Needling Myofascial Meridians?

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Beyond the Trigger Point...

Many clinicians needle. We are taught to dry needle trigger points and to needle the segmental innervation of the muscle involved. But should we do more? I think so, and here is one paper on incorporating needling myofascial meridians along with trigger points that supports that notion (1).

Since most of us treat patients that are ambulatory, we should be thinking of how a patient moves, especially through the gait cycle. Think of the kinetic chain in what I like to call “reverse engineering”, that is, from the ground up, rather from the torso down, in a closed chain fashion. This will profoundly effect the way you look at muscle function, for example: thinking of the vastus lateralis as a medial rotator of the thigh (yes, you read that right; think about it and try and get your head wrapped around it), or of the peroneus longus as an abductor of the lower leg and external rotator (assisting supination) during the latter half of the gait cycle. Reverse engineering gives you a whole new outlook on locomotion and human movement.

Tom Myers was insightful enough to write a great text talking about myofascial meridians or “lines of tissue stress ” describing the fascial connections of muscles utilized in a chain during movement (2). This built upon the original work of Valdimir Janda and his concepts of “loops and slings” (3), as well as the work of Paoletti (4) and Vleeming (5). 

In neurology, we have the conjoint concepts of temporal and spacial summation that can lead to some action on the part of the nervous system. They describe 2 ways that receptors or neurons can reach threshold and fire an action potential (6) .

Temporal summation is when a receptor or neuron is stimulated repetetively over time, with each potential bulding upon the previous, making the stimulus effectively larger and larger. If you were in a movie theater and the person seated behind you kept hitting the back of your seat repetitively (temporal summation), it would only be a matter of time before you turned around and said some thing to them(ie, you reached threshold).

Spacial summation is when a receptor or neuron is stimulated at multiple locations over time, with the potentials building and bringing the receptor or neuron closer to threshold.  Taking the same scenario as before, if many people began hitting your chair from multiple directions (spacial summation), it would be only a matter of time before you said something (ie: reached threshold).

These two things can work together as well, usually eliciting a result much faster, since the receptor or neuron is being hit multiple times from multiple directions and it can usually reach threshold faster.

Since one of our goals in needling is not only to reduce or eliminate the trigger point, but also to reduce pain and increase function, wouldn’t it make sense to take advantage of as much neurology as possible? How about more real estate (spacial summation) in a reasonable time frame from point to point (temporal summation)?

Needling appears to cause pain modulation, as well as many of its other effects,  through both peripheral and central mechanisms (7,8). Having our therapy stimulate more of these mechanisms should theoretically make our therapy more effective and improve outcomes. So, more needles may be a good thing, no? 

Getting back to the paper (1), they needled tender points (satellite trigger points?) along the lower portions of the “superficial back line” or “SBL”, along with points on the foot for plantar fascitis. The SBL contains plantar fascia, Achilles tendon, gastrocnemius,hamstrings, sacrotuberous ligament, and erector spinae. It continues to the suboccipital muscles and ends at the suboccipital muscles, galea aponeurotica of the skull and ultimately the frontalis muscle (2). They could have incorporated more, and perhaps had even better results, as the upper cervial spine contains one of the highest densities of mechanoreceptors in the body (9, 10), and afferent information from the upper 4 cervical neuromeres feed directly into the flocculonodular lobe of the cerebellum (11, 12).

So, how about incorporating myofascial meridians into your needling toolbox? The next time you see someone with a problem area, think about the kinetic chain that gets you there, starting from the ground up, and incorporate THAT into your treatment protocol. 

 

references:

1. Akhbari B, Salavati M, Ezzati K,  Mohammadi Rad S: The Use of Dry Needling and Myofascial Meridians in a Case of Plantar Fasciitis Journal of Chiropractic Medicine (2014) 13, 4348

2. Myers TW. Anatomy trains: myofascial meridians for manual and movement therapists. 2nd ed. Philadelphia: Churchill Livingstone; 2009.

3. Janda V, Vavrova M, Hervenova A, et al. Sensory motor stimulation. In: Liebenson C. ed Rehabilitation of the spine: a practitioners manual. 2nd edn. Lippincott Williams & Wilkins, 2006.

4. Paoletti S. The fasciae: anatomy, dysfunction & treatment. Eastland Press; 2006.

5. Vleeming A, Snijders C, Stoeckart R, Mens J. The role of the sacroiliac joins in coupling between spine, pelvis, legs and arms. In: Vleeming A, et al, editor. Movement, stability and low back pain. Churchill Livingstone; 1997. p. 5371

6. Levin & Luders (2000). Comprehensive Clinical Neurophysiology. New York: W.B. Saunders Company.

7. Dommerholt j Dry needling — peripheral and central considerations Journal of Manual and Manipulative Therapy 2011 VOL. 19 NO. 4 223-237

8.  Li-Wei Chou,  Mu-Jung Kao, Jaung-Geng Lin  ProbableMechanisms of Needling Therapies for Myofascial Pain Control Evidence-Based Complementary and Alternative Medicine Volume 2012, Article ID 705327, 11 pages doi:10.1155/2012/705327

9. Kulkarni V1, Chandy MJ, Babu KS  Quantitative study of muscle spindles in suboccipital muscles of human foetuses. Neurol India. 2001 Dec;49(4):355-9

10. Bogduk N Cervicogenic headache: anatomic basis and pathophysiologic mechanisms. Curr Pain Headache Rep. 2001 Aug;5(4):382-6.

11.   Luan H1, Gdowski MJ, Newlands SD, Gdowski GT  Convergence of vestibular and neck proprioceptive sensory signals in the cerebellar interpositus. J Neurosci. 2013 Jan 16;33(3):1198-210a. doi: 10.1523/JNEUROSCI.3460-12.2013.

12.  Seaman D Winterstein  Dysafferentation:   A Novel Term to Describe the Neuropathophysiological Effects of  Joint Complex Dysfunction. A Look at Likely Mechanisms of Symptom Generation  J Manipulative Physiol Ther 1998 (May);   21 (4):   267-280

An often overlooked culprit in hip pain...

We often find clinically that the quadratus femoris as becoming the 1st dysfunctional muscle of the deep 6 external rotators (1) and its pain referral pattern can mimic the piriformis (2) and piriformis syndrome (3) as well as hamstring insertional tendinitis.  It has also been implicated in some cases of femoroacetabular impingement (4)  as well as ishiofemoral impingement (5). It is active during walking stance phase, and moreso during stance while running as well as with a clamshell exercise with external rotation (6). It appears to be maximally lengthened with flexion and adduction or abduction, with internal rotation ( a great position of you need to stretch this muscle), and is deducted to be strongest going from a 60-90 degree flexed position into extension (ie: it has the with the largest moment arms observed for extension in the deduced force-length efficient range of 60-90° flexion)(7).

Needling this muscle can sometimes pose a challenge. Here is a demo of one way to accomplish it I often employ while needling some of the other surrounding hip musculature.

Consider the QF the next time you have someone with hamstring insertional pain, or diffuse hip pain that you are having a difficult time localizing.

  1. Personal observation
  2. Janet G. Travell , M.D., and David G. Simons, M.D., Myofascial Pain and Dysfunction: The Trigger Point Manual, The Lower Extremities vol. 2 (Baltimore: Williams & Wilkins, 1992) pp. 186-193.
  3. Dalmau-Carolà J Myofascial pain syndrome affecting the quadratus femoris Pain Pract. 2010 May-Jun;10(3):257-60. doi: 10.1111/j.1533-2500.2009.00347.x. Epub 2010 Feb 11

  4.  Diamond LEVan den Hoorn WBennell KLWrigley TVHinman RSO'Donnell JHodges PW. Coordination of deep hip muscle activity is altered in symptomatic femoroacetabular impingement.  J Orthop Res. 2016 Aug 11. doi: 10.1002/jor.23391. [Epub ahead of print]

  5. http://radsource.us/ischiofemoral-impingement-syndrome/
  6. Semciw, Adam I. et al. Quadratus femoris: An EMG investigation during walking and running Journal of Biomechanics , Volume 48 , Issue 12 , 3433 - 3439

  7. Vaarbakken KSteen HSamuelsen GDahl HALeergaard TBStuge B .Primary functions of the quadratus femoris and obturator externus muscles indicated from lengths and moment arms measured in mobilized cadavers. Clin Biomech (Bristol, Avon). 2015 Mar;30(3):231-7. doi: 10.1016/j.clinbiomech.2015.02.004. Epub 2015 Feb 11.

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Leg Pain? Are you SURE its a disc?

Gluteus minimus dysfunction is often present in gait disorders, including stance phase mechanical problems, since it fires from initial contact through pre swing, like it better known counterpart, the gluteus medius. It is interesting that the trigger point referral pattern of the gluteus minimus has a sciatic distribution, whereas the gluteus medius is more in the local area of the hip. 

 There are several, well known effects of dry needling:

decreased central sensitization

increased range of motion

changes in muscle activation

changes in the chemical environment surrounding a trigger point

changes in local and referred pain


and now we can add (not surprisingly), changes in autonomic function. The mechanism probably has something to do with pain and the reticular formation sending information down the cord via the lateral cell column (intermediolateral cell nucleus) or pain (nociceptive) afferents sending a collateral in the spinal cord to the dysfunctional muscle (Dr Ivo talks about these mechanisms in his dry needling and acupuncture lectures). 


Conclusions

The presence of active TrPs within the gluteus minimus muscle among subacute sciatica subjects was confirmed. Every TrPs-positive sciatica patient presented DN related vasodilatation in the area of referred pain. The presence of vasodilatation suggests the involvement of sympathetic nerve activity in myofascial pain pathomechanism.

BMC Complement Altern Med. 2015; 15: 72. Published online 2015 Mar 20. doi:  10.1186/s12906-015-0587-6PMCID: PMC4426539 Intensive vasodilatation in the sciatic pain area after dry needling

link to full text: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4426539/