Trigger Point Needling to Alleviate Pain

http://pain6.blogspot.com/2009/10/chronic-pain-referral.html
Trigger Point Needling is a commonly used method to alleviate pain from trigger points, which are knots or hardening of muscle fiber. The procedure is generally performed by a medical doctor or osteopath and can be either in the form of dry needling or the doctor may inject a pain killer such as lidocaine or even botox into the trigger point to ease the patient’s pain.

Injecting lidocaine into a trigger point is very similar to getting any type of injection, except that with a trigger point injection, the doctor wants the medicine to reach a specific area in a specific muscle as opposed to the medicine generally entering the patient’s system.

Lidocaine “is widely used for infiltration, nerve-block, and spinal anesthesia in a 0.5 to 2 percent aqueous or saline solution and is also applied to mucous membranes (2 to 4 percent) for mucosal anesthesia.” (1) Because lidocaine is a fast acting anesthetic, pain relief may be almost immediate depending upon the reason for the trigger point flareup.

According to Dr Janet Travell, “trigger point injection requires careful positioning of the patient and often needling at both the central and attachment trigger point regions to be successful.” (2) After trigger point injection the physician will also usually prescribe several visits to a physical therapist for “bimanual release of tightness in the vertical and diagonal muscle fibers” (3) of the muscle immediately surrounding the trigger point.

In addition the physical therapist will also prepare the trigger point for manipulation by either icing down the trigger point and surrounding muscle or applying a vapocoolant spray over the muscle and painful areas prior to manual manipulation.(4) The goal of both the injection and the physical therapy is to coax the trigger point to relax its tight grip on the muscle.

Figure 1 shows a perpendicular injection into a trigger point, which is the injection into the central area of the trigger point that was previously mentioned. Figure 1 also shows a similar injection into the trigger point at an angle in the inset picture. Many physicians will inject straight in and at angles to the right and to the left to insure reaching all areas of the trigger point needed to ease the patient’s pain.

Botox, or Botulinum Toxin Type A, is injected in a similar manner that lidocaine is injected. Botox is a drug developed from a toxin produced by the bacterium Clostridium botulinum, which is the same toxin that causes food poisoning or botulism. (5)

This is the same botox that dermatologists and plastic surgeons use to treat facial wrinkles to make their patients look younger. Doctors also use botox in small doses to treat “Cervical dystonia – a neurological disorder that causes severe neck and shoulder muscle contractions.” (6)

Cervical dystonia and the neck and shoulder muscle contractions are a fancy way of saying that the trigger points in those muscles are working overtime and causing the muscles to contract to the point of causing severe pain. If you can get the trigger points to relax their grip on the muscle, the pain will subside.

“Botox injections work by weakening or paralyzing certain muscles or by blocking certain nerves.” (7) A muscle that is weakened or cannot contract will also not be able to cause pain by overcontracting.

The negatives of botox are that its effect ony lasts from three to six months after which the needling procedure must be performed again to continue to ease the pain. Botox can also cause pain in the injection area and even worsen the symptoms that you are trying to eliminate.

When botox is used to treat cervical dystonia, the pain in the general area of the injection will increase somewhat for a week or ten days, after which the pain caused by the trigger points will ease or dissipate completely. However, the treatment can occasionally backfire by increasing pain in the injection area and never easing, leaving the patient in an even worse state of pain and never easing the pain.

Botox can also cause flu-like symptoms, headache and upset stomach. According to the Allegan, Inc. web site, which is the company manufacturing botox, other side effects may include: “dry mouth, discomfort or pain at the injection site, tiredness, headache, neck pain, and eye problems: double vision, blurred vision, decreased eyesight, drooping eyelids, swelling of your eyelids, and dry eyes,” problems swallowing, speaking, or breathing, or a spread of toxin effects to other areas of the body. (8)

Dry needling is performed in the same manner as injecting lidocaine or botox, however, no medicine is injected into the site. The needling itself is sometimes enough to induce the trigger point to relax. Dry needling can be performed by an acupuncturist or a medical doctor.

The following video is an example of how a doctor performs dry needling on the infraspinatus muscle:

The efficacy of any of the forms of needling will naturally depend upon the reason for the flare up of the trigger point. In the case of a trigger point flareup caused by trauma, such as an auto accident,the flareup may subside completely after treatment or may return because of permanent injury such as spinal cord injuries.

(1) Dictionary.com. http://dictionary.reference.com/browse/lidocaine, retrieved 10/25/2009.

(2, 3, 4) Myofascial Pain and Dysfunction: The Trigger Point Manual; Authors: Janet Travell, MD and David Simons, MD. p 491.

(5, 6, 7) Medline Plus – Botox. http://www.nlm.nih.gov/medlineplus/botox.html. Retrieved 10/26/2009.

(8) Botox Cosmetic. http://www.botoxcosmetic.com/. Retrieved 10/26/2009.

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