Dry needling, Intramuscular stimulation, IMS

Dry needling

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Dry needling is the use of a solid needle for therapy of muscle pain, sometimes also known as intramuscular stimulation.^[1] Dry needling contrasts with the use of a hollow hypodermic needle to inject substances such as saline solution, botox or corticosteroids to the same point. Such use of a solid needle has been found to be as effective as injection of substances in such cases as relief of pain in muscles and connective tissue. Analgesia produced by needling a pain spot has been called the needle effect.^[2] Acupuncture and dry needling techniques may be similar, but their rationale and use in treatment are quite different.^[3]

 Technique

In the treatment of trigger points for persons with myofascial pain syndrome, dry needling is an invasive procedure in which a needle, often an acupuncture needle, is inserted into the skin and muscle directly at a myofascial trigger point. A myofascial trigger point consists of multiple contraction knots, which are related to the production and maintenance of the pain cycle. Deep dry needling for treating trigger points was first introduced by Czech physician Karel Lewit in 1979.^[4] Lewit had noticed that the success of injections into trigger points in relieving pain was apparently unconnected to the analgesic used.^[2] Proper dry needling of a myofascial trigger point will elicit a local twitch response (LTR), which is an involuntary spinal cord reflex in which the muscle fibers in the taut band of muscle contract. The LTR indicates the proper placement of the needle in a trigger point. Dry needling that elicits LTRs improves treatment outcomes,^[5] and may work by activating endogenous opioids.^[4] Inserting the needle can itself cause considerable pain.^[4] No study to date has reported the reliability of trigger point diagnosis and physical diagnosis cannot be recommended as a reliable test for the diagnosis of trigger points.^[6][7] Chan Gunn introduced a type of dry needling called intramuscular stimulation in the 1980s that moved away from using trigger points.^[1] Baldry developed a version called superficial dry needling in 2005, in which the needle is inserted about 5-10mm into the tissue above the trigger point.^[1]

 Efficacy

A systematic review concluded that dry needling for the treatment of myofascial pain syndrome in the lower back appeared to be a useful addition to standard therapies, but that clear recommendations could not be made because the published studies are small and of low quality.^[5] A 2007 meta-analysis examining dry needling of myofascial trigger points concluded that the effect of needling was not significantly different to that of placebo controls, though the trend in the results could be compatible with a treatment effect. one study (Lorenzo et al. 2004) did show a short-term reduction in shoulder pain in stroke patients who received needling with standard rehabilitation compared to those who received standard care alone, but the study was open-label and measurement timings differed, limiting the use of the study. Again the small sample size and poor quality of studies was highlighted.^[8]

 Practice

Dry needling is practiced by physical therapists in many countries, including South Africa, the Netherlands, Spain, Switzerland, Canada, Chile, Ireland, the United Kingdom and New Zealand. In the United States, physical therapists in several states including Virginia, Maryland, Ohio, Colorado,^[9] Georgia, New Mexico, and Kentucky perform the technique, and several other states, including Louisiana and North Carolina, have recently updated board positions allowing the practice. Physical therapists are prohibited from penetrating the skin or specifically from practicing dry needling in Hawaii, Tennessee, New York, and Florida, though many states have no regulations on dry needling.^[10] Acupuncturists have argued that dry needling by physical therapists is infringing on their practice, but physical therapists argue that they are not practising acupuncture when dry needling.^[10] Whether dry needling is considered to be acupuncture depends on the definition of acupuncture, and opinions vary on whether trigger points correspond to acupuncture points or meridians.^[1]

 See also

• Trigger point
• Acupuncture
• Myofascial release

 

By: Robin Shepherd.
shepherd@intramuscularstimulation.com

Healing supplement Extract from The Times - March 1998 "If any therapy points to the medical future, it could be IMS or intramuscular stimulation. It combines acupuncture techniques with conventional knowledge, and seems to take healing into an area where orthodox and alternative medicine can be genuinely complementary to each other Known only to a few osteopaths and anaesthetists in the U.K., it is widely used in Canada, the United States and Sweden, and has has remarkable success in reducing chronic musculo skeletal pain. The Canadian professor and pain specialist who developed IMS over 20 years, Dr Chan Gunn, says: "Knowledge of IMS can provide an excellent bridge between Eastern and Western medicine, and not only does it bridge the gap , it transcends the limitations of both." IMS involves the insertion of acupuncture type needles into the body where muscles have shortened or contracted, or at points where muscle meets nerve. It is problems at these points that are often at the root of long term pain. One of Gunn's growing number of disciples in this country is Robin Shepherd, an Osteopath with a practice in Cranleigh, Surrey. He has been using IMS as a new accessory to normal osteopathic manipulation- with impressive results. "Manipulating muscles and ligaments is often not totally effective," he says. "Using IMS you get a rapid response in terms of muscle decontraction of tight muscles- and after that a healing of the muscle." In simple terms, the contracted muscle grabs on to the needle and then after a while relaxes; and this relaxation continues long after the needle has been withdrawn. Sometimes the needle itself is manipulated to bring about a mini-trauma and increase the effect. "You twiddle the needle to create a minor local injury and draw blood to the area," says Shepherd. "While the muscle is tight and contracted it can't heal properly- with IMS you are stimulating a healing process." So what's the difference between acupuncture and IMS? "With IMS you have to have anatomical knowledge, and medical examination and diagnosis, and the needles are inserted as indicated by examination," says Shepherd."With acupuncture, needles are inserted into non-scientific meridians, according to Chinese philosophy." And what do the Chinese think about IMS? "They won't listen to me," laughs Gunn, who first began to think about using needles after seeing acupuncture on a visit to China in the Seventies. Others take IMS much more seriously. In Sweden, there has been talk in medical circles of moves to nominate Gunn for a nobel prize. Gunn himself has no doubts about the efficacy of the technique. "It should be taught in all medical schools," he says, "because it is more effective than any other physical therapy."

Needles that bring relief from chronic pain Extract from The Times - 17/2/2000 An elderly woman with neck pain sits with two lines of needles stuck into her naked back; an amputee who has suffered 22 years of constant pain lies groaning as his right buttock gets similar treatment; and a middle aged woman with discomfort in several parts of her body has a row of needles protruding from her spine. This may sound uncomfortable, but the practice could herald a revolution in chronic-pain relief. The work has begun quietly at Addenbrooke's Hospital Cambridge, where a small team with limited resources is pioneering a technique called intramuscular stimulation (IMS). IMS, a needle technique that has been used in Canada and Sweden for many years, is often described as a "sort of scientific acupuncture". But instead of the "chi" energy and meridian lines of traditional Chinese medicine, it is concerned with the musculoskeletal system. The technique was developed from the 1970's onwards by the Canadian professor Dr Chann Gunn. Now two of his disciples, Dr Rajesh Munglani and Robin Shepherd have combined forces to show that IMS can have a dramatic effect in reducing chronic pain. Whatever the nature of chhronic pain, muscle spasm is often an integral part. IMS is based on a technique familiar to osteopaths, who induce relaxation in a muscle by tightening it and then letting go. The advantage with the needling is that it can go deep into the body- sometimes several inches- to hit the right spot. A knotted muscle will "grab" the needle and after a while "let go"- and carry on relaxing after the needle has been removed. An osteopath who saw the possibilities of IMS early on was Robin Shepherd, who began using to great effect in his practice in Surrey. When Munglani ran an IMS course at Addenbrooke's, Shepherd attended and the two men felt they could work together: Munglani with his anaesthetists background and obsession with getting closer to the roots of pain; Shepherd with his osteopaths skill at palpating to find to the exact points of problem muscle. Shepherd was so keen to pursue this partnership that he moved to the Cambridge area, where he divides his time between his work at Addenbrooke's and private practice. The pain relief service operates five days a week, dispensing advice to patients and also educating nurses and other health workers. But, due to limited resources, the Munglani and Shepherd double act only performs once a week. On their clinic day, when Munglani concentrates on thermocoagulation and PFR, while Shepherd taps in IMS needles, they see patients with chronic pain, all of whom have been referred by a GP or consultant. "I'm a needle phobic," says Victor Marsh, 40,"but I tried this because I was in so much pain." He lost his right arm in a motorcycle accident at the age of 18. He had lived with pain for years before coming to see Shepherd. His original reason for seeking help was phantom pains in his missing limb, but by the time he got to Addenbrooke's he had developed severe pain in his right leg and lower back. Two IMS treatments had given him relief. Now he was back for a third session, with Shepherd inserting three needles into his right buttock- one going in about four inches. When another needle goes into his leg, just above the knee, he shudders with pain and utters an agonised cry. "Yes, that's the spot," says Shepherd with a smile. "After treatment it's agony for a day," says Marsh, from Fulbourn, near Cambridge," but then it's better. The needling does seem to make the pain easier." Katherine Kenny is in her late seventies. She came in with severe neck pain that had plagued her for 10 years and found herself sitting with her head face down on a pillow and 10 of Shepherd's needles arranged in her upper back. "You've got wear and tear from overuse," Shepherd tells her. "You have relied on your shoulders for a long time. They have carried a lot of tension- while you have been caring for others and perhaps neglecting yourself." She nods in confirmation. "Knowledge of anatomy is essential if you are going to practice IMS ," says Shepherd. There are potential dangers. Areas around the front and side of the lower part of the neck, and at the centre of the base of the skull, are no-go zones. With the former there is the danger of pneumothorax and with the latter of damage to the brain stem. The needles stay in for up to 15 minutes. Shepherd removes them when he can feel that the muscle is ready to "let go". A clinical trail of IMS is due to start shortly at Addenbrooke`s with a comparative study of two groups of patients- one on IMS and one receiving "dummy" therapy. "Its an important therapy," says Shepherd. "But it needs some status and credibility before it can take off."

www.intramuscularstimulation.com