1. Dry Needling Muscles Pain and Trigger Point Therapy

2. Head & Neck Referral Areas
Spinal Region
Referral Area
Conditions Mimicked
Upper Cervical Spine (neck) C1-C4
Back of the head (occiput), back of the shoulders, angle of the jaw, face
Headaches, migraines, jaw problems, trigeminal neuralgia, tension in the shoulders
Middle / Lower Cervical Spine (neck) C5-C8
Arms, forearms, hands and fingers
Trapped / pinched nerve in the neck, tennis elbow, golfer's elbow, frozen shoulder

3. Muscles & Pain
Skeletal muscle accounts for 40% of body weight, and about 85% of human pain complaints.
Most Common Pain; neck, shoulder girdle, low back and hip girdle.
There are approximately 696 muscles in the body
Muscles are sprained when they are placed under an excessive physical load. The sprain does not normally affect the whole muscle, but is usually confined to one or two small muscles fibers within the main body of the muscle.
The sprain causes a rupture of a few muscle cells, producing initial pain and inflammation, and which usually settles within 1 -2 weeks. During this healing period it is possible to feel a painful taut band within the affected muscle where it has been sprained.
This taut band is often referred to as an active trigger point (TrP).

4. If the sprain is bad enough, sensitisation of the dorsal horn at the appropriate level in the spinal cord occurs AND it appears that whole muscle has gone into spasm.
Injured muscles are much less willing to relax increasing the likelihood of further injury and cramps.
In some people the pain resolves but the taut band remains, producing a latent trigger point (TrP), (hurts on certain movement)
A latent TrP does not normally cause pain unless it is prodded, rolled around, or stretched.
Vulnerable to further injury in the future as the latent trigger point may make the muscle less willing to lengthen or relax.
In a small proportion of people the TrP remains active long after the original injury.

5. Active Trigger Points
A history of sudden onset after an acute muscle overload, or a gradual onset with chronic overload.
A pattern of referred pain characteristic for the individual muscle. A taut palpable band within the muscle.
Weakness and restricted range of movement appropriate for the muscle involved.
Local tenderness on digital pressure.
A twitch response in the muscle on snapping the trigger point with the finger, or when needling the trigger point.
Reproduction of the patient's local and referred pain on examination and during injection treatment.
Resolution of the pain with specific treatment for the trigger point.

6. TPT Treatment Techniques
Reduce the pain generated by the TrP by using local methods.
Improve the suppleness of the muscle by using stretching techniques shortly after the treatment. These should also be continued at home regularly to maintain the improvement.
Strengthening the muscle afterwards to prevent vulnerability to further injury.
Using one without the other often results in failure. It is extremely important for patients to fully understand and accept the cause of the pain, the patterns of referred pain, and to accept responsibility for their own recovery by complying with the necessary stretch routines.

7. Spray and Stretch
A cool spray (vapo-coolant) is sprayed on the skin overlying the affected muscle, whilst the muscle itself is gently placed into it's maximum stretched position. The vapo-coolant spray helps inhibit the dorsal horn mechanisms responsible for keeping the muscle in a contracted state, allowing the TP to be deactivated by the stretching techniques
Positional Release
TP's are deactivated by positioning the patient in such a way that the affected muscle is shortened as much as possible. This minimised position is then held and supported by the therapist (with the patient in a completely relaxed state) for at least 90 seconds, before being slowly released back to normal again
◦At the heart of this technique is the supposition that muscles are sprained when placed under a physical load, usually when the muscle is at maximal stretch. The control system for that muscle (dorsal horn in the spinal cord, position or stretch receptors in the muscle) then exhibits a form of "memory" keeping the sprained part of the muscle in a contracted state. Minimising the length of the muscle for 90 seconds helps to reset the control system by reducing the degree of dorsal horn sensitisation and also by reducing the abnormal muscle position receptors activity.

8. Reciprocal Inhibition
At the heart of this technique is the supposition that muscles are sprained when placed under a physical load, usually when the muscle is at maximal stretch. The control system for that muscle (dorsal horn in the spinal cord, position or stretch receptors in the muscle) then exhibits a form of "memory" keeping the sprained part of the muscle in a contracted state. Minimising the length of the muscle for 90 seconds helps to reset the control system by reducing the degree of dorsal horn sensitisation and also by reducing the abnormal muscle position receptors activity.
◦At the heart of this technique is the supposition that muscles are sprained when placed under a physical load, usually when the muscle is at maximal stretch. The control system for that muscle (dorsal horn in the spinal cord, position or stretch receptors in the muscle) then exhibits a form of "memory" keeping the sprained part of the muscle in a contracted state. Minimising the length of the muscle for 90 seconds helps to reset the control system by reducing the degree of dorsal horn sensitisation and also by reducing the abnormal muscle position receptors activity.

9. Ischaemic Compression
TrP's are deactivated by the therapist applying firm pressure with a finger or thumb for at least minutes. This renders the point temporarily short of oxygen (ischaemic) allowing it relax.

10. Dry Needling
TrP's are deactivated by needling them with fine acupuncture type needles.
Different needling techniques include:-
▪Lift and thrust - where the needle is gently moved in and out of the TP
▪Periosteal pecking - where the surface of the bone underneath the muscle is gently tapped or scraped with the needle tip

11. Twizzelling - where the needle is gently rotated along its long axis until the muscle grips it, preventing it from being turned any further
▪ Moxibustion - where the needles are heated by burning hemp
▪ Electro-stimulus - where the muscle is stimulated by low current electrical impulses at alternating frequencies of 2 Hz and 80 Hz for minutes

12. Medical Interventions
Trigger Point Injections (TPI's)
TrP's are deactivated by injecting them with local anesthetic (lignocaine) and dilute steroid (triamcinolone). The local anesthetic immediately causes the TrP to relax, whilst the steroid component helps to reduce post-injection soreness.
Deep TrP's sometimes require electromyogram (EMG) guidance to improve the accuracy of the TPI. Superficial, easily palpable ones can be treated without such guidance.
Spinal Trigger Points are often treated with combination TPI's plus Spinal Manipulation

13. Trigger Point Injections with Botox
Many patients will respond to a series of three LA/steroid TPI's. Botox A injections should be considered in resistant cases (see below)
TrP's are deactivated by injecting them with Botulinum Toxin A (Botox A). Botox blocks motor nerve impulses from  reaching the injected muscle fibre, therefore producing pain relief because of intense relaxation. Botox binds irreversibly to specific receptors, producing muscle relaxation which lasts up to 3 months. Muscle tone slowly returns as new receptors are produced

14. Aim of Treatments
Treatment in your clinic should be aimed at three different areas:-
1) Reducing the pain to an acceptable level using medications, physical therapies, exercises, (injections, or surgery)
2) Addressing the psychological problems including anxiety and depression, abnormal pain beliefs, pain-avoidance behavior, abnormal coping mechanisms
3) Improving patient / family / workplace education and attitudes to the pain and it's management. 

15. References
painclinic.org.com