Dry Needling – Why it Works.

Dry needling has been around for millennia. Acupuncture, a form of dry needling, started about 3000 years ago in China.  It needs to be said, however, that acupuncture is different from dry needling in concept, although the same thin needles are used. (They are called dry needles in that there is no central channel through which to inject medication).

A study was done on 40 patients undergoing knee replacement surgery. They were split into two groups as follows:

Group 1 were anesthetized, and then dry needles were placed into the trigger points around the knee. Following that they were operated on.

Group 2 were anesthetized and then operated on.

Group 1, or those that were treated with dry needles, reported significantly lower pain levels and required fewer analgesics post-surgery.

Group 2 required significantly higher levels of pain medication after their knee replacement surgery. This was an incredibly important study in that many studies are marred by the expectation of help via the placebo effect. The fact that those receiving dry needling were already asleep removed the risk of the placebo effect taking place.

del Maral Mayoral – Dry needling treatments for myofascial trigger points – J Muscuskeletal Pain 2010;18:114-6.

Dry needling is an effective way of treating myofascial trigger points. A trigger point or “taut band” is a section of muscle that is noticeably thicker than the muscle alongside of it. You have probably felt that in your shoulder muscles or upper trapezius before. Think of a time when you had a stiff neck and tried to self-massage your shoulder. You might have come across an area where the muscle felt thicker. It might have even had a specific shape, like a small pea or it may have felt like a marble. You might also have come across a ‘ropey’ area, a few centimeters of really tough muscle. Pressing into that might have elicited a heightened sense of pain and yet as you massaged into that you started to feel some of your shoulder/neck pain reduce. Congratulations, at that point you gained your first bit of trigger point knowledge.

Why describe them as trigger points?
The concept is similar to pulling a trigger on a gun. You press on a gun’s trigger and the pain is felt by the person across the room.  A muscular trigger point can refer pain. So it’s possible to press on a trigger point and have the person complain about pain elsewhere.

Trigger points will often be found in certain patterns. I have found that people with trigger points on their left QL (lower back) will often have issues on their right shoulder. A glute medius trigger point will often be linked to a trigger point on the biceps femoris muscle.

How do we form trigger points?
For whatever reason, a section of the muscle tightens in what has been described as a taut band. The section of the muscle shortens compared to the healthy muscle alongside of it. This shortened muscle can cause postural imbalances. I have often used the illustration of a sail ship with two guide ropes that hold the mast in place. Shorten the one rope and the mast gets pulled to the shorter side.

The body is similar.  A tight muscle on the one side will pull that part of the body towards itself, consequently throwing the body off balance. The goal is to release the tight muscle/rope so that we can get the body/mast back into balance.

The ship captain notices that the mast is bent. What does he do? 1. Go to the bent point and wrap it with bandages, or, 2. Study the system and notice that one rope is tighter/shorter than the other rope.

I have come across  many people suffering from ITB who have gone for some form of physical therapy, only to have the therapist focus solely on the knee. ITB comes as a result of either ankle or hip issues and is often the result of both. ITB injuries have been described as the result of a nasty divorce between the ankle and the hip. In short, therapists need to look both up and down the kinetic chain in order to work out what is actually going on.

Two important principles when it comes to therapy.
1. It takes time to fully understand what is happening with an injury. The therapist needs time to pick up all the clues.
2. You also don’t want to pay a therapist for 10 sessions of work done without experiencing any improvement. Einstein explained that the ultimate definition of insanity is doing the same thing again and expecting a different result.

My personal journey.
I have found that the more I can visualize the muscle in question and build a 3D model in my mind of what is happening, the better I am able to both rehab and dry needle. This really depends on a deep kinesthetic awareness of what one is doing. Dry needling is an inexact science and is dependent on a mix of  science, anatomy, and an almost intuitive sense of where to head with the dry needle.

Lets get a bit deeper into the physiology of what  happens during dry needling.

Acetylcholine and Motor End Plates.

At the point where a nerve fiber enters a muscle you have an area called a motor end plate. This is the interface between the nerve and muscle. It is a communication point where the nerve either instructs the muscle to contract or relax. It’s at this point where the muscle also communicates with the nerve as to how it is feeling.

The chemical, acetylcholine is responsible for communication between the nerve ending and the muscle. Remember that all communication via nerves is electrical. If the muscle reports pain it will be via a chemical exchange between muscle and nerve at the end plate via acetylcholine.

I am going to use lockdowns as a metaphor. Imagine a non-corrupt health minister for a moment. (I know, it’s difficult thing to do). He/she begins to receive reports of increased infections. Graphs are studied and the realization begins to dawn that the country is going into another wave of infections. Bad news is heading into the central command. The minister then issues a decree that places the country into a lockdown to protect itself.
In the same way that a lockdown theoretically slows down the rate of infection, it will also damage the economy. A muscle spasm works in much the same way. Reports from the muscle shoot up to the brain and the brain puts the muscle in a spasm to protect it. This results in altered motor/movement patterns that put other structures at risk. We now have some muscles not working correctly and others working too hard. Think of a limp. One group of muscles is shut off, while another group of muscles work really hard.
Remember this: a sore muscle is trying to protect you, but it does come at a price.

The affected muscle now becomes hypoxic and ischemic (it doesn’t get enough blood or oxygen). This triggers an increase of acetylcholine at the motor end plate. Remember, that’s the section where the muscle and nerve meet. Acetylcholine heightens the sense of pain and a catch 22 situation takes place. More pain, more negative news, leading to a higher level of lockdown.

To make matters worse, reduced oxygen levels in the unhappy muscle now brings about a drop in pH. Higher acidity in the muscle contributes to hyperalgesia (an increased sensitivity to pain). Something that should hurt you on a scale of 3/10 now begins to take over your life, as your body reports pain at 6/10.
Sluka K.A. et al have written a number of studies on this. It’s a complex mechanism that would take too long to describe in a post such as this.

The issue here is that the muscle is not sure when to come out of lockdown. This is where things like dry needling, massage, warmth, hyperbaric oxygen therapy and kinesiology tape come in. They help signal to the muscle/brain that it can ease off.

Some of the wonderful things that happen when we insert a needle.

The needle makes a small hole or to put it more technically, a focal lesion. The lesion triggers cell migration. (Leung 2012, p.267) observes that the “damaged” muscle first inflames itself via calcitonin gene related peptide. The area around the needle often goes a bit more red during this process. The inflammatory phase brings an increase of oxygenated blood into the area. That is really good. Over the next few days the body begins to repair itself. This process calls into play cells that reduce inflammation in the area as they begin their repair work. That is also really good. An immediate score and a long term score.

The needle also causes a small, localized stretch in the structures it effects. It is thought that this small stretch allows sarcomeres to resume their resting length. Sarcomeres are small sections in the muscle that contract, they essentially comprise the working sections of the muscle.

It also seems that as the needle enters into the fascia, we get a distortion of the connective tissue. This chemically will release adenosine phosphate compounds that will cause vasodilation. Remember, more blood in stressed areas is always a good idea. (Lund 2015) Vasodilation washes out fatigued and or algesic substances, which may result in improved functioning of the muscle  Many involved in dry needling will rotate the needle just before pulling it out. Wu (2015) writes that this movement winds up the near-by collagen fibers, thus changing the immediate interstitial environment.

Dry Needling and your Brain.

When a dry needle is inserted into muscle it acts as an irritant. Mechanoreceptors,(nerves that are tuned in to feel pressure), send a message up the spinal cord to the parts of the brain that modulate and perceive pain. A message is then sent back down the nerve pathway. What happens chemically and electrically is difficult to describe in a short paragraph like this, suffice to say that serotonin, glutamate, opioid and adrenergic systems are activated thus resulting is a localized reduction of pain.

Deep in the brain the needle affects pituitary hormone release. Hong 2013, recorded that endorphins are released as a response to dry needling. The chemical is similar to an opioid in that is reduces both pain and stress. The big difference is that endorphins are produced in your brain and so they do not come with a list of unwanted effects.

At the same time we get a decrease in noradrenaline in the brain and hence a decrease in sympathetic nervous behavior. To put it simply, the person feels more Zen as a result of the needling. Leung (2012)

As a big fan of purposeful and daily breath work I find it interesting that Anderson, Wise et.al. report that patients with myofascial pain often present with abnormal breathing patterns, such as hyperventilation, which leads to respiratory alkalosis. Chaitow recommends that myofascial release is often made more effective if breathing patterns are corrected. I regularly get people to do deep breath work while dry needling.

The following is a list of conditions that have been improved by the inclusion of dry needling as a treatment modality: endometriosis, low back pain, irritable bowel syndrome, surgical pain, whiplash, shoulder impingement, fibromyalgia, whiplash, tension-type headaches, migraines, lateral epicondylalgia, fibromyalgia, and temporomandibular disorders.

I do hope that this blog has shed a bit of light on the important role that dry needling has when it comes to massage, myofascial release and injury rehab. I have found it an incredibly important add on to what I do and, as an added benefit, it should not hurt. I would estimate that 95% of people that I look after don’t report any pain as a result of needle work.

Yours in promoting pain free living,

Mike Roscoe.