12 Superficial dry needling
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 cramp-like 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 10–30 minutes before it can be released. Gunn’s contributions are described in detail in Chapter 14 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 following 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.
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 et al. (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 non-current 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.
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 have a genetically determined ability to secrete excessive amounts of endorphin antagonists (Peets & Pomeranz 1978, Han 1995, 2001).
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 5–10 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 2–3 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.