Chapter 13

Superficial Dry Needling

Peter Baldry (1920–2016)

Introduction

After a long and distinguished career with many contributions to a broad range of medical applications, not the least the field of dry needling, Dr. Peter Baldry has passed away. In honor and recognition of his many contributions, we have not altered this chapter from the first publication.

In the treatment of myofascial trigger point (TrP) pain, the Czech physician Karel Lewit was one of the first to advocate the insertion of a needle deep into the muscle in order to penetrate the TrP itself. Lewit (1979) stated ‘that the effectiveness of deep dry needling (DDN) is related to the intensity of pain produced at the trigger zone and to the precision with which the site of maximum tenderness is located by the needle’. Chan Gunn, a Canadian physician, has also written extensively in support of a technique denominated ‘intramuscular stimulation’ (Gunn, 1996). This involves inserting a needle deep into the muscle at a TrP site, but, unlike Lewit, Gunn is of the opinion that it is not necessary to penetrate the TrP itself. Nevertheless, it can be a somewhat distressing procedure because, as Gunn has stated, when a needle is inserted into a tightly contracted band of a muscle, the patient may experience a peculiar cramplike sensation as the needle is grasped, which at times can be excruciatingly painful. Furthermore, because the spasm is frequently prolonged and, due to this, the needle is so firmly grasped, it may take 10 to 30 minutes before it can be released. Gunn’s contributions are described in detail in Chapter 15 of this book.

Another advocate of DDN is Jennifer Chu, an American physician who is strongly influenced by Gunn. She reserved DDN specifically for the alleviation of TrP pain that occurs as a secondary event after the development of either a cervical or lumbar radiculopathy (Chu, 1997, 1999). Although the focus of this book is mostly on DDN, this chapter aims to describe an alternate needling approach to the management of patients with myofascial pain and TrPs.

Superficial dry needling

When starting to deactivate TrPs myself in the 1970s, it was initially my practice to employ Lewit’s deep dry needling technique. However, when in the early 1980s a patient was referred to me with pain down the arm from a TrP in the anterior scalene muscle, it seemed to me unduly hazardous to push the needle into the muscle itself because of the proximity to the apex of the lung. Thus I inserted it only into the subcutaneous tissues, immediately overlying the TrP. This proved to be all that was necessary; for after leaving the needle there for about 30 seconds, on taking it out, not only had the exquisite tenderness at the TrP site disappeared, but also the pain in the arm had been alleviated. This superficial dry needling (SDN) technique was then employed to deactivate TrPs present in deeper lying muscles in various parts of the body and found to be equally efficacious.

Macdonald and colleagues (1983), at Charing Cross Hospital in London, have provided evidence for the efficacy of SDN in a trial carried out on patients with pain arising from TrPs in the lower back. In their study, 17 patients with chronic myofascial pain in the lumbar region were divided into two groups. The treatment group had needles inserted to a depth of 4 mm at TrP sites. The control group had electrodes applied to the skin overlying TrPs with noncurrent carrying wires attached to a specially impressively adapted transcutaneous electrical nerve stimulation machine replete with flashing lights, dials, and a cooling system that made a ‘whirring’ sound! The results of this trial showed that the effectiveness of SDN is significantly greater than that of a placebo.

Variable reactivity to needle-evoked nerve stimulation

Felix Mann, a medical acupuncturist in London, was one of the first to stress that the responsiveness of individuals to needle-evoked nerve stimulation is widely variable with a minority being either particularly strong or weak reactors (Mann, 1992). There are now grounds for believing that the latter group of people has a genetically determined ability to secrete excessive amounts of endorphin antagonists (Peets & Pomeranz, 1978; Han, 1995, 2001).

Procedure recommended for the carrying out of superficial dry needling

In view of the above considerations, it is the authors’ practice (Baldry, 1995, 1998, 2001, 2002a, 2002b, 2005) when using SDN at a TrP site to initially insert a needle (0.3 mm in diameter and 30 mm long) into the tissues overlying the TrP to a depth of about 5 to 10 mm, thus allowing it to be self-standing and then leaving it in place initially for about 30 seconds. An active TrP is of such exquisite tenderness that the application of firm pressure to it gives rise to a flexion withdrawal reaction (the jump sign) and often to the utterance of an expletive (‘shout’ sign). On withdrawing the needle, pressure equal to that initially employed is reapplied to the TrP site to assess whether these two reactions have been abolished. This is usually the case, but if not, the needle is reinserted and left in the tissues for 2 to 3 minutes. Occasionally, in a particularly weak reactor, it is found necessary to stimulate even more strongly by reinserting the needle and not only leaving it there for an even longer period but also by intermittently twirling it. The reason for determining each patient’s responsiveness in this way is because exceeding a patient’s optimum needle stimulation requirement is liable to cause a temporary but nevertheless distressing exacerbation of pain. This having been said, it must be remembered that there is a small group of patients that are such very strong reactors that leaving a needle in situ for even 30 seconds is more than is required. In such cases, all that is necessary is to insert the needle into the tissues and to then immediately withdraw it.

The initial consultation

In view of all this, before SDN is embarked upon, it is necessary to inform the patient that any pain relief initially obtained may only last for 1 to 2 days and that conversely, but rarely, due to the particular technique adopted, there may be a temporary exacerbation of it. The patient should also be told that needling is initially carried out once a week and that after a time, when necessary, at increasingly long intervals. It also has to be explained that the number of treatment sessions, the length of time between each one and the period for which they have to be given is dependent on whether an individual is a strong, average, or weak responder, and on the length of time the pain has been present before treatment being started.

Systematic search for trigger points

As it is essential for needling to be carried out at every TrP, it is clearly important for the search for them to be done in a systematic manner. Then, after treatment, it is necessary to palpate the muscles in the affected region again to ensure that no TrP has been overlooked.

It is necessary at the first treatment session to deactivate only one TrP at a time, as by this means it is possible to assess whether or not the patient is a strong, weak, or average responder. Then on subsequent occasions, in everyone but strong reactors, all TrPs may be deactivated simultaneously.

Muscle stretching exercises

After each SDN, the patient should be encouraged to regularly stretch muscles that have become shortened as a result of the TrP activity. Any exercises designed to strengthen the muscles should, however, be avoided as these are liable to cause muscle overloading and the consequent reactivation of the TrP.

Measures to be taken to prevent trigger point reactivation

Clearly any pain relief obtained by the carrying out of SDN at TrP sites will not be maintained unless any underlying postural, anatomical, and biochemical disorders contributing to the initial development of TrP activity are recognised and corrected.

Postural Disorders

After treatment of TrP pain in the neck, the patient should be told to avoid postures that cause the cervical muscles to become persistently kinked, flexed, or hyperextended. Examples include overloading as a result of lying in bed reading a book for a prolonged period by the light of a bedside lamp, keeping the neck muscles persistently elevated such as when sitting at a computer for any length of time, and causing them to become kinked for a long period as result of sleeping with the head on either too few or too many pillows.

During the initial physical examination, note should be taken as to whether one shoulder is higher than the other. If so, this may be due to a C-shaped scoliosis caused by unequal leg length, with one leg being 6 mm or less shorter than the other with, as a consequence, sagging of the shoulder on the side opposite to that of the short leg. Alternatively, if due to an S-shaped scoliosis, the leg length difference should be 1.3 cm or more with sagging of the shoulder on the same side as the short leg. In order to assess whether or not there is lower leg length inequality, the patient should stand with the legs straight and the feet together so that the relative heights of both greater trochanter and iliac crests can be compared. Alternatively, lower leg length inequality may be established by radiological examination (Travell & Simons, 1992). However, although this is clearly a more accurate investigation, it is in the authors’ experience not one that is always necessary.

Whenever a lower leg length inequality is found, it is necessary to decide whether this is a true one requiring the heel on the shorter side to be raised by increasing the thickness of the heel of the shoe or if it is an apparent one due to shortening of the quadratus lumborum muscle as a consequence of TrP activity in it and therefore correctable by treating this.

Management of Stress

Persistent stress may not only be a cause of TrP activity developing, but it also may cause it to persist (McNulty et al., 1994). Banks and colleagues (1998) have found that TrP electromyography (EMG) activity increases dramatically in response to emotional stress. It therefore often follows that treatment directed to reducing this is essential. The authors’ preferred method in such a case is to employ hypnotherapy and to teach the patient to carry out autohypnosis on a regular basis in a manner similar to that employed by Hilgard and Hilgard (1994).

Biochemical Disorders

Gerwin (1992, 1995) has drawn attention to the importance of those with TrP activity of excluding various biochemical disorders that are liable to cause this to persist. These include lack of vitamin B12, hypothyroidism, low serum folic acid levels, and iron deficiency. With respect to the latter, Gerwin and Dommerholt (2002) reported that ‘of women with a chronic sense of coldness and chronic myofascial pain, 65% had a low normal or below normal serum ferritin due to an iron intake insufficient to replace their menstrual iron loss’.

Summary

In this chapter the treatment of TrP pain with superficial dry needling has been advocated. It has been stressed that patients may be either strong, average, or weak reactors. This is why initially needling should only be carried out at one TrP site at a time in order to avoid giving a strong reactor a greater stimulus than required and, by so doing, exacerbating the pain. It is necessary to explain to patients with this disorder that treatment is initially given once a week and that in those with a short history of pain, this is usually all that is required. In cases, however, in which pain has been present for some considerable time, it should be made clear that treatment is likely to be necessary at gradually increasing intervals for a much longer period. It has also been emphasised that in addition to the carrying out of SDN, it is necessary to diagnose and treat any underlying disorder that may contribute to the development of TrP activity such as skeletal deformities, stress, and biochemical deficiencies.