The science of Dry Needling & how it works!!
Physiological effects of dry needling
When a filiform needle is inserted into the muscle there a numerous physiological changes that take place to the muscle and/or fascia. On insertion of the filiform needle into ischemic tight muscle bands micro damage occurs to muscle tissue and fascia causing the production of inflammatory mediators (Leung 2012, p.267). The micro damage is due to the filiform needle bursting plasma membranes and causing neurogenic inflammation (Lund 2015). The micro damage to the muscle fibres initiates an inflammatory response increasing blood flow and oxygen to the ischemic area of the trigger point and facilitating physiological tissue healing and decreased pain (Lund 2015). Wu (2015) states that the micro damage promotes healing due to the local increase in blood flow and may be used to improve the function of muscles by decreasing muscle tension, improving range of motion, increasing coordination and decreasing pain (Cagnie 2013). When the needle enters the muscle there is a release of calcitonin gene related peptide via the axon reflex from thin sensory nerve endings, this causes vasodilation and increased blood flow to the area (Shinbara 2014, p.65). Shinbara (2014) also states that acetylcholine which gets released from cholinergic vasodilator nerves to possibly be the cause of the vasodilation. Furthermore mechanical stimulation to the endothelial tissue is believed to synthesis nitrous oxide as well as binding of vasodilators on receptors on the endothelium (Shinbara 2015). Interestingly Woehrle (2015) found that needling resulted in an increase in temperature and short term vasodilation which was similar to the subject’s pain distribution pattern when they used infrared thermovision. The response can often be seen with bright red skin surrounding the needle and a wheel may be seen post treatment (Wu 2015, p.15). The local twitch response is the contraction of the affected muscle fibres being needles which causes an involuntary spinal reflex (Cagnie 2013). When the involuntary contraction occurs the excessive acetylcholine which was released at the motor endplate gets used and the local ischemic tissue which was sustained by continuous contraction of the sarcomere relaxes as blood flushes in to the muscle fibres (Cagnie 2013). Another cause of the muscle relaxing as a result of the local twitch response is the opening of calcium ion channels allowing calcium ions to rush out and potassium to rush in (Lund 2015). This is believed to disturb the integrity of dysfunctional endplate through mechanical stimulation (Cagnie 2013). Another physiological effect of when the needle is inserted into muscle the tissue is a temperature and circulation increase which alters the cell membrane permeability which increases its ability to be affected by endogenous chemicals (Woehrle 2015).Refer to question 3. Another event that takes place when a filiform needle enters muscle is the penetration of the surrounding fascia. Leung (2011) suggests that this interrupts the fascia, distorting the continuity of the connective tissue by tugging on the elastic like fibres. This is hypothesized to activate local mechanoreceptors which then sends the initial neural signals (Leung 2011, p.263). Another part that connective tissue plays a role in is the release of adenosine phosphate compounds causing vasodilation. Lund (2015) states that the mechanical signalling through the extracellular matrix also causes vasodilation. It has also been found that if rotation of the needles occurs that the needle will grip the fibres of muscles and connective tissue causing an internal stretch of the tissues due to the production of surface tension and electrical attraction which is adequately enough to contribute to the mechanical effect of dry needling (Dommerholt 2013, p.36). Wu (2015) states that twirling of the needles winding up collagen fibres also changes the microenvironment of the interstitial tissue. The filiform needle results in mechanical stimulation of fibroblast, changing their cell shape and increasing their cross sectional area as the cell bodies spread out and expand (Lund 2015). It was observed that the remodelling of fibroblasts is important for sustaining the viscoelasticity properties of the tissue (Luind 2015). This counteracts fibrosis as seen in scar tissue and may result in dynamic changes of the actin cytoskeleton through purinergic receptors where high concentrations of purines e.g. ATP have been found close to the needle site (Lund 2015).
Neurological effects of dry needling
When a filiform needle is inserted into muscle there are numerous neurological changes and effects that take place centrally and peripherally. The peripheral changes resulting from the filiform needle entering muscle are as followed. Peripheral sensory nerve fibres locally set off action potentials around the network, known as the axon reflex which releases calcitonin gene-related peptide, an inflammatory neuropeptide (Wu 2015, p.14). This neuropeptide along with substance P activate mast cells and blood vessels resulting in blood vessel dilation and increasing muscle blood flow (Wu 2015, p.20). This causes vasodilation and it is believed that when increased blood flow occurs in the muscle that it washes out fatigued and or algesic substances which may result in improved functioning of the muscle (Shinbara 2014, p.65). In conjunction to this, action potentials also occur in the neurons of the dorsal root ganglion and afferent nerve trunk (Wu 2015, p.20). Dry needling eliciting a local twitch response also causes sympathetic cholinergic vasodilator nerves to release acetylcholine. When a filiform needle is inserted into muscle or more specifically the sensitive loci within taut bands it causes mechanical irritation via mechanoreceptors. Mechanotransduction takes place activating larger diameter alpha beta fibres and smaller diameter alpha delta fibres (Cagnie 2013). The needle is believed to disturb the pain cycle which involves peripheral nerves ascending the spinal cord to the brain areas which modulate and perceive pain, where the message then descends the spinal cord to the peripheral nerves resulting in nociception to the area (Lund 2015). These are the central changes as a result of dry needling. Leung (2012) found that needling activates brain nuclei by sending signals along the ventrolateral tract of the spinal cord modulating pain sensitisation by descending inhibition pathways. Action potentials were also found to occur in the dorsal horn of the spinal cord, neurons of dorsal root ganglion and afferent nerve trunks where Alpha beta and C-fibres are involved (Wu 2015, p.20). Alpha delta fibres and C-fibres are essential for pain modulation and the activity of the autonomic nervous system (Hong 2013, p.7). Dommerholt (2013, p.23) in particular states that it is slow conducting unmyelinated C fibre afferents. The signal passes through the spinal cord via the dorsal horn and to supraspinal centers. It is here that serotonin, glutamate, opioid and adrenergic systems are activated on the dorsal horn of the spinal cord reducing nociceptive inputs, as well as activation of diffuse noxious inhibitory control sending inhibition to the dorsal horn also reducing nociceptive inputs (Leung 2012, p.267). It was also found that activation of neural plasticity from the dorsal horn via long term potentiation and long term depression inhibits activation of C-fibres (Leung 2012, p.267). Supraspinal centers also activated correlating brain networks of the raphe nucleus, locus coeruleus, peri-aqueductal grey matter, prefrontal cortex, insula, cingulate cortex, caudate nucleus and amygdala which enhance the descending inhibition of nociception on the dorsal horn resulting in analgesia (Leung 2012). It appears that a common trend among the research is the fact that when a filiform needle is inserted into muscle peripheral nociceptive inputs travel through the ascending dorsal horn of the spinal cord and activate central inhibitory pain pathways (Fernandez-De-Las-Penas 2016, p.366).
Endocrine effects of dry needling
When a filiform needle is inserted into muscle there are numerous endocrine and immune responses that take place centrally and peripherally which can modulate pain or change the biochemistry of tissue. Centrally it may affect pituitary hormone release (Hong 2013, p.8). Hong (2013) suggests that the insertion of the filiform needle affects the hypothalamus quite significantly. In particularly the hypothalamic beta-endorphin system is thought to play a large role in mediating autonomic functions, releasing pituitary and gonadotrophin releasing hormones and other gonadotrophins (Hong 2013, p, 9). When the filiform needle is inserted into the muscles it causes cellular damage triggering the release of adenosine triphosphate which is hydrolysed to adenosine in the extracellular space (Takano 2012). One study by Nagaoka (2015) found that there was an increase of adenosine triphosphate, adenosine diphosphate and adenosine concentrations in extracellular fluid locally. Concluding that the concentrations of adenosine triphosphate and adenosine diphosphate contributed to the increase of muscle blood flow in response to the filiform needle entering the muscle (Nagaoka 2015). Adenosine triphosphate and adenosine diphosphst stimulate the production of nitrous oxide and adenosine binds to P2 receptors and A2 receptors on vascular smooth muscle and endothelium activating nitrous oxide (Shinbara 2014). It was found that endogenous opiate peptides have a role to play in the pain relieving outcome of dry needling, this was found both in laboratory and clinical results (Leung 2012). Wu (2015) states that when dry needling is done that this stimulates substance P, calcitonin gene related peptide, tryptase, histamine and serotonin. Leung (2012) found that dry needling causes decreased noradrenaline in the brain which projects to the forebrain and descends along the dorsolateral tract, increasing noradrenaline in the spinal cord which is anti-nociceptive depending on whether it binds to a2-adrenergic receptors or a1-adrenergic receptors which facilitate nociception (Leung 2012). Dry needling was found to causes the migration of mast cells and dendritic cells towards the lower dermis of blood vessels and subcutaneous tissue which aggregated to the needling site, increasing levels of substance P and calcitonin gene related peptide from the stimulation of the corresponding calcitonin gene related peptide nerve fibres and substance P nerve fibres (Wu 2015). This caused increased release of histamine, serotonin and trypase through degranulation of aggregated mast cells (Wu 2015). This results in somatostatin and other related neurotrophins augmenting descending inhibition of spinal afferent nociception (Leung 2012).
References
Hsieh, Y.-L. et al., 2014. Remote Dose-Dependent Effects of Dry Needling at Distant Myofascial Trigger Spots of Rabbit Skeletal Muscles on Reduction of Substance P Levels of Proximal Muscle and Spinal Cords. BioMed Research International, 2014, pp.1–11. Viewed 15/09/16. http://www.hindawi.com/journals/bmri/2014/982121/
Shinbara, H. et al., 2015. Contributions of nitric oxide and prostaglandins to the local increase in muscle blood flow following manual acupuncture in rats. Acupuncture in Medicine, 33(1), pp.65–71. Viewed 15/09/16. http://aim.bmj.com/lookup/doi/10.1136/acupmed-2014-010634
Nagaoka, S. et al., 2016. Contributions of ADP and ATP to the increase in skeletal muscle blood flow after manual acupuncture stimulation in rats. Acupuncture in Medicine, 34(3), pp.229–234. Viewed 15/09/16. http://aim.bmj.com/lookup/doi/10.1136/acupmed-2015-010959
Fernández-De-Las-Peñas, C. & Cuadrado, M.L., 2016. Dry needling for headaches presenting active trigger points. Expert Review of Neurotherapeutics, 16(4), pp.365–366. Viewed 15/09/16. http://www.tandfonline.com/doi/full/10.1586/14737175.2016.1152889
Dunning, J. et al., 2014. Dry needling: a literature review with implications for clinical practice guidelines. Physical Therapy Reviews, 19(4), pp.252–265. Viewed 15/09/16. http://www.tandfonline.com/doi/full/10.1179/108331913X13844245102034
Wu, M.-L. et al., 2015. Local cutaneous nerve terminal and mast cell responses to manual acupuncture in acupoint LI4 area of the rats. Journal of Chemical Neuroanatomy, 68, pp.14–21. Viewed 15/09/16. http://linkinghub.elsevier.com/retrieve/pii/S0891061815000319
Leung, L., 2012. Neurophysiological Basis of Acupuncture-induced Analgesia—An Updated Review. Journal of Acupuncture and Meridian Studies, 5(6), pp.261–270. Viewed 15/09/16. http://linkinghub.elsevier.com/retrieve/pii/S2005290112001215
Hong, H, 2013, Acupuncture: Theories and Evidence,World Scientific, Danvers. https://books.google.com.au/books?hl=en&lr=&id=nQW7CgAAQBAJ&oi=fnd&pg=PA3&dq=filiform+needle+effects+to+nervous+system&ots=zV1gXTTyzD&sig=rp2NoZ9woQD-4I4bquvRptU12Lw#v=onepage&q&f=false
Takano, T. et al., 2012. Traditional Acupuncture Triggers a Local Increase in Adenosine in Human Subjects. The Journal of Pain, 13(12), pp.1215–1223. Viewed 18/09/16. http://linkinghub.elsevier.com/retrieve/pii/S1526590012008309.
Lund, I. & Lundeberg, T., 2015. Effects triggered in the periphery by acupuncture. Acupuncture and Related Therapies, 3(2–3), pp.24–34. Viewed 27/09/16. http://linkinghub.elsevier.com/retrieve/pii/S2211766015000043.
Cagnie, B. et al., 2013. Physiologic Effects of Dry Needling. Current Pain and Headache Reports, 17(8), p.348. 27/09/16. http://link.springer.com/10.1007/s11916-013-0348-5.
