Intramuscular Manual Therapy / Trigger Point Needling
What is Intramuscular Manual Therapy?
Intramuscular Manual Therapy, also known as Trigger Point Needling or Dry Needling, is a cost effective and efficient technique for the treatment of myofascial pain and dysfunction.
The approach is based on Western anatomical and neurophysiological principles and should not be confused with the Traditional Chinese Medicine (TCM) technique of acupuncture (Travell & Simons 1999).
What can Intramuscular Manual Therapy help?
Conditions which respond to Intramuscular Manual Therapy include:
- Headaches
- Frozen Shoulder
- Tennis Elbow
- Muscle Spasms
- Fibromyalgia
- Sciatic Pain
- Hip Pain
- Knee Pain
- Repetitive Strain Injuries
Myofascial Trigger Points (MTrP)
A Myofascial trigger point is an area of elevated neurological activity located in muscle/ fascia (connective tissue) that may refer pain in a localized or peripheral manner.
The trigger points feel like lumps in the muscle or connective tissue that are extremely sensitive to pressure. Trigger points often become self perpetuating once they have taken hold. Releasing trigger points typically requires active treatment.
Each specific trigger point on the body has a referred pain or other symptom pattern. Myofascial TrPs can entrap the nerves, blood, and lymph vessels, causing a variety of symptoms that confuse doctors and patients alike. Therapy includes direct manipulative techniques externally and internally that will improve abnormal musculoskeletal physiology.
Specific exercises to stretch or strengthen certain muscles or muscle groups may be advised and taught.
Physicians Dr. Travell and Simons defined a myofascial trigger point as a "Hyperirritable spot in a skeletal muscle".
The spot is painful on compression and can give rise to characteristic referred pain, referred tenderness, motor dysfunction and autonomic phenomena.
Myofascial trigger points (MTrPs) are commonly seen in both acute and chronic pain conditions.
Hendler and Kozikowski cite Myofascial trigger points as the most commonly missed diagnosis in chronic pain patients.
Over the years it has been shown that it is possible to deactivate TrPs by injecting them with a large number of disparate substances (Lu & Needham 1980) The only reasonable inference drawn from this is that the pain relief obtained is not dependent on the specific properties that the substance may contain but rather on the stimulation of the needle used for the injection itself.
One of the first physicians to employ Intramuscular Manual Therapy extensively for this purpose was Dr Karel Lewit of Czechoslovakia . Lewit (1979) reported favorably on the use of this technique in a series of 241 patients with musculoskeletal pain.
The work of Hong and Jennifer Chu support Lewitt's work and emphasise the therapeutic importance of eliciting a LTR (local twitch response).
Intramuscular Manual Therapy may mechanically disrupt the integrity of the dysfunctional endplates within the trigger area - resulting in mechanical and physiological resolution of the TrPs. A fascinating new study by Jay Shah shows biochemical changes in the TrP following twitch elicitation. This was done by real time blood micro-sampling of the TrP as it was needled.
Many years of work by Drs David Bowsher and Peter Baldry show a strong pain inhibitory role played by Opioids released by needling stimulation of A Delta receptors.
Dr Chan Gunn in his I.M.S. approach and Dr Fischer in his segmental approach to Intramuscular Manual Therapy strongly advocate the importance of clearing TrPs area in both peripheral and spinal areas.
Today many Medical doctors, Physical Therapists, Chiropractors and Acupuncturists are using Intramuscular Manual Therapy effectively and extensively within their practices for the treatment of Myofascial Pain and Dysfunction.
How does Intramuscular Manual Therapy work?
1. Something causes pain. If it happens often enough or if the trauma is great enough, the pain signal may return through the Sympathetic Ganglion and activate Primany Afferent Nocioceptors (H) which will feedback to the spinal cord.
This will cause pain to continue instead of fade. It's called a Reflex Arc.
2. At the same time motor neurones may become stuck in a feedback loop/ reflex arc, facilitating muscle spasm. In some cases the reflex arc continues for years, even decades.
3. Introducing a new stimulus (i.e. the needle) impedes the reflex arc and has the effect of relaxing the muscle.
In this situation the original pain causes a self-sustaining cycle of pain. For more information see Pain by Dr. Howard L. Fields, McGraw Hill 1987 (ISBN: 978-0070207011)
How does Intramuscular Manual Therapy stop this cycle?
Putting a needle into a spasmed muscle causes the muscle to relax. This can be seen with an electromyogram.
Activity in a spasmed muscle reduces in amplitude and becomes regular instead of sporadic.
A spasmed muscle becomes a damaged muscle. Spasm reduces blood flow in the muscle. This means less oxygen and food to the muscle. Muscle fibers die off and get replaced by fiberous scar tissue. This in turn holds the muscle tight, prevents muscle metabolytes from leaving the muscle and causes continued spasm and pain.
What does Intramuscular Manual Therapy feel like?
Most people’s experience of needles is of those used in injections and blood tests.
Thin, Filament Needles which are used in Intramuscular Manual Therapy bear little resemblance to hypodermic needles. They are much finer and are solid rather than hollow. When the needle is inserted, the sensation is often described as a tingling or dull ache.
Needles are inserted either for a second or two, or may be left in place a little longer, depending on the effect required. During treatment, patients commonly experience heaviness in the limbs or a pleasant feeling or relaxation.
The benefits of Intramuscular Manual Therapy frequently include more than just relief from a particular condition. Many people find that it can also lead to increased energy levels, better appetite and sleep as well as an enhanced sense of overall well being.
Are there any side effects?
As long as the practitioner understands anatomy sufficiently there are very few side effects. Side effects are very rare but when they do happen the most frequent and the most serious is that of a pneumothorax. This is where a needle pierces the lung leading to its partial or full collapse. This happens mostly when a needle is inserted into the Trapezius muscle in a certain way and too deeply.
Is Intramuscular Manual Therapy the same as Acupuncture?
No. Acupuncture is based on the ancient Chinese philosphy of the balance of Yin and Yang. Needling certain points along 'meridians' aid this process.
Intramuscular Intramuscular Manual Therapy is a method of reducing chronic pathological muscle shortening using needles.
Where is Intramuscular Manual Therapy helpful and how does it work?
Many painful symptoms are caused by the development of myofascial trigger points within muscles and the connective tissue of the body. These can develop as a result of imbalances in the optimum functioning of the spine and peripheral joints, as a result of overuse or incorrect use of parts of the body, or as a result of a direct injury. These trigger points are capable of becoming a source of both local and referred pain.
Following the identification of these points, Intramuscular Manual Therapy techniques are capable of deactivating them and thus reducing the pain associated with them. Occasionally, as a result of injuries and particular spinal injuries severe muscle spasm can develop. Not only can this cause additional pain in itself, but it can also present the body from returning to its healthy state.
Intramuscular Manual Therapy is capable of releasing this spasm, thus allowing the body to return more quickly to normal and also to allow further treatment to be carried out. Sometimes pain arises as a result of chronic irritation and strain to structures of the body. With "Tennis Elbow" for example, there is chronic irritation at the attachment of the tendons to the bone. Inflammation and pain develops with the result that the muscles tighten and shorten. This causes further strain and a self-perpetuating cycle ensues. In this instance Intramuscular Manual Therapy of the affected tissues can stimulate local healing processes as well as releasing trigger points and shortened muscles.
For more information please email us at info@maherPT.com
Hong, C.Z. 1994b. Lidocaine injection versus Dry Needling to myofascial trigger point. The importance of the local twitch response. American Journal of Physical Medicine and Rehabilitation 73:256-263
Cummings, T.M., White, A.R. 2001. Needling therapies in the management of myofascial trigger point pain. Archives of Physical Medicine and Rehabilitation 82:986-992