Module One Dry Needling PDF

In association with
Presents
Dry Needling
Module One
2013
Brought to you by
Optimal Dry Needling Solutions United Kingdom, USA, Europe and Middle East.- 2013 1
This handout is not an original manuscript, but a collection of useful basic
principles, clinical techniques and theories pertaining to the field of needling.
As physiotherapists, acknowledgement must be made to the in-depth

contribution of Drs Janet Travell and David Simons, for our working knowledge
of myofascial pain syndromes.
Our personal opinion is that their books are

mandatory equipment
for those of us involved in dry needling, and
should be purchased and studied by all.
Recently published Myofascial Trigger Points by Dommerholt & Huijbrechts

(2010) is an excellent contemporary summary of the pathophysiology relevant
to this course. Further indebtedness is owed to the many years of practical
clinical work and research done by Drs Chan Gunn and Andrew Fischer who
have further improved the skill of therapists in this field and have, together
with David Bowsher, Peter Baldry, and C-Z Hong, given us plausible Western
rationale on which to base our techniques.
While this course in no way teaches acupuncture, we acknowledge the Great

Tradition of Chinese Medicine.
Enjoy this wonderful approach to therapy!
Claire Waumsley
BSc. Physio (Wits), Dr. Chinese Med. (AHPCSA)
Claire Waumsley has been involved in teaching Dry Needling and promoting
awareness of the myofascia as a potential source of pain since the mid 1990s. She
has run courses extensively within Southern Africa, the Middle East and more
recently the United Kingdom and India and is a co-founder of Optimal Dry Needling
Solutions.
Claire spent many years working in large rural hospitals in Namibia, Malawi and
South Africa before moving into private practice. She now runs a practice on the
Cape West Coast of South Africa. Over the years she has worked within Animal
Rehabilitation, predominantly in the equine field.
She has presented papers and posters at the 1 st International Congress on Animal
Therapy in Oregon USA, the SA National Veterinary Congress, the University of
Pretoria Pain Congress and the United Arab Emirates International Pain Congress,
2009.
Claire is qualified as a practitioner of Chinese Medicine with the AHPCSA and uses
these skills within her scope of Physiotherapy.
She is a grandmother of nine and a keen open water swimmer.
Bruce Barker
BA, BSc. Physio (Wits)
Bruce Barker holds a Bachelor of Arts degree as well as a B.Sc. (Physio ) degree and is
currently registered as a M.Sc candidate at the University of the Witwatersrand in
Johannesburg. He is working on a dissertation concerning the use of Dry Needling
therapy in rotator cuff injuries.
Bruce previously worked in the U.K. for the N.H.S, and now works in the private
sector, running two practices within Gautengs West Rand area.
He mainly sees patients with musculoskeletal problems, many of whom are in the
Gold Mining Industry. Bruce has been teaching Dry Needling courses for ODNS since
2002. He is the Chairman of the Dry Needling Physiotherapy Special Interest Group in
South Africa, and is passionate about using evidence-informed, clinically relevant,
bio-psycho-social therapies to help people in pain.
Bruce is a keen cyclist, dedicated husband and father of two young children.
Steven Stavrou
BSc. Physio (Wits), Dr. Chinese Med. (AHPCSA)
Steven operates a multi-disciplinary Integrated Health Centre in Sandton,

Johannesburg, with the focus on "healing through natural treatments and
rehabilitation". He is qualified both as a Doctor of Chinese Medicine and as a
physiotherapist. The centre offers a unique integration of both Western Medical
treatments and natural health intervention.
He has been lecturing Dry Needling for nine years and has developed a
comprehensive two-day course on the Temporomandibular Joint. Both Biopuncture
and Prolotherapy are two specialised treatments that he offers to his patients.
Steven is a keen runner, having completed several Comrades ultra-marathons. He is a

devoted husband and father to his wife and son.
Day One - Index
1. Needling Basics 6
Neurophysiology 6
Choice of Needles 9
Dangers and Special Considerations 10
Contra-indications 12
Pneumothorax 13
Superficial Needling 15
Reactor Types 17
Clean Field Techniques 18
Ethical Considerations for Dry Needlers 21
2. Myofascial Pain 22
MPS 23
Treatment Options for MTrPs 25
3. Selected Abstracts: Clinically Relevant Articles 29
4. Muscles 30
Gluteus Maximus 30
Gluteus Medius 32
Gluteus Minimus 34
Piriformis 36
Short lateral rotators 39
Gastrocnemius 40
Soleus 43
Selected Abstracts 45
5. References and Recommended Reading 50
Indemnity Form 52
DN Information 53
Consent Form 54
Feedback Form 55
Drawings originally by Barbara Cummings for Travell and Simons book, Myofascial Pain and Dysfunction.
Redrawn for this manual by Karen Korte, Darling, South Africa.
1. Needling Basics
S. D. N (Neurophysiology)
Referenced from the excellent work of Dr David Bowsher and Dr Peter Baldry
As Physios ...
A- (V. helpful) C-Fibre (V. Troublesome)
Small myelinated 111 b fibres Unmyelinated

Polymodal fibres
Conduction time Slow conducting

10x faster than C
Receptors just under Found in all tissues

the skin, muscle and fascia except the C.N.S.
Receptors high-threshold Polymodal receptors

mechano-thermal
All or nothing In tissue

NB! Responds to trauma, thus
pin prick and sudden thresholds at
heat different levels
First trauma pain Second trauma pain
Warns body of impending injury Slow to get message
Withdrawal response Immobilisation
Clinically not real Response to avoid

pain, rather a get out of the way pain further injury and allow
stillness for
regeneration
Via N.S. T. tract Via Paleothalamic tract
Parietal lobe Frontal cortex

of somatosensory cortex
Accurately localised pain Diffuse dull, aching pain
Unaffected by morphine Abolished by morphine
Research Reviews
Subcutaneous tissue fibroblast cytoskeletal remodeling induced by

acupuncture: evidence for a mechanotransduction -based mechanism.
Langevin HM, Bouffard NA, Badger GJ, Churchill DL, Howe AK.
Source Department of Neurology, Vermont Cancer Center, University of Vermont College of Medicine, Burlington,
Vermont 05405, USA. helene.langevin@uvm.edu
Abstract
Acupuncture needle rotation has been previously shown to cause specific mechanical stimulation of
subcutaneous connective tissue. This study uses acupuncture to investigate the role of mechanotransduction-
based mechanisms in mechanically-induced cytoskeletal remodeling. The effect of acupuncture needle rotation
was quantified by morphometric analysis of mouse tissue explants imaged with confocal microscopy. Needle
rotation induced extensive fibroblast spreading and lamellipodia formation within 30 min, measurable as an
increased in cell body cross sectional area. The effect of rotation peaked with two needle revolutions and
decreased with further increases in rotation. Significant effects of rotation were present throughout the tissue,
indicating the presence of a response extending laterally over several centimeters. The effect of rotation with two
needle revolutions was prevented by pharmacological inhibitors of actomyosin contractility (blebbistatin), Rho
kinase (Y-27632 and H-1152), and Rac signaling. The active cytoskeletal response of fibroblasts demonstrated
in this study constitutes an important step in understanding cellular mechanotransduction responses to
externally applied mechanical stimuli in whole tissue, and supports a previously proposed model for the
mechanism of acupuncture involving connective tissue mechanotransduction .
Copyright 2006 Wiley-Liss, Inc.Am J Physiol Cell Physiol. 2005 Mar;288(3):C747-56. Epub 2004 Oct 20.
Dynamic fibroblast cytoskeletal response to subcutaneous tissue stretch ex

vivo and in vivo.
Langevin HM, Bouffard NA, Badger GJ, Iatridis JC, Howe AK.
Source Department of Neurology, Vermont Cancer Center, University of Vermont College of Medicine, Given C423,
89 Beaumont Ave., Burlington, VT 05405, USA. helene.langevin@uvm.edu
Abstract
Cytoskeleton-dependent changes in cell shape are well-established factors regulating a wide range of cellular
functions including signal transduction, gene expression, and matrix adhesion. Although the importance of
mechanical forces on cell shape and function is well established in cultured cells, very little is known about these
effects in whole tissues or in vivo.
In this study we used ex vivo and in vivo models to investigate the effect of tissue stretch on mouse
subcutaneous tissue fibroblast morphology. Tissue stretch ex vivo (average 25% tissue elongation from 10
min to 2 h) caused a significant time-dependent increase in fibroblast cell body perimeter and cross-sectional
area (ANOVA, P <0.01). At 2 h, mean fibroblast cell body cross-sectional area was 201% greater in
stretched than in unstretched tissue. Fibroblasts in stretched tissue had larger, "sheetlike" cell bodies with
shorter processes. In contrast, fibroblasts in unstretched tissue had a "dendritic" morphology with smaller, more
globular cell bodies and longer processes. Tissue stretch in vivo for 30 min had effects that paralleled those ex
vivo. Stretch-induced cell body expansion ex vivo was inhibited by colchicine and cytochalasin D. The dynamic,
cytoskeleton-dependent responses of fibroblasts to changes in tissue length demonstrated in this study have
important implications for our understanding of normal movement and posture, as well as therapies using
mechanical stimulation of connective tissue including physical therapy, massage, & acupuncture
Choice of needles
Needle thickness
There are 2 scales which can be confusing - an Imperial one and a metric one.
Gauge (U.K.) 43 32 30 28 26
Metric (mm) 0.22 .026 0.32 0.38 0.45
For superficial 'pin-prick' stimulation we need a 13-25 mm length needle of 0.22-0.30 mm

thickness. When needling the face use the thinner needles (0.22 mm).
Once our needles are 50 mm or longer it is desirable to have a thickness of at least 0.35
mm, due to the depth and strength of muscle tissue penetrated.
1. Length stipulated does not include the hilt or handle of the needle.
2. Needle tips/points
Two main types: Japanese and Chinese

Japanese type: very sharp, long pointing for easy insertion, especially where
scar tissue is present
Chinese type: pine shape point, or 'olive kernel' shape for less hooking of
needle. Tends to push tissue out the way rather than slice through and best for
use when working to depths close to periosteum or, indeed, periosteal pecking
Stainless steel needles are adequate. Gold and silver needles are used occasionally by TCM
practitioner for specific energetic effects. Some needles are bronze or copper coated to give
addition of static' effects.
Please endeavour to use needles that come pre-packed with guide tubes as this is a far more
hygienic option.
Optimal Dry Needling Solutions United Kingdom, USA, Middle East and Europe 2013 9
Dangers and Special Considerations
Associated with Dry Needling
Aids and Hepatitis

Please read Clean Field Technique in this manual.
Pneumothorax
Please see the separate section on pneumothorax in this manual. Always work obliquely
and superficially in this area, never penetrating more than 1 cm over the inter-costal areas.
Danger exists especially with Emphysematous patients.
Proper needling of trapezius to avoid apex of lung and also upper fibres of quadratus
lumborum must be observed. When needling the thoracic spine area, needle always
caudally and medially. There may be a congenital hole in mid scapula area, so take care
needling infraspinatus.
Pericardium
Never apply current (e-stims) across pericardium area or in patients with pace maker.
Injuries
Injuries should not occur if anatomical knowledge is sufficient. Be sure to complete an
anatomy module. Any injuries should be reported to your malpractice insurer as soon as
possible.
Broken Needles
Should not occur if needle quality and integrity checked before treatment -and correct gauge
selected. Never re-use a needle!
If a break should occur, forceps may be used to extract needle and if this fails, surgical
removal.
Stuck Needle
This may happen during turning, or lifting of needle and needle cannot be withdrawn. It may
happen in nervous patient, or due to spasm in muscles, if twist or turn of needle too wide in
extent, resulting in entangling of tissue fibres. Ensure patient co-operation before the
technique is attempted.
Informed consent must be obtained in writing before any dry needling may be attempted.
Failure to obtain this consent is a criminal offense. To remove a stuck needle, first
wait and see if the needle becomes less stuck on its own. Never ignore the therapeutic use of
time. After a time, ask the patient to relax muscles and breathe deeply -withdraw needle on
the out breath giving pressure to skin adjacent to needle. If no result, massage around the
area (using your finger). You may also insert another small needle (0.25x25mm) close to the
stuck one and twiddle vigorously while maintaining a constant withdrawal pressure. Try low
frequency laser in the area for 30 seconds, and then withdraw. Moxa and other heating
modalities are other very comfortable options. NEVER needle to depth of needle hilt as
the needle can be drawn into body by spasm, patient coughing or moving. Leave at least
5mm-10mm free needle shaft.
Optimal Dry Needling Solutions United Kingdom, USA, Europe and Middle East.- 2013
Pregnancy
There are no studies that show than DN is contra-indicated in pregnancy. However, it is
wise to note that extreme caution should be shown with pregnant women, especially in
the first trimester. Do not needle lumbar points as these may have referral effect to
uterus. Do not needle over pregnant abdomen/ uterus as you dont want in any way to be
accused of causing a miscarriage.
Fainting
This may occur in tense, nervous or tired patients. Treat patients lying down if possible. Use
fewer rather than many needles at first session or until you have established the reactor
type. In the event of a patient becoming pale, nauseous, or excessively sweaty/ faint, remove
all needles and lay patient with legs elevated -higher than head. Ensure adequate ventilation.
Fainting is rare. A rest of 10 -15 minutes should suffice with a hot drink if necessary.
(Hydration after any myofascial therapy is necessary).
Do not attempt needling again the same day.
Local Infections
This is rare as the subcutaneous tissues have a high resistance against thin needle puncture.
Concomitant use of the safety precautions in this manual will further protect the
practitioner and the patient. The clean field technique applies here.
Infection may be caused by inadequate sterilisation of needle, or traumatising the tissue by

inexperienced needling. Patients with bacterial endocarditis may need to be on antibiotics
for needling.
Bleeding
Avoid needling major blood vessels. Venepuncture is not the aim of dry needling. Patients
on anti-coagulants should not be needled vigorously or deeply. Hemophiliacs may be
needled with permission of their physician and may need a proactive dose of clotting factor.
Bent Needle
Bent needles may be caused by the patient moving his position during needling. Be sure the
patient is in a comfortable position before you start. Note that a sudden increase in needle
sensation may lead to severe muscle contraction (i.e. a local twitch response). If the needle
strikes against bone, the patient may also move involuntarily, but this is uncommon.
Avoid sudden increase in stimulation. The patient must be comfortable and told not to move
body during treatment. A strong Local Twitch Response may often bend needles, and the
patient must be reassured that this LTR is actually a good thing!
Inspect angle of bend and withdraw in direction of obliquity - if double bend, withdraw
gently step by step to prevent breaking of needle. Be gentle. Never withdraw forcefully.
Small shaking movements of needle may release it. Use time therapeutically.
Muscle Memory
Sometimes needling stress muscles where there has been a somatisation of an unpleasant
event-may lead to an emotional release esp. in stress muscles like Upper traps, Temporalis.
Contra-indications to Dry Needling
There are relatively few absolute contra-indications associated with dry needling. Those
that do exist are summarized as below.
Absolute contra-indications:
Lack of signed informed consent
Existing infection at the site
Patient phobia of needles
Patient unable to remain still or follow instructions
Therapist is not qualified in the correct technique for a given area
Allergy to surgical steel
Acute cardiac arrhythmia
Relative contra-indications:
All of the following patients may be needled if the listed precautions are adhered to:
Haemophiliacs Consult the patients specialist prior to needling. May need plasma
beforehand
Warfarin/ heparin take care to not needle vigorously; the actual risk has been
shown to be minimal (Geriatrics Aging 2008:11920:93-97)
Pregnancy Needling is NOT contra-indicated but please take care especially in the first
trimester. Needle with fewer needles and avoid the lower back and stomach areas.
This is a reasonable precaution rather than a contra-indication per se.
E-stims. These are only contra-indicated in the face, on the periosteum, and across the
chest ( if the patient has a pacemaker)
Muscle trauma: do not needle acutely injured muscles. You may however needle
superficially in the area to decrease pain and swelling.
Pneumothorax
The single biggest cause of concern among physiotherapists with regard to the dangers of
needling concerns pneumothoraces. There have been a number of such cases reported to
the malpractice insurers, and responsible therapists must take great care to avoid this
unwanted consequence. It is vital to carry malpractice insurance.
Definition
A pneumothorax is the name given to the condition where air or gas accumulates in the
pleural space, causing the characteristic dyspnoea, tight-chestedness and anxiety.
Causes
A Pneumothorax may develop spontaneously or be due to some form of trauma:
Spontaneous pneumothoraces may be either primary, where there is no underlying lung

pathology, or secondary where conditions like COPD, emphysema, asthma, Cystic
Fibrosis, T.B., certain forms of interstitial lung disease or cancers are present. Primary
spontaneous pneumothoraces occur predominantly in tall thin men between 20 and 40
years of age, and are due to the rupture of a bleb or a bulla in the lung. 9000 cases are
reported in the USA annually. Cigarette smoking and familial history are associated with
increased risk. Risk of recurrence is 50%.
Secondary pneumothoraces are serious events and are fatal in 15% of cases even if
treated.
Traumatic pneumothoraces may be caused by either blunt trauma as in a car

accident, or by penetrating trauma as in a knife wound or a needle stick
injury. For dry needlers the areas of risk are the anterior and posterior chest walls,
with particular reference to the rotator cuff muscles, the pectoral girdle, the
Sternocleidomastoid and the Scalenes. Please take care to follow the instructions
in the areas closely to avoid causing a pneumothorax.
Pathology
The air accumulates in the pleural space as it cannot drain out. This causes increasing
pressure on the lung tissue which may collapse under the pressure (tension
pneumothorax). The pressure may increase to such an extent that the mediastinum is
compromised, leading to a cardiac tamponade and death. Prompt insertion of an
underwater IC drain is required. Small pneumothoraces, however, resolve without
intervention in 10-14 days.
Signs and symptoms
Sudden and sharp chest pain made worse by breathing deeply.
Dyspnoea (SOBAR)
Tight chest
Very easily fatigued
Tachycardia
Bluish skin tinge as oxygen concentration drops
Acute anxiety and stress
Nasal flaring
Falling blood pressure
Diminished or absent breath sounds on auscultation
Tests
Chest X-Rays and arterial blood gasses are confirmatory.
What should I do if I suspect my patient has a Pneumothorax?

Send them to hospital immediately and have a CXR done. Give the history of where you
needled and how deeply. Note everything down accurately. If you are careful this will
never be a problem for you.
Advice for patients who have previously had a pneumothorax
Avoid high altitudes
Avoid SCUBA diving
Avoid uncompressed aircraft
Stop Smoking
Consult www.pneumoworld .org for a patient friendly site
Superficial Needling
Acute Chronic
Suitable analgesics Multiple pain areas likely to return, e.g.

unavailable, e.g. trauma, fibromyalgia, M.E., R.S.I., cancer pain.
Analgesics undesirable, Active scar referral. Needle diagonally
e.g. fracture or soft under scar and over scar referral areas,
tissue trauma in e.g. amputation, old surgical scars.
presence of possible (Note - cutting injury more likely to
head injury. cause neural dysfunction than crush
injury).
Acute muscle injury Anatomically superficial areas, e.g.

muscles in protective ligaments, fat pads, tendons,
spasm. Needle lightly face, ear and anatomically delicate
over direct skin area, areas.
e.g. Torticollis, calf tears,
back spasms,
headaches.
Key points to remember!

Patient's consent written, signed
Patients comfort
Wipe down area and therapist's hands with spirits / swab or Steri 601,
Hibitane, Steri 601, Dermabac, etc.
Sterile, single-use, needles
With physiotherapists, needling is most often used as a 'combination

'treatment'. Hot packing pre-needling will help to relax the patient (take
care not to heat too large an area - especially over the dorsal spine as this
may lead to drop in blood pressure and increased risk of fainting).
It is preferable to needle at the end of treatment once mobilization /

stretching, etc. has been done. This is for two reasons:
1. You have a better idea of patient's sensitive areas. Patient has

more confidence in you as a therapist now. Do not to massage
after skin puncture due to leakage of body fluids - (HIV & Hepatitis).
2. We are making use of A- stimulation of the bodys Opioid mediated
analgesic system. This may make the patient drowsy if overstimulated.
Notwithstanding the above, it is necessary to therapeutically stretch the

needled tissue after needling for maximal effectiveness of the technique.
What do I tell the patient?
The patient may be told that the pain he is feeling no longer serves a useful purpose - only of
Irritant value - therefore we want to jam its transmission to consciousness by needling -and
also increase the body's release of its own opioid pain relieving substances. Explain that
although not as painful as an injection (where we have a wide diameter needle with a
cutting edge), the dry needle has a fine gliding point and only a pin prick will be felt. This
may be followed by a numbing, or on occasion, an aching sensation.
For easy insertion the patient may be asked to breathe in, and the needle withdrawn during
an out breath. The needles may be left in 60 seconds to a few minutes when doing
superficial needling, or stimulated to numbness.
Please note that we do need the client to feel the initial pin prick sensation which tells us
that the OMAS has kicked in.
On removal, compression with a cotton swab to adjacent area facilitates withdrawal and will
stop any spotting if needling a vascular area.
Skin and subcutaneous tissue provide efficient defense, immune and repair processes in
response to any tissue damage regardless of how minor the assault. Therefore sepsis is
generally not a problem - however reasonable sterility of technique should be adhered to.
The patient should have an immediate effect of pain relief to a greater or lesser extent. This
depends on their reactor type. Depending on the condition treated this may last from half an
hour to a few days and in some instances one treatment is all that is required. The effect of
treatment is generally accumulative and patients should be encouraged to move more freely
once his pain has been dampened. Movement improves blood and oxygen supply to affected
areas, and brings in an effect of on-going A- pain inhibition.
Superficial needling may be done daily, 2-3 times a week - or as necessary. Care being taken
to preserve skin and tissue integrity and to prevent the patient from becoming needle shy.
It is possible that the patient may feel somewhat drowsy or disorientated after needling
and should therefore be warned not to go rushing into heavy traffic etc. directly after his
treatment. Refer to the section on reactor types for more detail here.
Reactor types
The clients neurochemical response to needling
Dr Felix Mann spoke of it being as important to know who to needle as how to needle.
Reactor types could be classified into:

Hyper strong
Strong
Normal
Slow
Non-responder (10% of the population responds poorly to medical morphine)
Care should be taken when treating:

Asthmatics
Migraine sufferers
Diabetics
Neurological conditions where membrane stabilization a problem
Fibromyalgia where serotonin mechanisms disturbed.
These patients generally respond well to needles but need to begin with only one or two
needles and the therapists then gauges the patients response to the treatment before giving
stronger treatment.
Understanding the opioid and serotonin aspect of needling will help us to determine when
dry needling is appropriate, e.g. just before an exam or sporting event could well fuzz the
clarity of decision making!
Anecdotally however, you can expect bright-eyed, blonde haired, allergic people to do well
(strong reactor, fewer needles), and drug addicts, severely depressed and chronic pain
sufferers to need a little more needling (Slow reactor).
Clean Field Techniques
Dry needling is an invasive technique. Care must be taken to ensure the safety of both
patient and therapist when using the technique.
The Basic Working Environment

The premises where the technique is performed should comply with regulations as set out
in the relevant Government Gazette1 .
The premises must conform to the professional guidelines for the practice of Physiotherapy
as these pertain to either hospital or rooms treatments. Such premises must include a
hygienic hand washing facility.
Home visits: The standards here should adhere as closely as possible to the clean
technique described below, with the proviso that no treatment should expose the
patient to harm. All related waste should be removed from the site.
Ethical Considerations
No therapist may practise any technique for which he/she has not been adequately trained.
It is the responsibility of each practitioner to ensure they have this training. The therapist is
required to obtain written informed consent from the patient before treatment. Such
consent must include informing the patient of the exact technique to be employed, the
potential risks of the technique and the likelihood of a measure of discomfort. Of particular
concern is the risk of causing a pneumothorax. This must be clearly explained in a written
document. See Appendix 1 Dry Needling Information.
The treatment area should comply with the Clean working environment principle
The treatment room should be free from dirt and dust, and should have a special working
area, such as a table covered with a sterile towel, on which sterile equipment should be
placed. This equipment (incl. containers of needles, cotton wool balls, and 70% alcohol, or
similar disinfectant e.g. Dermabac) should be sealed or covered with a sterile towel until
needed for use. Adequate light and ventilation should be provided throughout the
treatment rooms.
In all circumstances there must be sufficient space for a clean field of equipment, with
adequate lighting.
The Practitioner should have clean hands

Practitioners should always wash their hands before treating a patient. Washing the hands again
immediately before the needling procedure is particularly important in preventing infection, and
should include thorough lathering with soap, scrubbing the hands and fingernails, rinsing under
running water for 15 seconds, and careful drying on a clean paper towel. Thereafter, a
dermoprotective gel (Dermabac, Steritec, etc.) should be applied to the therapists hands and be
allowed to air-dry. (The use of gloves and alcohol swabs for protection of both therapist and
patient is recommended if a dermoprotective gel is not used).
1
In South Africa = No. 15907 of 12 August 1994. Of special reference here are sections 20 (Consulting rooms), 28 and Annexure 1, which
pertains to this section (Performance of Professional Acts).
Preparation of needling site
The needling sites need to be clean, free from cuts, wounds or infections. The area to be
treated should be covered with a dermoprotective gel (Dermabac, Steritec, etc.) and be
allowed to air-dry. If such a gel is not used, then the area to be needled should be swabbed
with 70% ethyl or isopropyl alcohol from the centre to the surrounding area using a rotator
scrubbing motion, and the alcohol allowed to dry.
The patient should be treated in a well-supported position. This is most commonly prone,
supine or side lying. Where a seated position is used, the patient must be supported such
that the risk of falling, as a result of fainting, is avoided.
Sterile needles and equipment

Only single-use, pre-sterilised, disposable solid needles, with or without a guide tube may
be used. Where a guide tube is used, this must be pre-packed with the needle. Re-usable
needles are not acceptable. The needles should be opened in front of the patients. The
needle should be made of stainless steel and may have a copper, plastic or rubber handle.
Clean cotton wool, either sterile or unsterile, must be used upon withdrawal of the needle.
The wad is to be pressed against the skin and the shaft of the needle as it is withdrawn to
limit any fluid leakages. Pressure should be maintained for 5 seconds per needle. Additional
pressure for up to 3 minutes should be applied if the wound leaks or if a haematoma arises.
Haemophiliacs should not be treated using needles without written consent from the
patients doctor.
A disinfectant must be used on both the therapists hands and the treatment area
immediately prior to treatment. Therapists must use either 70% isopropyl alcohol swabs or
a residual disinfectant (Dermabac, Steritec etc) to achieve this. Single-use sterile gloves
should be used if no residual disinfectant is used.
All needles should be disposed of in a clearly marked yellow sharps bin. The bin must
clearly state Danger - Contaminated needle. This bin should be disposed of in an
appropriate fashion by a medical waste company, when three quarters full.
This is to avoid the risk of needles accidentally bouncing out when attempting to force the
needle into an overly full container.
All swabs should be disposed of in a red biohazard bin. This must then be disposed of by a
medical waste company in an appropriate fashion.
Guide tubes and the plastic inserts that accompany them are to be disposed of as
domestic/non-clinical waste.
Aseptic technique
A no touch technique should be followed with respect to the shaft of the needle. Where
touching is necessary, use a sterile cotton wool swab as means of contact.
In case of a needle stick injury, the therapist should do as follows:
Encourage free bleeding from the area

Wash thoroughly with disinfectant
Follow the approved local needle stick protocol, or where this does not exist, consult their GP or
Casualty department as soon as possible
Note that the therapist is encouraged to know his/her own status independent of any
exposure to risk
References:
1. British Acupuncture Council Code of Safe Practice
2. WHO guidelines on acupuncture safety
Ethical Considerations for Dry Needlers
Ethical:
Moral
Honourable
Correct
Fair
Right
All patients have a right to a healthy safe environment:
Clinical waste disposal

Sharps bin only!
Sharps bin mounted on wall/ place where it cannot be knocked over or accessed by
children
Only sharps into sharps bin / no cotton wool!
No needles home to show family
Medical waste bins for soiled cotton wool and swabs
Informed consent
Every person has the right to participate in decision making for his/her health.
Information to be given to patient:

Needle will pierce your skin
Possibility of manual or electrical stimulation
Possibility of temporary fatigue, well-being, euphoria, aggression or fainting!
Possibility of some treatment soreness or bruising
Need for patient compliance, keep still during treatment and after treatment,
exercise as instructed
Remember that a translator may be required
Signed consent
2. Myofascial Pain
Myofascial Trigger Points (MTrPs)
Working hypothesis
MTrPs are sites of muscle injury where local biochemical changes lead to sustained
muscle contraction, compression of blood vessels and a local energy crisis that causes
hypoxia this situation perpetuates the release of inflammatory cytokines and
nocioceptive (pain producing) substances.
Ref. Skidar, Shah, Danhoff & Gerber.
Recognition
MTrPs are tender nodules within taut bands of muscle. Normal muscle does not contain
taut bands.
Once activated, MTrPs may cause:
Motor aspects: disturbed motor function, muscle weakness due to inhibition, muscle
stiffness & restricted range of motion
Sensory aspects: local pain referral, peripheral & central sensitization
Autonomic Aspects: pilomotor, vasomotor and visceral referral, where there are
MTrPs in the head and neck region, dizziness, tinnitus or tearing
State of activation
Active TrPs spontaneously refer both local & distant pain & often general motor
dysfunction
Latent Trigger points levels lower: commonly only motor effects

from TrPs disturbing MAPs, joint biomechanics, and muscle power
Myofascial Pain Syndrome (MPS)
A regional pain disorder characterised by the presence of MTrPs

The transformation of the tender nodule (MTrP) into a myofascial syndrome is
poorly understood.
But research has shown the presence of inflammatory mediators and muscle
nocioceptor activators in the immediate region of the dysfunctional neuromuscular
endplate of the TrP.
Bradykinin, 5-HT and H sensitise the muscle nocioceptors and these are then more
easily activated and may respond to normal innocuous and weak stimuli such as light
pressure and muscle movement. This low-grade nocioceptive input will contribute to CNS
sensitization and possible development of neuropathic pain states.
Niddam DMs results with neuroimaging data suggest that hyperalgesia from
MTrPs is processed in similar regions to other pain conditions. However, abnormal
hippocampal hypoactivity suggest that dysfunctional stress responses may play an
important role in the generation and maintenance of hyperalgesia from MTrPs in
MPS.
Prevalence of MTrPs in chronic pain states

Fishbain DA et al: Myofascial pain syndrome was diagnosed in 85% of
persons evaluated in a pain rehabilitation referral centre.
Gerwin RD: In a pain treatment referral program within a large neurological

practice found that 93% of patients with musculoskeletal pain had TrPs.
Development of MTrPs
Overload: Excessive concentric contractions, and/or eccentric

overloading
Over-use: Repetitive loading actively, or poor postural biomechanics
Adverse metabolic factors. Certain medications may predispose MTrP

development, e.g. Cholesterol drugs. Also exercise in extreme weather
conditions, or when nutrition is suboptimal.
Psychologically stressed states predispose to up-regulate MTrPs
Secondary to abnormal CNS activity
The Local Twitch Response
An LTR is a brisk transient contraction of the palpable taut band of muscle fibres.
Whereas it may be elicited by snapping palpation, working manually across the taut
band, it is most reliably and easily achieved by accurate needle insertion.
The needle is repeatedly manipulated to mechanically deactivate the MTrP . This LTR is a
local phenomenon, distinct from the Jump sign where the entire limb or even the
entire patient jerks in response to the stimulus. Clinically, the use of a needle is able to
reproduce an LTR far more consistently than can be achieved by snapping palpation. This
is in part due to the inaccessibility of some deeper muscles (Gluteus Medius, multifidi,
etc.), but mostly due to the needles ability to mechanically disrupt a relatively focused
area and change the local blood supply channels, thereby counteracting the local
energy crisis in a way that blunt palpation rarely can.
The LTR is seen as the key element in deep muscular dry needling. It is as important to
intramuscular needling as a pinprick is to superficial needling. It signals that the needle has
reached that part of the MTrP that will be most therapeutically effective. The LTR is
completely involuntary & cannot be mimicked by the patient. As a spinally mediated reflex,
it is not subject to supraspinal influences.
Meticulous accuracy by palpation is required to localise, and then fix the trigger point
between the fingers of the therapist needling the patient. The LTR is the most difficult
of the MTrP characteristics to reproduce reliably (Gerwin, et al 1997).
A single hand insertion technique is required to elicit and monitor this effect. The LTR is
felt by the patient to be deeply uncomfortable or even excruciatingly painful. It should
reproduce the patients pain. The severity of the pain frequently associated with the LTR
suggests that it can originate from stimulation of sensitised nocioceptors in the MTrP area.
Treatment Options for MTrPs
1. Trigger Point Injection & Dry Needling

Several studies indicate that in terms of the immediate inactivation of MTrPs,
Dry Needling alone is comparable to the injected use of analgesics like lidocaine,
procaine and even of Botox Type A (Jaeger & Skootsky 1987, Hong 1994,
Wheeler et al 1998 ).
The advantage in using a local anesthetic appears to be in the decreased amount of

post treatment soreness.
Dry Needling is far and away the most successful technique for the eliciting
of an LTR.
It mechanically disrupts the integrity of the dysfunctional end plate and

the affected MTrP, causing bleeding and consequent oxidated blood supply
increase.
This effect is allied to the increase in healing stimulated by the release of

platelet derived growth factor (PDGF), which attracts cells, induces DNA
synthesis and stimulates collagen and protein formation
Needling also disrupts the cell membrane of the muscle fibres, discharging a
brief burst of injury potential like electrical activity, called the insertional
activity or current of injury.
-2
This current has been known to generate up to 500amps.cm , and last for 3-4
days. This current is important in muscle repair and regeneration.
Needling of a muscle causes a local release of potassium due to the damage of

the sarcolemma fibres as the needle passes through. This causes a
depolarization block of the nerve fibres in areas where potassium reaches
sufficient concentration.
Needling causes the release of endogenous opioids through the stimulation of A-

fibres which activate multiple analgesic systems in the brain and spinal cord
2. Muscle Stretch
In acutely activated MTrPs, simple focused therapeutic stretches are remarkably
effective. These should always:
o Be done slowly (20-30 seconds)
o In a pain-free range of movement while still achieving a stretch effect
o Be accompanied by controlled breathing
Therapeutic stretches may be enhanced by:
Using hot/cold modalities (Hot pack, Spray & Stretch)
Post-isometric relaxation (Lewitt)
Reciprocal inhibition techniques
Facilitatory eye movements
Visualisaton
3. Trigger point release

In previous years, the term Ischaemic Compression was used for this technique.
This is unsatisfactory for two reasons.
i. There is no convincing experimental evidence that substantiates the

suggestion that ischaemia is the primary driver of the techniques success.
ii. The name has lead clinicians to apply unnecessary, excessive and often
painful force to the patient, which is counterproductive and unethical.
The technique now recommended conforms more to the concept of barrier release
more common in osteopathic circles. The therapist applies a gentle gradually
increasing pressure on the MTrP until a definite increase in the resistance is
encountered (the Barrier). At the same time, the patient begins to feel a degree of
discomfort. By simply maintaining this degree of minimal discomfort, the palpable
tension barrier releases after 30 seconds or sooner. This gentle yet effective
procedure may be repeated until complete relief is felt. It has the advantage of
allowing the patient to be part of the treatment as he/she gives constant feedback
on the initially the discomfort, and then the relief levels. The process is vital for the
patient to learn how far he/she can work in self-treatment. It works equally well
with non-human patients like horses and dogs.
The key is in listening to the patients tissue and adjusting the therapeutic
process to the bodys pace.
4. Deep stroking massage
Sometimes called stripping, this consists of repetitive deep short strokes at the area
of the tender spot, 10-12 repetitions, every 2-3 days for 6 weeks. There may be
impressive bruising, and may elicit emotional responses. It is a painful procedure to
be used sparingly with refractory, tenacious MTrPs. The effectiveness is
theoretically due to the mechanical elongation of contracted sarcomeres within the
contraction knots. Intracellular myoglobin, which is normally contained within the
sarcomere, can be found experimentally after this procedure over a MTrP, whereas
similar techniques on normal muscle do not. This strongly supports the theory that
dysfunctional end plates which are implicated in MTrP formation - are more
susceptible to mechanical trauma than normal endplates are.
5. Post treatment procedures

Precise protocols differ on exactly what should be done and how often.
However, it is clear that movement of the needled muscle, and even the skin of the
superficially needled area, is critical. Normal movement must be superimposed
onto a newly released muscle and the process of proprioceptive training begun as
soon as possible to combat poor movement patterns and adaptive behaviors. This
aids the normalisation of sarcomere lengths which were previously unequal in their
middle and end ranges. It is vital to reprogram muscle lengths for normal muscle
function. Remember that the concept of central sensitization in chronic pain is
crucial.
Waumsley suggests moving the needled muscle through the full available active
range of movement 3 times. This movement from a fully shortened to a fully
lengthened position should be done slowly, with a gradual subjective easing of
patient stiffness by the second and third cycles.
Barker favours passive stretching of the affected muscle for 3x30 seconds,
combining this with both post-isometric relaxation techniques and active inhibitory
stretches taught beforehand to the patient.
Stavrou favours a combination of active and passive stretching with low intensity
isometric contractions in some patients
A home stretching programme which progresses to a strengthening programme

is vital. This should begin as soon as possible- within pain limits- as the -
stimulation helps ease post-treatment soreness. Attention to causative
factors, posture and diet should be part of all physio programmes.
Strenuous activity like jogging, gym, normal sporting activity, tennis, etc. should be
avoided for 24 hours to allow healing of the insertional damage.
Ice and heat may be applied as appropriate: Ice for bruises and swelling, gentle
heat for pain.
NSAIDs are of little value in MPSs, but patients should not be advised to
discontinue that which has been prescribed for them.
6. Periosteal Pecking Technique
Description of technique:
Periosteal pecking is a form of needling therapy in which the periosteum is
stimulated with the tip of a needle. The tip is repeatedly applied to the tender area
of the periosteum (5-10mm wide), 2-4 times per second for approximately 10
seconds (Hansson et al 2008). Some therapists use as few as 2 or 3 pecks. Felix
Mann suggests that only a single light peck may be sufficient.
The principle mechanism of action is purported to be the stimulation of large

diameter A- fibres within the sclerotome. Brattberg (1983) showed greater
efficacy for Periosteal pecking in Lateral epicondylitis patients than Steroid
injections. Hansson et al (2008) showed equal efficacy for intramuscular dry
needling and periosteal pecking in a mixed sample of back and neck pain patients
when pain changes using a VAS were analysed.
Special precautions:
Do not apply electrical stimulation through periosteal needles.
3. Selected Abstracts: Clinically Relevant Articles
Treatment of Myofascial Pain Syndrome

Hong, C Z;
Curr Pain Headache Rep. 2006 Oct; 10(5):345-9
Myofascial pain syndrome (MPS) is caused by myofascial trigger points (MTrPs)

located within taut bands of skeletal muscle fibers. Treating the underlying
etiologic lesion responsible for MTrP activation is the most important strategy in
MPS therapy. If the underlying pathology is not given the appropriate treatment, the
MTrP cannot be completely and permanently inactivated. Treatment of active
MTrPs may be necessary in situations in which active MTrPs persist even after the
underlying etiologic lesion has been treated appropriately. When treating the active
MTrPs or their underlying pathology, conservative treatment should be given
before aggressive therapy. Effective MTrP therapies include manual therapies,
physical therapy modalities, dry needling, or MTrP injection. It is also important to
eliminate any perpetuating factors and provide adequate education and home
programs to patients so that recurrent or chronic pain can be avoided.
Myofascial Trigger Points: An Evidence-Informed Review

Dommerholt J,Bron, Franssen J,
2006. The Journal of Manual & Manipulative Therapy Vol. 14 No. 4, 203 - 221
Abstract: This article provides a best evidence-informed review of the current scientific
understanding of myofascial trigger points with regard to their etiology,
pathophysiology, and clinical implications. Evidence-informed manual therapy integrates
the best available scientific evidence with individual clinicians judgments, expertise,
and clinical decision-making. After a brief historical review, the clinical aspects of
myofascial trigger points, the interrater reliability for identifying myofascial trigger
points, and several characteristic features are discussed, including the taut band, local
twitch response, and referred pain patterns. The etiology of myofascial trigger points
is discussed with a detailed and comprehensive review of the most common
mechanisms, including low-level muscle contractions, uneven intramuscular pressure
distribution, direct trauma, unaccustomed eccentric contractions, eccentric
contractions in unconditioned muscle, and maximal or sub-maximal concentric
contractions. Many current scientific studies are included and provide support for
considering myofascial trigger points in the clinical decision-making process. The
article concludes with a summary of frequently encountered precipitating and
perpetuating mechanical, nutritional, metabolic, and psychological factors relevant for
physical therapy practice. Current scientific evidence strongly supports that awareness
and working knowledge of muscle dysfunction and in particular myofascial trigger
points should be incorporated into manual physical therapy practice consistent with
the guidelines for clinical practice developed by the International Federation of
Orthopaedic Manipulative Therapists. While there are still many unanswered questions in
explaining the etiology of myofascial trigger points, this article provides manual
therapists with an up-to-date evidence-informed review of the current scientific
knowledge.
4. Muscles
Gluteus Maximus Muscle L5, S1, S2
Normal Problem factors
Innervation L5, S1, S2
Function: Isometric Assists Force closure of

SIJ & tenses ITB (with
TFL)
Concentric Hip extension incl. rising

from seated position
Eccentric Limits hip flexion
Common MTrP causes Prolonged sitting

Prolonged uphill walking
Freestyle swimming
Starting position Contralateral Sy ly, pillow

between flexed knees
Palpation landmarks Iliac crest

Sacrum
Greater trochanter
Possible needle sizes 0.30x40mm-0.30x50mm Excess adipose tissue
Grip Flat palpation near Keep non-dominant hand

sacrum, but pincer for free in contact with muscle
border being needled
Direction of insertion Obliquely toward ASIS Avoid pushing the needle

at sacral level or towards deeper than Glut Max
your finger when pincer-
gripping free border
Special precautions Avoid sciatic nerve as it runs laterally from anterior

to the sacrum, to turn caudally in the mid third of
buttock
Gluteal Region
Gluteus Maximus (referred pain patterns)
Gluteus Medius Muscle L4, L5, S1
Innervation L4, L5, S1
Function: Isometric Resists adduction i.e.

prevents Trendellenburg
Concentric Hip abduction
Resists adduction i.e.

Eccentric prevents Trendellenburg

Freestyle swimming


Sacrum
Greater trochanter
Possible Needle sizes 0.30x40mm-0.35x75mm Excess adipose tissue
Grip Flat palpation near sacrum, Keep non-dominant hand in

but deep palpation for more contact with muscle being
lateral TrPs needled
Direction of insertion Perpendicular Avoid periosteal peck of ilium

unless intended
Special precautions Avoid sciatic nerve, which runs vertically between the
ischial tuberosity and the greater trochanter
Gluteus Medius (referred pain patterns)
Gluteus medius muscle needling position
Gluteus Minimus Muscle L4, L5, S1
Innervation L4, L5, S1
Function: Isometric Stabilization of femoral head in

acetabulum
Concentric Medial hip rotation (ant. fibres)

Lateral hip rotation (post. fibres)
Eccentric Check-reign rotation

Freestyle swimming

Supine for anterior fibres

Sacrum
Greater trochanter
TFL
Possible Needle sizes 0.35X75mm Excess adipose tissue
Grip Flat palpation Keep non-dominant hand in

contact with muscle being
needled
Direction of insertion Toward ilium
Special precautions Avoid sciatic nerve, which runs vertically between the ischial
tuberosity and the greater trochanter
Gluteus Minimus (referred pain patterns)
Piriformis Muscle S1, S2
Innervation S1, S2
Function: Isometric Stabilization of femoral

head in acetabulum
Lateral hip rotation (in hip

Concentric extension) NWB
Hip abduction when hip is
at 90 degrees of flexion
NWB
Eccentric Check-reign medial + FAIR test

rotation
Common MTrP causes Prolonged walking

Prolonged sitting
Starting position Contralateral Sy ly, hip

flexed to 90 degrees and
in adduction, no pillow
between knees
Palpation landmarks Draw a line from the

sciatic foramen to the
greater trochanter.
Needle just superior to
this line at the junction of
the lateral and middle
third of this line.
Possible Needle sizes 0.30x50mm-0.35x60mm Excess adipose tissue

(slim patient);
0.35x75mm-0.35x100mm
(large patient)
Grip Flat palpation Keep non-dominant hand

in contact muscle being
needled
Direction of insertion Perpendicular Deep vascular bed below

piriformis, avoid vigorous
needling
Special precautions Avoid sciatic nerve, which runs vertically between

the ischial tuberosity and the greater trochanter
36
Piriformis and Short Lateral Rotators
37
Piriformis position for Needling
Photograph showing
2 needles into the
Piriformis muscle at
the junction of the
middle and lateral
thirds of the
muscle.
The Piriformis muscle in a needling position
Short Lateral Rotators of the Hip
Obturator Internus, Externus and Gemelli are external to the pelvis

and attach to the greater trochanter
Obturator internus is however also intra pelvic
GOGO = Gemelli sup, Obt int, Gemelli inf, Obt ext
These short rotators externally rotate the thigh in all positions
Sciatic nerve lies anterior to the piriformis but posterior i.e. on top of the
gemelli and obturators
Referred symptoms as for the piriformis - remember that these muscles are commonly
involved with piriformis, as the coccygeus (ischiococcygeus) and levator ani muscles
may be.
Needling: Obturator Internus
Patient side lying:
Approach below the inferior

angle of the sacrum directly
above the ischium 50mm
for medial section; needle
perpendicular or medially
Laterally approach below
insertion of piriformis at
the greater trochanter;
needles inserted laterally
towards greater
trochanter; 0.30x30mm-
0.35x50mm
Avoid Sciatic nerve which
runs posteriorly over the
bellies of the short lateral
rotators
Quadratus femoris attaches medially to the antero- lateral surface of the ischium and
laterally to the femur.
Obturator externus attaches medially to the obturator membrane and laterally to the femoral
trochantor deep to Quadratus femoris.
Gastrocnemius Muscle Group
Innervation S1, S2 (Tibial n)
Function: Isometric Assists with knee and ankle

stability esp. in dysfunctional
postures
Concentric Plantar flexion when knee is High heel shoes

extended
Eccentric Check-reign dorsi-flexion Sway back posture
Common MTrP causes Shoes, posture, sprains, Plantar fasciitis

fractures, night cramps,
intermittent claudication
Starting position Supine FABER or Crook

lying (medial)
Contralateral sy ly (lateral)
Palpation landmarks Identify gastrox, soleus and

lateral compartment
Possible Needle sizes 0.3X30mm-0.35x50mm Excess adipose tissue
Grip Lumbrical Avoid needling into deep posterior

compartment
Direction of insertion Toward your gripping fingers Avoid pushing the needle into your
own finger
Special precautions Vigorous needling in deep compartment may cause a

compartment syndrome. This muscle is well endowed with
proprioceptors and may be extremely sore post needling.
Gastrocnemius Muscle (referred pain patterns)
Medial Gastrocnemius in FABER position
Medial Gastrocnemius superior portion
Soleus the Joggers heel
Innervation S1, S2 (Tibial n)
Function: Isometric Assists with ankle stability
Plantar flexion independent High Heel shoes

Concentric of knee position especially
powerful movements
Eccentric Check-reign dorsi-flexion Sway back posture
Common MTrP causes Shoes, posture, sprains, Plantar fasciitis

fractures, night cramps, Heel spur
intermittent claudication.
Note that the tibial nerve may
be entrapped by soleal
MTrPs in the soleal canal
Starting position Supine FABER or Crook If you cant get a good lumbrical
lying (medial) grip, then passively plantar flex
Contralateral sy ly (lateral) the ankle first
Palpation landmarks Identify gastroc, soleus and

lateral compartment.
Fibula in side-lying
Possible Needle sizes 0.3X30mm-0.35x50mm Excess adipose tissue
Grip Lumbrical belly medial Avoid needling into deep

Lateral deep palpation posterior compartment
Direction of insertion Towards the TrP Beware deep tibial vessels

centrally mid-calf
Special precautions Vigorous needling in deep compartment may cause a

compartment syndrome.
This muscle is well endowed with proprioceptors and a
deep venous plexus, and may be extremely sore post
needling.
Soleus Muscle (referred pain patterns)
Photograph showing the correct pincer grip and needling of the medial calf.
A = Gastrocnemius and B = Soleus

Selected Abstracts
Cummings TM, White AR. Needling therapies in the management of myofascial trigger
point pain: a systematic review. Arch Phys Med Rehabil 2001; 82:986-92.
Objective:
To establish whether there is evidence for or against the efficacy of needling as a treatment
approach for myofascial trigger point pain.
Data Sources:
PubMed, Ovid MEDLINE, Ovid EMBASE, the Cochrane Library, AMED, and CIS COM
databases, searched from inception to July 1999.
Study Selection:
Randomized, controlled trials in which some form of needling therapy was used to treat
myofascial Pain
Data Extraction:
Two reviewers independently extracted data concerning trial methods, quality, and outcomes.
Data Synthesis:
Twenty-three papers were included. No trials were of sufficient quality or design to test the
efficacy 9f any needling technique beyond placebo in the treatment of myofascial pain. Eight
of the 10 trials comparing injection of different substances and all 7 higher quality trials found
that the effect was independent of the injected substance. All three trials that compared dry
needling with injection, found no difference in effect.
Conclusions:
Direct needling of myofascial trigger points appears to be an effective treatment, but the
hypothesis that needling therapies have efficacy beyond placebo is neither supported nor refuted
by the evidence from clinical trials. Any effect of these therapies is likely because of the needle or
placebo rather than the injection of either saline or active drug. Controlled trials are needed to
investigate whether needing has an effect beyond placebo on myofascial trigger point pain.
Key Words:
Acupuncture; Injections; Myofascial pain syndromes; Randomized controlled trial;
Rehabilitation; Trigger points, myofascial.
Hong C-Z, Kuan T-S, Chen J-T, Chen S-M. Referred pain elicited by the palpation
and by needling of myofascial trigger points: A comparison. Arch Phys Med Rehabil
1997;78:957-960.
Objectives:
To investigate the occurrence of referred pain (ReP) elicited by palpation (Pal-ReP) or by needle
injection (Inj -ReP) of myofascial trigger points (MTrP), and to assess the correlated factors,
including the pain intensity of an active MTrP and the occurrence of a local twitch response
(LTR).
Design: Correlational study
Patients: Ninety five patients who were treated with MTrP injections.
Interventions: MTrP injections
Main outcome measures: Pain intensity of MTrP and occurrence of Pal-Rep, Inj-Rep, and LTR.
Results: Both Pal-Rep and Inj -Rep were elicited in 53.9% of MTrPs. Inj-Rep, but not Pal-Rep, was
elicited in 3 3.7% of MTrPs. Both Pal-Rep and Inj -Rep were unobtainable in 12.3% of MTrPs. The
occurrence of ReP was significantly correlated to the Pain intensity of active MTrP and the
occurrence of LTR.
Conclusions:
Rep could be elicited more frequently by needling than by palpation. The frequency of
occurrence in ReP mainly depends on the pain intensity of an active MTrP.
Novel Applications of Ultrasound Technology to Visualize and
Characterize Myofascial Trigger Points and Surrounding Soft Tissue
Siddhartha Sikdar, Ph.D., Jay P. Shah, M.D., Tadesse Gebreab, B.S., Ru-Huey
Yen, B.S., Elizabeth Gilliams, B.S., Jerome Danoff, P.T., Ph.D., and Lynn H.
Gerber, M.D.
Conf Proc IEEE Eng Med Biol Soc. 2010;2010:5302-5.
2 Understanding the vascular environment of myofascial trigger points using

ultrasonic imaging and computational modeling.
Sikdar S, Ortiz R, Gebreab T, Gerber LH, Shah JP.
2.1 .1 Source Department of Electrical and Computer Engineering, George Mason University, Fairfax, VA 22030,
USA. ssikdar@gmu.edu
2.1.2 Abstract
Myofascial pain syndrome (MPS) is a common, yet poorly understood, acute and chronic pain condition. MPS is
characterized by local and referred pain associated with hyperirritable nodules known as myofascial trigger points
(MTrPs) that are stiff, localized spots of exquisite tenderness in a palpable taut band of skeletal muscle. Recently, our
research group has developed new ultrasound imaging methods to visualize and characterize MTrPs and their
surrounding soft tissue. The goal of this paper was to quantitatively analyze Doppler velocity waveforms in blood vessels
in the neighborhood of MTrPs to characterize their vascular environment. A lumped parameter compartment model was
then used to understand the physiological origin of the flow velocity waveforms. 16 patients with acute neck pain were
recruited for the study and the blood vessels in the upper trapezius muscle in the neighborhood of palpable MTrPs were
imaged using Doppler ultrasound. Preliminary findings show that symptomatic MTrPs have significantly higher peak
systolic velocities and negative diastolic velocities compared to latent MTrPs and normal musc le sites. Using
compartment modeling, we show that a constricted vascular bed and an enlarged vascular volume could explain the
observed flow waveforms with retrograde diastolic flow.
Chin Med. 2011 Mar 25;6:13.
Myofascial trigger points: spontaneous electrical activity and its consequences for
pain induction and propagation.
Ge HY, Fernndez-de-Las-Peas C, Yue SW.
Source Center for Sensory-Motor Interaction (SM I), Department of Health Science and Technology, Aalborg University, Aalborg
DK-9220, Denmark. ghy@hst.aau.dk.
Abstract
Active myofascial trigger points are one of the major peripheral pain generators for regional and generalized
musculoskeletal pain conditions. Myofascial trigger points are also the targets for acupuncture and/or dry needling
therapies. Recent evidence in the understanding of the pathophysiology of myofascial trigger points supports The
Integrated Hypothesis for the trigger point formation; however unanswered questions remain. Current evidence shows
that spontaneous electrical activity at myofascial trigger point originates from the extrafusal motor endplate. The
spontaneous electrical activity represents focal muscle fiber contraction and/or muscle cramp potentials depending on
trigger point sensitivity. Local pain and tenderness at myofascial trigger points are largely due to nociceptor sensitization
with a lesser contribution from non-nociceptor sensitization. Nociceptor and non-nociceptor sensitization at myofascial
trigger points may be part of the process of muscle ischemia associated with sustained focal muscle contraction and/or
muscle cramps. Referred pain is dependent on the sensitivity of myofascial trigger points. Active myofascial trigger points
may play an important role in the transition from localized pain to generalized pain conditions via the enhanced central
sensitization, decreased descending inhibition and dysfunctional motor control strategy.
Clin Biomech (Bristol, Avon). 2010 Oct;25(8):765-70. Epub 2010 Jul 27.
3. Muscle activation patterns in the scapular positioning muscles during loaded

scapular plane elevation: the effects of Latent Myofascial Trigger Points.
Lucas KR, Rich PA, Polus BI.
3.1 .1 Source Musculoskeletal Research Centre, Level 2, HS3, Faculty of Health Sciences, La Trobe University,
Bundoora 3086, Australia. K.Lucas@latrobe.edu.au
3.1.2 Abstract
3.1.2.1 BACKGROUND:
Latent Myofascial Trigger Points are pain -free neuromuscular lesions that have been found to affect muscle activation
patterns in the unloaded state. The aim was to extend these observations to loaded motion by investigating muscle
activation patterns in upward scapular rotator muscles (upper and lower trapezius and serratus anterior) hosting Latent
Myofascial Trigger Points simultaneously with lesion-free synergists for shoulder abduction (infraspinatus and middle
deltoid). This approach allowed examination of the effects of these lesions on both their hosts and their lesion-free
synergists in order to understand their effects on the performance of shoulder abduction.
3.1.2.2 METHODS:
Surface electromyography was employed to measure the timing of onset of muscle activation of the upper and lower
trapezius and serratus anterior (upward scapular rotators), infraspinatus (rotator cuff) and middle deltoid (abductor of the
arm) initially without load and then with light (1-4 kg) dumbbells. Comparisons were made between control (no Latent
Trigger Points; n=14) and Latent Trigger Point (n=28) groups.
3.1.2.3 FINDINGS:
The control group displayed a relatively stable sequence of muscle activation that was significantly different in timing and
variability to that of the Latent Trigger Point group in all muscles except middle deltoid (all P<0.05). The Latent Trigger
Point group muscle activation pattern under load was inconsistent, with the only common feature being the early
activation of the infraspinatus.
3.1.2.4 INTERPRETATION:
The presence of Latent Trigger Points in upward scapular rotators alters the muscle activation pattern during scapular
plane elevation, potentially predisposing to overuse conditions including impingement syndrome, rotator cuff pathology
and myofascial pain.
J Headache Pain. 2011 Feb;12(1):35-43. Epub 2011 Feb 27.
Referred pain from myofascial trigger points in head and neck-shoulder muscles
reproduces head pain features in children with chronic tension type headache.
Fernndez-de-las-Peas C, Fernndez-Mayoralas DM, Ortega-Santiago R, Ambite-Quesada S, Palacios-Cea D,Pareja
JA.
Source Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Facultad de Ciencias de
la Salud, Universidad Rey Juan Carlos, Avenida de Atenas s/n, 28922 Alcorcn, Madrid, Spain. cesar.fernandez@urjc.es
Abstract
Our aim was to describe the referred pain pattern and areas from trigger points (TrPs) in head, neck, and shoulder
muscles in children with chronic tension type headache (CTTH). Fifty children (14 boys, 36 girls, mean age: 8 2) with
CTTH and 50 age- and sex- matched children participated. Bilateral temporalis, masseter, superior oblique, upper
trapezius, sternocleidomastoid, suboccipital, and levator scapula muscles were examined for TrPs by an assessor
blinded to the children's condition. TrPs were identified with palpation and considered active when local and referred
pains reproduce headache pain attacks. The referred pain areas were drawn on anatomical maps, digitalized, and also
measured. The total number of TrPs was significantly greater in children with CTTH as compared to healthy children (P <
0.001). Active TrPs were only present in children with CTTH (P <0.001). Within children with CTTH, a significant positive
association between the number of active TrPs and headache duration (r (s) = 0.315; P = 0.026) was observed: the
greater the number of active TrPs, the longer the duration of headache attack. Significant differences in referred pain
areas between groups (P <0.001) and muscles (P <0.001) were found: the referred pain areas were larger in CTTH
children (P <0.001), and the referred pain area elicited by suboccipital TrPs was larger than the referred pain from the
remaining TrPs (P <0.001). Significant positive correlations between some headache clinical parameters and the size of
the referred pain area were found. Our results showed that the local and referred pains elicited from active TrPs in head,
neck and shoulder shared similar pain pattern as spontaneous CTTH in children, supporting a relevant role of active
TrPs in CTTH in children
An in vivo microanalytical technique for measuring the
local biochemical milieu of human skeletal muscle
1
Jay P. Shah,1 Terry M. Phillips,2 Jerome V. Danoff, 1,3 and Lynn H. Gerber
1
Rehabilitation Medicine Department, Clinical Research Center, National Institutes of
Health; 2Ultramicro Analytical Immunochemistry Resource, Division of Bioengineering and
Physical Science, Office of Research Services, National Institutes of Health, Bethesda, Maryland;
and 3Department of Exercise Science, George Washington University, Washington, DC
Submitted 14 April 2005 ; accepted in final form 11 July 2005
4.1 ABSTRACT
Myofascial pain associated with myofascial trigger points (MTrPs) is a common cause of
nonarticular musculoskeletal pain. Although the presence of MTrPs can be determined by soft tissue
palpation, little is known about the mechanisms and biochemical milieu associated with persistent
muscle pain. A microanalytical system was developed to measure the in vivo biochemical milieu of
muscle in near real time at the subnanogram level of concentration. The system includes a microdialysis
needle capable of continuously collecting extremely small samples (0.5 l) of physiological saline
after exposure to the internal tissue milieu across a 105-m-thick semi-permeable membrane. This
membrane is positioned 200 m from the tip of the needle and permits solutes of<75 kDa to diffuse
across it. Three subjects were selected from each of three groups (total 9 subjects): normal (no neck
pain, no MTrP); latent (no neck pain, MTrP present); active (neck pain, MTrP present). The
microdialysis needle was inserted in a standardized location in the upper trapezius muscle. Due to
the extremely small sample size collected by the microdialysis system, an established microanalytical
laboratory, employing immunoaffinity capillary electrophoresis and capillary
electrochromatography, performed analysis of selected analytes. Concentrations of protons,
bradykinin, calcitonin gene-related peptide, substance P, tumor necrosis factor-, interleukin-1 ,
serotonin, and norepinephrine were found to be significantly higher in the active group
than either of the other two groups (P < 0.01). pH was significantly lower in the active group than
the other two groups (P < 0.03). In conclusion, the described microanalytical technique enables
continuous sampling of extremely small quantities of substances directly from soft tissue, with
minimal system perturbation and without harmful effects on subjects. The measured levels of
analytes can be used to distinguish clinically distinct groups.
myofascial trigger points; musculoskeletal pain; microdialysis; soft tissue pain; p ressure pain
threshold.
5. References and Recommended Reading
1. Baldry, P. 1992. Acupuncture, Trigger Points and Musculoskeletal Pain, Churchill and
Livingstone
2. Bowsher, D. 1998. Mechanisms of Acupuncture. Medical Acupuncture, Filsche &
White, Churchill Livingstone
3. Bruckner, P. & Kahn, D. 1993. Clinical Sports Medicine, McGraw Hill
4. Butler, D. 1991. Mobilisation of the Nervous System, Churchill Livingstone
5. Dommerholt.J & Huijbreghts. P. Myofascial Trigger Points. Jones & Bartlett . 2011
6. Filshie, J & White, A. 1998. Medical Acupuncture, Churchill Livingstone
7. Gerwin, R.D., Shannon, S., Hong, C-Z., Hubbard, D., Gevirtz, R. 1997. Interrater
reliability in myofascial trigger point examination. Pain 69:65-73
8. Gunn, C. 1989. Treating Myofascial Pain: Intramuscular Stimulation, University of
Washington
9. Hong C-Z, Hsueh T C. 1996. Difference in pain relief after trigger point injections in
myofascial pain patients with and without fibromyalgia. Arch Phys Med Rehabil
77(11 ):1 161-1166.
10. Hong CZ. 1994. Lidocaine injection versus dry needling to myofascial trigger point.
The importance of the local twitch response. Arch Phys Med Rehabil 73:256-263
11. Hong, C-Z., Kuan, T-S., Chen, J-T., Chen, S-M. 1997. Referred Pain Elicited by
Palpation and by needling of Myofascial Trigger Points: A Comparison. Arch Phys
Med Rehabil 78:957-960
12. Hooshmand, H. 1993. Chronic Pain: Reflex Sympathetic Dystrophy, C.R.C. Press,
Tokyo
13. Melzack & Wall. The Challenge of Pain, Penguin
14. Jimbo S, Atsuta Y, Kobayashi T, Matsuno T. 2008. Effects of dry needling at tender
points for neck pain (katakori): near-infrared spectroscopy for monitoring
oxygenation of trapezius. Journal of Orthopaedic science, 13:101-106
15. National Commission for Certification of Acupuncturists (1989) Clean Needle
Technique for Acupuncturists
16. Oschman, J. 2002. Energy Medicine, The Scientific Basis. Churchill Livingstone.
17. Rachlin, Edward. 1994. Myofascial Pain and Fibromyalgia. Mosby Shah JP,
Phillips TM, Danoff JV, Gerber LH. An in vivo micro analytical technique for
measuring the local biochemical milieu of human skeletal muscle. J Appl Physiol
2005;99(5): 19771984 [Epub 2005 Jul 21].
18. JayP. Shah. 2008. Integrating Dry Needling with New Concepts of Myofascial Pain,
Muscle Physiology, and Sensitization. Chapter 5 of Contemporary Pain Medicine:
Integrative Pain Medicine: The Science and Practiceof Complementary and Alternative
Medicine in Pain Management Edited by: J. F. Audette and A. Bailey Humana Press,
Totowa, NJShipton, E.A.. Pain: Acute and Chronic, Witwatersrand University Press
19. Simons, D. 1990. Muscular Pain Syndromes, Advances in Pain Research, Volume 1,
Raven Press.
20. Simons, David. 2001. Muscle Pain. Understanding its Nature, Diagnosis and
Treatment. Lippincott, Williams & Wilkins.
21. Travell, S. & Simons, D. 1983. Myofascial Pain and Dysfunction, Williams & Wilkins.
22. Whyte Ferguson L. & Gerwin R. Clinical Mastery in treatment of Myofascial pain.
Lippincott Williams & Wilkins. 2005
23. Webb, J. 1986. Pain Control via Dorso-lumbar Sympathetic flow,
Australian Journal of Physiotherapy 32(2).
24. Wells, J.C.D. & Woolf, C.J. 1991. Pain Mechanisms and Management, Volume
47(3). Churchill Livingstone.
25. Wheeler, A.H., Goolkasian, P., Gretz, S.S. 1997. A randomised double blind
prospective pilot study of Botulinum Toxin Injection for Refractory, Unilateral,
Cervicothoracic, Paraspinal Myofascial Pain Syndrome. Spine 23(15):1662-1664.
25. Wheeler, A.H., Goolkasian, P., Gretz, S.S. 1997. A randomised double blind
prospective pilot study of Botulinum Toxin Injection for Refractory, Unilateral,
Cervicothoracic, Paraspinal Myofascial Pain Syndrome. Spine 23(15):1662-1664.
Indemnity Form
For Use on the Dry Needling Courses Only
1. I, ................................................................................................................. (the
undersigned) hereby give my consent to be dry needled by any of my co-participants
and the demonstrator in ways consistent with the content of the Optimal Dry
Needling Solutions course, in association with Club-Physio and The Dry Needling
Institute.
2. I have read and understood the document called Dry Needling Information and
have had sufficient opportunity to ask any questions that I want to.
3. I agree to expose the appropriate area of my body being needled, and to loosen or
remove such clothing as may be necessary for the technique to be performed
properly.
4. I indemnify Optimal Dry Needling Solutions and all of its lecturers and course
organisers against any claim which may arise from this course.
5. I acknowledge that I personally carry appropriate Malpractice insurance.
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(Course Participant) (Date)
Dry Needling information
Your physiotherapist has offered to treat you using a technique called Dry Needling. This
information leaflet explains more about this technique.
Dry Needling is a very successful medical treatment which uses very thin needles without any
medication (a dry needle) to achieve its aim. Dry Needling is used to treat pain and dysfunction
caused by muscle problems, sinus trouble, headaches, and some nerve problems. It is not at all
the same as acupuncture. Acupuncture is part of Traditional Chinese Medicine, whereas dry
needling is a western medicine technique.
Dry Needling works by changing the way your body senses pain (neurological effects), and by
helping the body heal stubborn muscle spasm associated with trigger points (myofascial effects).
There are additional electrical and chemical changes associated with dry needling therapy which
assist in the healing process. It is important to see the needles as just one part of your overall
rehabilitative treatment. Dry needling is not a miracle cure it is a normal part of physiotherapy. It
is vital that you do the exercises and follow the advice your therapist gives you in conjunction with
the needling for optimal recovery.
Your therapist has been specifically trained in the various needling techniques. The therapist will
choose a length and thickness of needle appropriate for your condition and your body size, and then
insert it through the skin at the appropriate place. You will feel a small pinprick. Depending on the
type of needle technique chosen by your therapist, you may also feel a muscle ache and a muscle
twitch. These are all normal and good sensations, and mean that you will experience good relief
from your symptoms.
In general, there is very little risk associated with this technique if performed properly by a trained
physiotherapist. You may have a little bruising around the needle site, much the same as you would
with any injection. On rare occasions, people may feel very happy, tearful, sweaty or cold. These
symptoms all fade quickly. Fainting may occur in a very small minority of people. There are no
lasting ill effects of these side effects.
If you are being treated in the shoulder, neck or chest area, there is an additional risk that involves
your lung. If the lung itself is punctured, you may develop a condition called a pneumothorax (air in
the space around the lung). This is a rare but serious problem, and you should go directly to a
hospital casualty department without panicking if it occurs. The symptoms of this event include
shortness of breath which gets worse, sudden sharp pain each time you breathe in, a bluish tinge to
your lips, and an inability to catch your breath. The treatment is very successful for this rare but
possible complication.
If you are happy to continue with the therapy as suggested by your therapist, and have asked any
questions that you may want to, then please sign the consent form attached to this page, and hand
it to your physiotherapist.
Please keep this information page for your own records.
Optimal Dry Needling Solutions
Consent for Dry Needling Treatment
This document is to be read in conjunction with the information sheet titled
Dry Needling information
1. I (full name), . in my
capacity as:
Please circle which of the following two applies in your case:
The patient (if aged 18 or over),

Or
The parent or legal guardian, of
. (patients full name)
Who is my: Spouse / Child / Grandchild / Parent / Sibling / Foster Child / Ward
(please circle the appropriate term)
do hereby give my consent for the performance of dry needling therapy by the
physiotherapist named ............................................................................................. at
the physiotherapy practice. I understand that the therapist is appropriately
qualified and trained to perform the required therapy.
2. The areas of the body that I consent to have dry needled are:
3. I am satisfied that the technique has been fully explained to me, and that my
concerns have been addressed and that my questions have been answered to my
satisfaction. I have read the attached information sheet called Dry Needling
information, and am in a satisfactory position to weigh up the risks and limitations
of the technique as regards known side effects.
4. I understand that the technique is performed within a rehabilitative framework and
that I must follow instructions as given by the physiotherapist.
5. I understand that in the event of any litigation arising consequent to this
therapy, it can only be done within the jurisdiction of the Magistrates Court. The
applicant will be responsible for his own and the defendants legal costs.
7. I hereby indemnify the therapist and the practice against any liability arising from
unforeseen or unknown consequences.
Date: .................. Time: ................ Place: ...........................
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In association with

As physiotherapists, acknowledgement must be made to the in-depth

Our personal opinion is that their books are

Recently published Myofascial Trigger Points by Dommerholt & Huijbrechts

While this course in no way teaches acupuncture, we acknowledge the Great

Enjoy this wonderful approach to therapy!

She is a grandmother of nine and a keen open water swimmer.

Steven operates a multi-disciplinary Integrated Health Centre in Sandton,

Steven is a keen runner, having completed several Comrades ultra-marathons. He is a

Redrawn for this manual by Karen Korte, Darling, South Africa.

A- (V. helpful) C-Fibre (V. Troublesome)

Small myelinated 111 b fibres Unmyelinated

Conduction time Slow conducting

Receptors just under Found in all tissues

Receptors high-threshold Polymodal receptors

All or nothing In tissue

First trauma pain Second trauma pain

Warns body of impending injury Slow to get message

Withdrawal response Immobilisation

Clinically not real Response to avoid

Via N.S. T. tract Via Paleothalamic tract

Parietal lobe Frontal cortex

Accurately localised pain Diffuse dull, aching pain

Unaffected by morphine Abolished by morphine

Subcutaneous tissue fibroblast cytoskeletal remodeling induced by

Dynamic fibroblast cytoskeletal response to subcutaneous tissue stretch ex

For superficial 'pin-prick' stimulation we need a 13-25 mm length needle of 0.22-0.30 mm

Two main types: Japanese and Chinese

Aids and Hepatitis

Do not attempt needling again the same day.

Infection may be caused by inadequate sterilisation of needle, or traumatising the tissue by

Spontaneous pneumothoraces may be either primary, where there is no underlying lung

Traumatic pneumothoraces may be caused by either blunt trauma as in a car

What should I do if I suspect my patient has a Pneumothorax?

Consult www.pneumoworld .org for a patient friendly site

Suitable analgesics Multiple pain areas likely to return, e.g.

Acute muscle injury Anatomically superficial areas, e.g.

Key points to remember!

With physiotherapists, needling is most often used as a 'combination

It is preferable to needle at the end of treatment once mobilization /

1. You have a better idea of patient's sensitive areas. Patient has

Notwithstanding the above, it is necessary to therapeutically stretch the

The clients neurochemical response to needling

Reactor types could be classified into:

Care should be taken when treating:

The Basic Working Environment

The Practitioner should have clean hands

Sterile needles and equipment

In case of a needle stick injury, the therapist should do as follows:

Encourage free bleeding from the area

All patients have a right to a healthy safe environment:

Clinical waste disposal

Information to be given to patient:

Myofascial Trigger Points (MTrPs)

Once activated, MTrPs may cause:

Sensory aspects: local pain referral, peripheral & central sensitization

Latent Trigger points levels lower: commonly only motor effects

A regional pain disorder characterised by the presence of MTrPs

Prevalence of MTrPs in chronic pain states

Gerwin RD: In a pain treatment referral program within a large neurological

Overload: Excessive concentric contractions, and/or eccentric

Over-use: Repetitive loading actively, or poor postural biomechanics

Adverse metabolic factors. Certain medications may predispose MTrP