Many chiropractors perform acupuncture (or dry needling) as an adjunct to their practices to improve patient outcomes.
And most are taught to dry needle trigger points and sometimes needle the segmental innervation of the muscle involved. But should you do more? Recent research suggests that needling myofascial meridians along with trigger points achieves superior outcomes.1
Because most doctors treat patients who are ambulatory, they should think about how their patients move, especially through the gait cycle.
Consider how the kinetic chain works from a “reverse-engineering” perspective, that is, from the ground up rather from the torso down, in a closed-chain fashion. This can profoundly affect the way you look at muscle function.
For example: You can think of the vastus lateralis as being a medial rotator of the thigh, or the peroneus longus as being an abductor of the lower leg and external rotator (assisting supination) during the latter half of the gait cycle. Reverse engineering gives you a new outlook on human movement.
Two modes of action
Thomas Myers wrote an excellent text on the subject of myofascial meridians, or lines of tissue stress, describing the fascial connections of muscles functioning as a chain during movement.2 This built on the original work of Valdimir Janda and his concepts of “loops and slings,” as well as the work of Paoletti and Veeming.3-5
In neurology, people have the conjoined concepts of temporal and spatial summation that can lead to some type of action on the part of the nervous system. They describe two ways that receptors or neurons can reach threshold and fire an action potential.6
Temporal summation occurs when a receptor or neuron is stimulated repetitively over time, with each potential building upon the previous, making the stimulus increasingly 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 something about it (i.e., reached the point of threshold).
Spatial summation occurs 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. Using the same example as before, if many people began hitting your chair from multiple directions (spatial summation), it would be only a matter of time before you said something (i.e., reached the point of threshold).
These two types of summation can work together as well, usually eliciting a result much faster, as the receptor or neuron is being hit multiple times from multiple directions and it can reach threshold in less time.
Because the goals of needling are not only to reduce or eliminate a trigger point but also to reduce pain and increase function, wouldn’t it make sense to take advantage of as much neurological theory as possible? How about affecting more real estate (spatial summation) in a reasonable time frame from point to point (temporal summation)?
Needling appears to result in pain modulation (among its many other effects), through both central and peripheral mechanisms.7,8 Having your therapy stimulate more of these mechanisms should theoretically make it more effective and improve outcomes. Thus, one may surmise that more needles may be a good thing.
With respect to the first paper cited, the researchers needled tender points (satellite trigger points) along the lower portions of the “superficial back line” (SBL), along with points on the foot for plantar fascitis.1
The SBL contains plantar fascia, the Achilles tendon, gastrocnemius, hamstrings, sacrotuberous ligament, and erector spinae. It continues to the suboccipital muscles and ends at the galea aponeurotica of the skull (and ultimately the frontalis muscle).2 They could have worked over a larger area and perhaps found even better results, as the upper cervical spine contains some of the highest densities of mechanoreceptors in the body, and afferent stimuli from the upper four cervical neuromeres feed directly into the flocculonodular lobe of the cerebellum.9-12
Given the discussion above, there are compelling reasons why you should consider 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 needling protocol.
Ivo Waerlop, DC, DABCN, practices in Dillon, CO and teaches acupuncture and dry needling seminars in the U.S. and Canada. You can read more articles and learn about upcoming seminars on his blog at: www.rehabchalktalk.com. He can be reached at rehabchalktalk@gmail.com.
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;13,43-48.
2 Myers TW. (2009). Anatomy trains: myofascial meridians for manual and movement therapists. (2nd ed.). Philadelphia: Churchill Livingstone.
3 Janda V, Vavrova M, Hervenova A., et al. (2006). Sensory motor stimulation. in: C. Liebenson (Ed.) Rehabilitation of the Spine: A Practitioner’s Manual. (2nd ed., pp. 517-19). Baltimore: Lippincott Williams & Wilkins.
4 Paoletti S. (2006). The Fasciae: Anatomy, Dysfunction and Treatment. Seattle, WA: Eastland Press.
5 Vleeming A., Snijders C., Stoeckart R., Mens J. (1997). The role of the sacroiliac joins in coupling between spine, pelvis, legs and arms. In: Vleeming A. (Ed.) Movement, Stability and Low Back Pain. (pp. 53-71). London, UK: Churchill Livingstone.
6 Levin K, Luders HO. (2000). Comprehensive Clinical Neurophysiology. New York: Saunders.
7 Dommerholt J. Dry needling-peripheral and central considerations. Journal of Manual and Manipulative Therapy. 2011;19(4):223-237.
8 Chou L, Kao M, Lin J. Probable Mechanisms of Needling Therapies for Myofascial Pain Control. Evidence-Based Complementary and Alternative Medicine. 2012;Article ID 705327:11.
9 Kulkarni V, Chandy MJ, Babu KS. Quantitative study of muscle spindles in suboccipital muscles of human foetuses. Neurol India. 2001;49(4):355-9.
10 Bogduk N. Cervicogenic headache: anatomic basis and pathophysiologic mechanisms. Curr Pain Headache Rep. 2001;5(4):382-6.
11 Luan H, Gdowski MJ, Newlands SD, Gdowski GT. Convergence of vestibular and neck proprioceptive sensory signals in the cerebellar interpositus. J Neurosci. 2013;33(3):1198-210a.
12 Seaman DR, Winterstein JF. Dysafferentation: a novel term to describe the neuropathophys- iological effects of joint complex dysfunction. A look at likely mechanisms of symptom generation. J Manipulative Physiol Ther. 1998;21(4):267-280.
