Dr Ma’s System of Integrative Dry Needling

Modernization of Manual Medicine

  • JUNE, 2016, GERMANY. Dr. Ma presented his new Dry Needling course for USA military Special Forces.

Introduction

BIOMEDICAL ACUPUNCTURE
for Sports and Trauma Rehabilitation
Dry Needling Techniques

It should be emphasized that the modern modality known as dry-needling acupuncture does not share any common foundation with traditional Chinese acupuncture, which is based on ancient Chinese philosophical and cultural concepts. The term acupuncture is used here in the sense of its original Latin roots: acus (needle) and punctura (puncture or piercing).

Introduction to the textbook by Dr. Y.T Ma

Dry-needling acupuncture is a new medical modality for treating patients with soft-tissue pain and sports injuries.

Sports are skilled and specialized activities requiring actions that are highly-coordinated among different body systems. The nerves, muscles and skeletal system must cooperate in elaborate patterns of activity according to a precise timing sequence. If a muscle cannot conform with the current timing and pattern, the coordination is broken and the speed and precision of the performance will be impaired, possibly resulting in injury.

In clinical terms optimal performance is dynamic and needs continuous maintenance. Many factors, especially overtraining, can obstruct the achievement of optimal performance. Sports scientists, doctors, coaches and athletes are always seeking more effective procedures for treating intrinsic muscular fatigue and other problems, and now dry-needling acupuncture offers a solution.

The use of needling to improve performance in sport and to treat related problems and injuries is not new. In China from ancient times all Kung Fu masters were also masters of acupuncture. Today, although clinical successes in treating athletes with needling therapy are reported from time to time, the full potential of dry needling in sports medicine has not been recognized for at least three reasons.

First, the majority of practitioners do not understand the physiological mechanisms of dry needling, and so their practice is mostly empirical, based on their personal clinical experience.

Secondly, although empirical practice can produce good results, sometimes even apparent miracles, in most cases the results are not as good as they could be. For example, insufficient recovery between training sessions and competition and delayed onset muscle soreness [DOMS] are common problems in most active athletes, and many athletes never take the time for complete regeneration and repair. This makes them prone to injury, impairs their performance and ultimately may shorten their sporting career. Dry needling is the most effective therapy discovered so far for helping athletes to recover completely from those conditions, as long as the practitioners know the underlying mechanisms of needling and understand how to correctly use the needles. This especially true in athletes who do not show any physical signs of pathology but are affected by deep physiological stress which can lead to future injury or premature tissue degeneration.

Thirdly, many practitioners only concentrate on needling trigger points, when research tells us there are at least three other types of myofascial conditions affecting athletes, each of which requires a different needling technique.

This book provides a thorough and complete explanation of how to treat soft-tissue dysfunction and prevent the development of chronic injuries in sports training and exercise, and it includes specific needling procedures for achieving maximal recovery from training and competition, DOMS and overtraining syndrome. Athletes can substantially improve their physical performance by means of regular use of the de-stressing therapy introduced in this book, and they can also achieve complete recovery from intrinsic fatigue, overtraining and musculoskeletal stress, as well as increasing the integration of all their physiological systems.

It should be emphasized that the modern modality known as dry-needling acupuncture does not share any common foundation with traditional Chinese acupuncture, which is based on ancient Chinese philosophical and cultural concepts. The term acupuncture is used here in the sense of its original Latin roots: acus (needle) and punctura (puncture or piercing).

In recent years the unique efficacy of dry-needling therapy has been recognized by an increasing number of medical doctors, physical therapists, doctors of chiropractic, occupational therapists and others, who have appreciated its value and incorporated it into their clinical practices. “Dry”, as opposed to “wet” needling, is defined by Drs. Janet G. Travell and David G. Simons as “needling the soft tissue without injection of any liquid substance to treat human pathology” in chapter 3 of their now-classic “Myofascial Pain and Dysfunction – The Trigger Point Manual”[1]

They also state: “In comparative studies, dry needling was found to be as effective as injecting an anesthetic solution such as procaine or lidocaine in terms of immediate inactivation of the trigger point.” (pp. 151-152). Their ground-breaking work and other innovative needling methods such as the approach of Dr C. Chan Gunn, which is known as Intramuscular Stimulation (IMS), have laid the foundation of what is now known as the new modality of dry-needling acupuncture.

Clinically, soft-tissue pain is an aspect of soft-tissue dysfunction and may include myofascial pain, other musculoskeletal pain, fibromyalgia and other soft-tissue pathology. Soft-tissue injury is present in most types of sports injury. Dry-needling acupuncture is a very effective modality for treating acute and chronic soft-tissue damage. An additional clinical benefit of dry needling is that it is effective in preventing the chronic injuries which result from repetitive overuse of muscles as is commonly seen in sports and physical exercise.

Dry-needling acupuncture is a unified system which successfully combines both systemic and analytical approaches. Practitioners should not treat local symptoms only, but also need to restore the systemic homeostasis of their patients.

In contrast to wet needling,the clinical procedure of dry-needling acupuncture emphasizes more tissue healing than pain relief, more systemic approach than treatment of local pathology, and both post-injury treatment and pre-injury prevention.

Lesion mechanisms of dry needling

Understanding the basic physiological mechanisms of dry needling is of the most fundamental importance to the practitioner. These mechanisms can be seen in two important aspects: the actual process of stimulation by needles, and how the needling stimulation brings about therapeutic effects.

Needling is both a physical disturbance to soft tissue and a minute biological traumatic inoculation into soft tissue. The physical movement and manipulation of the needles in deep tissues increase the tension of the muscle fibers and connective tissue and create the effect of mechanical signal transduction, which leads to self-healing.

A minute traumatic lesion and the lesion-induced inflammation remain in the tissue when the needle is removed. The diameter of a skeletal muscle fiber is 50 mm and the average diameter of the dry needles used in clinical practice is about 250 mm (gauges 32-36). Therefore if a needle is inserted into a muscle, perpendicularly to the fibers, to a depth of 1 cm, it may break at least 1,000 muscle fibers. If the needle is inserted deeper into the muscle, with manipulation, tens of thousands of muscle fibers, as well as some capillaries and nerve endings, may be broken or injured by it.

Our brain identifies the traumatic lesion in the soft tissue and directs biological systems, including the cardiovascular, immune and endocrine systems, to replace the damaged tissue with the same type of fresh tissue within a few days. In this way self-healing starts in the location of the needling. In addition to this local healing effect, the lesion also induces systemic effects to restore homeostasis through a number of reflex processes at different levels of the central nervous system.

It should be emphasized that dry needling, as a non-pharmaceutical modality, promotes self-healing by reducing the mechanical and biological stress of the body. Some patients with soft-tissue pain will achieve self-healing without any medical intervention after a sufficient period of time. Nevertheless, dry needling accelerates this self-healing process and reduces unnecessary suffering. This acceleration also helps to prevent the development of chronic pathology. Without this understanding there is a potential for confusion. For example, a recent study[8] showed that in the first 10 weeks of treatment a needling-treated group experienced a much higher level of improvement (4.4 points) than a group treated with conventional methods (2.1 points). After 52 weeks, however, there was little difference between the group treated with needling and the control group. This result is objective and can be correctly interpreted if the physiological nature of needling therapy is understood: both groups achieved self-healing by the end of the research period (52 weeks), but the group treated with needling suffered much less and had less potential for developing chronic pain than the control group. This is the clinical value of dry-needling therapy.

Dry needling is a specific therapy for restoring soft-tissue dysfunction

Dry needling creates minute lesions in specific areas of soft tissue so as to normalize the soft tissue dysfunction without the involvement of any pharmacological process. By its physiological nature, dry needling is a specific therapy for myofascial pain and other soft-tissue dysfunction. Muscle accounts for 50% of human body mass, and so most human pathological conditions involve soft-tissue dysfunction, whether in the case of physical injuries such as muscles damaged by overuse in daily life or in sporting activity, or in cases like Parkinson’s disease, drug addiction, stroke or cancer.

Of all the types of soft-tissue dysfunction, pain is the most common neurological disorder, affecting at any given time about 35% of the North American and European population. More than $100 billion is spent every year for pain management. Recent studies suggest that more than 6 in every 10 adults over the age of 30 experience chronic pain. Expenditure on the relief of back and neck pain alone has risen to more than $80 billion per year in the United States, – a dramatic increase over the past 8 years. In addition to the lost productivity of employees who can no longer work because of pain, an estimated $64 billion per year is lost due to the reduced performance of workers who continue to work while in pain. [6]

Dry needling as a specific soft-tissue therapy is a valuable modality which has few or no side-effects if practiced properly. Several evidence-based studies show that needling is more effective than conventional therapy for back pain. [7,8] This is because dry needling therapy emphasizes and promotes the healing of tissue, with pain relief as a result or positive “side-effect”.

In sports medicine, it is not uncommon, among both professionals and amateurs, for injured athletes to be permanently disabled due to their treatment being focused on pain relief rather than on the restoration of optimum function.

A systemic approach is necessary in dry-needling acupuncture

Clinical observation and evidence-based research [9] reveal that an injury produces both local symptoms and systemic dysfunction, especially in active athletes. Systemic dysfunction will continue if treatment is directed only at local symptoms. For example, knee pain can affect how the muscles are used to control the gait of the other leg, the movement of both feet and the hips, the spinal balance from the sacral to the cervical regions, and the functioning of the neck and even the eye muscles. The patient may not consciously realize this chain of dysfunction in their body, but an experienced clinician can easily recognize the interrelationship and identify the systemic dysfunction. Our brain, specifically the hypothalamus, will also subconsciously register this systemic dysfunction.

The interrelationship between local pathology and systemic dysfunction is felt in both the central and peripheral nervous system, and in the musculoskeletal system. Visceral physiology can be affected as well. For example, a sensitized trigger point on the iliotibial band, related to lower limb dysfunction, will increase the sensitivity of trigger points on the pectoralis major muscle. Both local symptoms and systemic dysfunction should therefore be treated at the same time to achieve restoration of homeostasis. This systemic approach is essential in the treatment of athletes to rehabilitate the current injury as well as to prevent injury in the future.

This systemic chain reaction of local symptoms is registered in the nervous and musculoskeletal systems, and will affect physiologic homeostasis which is regulated by the hypothalamus. The Integrative Neuromuscular Acu-reflex Point System (INMARS), which is introduced in this book, is a way of tracking the degree of both physical and physiological homeostasis, thus providing a map for restoring the homeostasis of the system.

Four types of myofascial pain and their different pathology

The majority of clinical pain is myofascial. It has been reported that 85% of back pain and 54.6% of chronic headache and neck pain is myofascial pain.[2] We currently categorize myofascial pain into four types:

(1) trigger points,

(2) muscle spasm,

(3) muscle tension, and

(4) muscle deficiency.

Each type of myofascial pain requires a different dry-needling technique and will follow its own healing pattern. Unfortunately many clinicians are trained to concentrate on trigger points to the exclusion of the other types of myofascial pain. Such narrow emphasis is contrary to the clinical realities [3] and reflects a lack of understanding of the pathophysiolology of myofascial pain.

Myofascial pain includes various types of soft-tissue dysfunction. An analysis of such soft-tissue pain involves at least the following types of pathology:

(1) tissue inflammation,

(2) tissue contracture,

(3) microcirculatory deficiency, which includes blood and

lymphatic circulation, ischemia and/or edema,

(4) trophic deficiency, including tissue degeneration,

(5) tissue adhesion,

(6) scarring of tissue and

(7) biomechanical imbalance of the musculoskeletal system,

including improper posture.

Soft-tissue pain, especially chronic pain, always involves all these dysfunctions and clinicians should treat all of them to achieve the optimum level of pain relief and recovery of tissue function. For example, when a joint is out of alignment, it causes both the attached and opposing muscle groups to be shortened or lengthened, which compromises the surrounding neuromuscular structures and connective tissues.

Muscle spasm, muscle tension and increased sympathetic output ensue, which results in soft-tissue pain, the development of trigger points, edema, ischemia, and tissue degeneration. If the condition continues to the point of becoming chronic, tissue adhesion and the formation of scar tissue will occur and central sensitization will follow.

Myofascial trigger points are small, circumscribed, hyperirritable foci in muscles and fascia, often found within a firm or taut band of skeletal muscles. [4] Trigger points may also occur in ligaments, tendons, joint capsules, skin and periosteum. They have been described as tender nodes of degenerated tissue that can cause local and radiating or referred pain. The extent of the area of referred pain has been defined as the zone of reference.

Please note that referred pain patterns do not correspond to dermatomal, myotomal or sclerotomal patterns and that the patterns of referred pain from a particular trigger point are not always the same. Myofascial pain symptoms presented by a patient may include pain, muscle weakness, decreased joint motion, and paresthesia, as well as autonomic symptoms like sweating, lacrimation, localized vasoconstriction, and pilomotor activity.

Trigger points show dynamic features. They can be asymptomatic (latent) or symptomatic (active). Primary trigger points develop independently and are not related to trigger-point activity elsewhere. Secondary trigger points develop in neighboring and anatagonistic muscles as the result of stress and muscle spasm. Satellite trigger points appear in the area of referred pain as the result of persistent resting motor unit activity.

Muscle spasm is the involuntary contraction of muscle caused by acute or chronic trauma, excessive tension, or visceral disorder. An untreated spasm will lead to decreased blood flow in the muscle and edema in the tissue, which initiates a vicious cycle of more muscle spasm and pain.

Muscle tension is defined by Hans Kraus as “a prolonged contraction of a muscle or muscle groups beyond functional or postural need”.[5] Muscle tension may have postural, emotional, or situational causes. Improper posture, negative emotional experience such as unresolved anger, or psychological stress, such as in a workplace atmosphere or in the build-up to a goal event, can cause muscle tension and result in muscle pain.

Muscles are considered deficient when they are weak or stiff and proper posture and muscle function cannot be maintained. Muscle deficiencies can be a source of pain and make a person prone to injury. The fact that weakened abdominal muscles can cause back pain is a typical example of this causal connection.

Clinicians should keep in mind that chronic pain may involve all types of soft-tissue dysfunction and varied techniques should be incorporated to achieve maximal healing and restoration of function. There is considerable clinical evidence that focusing only on pain, and ignoring healing of soft tissue, can be disastrous for athletes.

The unique efficacy of dry-needling acupuncture in sports medicine

Some athletes resort to drugs to achieve better performance, and they risk paying a high price for this in the future. Anabolic steroids greatly increase the risk of cardiovascular damage, heart attacks and stroke, because they cause hypertension, a decrease in high-density blood lipoproteins and an increase in low-density lipoproteins. The consumption of male sex hormones by male athletes can decrease testicular function, causing both lowered sperm formation and a reduction in the natural secretion of testosterone. The use of amphetamines and cocaine ultimately leads to a deterioration of performance. Some athletes have died during athletic events because of the interaction between such drugs and the norepinephrine and epinephrine which are naturally released during high levels of activity by the sympathetic nervous system. One cause of death under these circumstances is over-excitation of the heart, leading to ventricular fibrillation, which is lethal within seconds. Dry-needling therapy can be seen as a safe

means of enhancing performance. Dry needling reduces mechanical and intrinsic stress in the musculoskeletal system. This increases the efficiency of energy consumption and will therefore increase the endurance of the musculoskeletal system and thus improve physical performance. In addition, regular dry needling as a “maintenance” factor improves recovery and regeneration from the damage causes by training and competition, enabling the athlete to recover faster and continue to train at a higher level, thereby also potentially increasing performance.

The difference between dry needling and wet needling therapy

Dry and wet needling share many common mechanisms but there are significant differences between the two modalities. Dry needling can be used alone or in combination with wet needling to treat soft-tissue pain, and when they are used together dry needling is a very good adjunct procedure to wet-needling therapy. Dry needles inoculate minute lesions in soft tissue, and so multiple points can be needled in one treatment session and the same procedure can be repeated many times until maximal healing is achieved. In addition, a needling procedure for preventing injuries can be repeated and so maintain healthy homeostasis.

For example, when treating low-back pain, the lumbar muscles, gluteal muscles, hamstring muscles, calf muscles, hip flexor muscles, abdominal muscles, iliotibial band, pectoral muscles, and even neck muscles can be treated in the same session. The same procedure can be repeated in subsequent sessions until complete healing is achieved. The same needling procedure will also be effective with asymptomatic healthy persons for preventing low-back, hip and neck problems.

A brief history of dry-needling acupuncture

Like any medical procedure, dry-needling acupuncture has gone through a period of development and may now be considered to be reaching its maturity. Dry needling as a medical technique has been observed in various human civilizations for over two millennia. From historical literature we know that it appeared in Egypt, Greece, India, Japan, and China. The Chinese, as we know, systematically preserved this technique, developed its medical value and formulated the well-known acupuncture of Traditional Chinese Medicine (TCM), widely acknowledged as one of the great inheritances of Chinese civilization.

Modern dry needling started in the 1930s in England and developed to maturity in the United States (see Chapter 10). Drs. Janet G. Travell and David G. Simons did comprehensive clinical research that led them to define and locate most of the important trigger points of skeletal muscles in the human body. They also noticed the relationship between trigger points and internal visceral pathology (see Chapter 49 [1]). From the beginning they noticed that trigger points affect the posture and biomechanical balance of the musculoskeletal system. Other clinicians like Dr. C. Chan Gunn contributed different dry needling techniques (Intramuscular Stimulation). [11] These researchers created the foundation of the analytical approach in dry needling therapy. Then came the synthetic approach.

Dr. Ronald Melzack found that more than 70% of the classic meridian acupoints corresponded to commonly used trigger points. [12] Then, the discovery of homeostatic trigger points by Dr. H.C. Dung, Professor of Anatomy at the University of Texas Health Science Center at San Antonio, advanced our understanding of the connection between homeostatic trigger points and the principle of the central innervation of trigger points (see Chapters 7-8). Dr. Travell had herself paid attention to Dr. H.C.Dung’s work (personal communication between Dr. J.G. Travell and Dr. H.C. Dung in 1984 and personal communication between Dr. H.C. Dung and the author).

With 40 years of clinical experience and medical training, the author found that both the analytical and synthetic approach could be organically integrated into a new modality, modern dry-needling therapy. Working in the neuroscience program of the National Institutes of Health and in the physical therapy department of the University of Iowa, the author did research on pain relief and the neuropharmacology of the central nervous system, kinesiology, cognitive neural science, and neurology. The author was able to incorporate all these fields into dry-needling therapy.

For the last ten years, the author and his colleagues in the US, China, Germany, Brazil and other countries have used dry-needling acupuncture to treat thousands of patients including elite athletes. All this research and clinical experience have helped to develop the system of dry-needling into its current form.

As with any modern medical technique, our current knowledge is built on the past. We constantly evolve new wisdom and demolish old dogma. We forge new perspectives in our practice and continually redefine its goal. This dynamic process keeps our knowledge advancing without stagnancy and fossilization, and in this way dry-needling acupuncture will continue to grow.

Conclusion

Dry-needling therapy is easy to learn and offers unique efficacy in treating soft-tissue dysfunction. Increasing numbers of medical doctors, physical therapists, doctors of chiropractic, occupational therapists, physician assistants and nurses have recognized the clinical value of dry-needling therapy and are learning this modality and using it with their patients.

The ultimate purpose of dry-needling is to integrate physiological systems to achieve homeostasis for better body fitness. This integration is achieved by normalizing tissue dysfunction caused by local or systemic pathology.

Many studies have shown that people who maintain an appropriate level of body fitness will have the additional benefit of prolonged life. Especially between the ages of 50 and 70, studies have shown mortality to be three times less in the most fit people than in the least fit.[13] Athletically fit people have more body reserves to call on when they do become sick. Proper exercise, good nutrition and regular de-stressing treatment can help body fitness for adults of all ages.

Based on a foundation of biomedical principles, dry-needling can be practiced in many different ways according to any particular medical field. There is no necessity that dry needling should be restricted to a particular style or technique. Every medical professional can develop their own style of dry needling once they understand the physiological mechanisms that underlie it.

Dry-needling therapy is not the acupuncture of traditional Chinese medicine (TCM)

Dry needling has been developed on a foundation of the general principles of Western medical science. The understanding and practice of dry needling require that the practitioner has formal medical education, with comprehensive training which should include basic science as well as clinical courses like human anatomy, physiology, pathology, neurology, clinical diagnosis, etc. In addition, practitioners need to have clinical experience of dealing with patients in terms of personal interaction, recording of medical history, and so on.

Traditional Chinese acupuncture developed about 3000 years ago as an empirical clinical procedure. We have inherited much valuable experience from this ancient healing art, but this does not equal and cannot replace modern medical training, even though physiologically traditional acupuncture is a type of dry-needling therapy.

Confusion about traditional acupuncture can be avoided if we understand more of the history of its development. The distinguished scholar Professor Chen Fang-zheng, senior researcher of the Chinese Academy of Science and former director of the Institute of Chinese Culture at the Chinese University of Hong Kong, wrote in his recent book Heritage and Betrayal: A Treatise on the Emergence of Modern Science in Western Civilization (San Lian Shu Dian Press, Beijing, April 2009) that modern science could not evolve in Chinese culture as it did in the West because the ancient Chinese did not develop a method of logical enquiry into the objective world but focused only on practical aspects of their life. The same holds true in the development of traditional Chinese medicine.

Professor Chen Xiao-ye of the Academy of Chinese Medicine in Beijing also stated, in a personal communication to the author, that Traditional Chinese Medicine accumulated a great corpus of clinical experience but did not develop consistent theories, so that today we have to formulate modern theories to explain their traditional methods. Professor Huang Long-xiang, Vice-President of the Acupuncture Institute at the Academy of Chinese Medicine in Beijing came to the conclusion that the “meridian channel” theory of TCM has successfully accomplished its historical mission of preserving and developing acupuncture; now it has become the narrow neck of the bottle which is impeding further development of acupuncture medicine in the 21st century. [10]

For six decades, since the 1950s, the Chinese government has invested huge financial and human resources in studying acupuncture meridians. Researchers discovered and confirmed many “meridian phenomena” but no independent anatomical channels were found to match the meridian concept.

Such research, however, is not wasted because it has clearly shown us that the concept of meridians was invented by the ancient doctors and that many “meridian” phenomena are of unknown physiology, but do have some relation to physical tissue, especially to our nervous system. Many laboratory scientists claim that they have discovered or confirmed the existence of meridian channels from research such as infrared imaging or similar procedures. If these researchers understood the neuroanatomy of the peripheral nervous system, the neurology and pathophysiology of the human body, and if they knew clinical needling mechanisms and had experience with real patients, they would interpret their results differently and reach different conclusions.

Why do many modern clinicians still cling to meridian theories if meridians are a human invention? There are social and empirical reasons. Practically, acupuncture based on meridian theory works. It is not uncommon in human intellectual history for mistaken theories to work quite well in terms of the empirical results. Also, in the tradition of Chinese medicine, theories and facts are not well differentiated and theories are often treated as facts.

The concept of meridians is a typical example of such confusion. Facts were often trimmed to fit the theories, which, in the words of Professor Huang Long-xiang, is like cutting the foot to fit the shoe.[10]

Chinese medicine developed very slowly in the last 2,000 years because in both theory and practice it was subject to the dominance of traditional philosophy over human experience. Traditional Chinese medicine is no longer able to develop on its own as it is heavily dependent on a philosophical foundation that has become stagnant and fossilized. The theories of traditional acupuncture are no longer adequate for explaining the clinical mechanisms, benefits and limits of dry needling.

We do not need to create new theories to explain how dry needling works. As with any modern medical procedure, the mechanisms, physiology, and clinical procedure of dry needling are based on universal scientific rules, the rules we discovered in mathematics, physics, chemistry, and biology.

Dry needling acupuncture has brought new concepts, a new system, a new interpretation and a new approach to learning and practicing healing therapy with needles. Both practitioners and patients will greatly benefit from this new approach.

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Kraus H: Muscle deficiency, in Myofascial pain and fibromyalgia, ES Rachlin, IS Rachlin (eds), 2ne ed., Mosby, St. Louis, 2002.
Bonica JJ: Management of myofascial pain syndromes in general practice. JAMA 732-738, June 1957.
Kraus H (ed): Diagnosis and treatment of muscle pain. Chicago, Quintessence, 1988.
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11. Gunn CC: Gunn approach to the treatment of chronic pain: Intramuscular stimulation for myofascial pain of radiculopathic origin, Churchill Livingstone, 2nd ed., 1996.
Melzack R, Stillwell DM, Fox EJ: Trigger points and acupuncture points for pain: correlations and implications. Pain: 3: 3-23, 1977
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