegro et al., 2009). Examples of visceral disease and their associated pain referral include myocardial infarction with the left pectoralis major, ureteral colic with the iliocostalis, dysmenorrhea and interstitial cystitis with the lower abdominals, cholecystectomy with the latissimus dorsi, and pleurisy with thoracic multifidi (Boissonault & Bass, 1990). A single session of DN to the thoracolumbar multifidi and iliocostalis lumborum in a patient with constipation resulted in a complete resolution of his symptoms. DN of the abdominal muscles in patients with endometriosis can quickly relieve the symptoms (Jarrell et al., 2005). Furthermore, wet needling of the abdominal muscles can improve the severity of chronic pelvic pain (Montenegro et al., 2015) and dysmenorrhea (Huang & Liu, 2014). Because myofascial pain syndromes may predict, outlast, or mimic visceral disease, a detailed knowledge and awareness of visceral-induced pain patterns is essential for accurate differential diagnosis.

Dry needling of the trunk muscles

Some of the muscles on the trunk are covered in other chapters. The pectoralis major and minor muscles are discussed in Chapter 8. The iliacus muscle, gluteal muscles, and pelvic muscles are reviewed in Chapter 11.

Rhomboid Major and Minor Muscles

• •  Anatomy:
  
  
  
  1. 1. The rhomboid major muscle arises from the spinous processes and supraspinous ligaments of the second to fifth thoracic vertebrae and descends laterally to the medial border of the scapula between the root of the spine and the inferior angle with direct attachments to the serratus anterior muscle (Porterfield & DeRosa, 1995). Anatomical variations of the origin of this muscle have been reported (Lee & Jung, 2015) with the upper end of the origin of the ligamentum nuchae between C5 and C6 on the left and the ligamentum nuchae of C6 on the right. The lower end of the origin of this muscle was the spinous process of T4 on the left and the spinous process of T2 on the right.
     
  2. 2. The rhomboid minor muscle runs from the distal ligamentum nuchae and the spines of the 7th cervical and first thoracic vertebrae to the base of the triangular surface of the medial end of the scapula spine. An anatomical variation of the origin of this muscle has also been described, with it coming from the ligamentum nuchae between C5 and C6 on the left and the ligamentum nuchae at C6 on the right (Lee & Jung, 2015).
  
  
• •  Function: Both muscles retract the medial border of the scapula superiorly and medially.
  
• •  Innervation: Dorsal scapular nerve C4-C5, via the upper trunk of the brachial plexus.
  
• •  Referred pain: Pain is projected to the medial border of the scapula and superiorly over the supraspinatus muscle. However, in clinical practice, the referred pain pattern of the rhomboid muscles appears to include the referred pain patterns originally attributed to the serratus superior posterior muscle with pain projecting as a deep ache to the anterior surface of the scapula, posterior aspect of the scapula and shoulder, triceps region, olecranon, ulnar side of the forearm and hand, and the entire fifth digit.
  
• •  Needling techniques:
  
  
  
  1. 1.  The patient lies prone with the arm at the side hanging off the table or in the hammerlock position. Secure the TrP over a rib between the proximal phalangeal joints of the index and middle fingers, which are placed in the intercostal spaces above and below. Insert the needle perpendicular to the skin in between the distal phalangeal joints, and angle it tangentially toward the TrP, while staying over the rib (Fig. 10.1). If the TrP cannot be positioned directly over a rib, needle the muscle over the closest rib without aiming for the TrP.

• 
  
  
  
  1. 2.  Using a 5-cm needle, insert the needle perpendicular to the skin close to the TrP. Direct the needle perpendicular to the direction of the individual ribs in a shallow to gradually deeper fashion toward the TrP (Fig. 10.2). This technique is always performed in a ‘downhill’ fashion, which, depending on the curvature of the spine at the TrP location, is either in a caudal or cranial direction.

• •  Precautions: The lungs can easily be penetrated if the intercostal spaces are not blocked with the fingers with the first technique. The needle should always be directed toward the rib, with the fingers remaining in the intercostal spaces. With the second technique, the lungs can be reached when a needle shorter than 5 cm is being used or when the needling is performed in an ‘uphill’ direction.

Middle Trapezius Muscle

• •  Anatomy: The middle trapezius muscle attaches medially to the spinous processes and the supraspinous ligaments of C7-T3. Its fibres run transversally to attach laterally to the superior lip of the scapular spine and to the acromion. Johnson and colleagues (1994) described that the muscle originates from C7 and T1 with the C7 fascicle attaching to the acromion and the T1 fascicle attaching to the scapular spine.
  
• •  Function: The superior fibres assist with scapular adduction and serve as part of the force couple for upward rotation of the scapula. The inferior fibres adduct the scapula. The entire muscle assists with scapular stabilisation during flexion and abduction of the arm.
  
• •  Innervation: The spinal portion of the spinal accessory nerve (cranial nerve XI) supplies motor fibres (Standring, 2016). The spinal accessory nerve forms an anastomosis with fibres from C2-C4 (Caliot et al., 1989; Kim et al., 2014; Lanisnik et al., 2014; Brennan et al., 2015). Although it is thought that these fibres carry sensory information, there is electromyographic (Pu et al., 2008; Kim et al., 2014) and histochemical (Pu et al., 2008) data that shows that the nerves have both sensory and motor functions, thereby contributing to some degree to contraction of the three portions of the trapezius muscle. The motor input from the C2-C4 nerves is not consistently present or is irregularly innervated to the three parts of the muscle when it is present (Kim et al., 2014).
  
• •  Referred pain: TrPs may refer to the acromion. A superficial burning pain may be felt in the interscapular region.
  
• •  Needling techniques:
  
  
  
  1. 1.  The patient lies prone with the arm at the side hanging off the table or in the hammerlock position. Secure the TrP over a rib between the proximal phalangeal joints of the index and middle fingers, which are placed in the intercostal spaces above and below. Insert the needle perpendicular to the skin in between the distal phalangeal joints, and angle it tangentially toward the TrP, while staying over the rib (Fig. 10.3). If the TrP cannot be positioned directly over a rib, needle the muscle over the closest rib without aiming for the TrP.

• 
  
  
  
  1. 2.  Another technique involves securing the taut band via a pincer grip with the TrP between the index finger and the thumb. The needle is inserted perpendicular to the skin in between the index and middle finger and directed toward the TrP and the underlying thumb (Fig. 10.4).

• 
  
  
  
  1. 3.  Using a 5-cm needle, insert the needle perpendicular to the skin close to the TrP. Direct the needle perpendicular to the direction of the individual ribs in a shallow to gradually deeper fashion toward the TrP. This technique is always performed in a downhill fashion, which, depending on the curvature of the spine at the TrP location, is either in a caudal or cranial direction, similar to needling the rhomboid muscles (Fig. 10.5).

• •  Precautions: With the first approach, the lungs can easily be penetrated if the intercostal spaces are not blocked with the fingers or the muscle held in a pincer palpation. The needle should always be directed toward the rib with the fingers remaining in the intercostal spaces or towards the thumb. The second technique has no specific lung field precautions; however, with the third technique, the lungs can be reached when a needle shorter than 5 cm is being used or when the needling is performed in an uphill direction.

Lower Trapezius Muscle

• •  Anatomy: The lower trapezius muscle attaches medially to the spinous processes and the supraspinous ligaments of T4-T12. Its fibres run supero-laterally and attach to an aponeurosis on the medial end of the spine of the scapula. Johnson and colleagues (1994) concluded that the lower part of the trapezius muscle starts at T2 with fascicles arising from the spinous processes. The fascicles from T2 to T5 converge to a common aponeurotic tendon that attach on the scapula at the deltoid tubercle. According to the authors, fascicles from T6 to about T10 insert into the medial border of the deltoid tubercle. Lower fascicles insert into the lower edge of the deltoid tubercle.
  
• •  Function: The muscle acts synergistically with the lower portion of the serratus anterior and the upper trapezius muscles in upward rotation of the glenoid fossa. Electromyographic studies support that the muscle is active during upward rotation activities along with the upper and middle trapezius (Ebaugh et al., 2005; Pizzari et al., 2014).
  
• •  Innervation: The spinal portion of the spinal accessory nerve (cranial nerve XI) supplies motor fibres (Standring, 2016). The spinal accessory nerve forms an anastomosis with fibres from C2-C4 (Caliot et al., 1989; Kim et al., 2014; Lanisnik et al., 2014; Brennan et al., 2015). Although it is often thought that these fibres carry only sensory information, there is electromyographic (Pu et al., 2008; Kim et al., 2014) and histochemical (Pu et al., 2008) evidence that the nerves have both sensory and motor functions, thereby contributing to some degree to contractions of the three portions of the trapezius muscle. The motor input from the C2-C4 nerves is, however, not consistently present or is irregularly innervated to the three parts of the muscle when it is present (Kim et al., 2014).
  
• •  Referred pain: TrPs may refer to the posterior neck and adjacent mastoid region, to the acromion, and to the suprascapular and interscapular regions.
  
• •  Needling technique:
  
  
  
  1. 1.  The patient is positioned in prone with the arm at the side hanging off the table or in the hammerlock position. Secure the TrP over a rib between the proximal phalangeal joints of the index and middle fingers, which are placed in the intercostal spaces above and below. Insert the needle perpendicular to the skin in between the distal phalangeal joints, and angle it tangentially toward the TrP, while staying over the rib (Fig. 10.6). If the TrP cannot be positioned directly over a rib, needle the muscle over the closest rib without aiming for the TrP.

• 
  
  
  
  1. 2.  Another technique involves securing the taut band via a pincer grip with the TrP between the index finger and the thumb. The needle is inserted perpendicular to the skin in between the index and middle finger and directed toward the TrP and the underlying thumb (Fig. 10.7).

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