Debate: Superficial or Deep Needling
Dr Peter Baldry
Pershore, Worcestershire, England
(Summary of Peter Baldry's contribution to the debate)
In my experience the majority of patients with the myofascial pain syndrome have uncomplicated primary myofascial trigger point (MTrP) nociceptive pain. In addition, there is a small number who have concomitant MTrP nociceptive pain and nerve root compression pain. These latter patients are divided into 2 groups. A group in which nerve roots are compressed by a muscle that has become shortened as a result of MTrP activity. And a group in which there is spinal nerve root compression pain, usually due to either spondylosis or disc prolapse and the secondary development of MTrP nociceptive pain.
Primary MTrP nociceptive pain.
The commonest reason for the development of primary MTrP nociceptor activity is trauma to a muscle either as a result of direct injury to it or because of it becoming overloaded. A MTrP contains motor end plates, large and small sensory afferent fibres, sympathetic fibres and blood vessels. The effect of trauma is to release chemicals which activate the MTrP's Group 1V sensory afferent nociceptors with, as a consequence, the production of nociceptive pain. And following this other chemicals then sensitise these nociceptors and cause the MTrP to become exquisitely tender.
The sensory afferent barrage set up by these activated and sensitised nociceptors is responsible for the development of neuroplastic changes in dorsal horn neurones .(central sensitisation). This neuropathic component has several effects including the perpetuation of MTrP pain. A ketamine-like drug , without it's undesirable side effects, is urgently needed to combat this.
Treatment of primary trauma-induced MTrP nociceptive pain.
In the 1970's I used deep dry needling (DDN) for alleviating this type of pain. Then in the early 1980's, for reasons to be discussed in the debate, I found that superficial dry needling (SDN) is equally effective It's other advantages are that it is painless, safe and easy to carry out. I have therefore continued to use this technique for the past 20 years and have taught a large number of doctors and physiotherapists in various countries how to carry it out.
Patients divide themselves into strong, average and weak responders to dry needle stimulation. And a great advantage of SDN over DDN is that with the former, unlike the latter, the strength of the stimulus can readily be adjusted to suit an individual patient's requirement.
For successful treatment with SDN it is essential to locate and deactivate all of the pain-producing MTrPs. And following treatment the patient should carry out muscle stretching exercises on a regular basis. It is also essential to correct any factor liable to bring about MTrP re-activation.
Concomitant MTrP nociceptive pain and radiculopathic pain.
For the relatively small number of patients where spinal radiculopathic pain is complicated by the secondary development MTrP nociceptive pain DDN is required. There are various ways of carrying this out. Chu's twitch-obtaining intramuscular stimulation (TOIMS) would seem to have much to commend it. DDN, however, is extremely painful, has a liability to cause structural damage and that inflicted on blood vessels leads to the development of much post-treatment soreness.
Baldry PE 1993 Acupuncture, trigger points and musculoskeletal pain, 2nd edn. Churchill Livingstone, Edinbuirgh
Baldry PE 2001 Myofascial pain and fibromyalgia syndromes. Churchill Livingstone. Edinburgh