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780443 054228
The Gunn Approoch to the
TREATMENT OF CHRONIC PAIN
For Churchill Livingstone
TREATMENT OF
CHRONIC PAIN
Intramuscular Stimulation for
Myofascial Pain of Radiculopathic Origin
C. Chan Gunn MD
Clinical Professor, MuJtidisciplinary Pain Center,
University of Washington Medical SchooL Seattle, USA
Foreword by
CHURCHILL
LIVINGSTONE
NEW YORK EDINBURGH LONOON MADRID MELBOURNE SAN FRANCISCO AND TOKYO 1996
CHURCHILL LiVI CSfONE
Medical Division of Pearson Professional Limited
ISB 044305422 3
Neither the publishers nor the author will be liable for any
loss or damage of any nature occasioned to or suffered by
any person acting or refraining from "cting as a rl'Suit of
reliance on the material contained in this publication.
Tho
-.
poley ilio 11M
_ .......
!rom SUltlinlblllorHtI
Pnxluced by Longman Singapore Publishers (Pte) Ltd.
Printed in Singapore
I
Contents v
Contents
Dr. Chan Gunn has been a clinical member of the University of Washington
Multidisciplinary Pain Center and a consultant at the Center's Pain Clinic
since 1983. During this time we have come to value his expertise in diagnosis
and treatment of many difficult chronic pain patients. His stimulating and
informative teaching sessions have been enjoyed by trainees, staff and visiting
physicians on a regular basis adding to the quality of our instruction and
patient care. This manual is a thorough and concise guide to diagnosis and
therapy as taught by Dr. Gunn.
Dr. Gunn has made significant contributions to the understanding of
chronic pain by introducing a theoretical basis which explains many of
the enigmatic problems seen in chronic pain clinics. His work has emerged
as the end product of his extensive experience with injured workmen. His
methods, which can be used in everyday medical practice, are an innovative
neurologic approach that yields effective, safe and inexpensive treatment for
the many patients who might otherwise remain without pain relief. The
importance of his approach can be appreciated if one understands the
magnitude of the chronic pain problem and the failures of conventional
medicine.
Dr. Gunn considers persisting pain to be the result of subtle dysfunction
in the nervous system that often goes unrecognized. His theory is validated
by parallel findings and demonstrations by regional anesthesiologic
procedures. However, anesthesiologists have limited their work to extreme,
and therefore, more dramatic cases and have not applied the same
principles to more ordinary, trauma-related injuries. Moreover, their
treatments can only be delivered by highly trained regional nerve block
specialists, and such treatments carry some risk. Dr. Gunn's independently
derived, practical approach can be of great value to a large number of
patients with minimal dependence on expensive technology and highly
trained specialists.
Like acupuncturists, Dr. Gunn employs needle stimulation without drugs,
but his methods are grounded in a solid, physiological conceptual scheme.
His theory accounts for the persisting pain and fatigue seen in many patients
who suffer for years following a traumatic injury or accident. By using energy
(electrical energy, mechanical force, current of needle-induced injury), the
therapist using his methods can elicit spinal reflexes and central nervous
system responses that promote healing, and more important, rehabilitation.
His procedures are a viable alternative to the prescription of drugs, which
foster toxicity, and to surgery which all too often causes more harm than
benefit.
viii
Joh
Proy . Loeser MD
sor, Neurological Surgery & Anesthesiology
Director, Multidisciplinary Pain Center
C. Richard Chapman PhD
Professor Anesthesiology,
Psychiatry and Behavioral Sciences
and Psychology
Myofascial pain syndromes plague both patients and those who try to provide
relief. Criteria for diagnosis and treatment have not been widely accepted;
outcome studies are few. Most of our successes have come from the dedicated
efforts of a small number of physicians who have made myofascial pains the
subjects of their lives' work. My friend and colleague, Chan Cunn, has been
one of the most creative and successful practitioners in this vexatious field.
He has not only developed a useful conceptual framework that explains the
physical findings but also has perfected a simple and effective treatment
technique. Although this book summarizes his thoughts and treatment
techniques, it cannot begin to be as useful as a learning tool as observing
Chan Cunn examine and treat a patient. I am delighted that the First Edition
of his text has now been translated into Japanese so our colleagues in that
country can learn of his methods. Dr. Cunn has greatly enriched the treatment
of patients at the University of Washington Multidisciplinary Pain Center;
those who read and master this book will be able to bring effective pain relief
to their patients.
John D. Loeser MD
Director, Multidisciplinary Pain Center
Professor, Neurological Surgery and Anesthesiology
Foreword ix
I
,
Foreword
I
Preface to Second Edition
Acknowledgements
Thomas F. Hornbein MD
Professor and Former Chairman, Acupuncture Foundation of Canada
Anesthesiology; Professor,
Physiology and Biophysics, University of American Academy of Acupuncture
Washington
Introduction
controls who did not have pain. The been given to this category of pain,
significant finding was that patients but because neuropathy is almost
who were disabled for a long period invariably at the nerve root,
had tenderness in muscles belonging "radiculopathic" pain is a more
to affected myotomes. Tender points appropriate name.
are therefore sensitive indicators of I became interested in acupuncture
radicular involvement and differentiate a in 1974. An early observation was
simple mechanical low back strain (which that most acupuncture points
usually heals quickly) from one with correspond to known neuroanatomic
neural involvement which is slow to entities, such as muscle motor points
improve (Appendix 3). or musculotendinous junctions.
My next study of 50 patients with Traditional acupuncturists
"tennis elbow" showed that tender emphasize the importance of pro
points at the elbow were related to ducing the subjective sensation of
cervical spondylosis and radiculo Teh Ch'i or Oeqi when the needle
pathy. Treating the neck, but not the penetrates muscle and is grasped by
elbow, provided relief (Appendix 4). a contracture. Failure of a needle to
A study of pain in the shoulder produce needle-grasp signifies that
similarly implicated radiculopathy in the muscle is not shortened and will
the cervical spine (Appendix 5). not respond to needle treatment.
Further careful examination of Traditional Chinese medicine has
patients with chronic pain revealed long recognised that this category of
additional signs of radiculopathy. A chronic pain is never present without
pattern began to emerge-patients who associated muscle shortening from
have pain, but no obvious signs of injury, contracture.
generally have subtle but discernible We tested dry needling in a
signs of peripheral nerve involvement. randomized clinical trial but, unlike
This is an important observation traditional Chinese acupuncture,
because there is no satisfactory in our approach (which was the
laboratory or imaging test for early beginning of IMS) patients were
neural dysfunction. IMS's method needled at muscle motor points. The
of examination is now recommended group that had been treated with
as part of the evaluation process in needling was found to be signifi
Bonica's textbook T he Management cantly better than the control group
of Pain. (Appendix 6). (This clinical trial was
Medical diagnosis traditionally also determined as a significant study
assumes that pain is a signal of injury by the 1979 Volvo Competition
or inflammation conveyed to the Awards Committee.)
CNS via healthy nerves. However, A paper proposing that causalgia
our studies have led us to conclude is a manifestation of denervation
that pain can arise, when there is supersensitivity was read at the
no injury or inflammation, from 1979 meeting of the International
radiculopathy that accompanies Association for the Study of Pain
incipient spondylosis (Appendix 2- (IASP).
this paper was determined as a An interesting observation in
significant study by the 1979 Volvo patients with neuropathic pain was
Competition Awards Committee). the finding of hair loss in affected
The term "neuropathic pain" has dermatomes. If treatment is given
Introduction xvii
-early and effectively, hair sometimes treated; the effects of needling can
returns. We wondered whether a appear very quickly and progress
deficit of the trophic factor was to can be monitored through
blame, and whether there is a similar objective physical signs.
deficit of the factor in male pattern
Our conclusion is that muscle
hair loss (Appendix 7).
shortening, autonomic changes,
IMS differs from traditional
and sometimes pain, are natural
acupuncture in that it:
occurrences and epiphenomena of
requires a medical examination radiculopathy (Appendix 1), and
using our early signs of they all occur according to Cannon
radiculopathy and Rosenblueth's law of
requires a medical diagnosis that denervation. Our radiculopathy
implicates spondylosis model is able to explain many
uses neuroanatomic points that are puzzling chronic pains that are not
found in a radicular or segmental caused by injury or inflammation,
pattern, instead of using such as low back pain, tennis elbow,
traditional acupuncture points whiplash and fibromyalgia
determines the points to be (Appendix 8).
An overvieYl
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LEFT BLANK
An introduction to radiculopathic pain 3
vasomotor
sudomotor
pilomotor.
Vasoconstriction generally
differentiates neuropathic pain from
inflammatory pain; with neuropathic
pain, affected parts are perceptibly
colder, and retained catabolites from
ischemia may exacerbate the pain.5
There may be increased sudomotor
activity, and the pilomotor reflex is
often hyperactive and visible in
affected dermatomes ("goose
bumps"). 15,32
There can be interaction between
pain and autonomic phenomena. A
stimulus such as chilling, which
excites the pilomotor response, can
precipitate pain; vice versa, pressure
upon a tender motor point can pro
voke the pilomotor and sudomotor
reflexes.
Shortened intrinsic back muscles have compressed the
Increased tone in lymphatic vessel
disc and impinged on the nerve root. The irritated root
further shortens muscles in both rami, thus further smooth muscle, and increased
irritating the nerve root. permeability in blood vessels3 7 can
An introduction to radiculopathic pain 9
Lt Seal
100 uV
Rt Seal
100 uV
Normal muscle
I I
,'" I
Shortened muscle with
I
palpable, tender/painful bands
Shortening
& trigger points
IMS-the technique
Neuropathic pain affects all target Charcot joint. By contrast, IMS dry
structures innervated by the nerve, needling, which is more effective, has
including joints, muscles, and their few iatrogenic side-effects (minor
connective tissue attachments. While localized bleeding and accidental
pain may present primarily in a pneumothorax).27 We prefer IMS dry
muscle (e.g. shortening in the tibialis needling for all of these reasons and
anterior muscle causing "shin others as described below.
splints"), or in a tendon (e.g.
shortening of the biceps brachii
NEEDLE TECHNIQUE
muscle straining its tendon and
producing "bicipital tendonitis"), or The technique of inserting a needle is
in a joint (e.g. shortening of the simple, but good results require a
quadriceps femoris muscles giving correct diagnosis, a knowledge of
rise to kree joint pain), all target muscle anatomy, and practice,
structures are affected to varying especially to accurately reach deep
degrees, and the common perpetrator muscle points. We use a fine solid
of pain in all these structures is needle (30 gauge or less), usually 1 or
muscle shortening. 2 inches long, in a plunger-type
We have found that muscle shortening needle holder. The plunger allows the
can be released when painful trigger length of the needle to be varied
points in the muscle are desensitized. according to the thickness of the
Invariably, when muscle shortening is muscle treated. The pointed tip of the
relieved, pain, whether in muscle, tendon, solid needle is less traumatic than the
or joint, is alleviated. beveled, cutting edge of a hollow
The most effective way to needle; its flexible and springy
desensitize painful points is to use an quality, unlike that of a rigid hollow
intramuscular technique. Injections of needle, transmits the nature and
local anesthetic, with or without consistency of tissues penetrated.
steroids, or saline, may be used; When it enters normal muscle, the
however, injections of medication, needle meets with little resistance;
especially steroids, can cause side
effects such as infection, impaired
healing, weakened tissue elements,
local atrophy of fatty tissue and
"dimpling" of skin, skin pigmenta
tion, inflammation due to crystal
deposits, suppression of the hypo
thalamic-pituitary axis, localized
bleeding, accidental pneumothorax,
and joint destruction by avascular 7
necrosis that sometimes imitates a
12 A n overview
treated, reflex stimulation can extend with chronological age: many older
to paraspinal muscles, and neck individuals have less wear and tear
range can likewise improve. than younger ones whose muscula
Localized conditions such as tennis ture has undergone repeated physical
elbow may require only one or two or emotional stress35 or surgery.
treatments.
FIBROSITIS AND
RESPONSE IN LONG FIBROMYALGIA
STANDING DISORDERS
The term "fibromyalgia" was coined
In conditions of recent onset, when in 1976 to replace "fibrositis". It
painful points are not numerous, a describes a soft tissue disorder in
few treatments separated by days which young adults aged 25-50 "hurt
may resolve the pain. But in long all over", complaining of widespread
standing disorders, e.g. chronic low muscle and joint pain, poor sleep,
back pain, there are many shortened morning stiffness, fatigue and specific
muscles and, more often than not, "tender points" above and below the
they include much fibrotic tissue. waist. In addition, some patients
These fibrotic muscles do not respond report numbness, cold extremities,
as well as normal muscle to needle weakness, "restless legs", abdominal
stimulation. Response is less dramatic upsets or menstrual irregularities.
and parallels the extent of fibrosis. There may be stress-linked
Since all gradations of fibrotic symptoms such as irritable bowel
conversion can exist, the outcome of syndrome, headaches and TMJ. It
treatment can vary from individual to affects about 3% of the general
individual, from muscle to muscle, population, afflicting twice as many
and even from one part of the women as men. Many sufferers feel
muscle to another. Fibrotic muscle too weak to work and incur large
necessitates more frequent and compensation costs.
extensive needling; release is limited The disorder may be precipitated
to individual bands treated, and all by some distressing event such as
tender bands require attention. whiplash injury, divorce, bereave
Treatment of chronic fibrotic ment or other emotional experience.
conditions, therefore, represents Because X-rays and routine labora
many more needle insertions per tory tests yield no underlying organic
session, or more sessions with the abnormalities, sufferers are often told
same number of penetrations. Several that there is "nothing wrong". In
sessions (also separated by days) are 1990, the America College of
customarily needed.16 When fibrosis Rheumatology (ACR) recommended
is extreme, the needle-grasp is not diagnostic criteria that require:
elicited, even when the needle is
vigorously twisted. This indicates Diagnosis must exclude other
that fibrosis has most likely displaced diseases.
virtually all striated muscle tissue, Pain in at least 11 of 18 tender
that contracture is not the cause of point sites on digital pressure,
pain, and that this method of treat evaluated by pressing with the
ment is not likely to help. The extent thumb or first two or three fingers
of fibrosis does not necessarily equate at a pressure of approximately
14 A n overview
l. Asbury A K, Fields H L 1984 Pain due to 12. Gaw A C, Chang L W, Shaw L C 1975
peripheral nerve damage: an hypothesis. Efficacy of acupuncture on osteoarthritic
Neurology 34: 1587-1590 pain. New England Journal of Medicine
2. Bonica J J 1953 The management of pain. 293: 375-378
Lea and Febiger, Philadelphia 13. Gunn C C 1978 Transcutaneous neural
3. Bonica J J 1979 Causalgia and other reflex stimulation, acupuncture and the current
sympathetic dystrophies. In: Bonica J J, of injury. American Journal of
Liebeskind J C, Albe-Fessard D G (edsl Acupuncture 6: 3; 191-196
Advances in pain research and therapy, vol 14. Gunn C C, Milbrandt W E 1976 Tenderness
3. Raven Press, New York, pp 141-166 at motor points-a diagnostic and
4. Bradley W G 1974 Disorders of peripheral prognostic aid for low back injury. Journal
nerves. Blackwell Scientific Publications, of Bone and Joint Surgery 6: 815-825
Oxford 15. Gunn C C, Milbrandt W E 1978 Early and
5. Calliet R 1977 Soft tissue pain and subtle signs in low back sprain. Spine
disability. F A Davis, Philadelphia 3: 267-281
6. Chapman C R, Benedetti C, Colpitts Y, 1 6 . Gunn C C, Milbrandt W E 1980 Dry
Gerlach R 1983 Naloxone fails to reverse needling of muscle motor points for
pain thresholds elevated by acupuncture: chronic low-back pain; a randomized
acupuncture analgesia reconsidered. Pain clinical trial with long-term follow-up.
16: 16--29 Spine 5: 3; 279-291
7. Chiang C Y, Chang C T, Chu H L, Yang L F 1 7 . Gunn C C 1977 The neurological
1973 Peripheral afferent pathway for mechanism of needle-grasp in
acupuncture analgesia. Scientica Sinica acupuncture. American Journal of
16: 210-217 Acupuncture 5: 2; 115-120
8. Culp W J, Ochoa J 1982 Abnormal nerves 1 8. Gunn C C, Milbrandt W E 1976 Tennis
and muscles as impulse generators. Oxford elbow and the cervical spine. Canadian
University Press, New York Medical Association Journal 114: 803-809
9. Ernest M, Lee M H M 1985 Sympathetic 19. Gunn C C, Milbrandt W E 1976
vasomotor changes induced by manual Acupuncture loci: a proposal for their
and electrical acupuncture of the Hoku classification according to their relation-
Point visualized by thermography. Pain ship to known neural structures. American
21: 25-34 Journal of Chinese Medicine 4: 183-195
10. Fields H L 1987 Pain. McGraw-Hill, 20. Howe J F, Loeser J D, Calvin W H 1977
New York Mechanosensitivity of dorsal root ganglia
11. Galvani A 1953 Commentary on electriCity. and chronically injured axons: a
Translated by Robert Montraville Green. physiological basis for the radicular pain
Elizabeth Licht, Cambridge of nerve root compression. Pain 3: 24-41
Treating chronic pain 19
. Intramuscular
stimulation in
practice
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Summary 23
Summary
'non-psychologic
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LEFT BLANK
Guidelines for diagnosis 25
Autonomic
Vasoconstriction: affected parts
are perceptibly colder.
Sudomotor activity: excessive
sweating may follow painful
movements or occur after needle
treatment.
Pilomotor reflex is often hyper
active and visible as "goose-bumps"
in affected dermatomes (A). The
Pilomotor reflex (A). reflex can be augmented by press
ing upon a tender motor point,
especially the upper trapezius.
Trophedema (8), commonly called
"cellulite" by the layperson, can be
found over affected regions by
"skin rolling", that is, by squeezing
an area of skin and subcutaneous
tissue. In trophedema, the skin is
tight and wrinkles absent; subcuta
neous tissue consistency is firmer;
and the peau d' orange effect and
the Matchstick test may be positive.
Trophic changes may occur in skin
and nails, and there may be
dermatomal hair loss.
Motor
Because pain is primarily related to
muscle, signs in muscle are the most
Trophedema (8). relevant and consistent:
Muscle shortening: this key sign
may be palpated as ropey bands in
muscle which are, in long-standing
conditions, sometimes fibrotic
(contractures). Focal areas of
tenderness and pain in contrac
tures are often referred to as
"trigger points". Tender points are
usually in the proximity of the
painful area, but, in radiculopathy,
they can be found throughout the
myotome, contralaterally, and in
paraspinal muscles.
Limitation of joint range may
Matchstick test. result from muscle shortening.
Guidelines for diagnosis 27
I DENTIFICATION OF
I NVO LVED SEGM ENTS
In radiculopathy, signs are found
in the affected segment, in its
dermatome, myotome, and sclero
tome and in the territories of both
anterior and posterior primary rami.
Generally, signs are symmetrical:
even when symptoms are unilateral, Dermatomal hair loss.
there are latent signs on the
contralateral side.
Signs of radiculopathy, especially
in muscles, identify the levels of
segmental involvement (see Table 11).
For example, pain may be felt in the
knee and patella, but tenderness and
painful bands in the quadriceps
femoris muscles implicate L2-L4.
When painiul bands are also found
in muscles supplied by the posterior
primary rami (the erector spinae
muscles) at the same segmental
levels, the nerve root is involved.
The entire spine must be
examined. The paraspinal muscles
should not be summarily dismissed
as a collective group. Each indivi
dual constituent muscle (e.g. the
iliocostalis lumborum) can be
palpated and treated if necessary.
Furthermore, because many
paraspinal muscles such as the
longissimus extend throughout most
of the length of the spine, the entire
spine is examined even when
28 Intramuscular stimulation in practice
I ncreased traction
causes "tendonitis".
Increased traction in
synovial sheath causes
"tenosynovitis" .
I ntensified pressure of
sesamoid bone onto bone
increases wear and tear,
e . g . , chondromalacia
Shortened m uscle
symptoms are localized to one region. there can be abrasion and pain, e.g.
For example, low back pain is most "chondromalacia patellae" .
common at L5-S1; but, more often Increased traction at the muscle
than not, higher segmental levels are origin and / or insertion can cause
involved, frequently reaching dorsal pain (e.g. "lateral epicondylitis" ).
levels. Contracture in deep muscles When the muscle and / or tendon
can only be demonstrated by needle is long, the pain can manifest
exploration. some distance away. For
example:
- The flexor digitorum longus
Specific effects muscle can produce pain in the
sole.
Muscle shortening can produce pain
- The flexor digitorum profundus
in a variety of ways:
muscle can produce pain at the
Muscle shortening can produce bases of distal phalanges.
primary muscle pain, and its -The erector spinae (longissimus)
release eases the pressure in muscle can produce headache or
intramuscular nociceptors. pain in the neck.
Muscle shortening mechanically - The gluteus maximus and tensor
stresses tendons, increasing wear fasciae latae muscles can pull
and tear. "Tenosynovitis", upon the iliotibial tract and
"tendonitis", or "trigger finger" cause pain at the lateral aspect
can occur. of the knee (lateral condyle of
If a sesamoid bone is in the tendon, tibia).
Guidelines for diagnosis 29
A
/.
Treatment goals
The primary objective is not to
produce analgesia, but to desensitize
supersensitive structures and restore
motion and function.
Release muscle shortening. This
improves the range of joint motion.
Muscle shortening is an inherent
ingredient of musculoskeletal pain
and its release forms the primary part
of treatment. Impinged nerve
32 Intramuscular stimulation in practice
N EEDLE TECHNIQUE
Choice of needles
We use stainless steel acupuncture
needles: these are finer than hypo
dermic needles, and their pointed tips
minimize trauma to nerves and other
tissues. The fine needle allows
multiple, closely spaced insertions
(sometimes only a few millimeters
apart) into individual muscle
fasciculi.
The whippy nature of the fine
needle transmits the character of
penetrated tissues (e.g. fibrous tissue)
to the therapist: the procedure is
Treatment and needle technique 33
Finding points
Using a point-finder or neurometer
The most effective sites for the release In recent years, the dermometer, now
of spasm are situated at the muscle's renamed the neurometer, has been
zone of innervation which lies deep adopted for point location. The
under the motor point, and at neurometer is a simple instrument
musculotendinous junctions. powered by dry cells (generally
Musculotendinous junctions are 9-21 V) and consists of a milli
easily located by palpation: they are ammeter with a probe and ground or
Needle insertion
The direction of needle insertion is
generally perpendicular to the skin.
To facilitate penetration and to avoid
handling the needle, a tubular guide
may be used . Nothing or a brief, sharp
prick may be felt when the needle
penetrates skin. Therefore the needle
is given a swift tap to penetrate skin.
This is important as it minimizes the
harp pain of penetration, especially
m hyperpathic conditions.
When many bands require treat
ment, several needles may be
deployed. A number, e.g. eight, are
inserted into tender muscles. When
indifferent electrode. The indifferent
spasm is released in these muscles
electrode is held in the hand of the
some minutes later, the needles are
patient while the probe explores the
withdrawn and reinserted into
body surface for areas where resist
another selection of muscles.
ance to direct current is lowest. When
The use of only one needle, held
the probe alights on such a point, it
in a plunger-type needle holder, is
emits an audible signal and the milli
recommended as it is most conve
ammeter shows a higher reading.
nient when many muscles require
.
he neurometer is not specific; it treatment. The plunger-type needle
mdicates a skin point that has low
holder allows great accuracy and
electrical resistance (e.g. over a zone
control in muscle needling. Accurate
of innervation), but not all such
penetration releases spasm more
points are necessarily motor points.
quickly, and the same needle can be
In practice, a neurometer is not
employed sequentially at multiple
always necessary because muscle
loci. With the plunger-type needle
bands that require attention are, as a
holder, the speedy release of muscle
rule, palpable and tender, and thus
shortening permits the outcome of
easily found.
needling to be assessed as treatment
proceeds.
best when the stimulation frequency its effect is superficial and does not
allows the muscle to relax between equal that of the needle.*
contractions and not summate to
produce tetanic contraction. The sum
Treatment of fibrotic
mation frequency (about 30-100 Hz)
contractu res
varies from muscle to muscle, e.g.
that of the soleus muscle at about When fibrosis has become a feature of
30 Hz is much lower than that of the muscle shortening (i.e. contractures),
tibialis anterior muscle at about 1 00 Hz. response to treatment is less reward
A hand-held point-finder is also ing. Treatment of extensively fibrotic
useful to relax contracture. See page contractures necessitates more
1 22. frequent and extensive needling.
Release is limited only to individual
muscle bands treated: to relieve pain
Low level laser therapy
in such a muscle, all tender bands
(LLLT)
require needling. This implies more
Low level laser therapy (LLLT) uses needle insertions per session, or
low energy lasers in order to achieve more sessions with the same number
therapeutic effects. Conventional of insertions.
light is a mixture of all colors Multiple needle insertions, some
emitting in all directions. Laser light times as closely spaced as a few
is monochromatic, coherent, and millimeters apart, may be necessary
polarized. Infra red laser light is to release a muscle band. The pointed,
suitable for deeper lesions. LLLT is "a traumatic" needle produces
safe to use: photo-energy emission is minimal trauma, but occasionally
low and treatment is painless, aseptic, small blood vessels may be pierced,
and non-thermal. There are no known and the patient should be warned
significant side-effects. There has that there may be some soft tissue
been no report of eye injury from low swelling and bruising. Occasionally, a
level laser, although care must be bulge may appear at the site of
taken not to stare into the probe. insertion. Digital pressure applied for
Light from LLLT lasers does not a few minutes, or low level laser
induce cancer growth. therapy (LLLT) electrical stimulation
LLLT has anti-inflammatory and will relax this. When all palpably
analgesic properties; it accelerates the tender bands have been needled,
wound healing process. LLLT is allodynia and joint range should
useful in myofascial pain and works improve within minutes.
well for conditions such as epicondy Patients should be told that there
litis, TMJ dysfunction, pain in the may be minor discomfort and some
neck, herpes simplex, herpes zoster bruising from the needling for a day
and post-zoster neuralgia, rotator cuff or two, and that the pain may
syndrome (frozen shoulder), carpal occasionally become worse before it
tunnel syndrome, acute and low back improves.
pain, sprain and post-traumatic
swelling (hematoma). Laser therapy,
with the benefit of painless healing, is
'Pontinen P J 1992 Low level laser therapy as a
widely used instead of needles. Its medical treatment modality. Art Urpo,
use complements needle therapy, but Tampere.
Treatment and needle technique 37
I
General examination
(
the gluteal muscles on the supporting
leg can contract normally. (
Positive? Rare: congenital
dislocation of the hip; coxa vara; Cl
m
fracture of the neck of femur;
Z
osteochondritis deformans
m
juvenilis. "
Not [MS.
Weak elevation or false positive? r-
Common: weak gluteal muscles
m
especially gluteus medius.
><
See Dorsal back and Buttock.
Check gluteal muscles and low
J:
back (L5-S1).
See Dorsal back and Buttock. Z
Spinal curves and range -I
Any scoliosis?
See Lumbar back. 0
Increased dorsal kyphosis? Z
See Lumbar back.
Loss of lumbar lordosis?
See Lumbar back.
Forward flexion
Note that flexion in hips may permit
a full range of motion, despite a stiff
back.
When fully flexed, is one side more
prominent than the other?
See Lumbar back.
Is the tip of any spinous process
more prominent? A more
prominent spinous process may
indicate a level of dysfunction. It
is often easier to feel for a slightly
raised spinous process by
palpating with the palm of the
hand, feeling with the thenar or
hypothenar pads. Press upon the
process-tenderness indicates
ongoing pathology.
See Lumbar back.
42 Intramuscular stimulation in practice
Shoulders
Is one shoulder higher? If so, is this
z caused by trapezius/ levator
o scapulae shortening on that side?
See Shoulder.
l
Due to mid-dorsal scoliosis?
e:(
See Shoulder.
Z
Are both shoulders held too high
:E (chronic anxiety)?
e:( See Shoulder.
>< Examine neck and shoulders.
w See Shoulder.
....
e:(
Glenohumeral range
a:: Fix the scapula with one hand
w holding the tip of scapula between
Z thumb and index finger, then
w passively abduct the arm.
" Limited on one side? (N 70-80
=
degrees.)
See Shoulder.
Examine shoulder.
See Shoulder.
Neck
Forward flexion: chin should reach
chest.
See Cervical spine.
Lateral rotation: 60-70 degrees, but
when forced, chin should almost
reach shoulder.
See Cervical spine.
Lateral bending: about 45 degrees.
See Cervical spine.
Extension: the examiner's finger is
trapped between the occiput and
C7 spinous process.
See Cervical spine.
Limited? Painful? Examine neck.
See Cervical spine.
General examination 43
Radial pulses
The combined modified Adson's and
costoclavicular maneuver is a test
for thoracic outlet syndrome. With
the patient seated, take the radial
pulse on the affected side. Continue
to note the pulse while performing
the following:
C)
To test for scalenus anterior m
impingement, while continuing to Z
take the pulse, have the patient m
take a deep breath, hold chin up, ::a
extend head.
To check for scalenus medius I""
impingement, lift and abduct the m
arm to a horizontal position and ><
have the patient rotate the head
away from the affected side. J:
To see if the neurovascular bundle
is compressed by insertion of the Z
pectoralis minor at the coracoid
process, hyperabduct and hyper -I
extend the arm, lifting it above the
o
level of the patient's head.
Z
Positive (pulse loss occurs)?
See Cervical spine and Shoulder.
PATIE NT SUPINE
Lower extremities
The examination of the lower
extremities must always include the
lumbar back.
Hips
Fabere (F-Ab-ER-E) sign. When
z the heel of the painful side is placed
o on the knee of the other leg, the knee
on the affected side remains elevated
I and cannot be depressed; i.e. there is
pain on attempted Flexion, Abduc
Z tion, External Rotation, and Extension.
1:
Patrick's sign is a different test;
it resembles the Fabere sign, but in
Elbows Hands
Is extension limited? Is the Muscle wasting? Trophic changes
problem in the joint? in nails?
Not IMS. See Wrist.
Are biceps, brachioradialis, and Cold fingers? Peripheral cyanosis?
brachialis shortened? See Wrist.
See Elbow. Tender interossei muscles?
Is flexion limited? Is the problem See Wrist.
in the joint? Clawing? Examine wrist flexors. G')
Not IMS. See Elbow. m
Are triceps shortened? Dupuytren's contracture? Examine Z
See Elbow. wrist flexors, especially palmaris m
:%J
longus.
Radioulnar joints See Wrist. r-
Is pronation limited? Check
m
supinator and biceps. PATIENT P RO N E ><
See Elbow.
Use a thin (about 4") pillow placed
Is supination limited? Examine
under the abdomen to straighten J:
pronators, flexor carpi radialis,
anconeus. lumbar lordosis; allow the arms to Z
See Elbow. hang down by the sides of the couch,
drawing the scapulae laterally and -I
exposing the posterior thorax.
Wrists
o
Flexion limited? Check wrist Gently run the point of a pin down
Z
extensor muscles. the body, crossing dermatomes.
See Elbow. Segmental hyperpathia indicates
Extension limited? Check wrist the level of dysfunction.
flexor muscles. Check for skin temperature
See Wrist. (significant changes are usually
perceptible by palpation).
See Back.
46 Intramuscular stimulation in practice
"
m
o
z
I""
m
><
J:
z
-I
o
z
THIS PAGE INTENTIONALLY
LEFT BLANK
Regional examination and specific treatment 51
Cervical spine
EXAMINATION
n
Identify bony landmarks m
::rJ
Find the external occipital pro <
tuberance and superior nuchal line.
The spinous process of C2 (axis) is the n
first palpable bony point below the
r-
external occipital protuberance. The
next easily palpable spinous process
is C7. Identify transverse processes of Trapezius ---!Ui.;1rlrf'- \
Cl (atlas) which are palpable about
Z
1 inch inferior to the tips of the m
mastoid processes. To count the
vertebrae, begin with T1 : each
spinous process overlies the body of
the vertebra below it. For example, minor
the spinous process of C6 overlies the and
body of C7. major
Trophedema in the \I
suboccipital region
This is an important area where
trophedema often appears. Soft tissue
appears boggy, and the occiput cannot
be palpated. The upper musculo
tendinous ends of the trapezius and
semispinalis capitis muscles can be
enthesopathic and thickened. When
the head is forward flexed, these
appear very prominent on one or
both sides, and are very tender.
Palpate muscles
Palpate for tender, taut bands of
shortening in muscles. Unless there
is extensive fibrosis, not all muscles
require treatment, as reflex stimula
tion from treated muscles can spread
52 Intramuscular stimulation i n practice
Layer 1
This includes the superficial extrinsic
w Splenius I;;; muscles: the trapezius, latissimus dorsi,
Z capitis
levator scapulae, and rhomboids which
a.
connect the upper limb to the axial
\I) skeleton. Also see Upper limb.
..J
Layer 2
Layer 3
This layer is formed by the erector
spinae muscle. In the neck, it is
represented by the longissimus capitis
and cervicis muscles. (These extend
from the pelvis: the capitis inserts
Longissimus into the mastoid process, and the
capitis ----T+-f Longissimus cervicis into the posterior tubercles of
the transverse processes of C2-C6.)
Regional examination and specific treatment 53
Layer 4
This is the deep layer of intrinsic back
muscles: the semispinalis capitis (the
transverse processes of the upper
thoracic and the articular processes of
the lower cervical vertebrae, into the Semispinalis
occipital bone between superior and capitis ---+-',-!i-
inferior nuchal lines near the Rotatores
midline), the multifidi, and rotatores Multifidi n
(also see Back). m
::u
<
Lateral aspect of neck
This includes the levator scapulae (the n
posterior tubercles of the transverse )0
processes of the upper cervical r
vertebrae to the vertebral border of
(I)
the scapula between the superior "V
angle and spine of scapula), scalenus
anterior (the scalene tubercle of the Z
first rib to the anterior tubercles of the m
middle cervical vertebrae), scalenus
medius (the upper surface of the first
rib behind the subclavian groove to
the posterior tubercles of the middle
cervical vertebrae), scalenus posterior
(the posterior part of the second rib to
the posterior tubercles of the lower
cervical vertebrae), sternomastoid (the
medial head from the manubrium
sterni, the lateral head from the
upper surface of the medial third of
the clavicle to the mastoid process
and the lateral part of the superior
nuchal line).
Forward flexion
The chin should reach the chest. Any
limitation is caused by shortening in
the splenius capitis and cervicis, semi
spinalis capitis and cervicis, iliocostalis
cervicis, longissimus capitis and cervicis,
trapezius, and interspinalis muscles.
54 Intramuscular stimulation in practice
Lateral rotation
This should be 60 degrees, but with
persuasion the chin should almost
reach the anterior shoulder. Any
limitation is caused by shortening in
the contralateral splenius capitis and
cervicis, sternomastoid, scaienes,
longissimus capitis, multifidus, levator
w scapulae muscles, and the ipsilateral
Z upper trapezius muscle.
A
." Lateral tilting
This should be 45 degrees. Limitation
...
is indicated by palpable shortening in
c(
the contralateral muscles, especially
u
the scalenes.
>
a:
w TREATMENT
U Treatment o f the neck should include
treatment to the shoulders and upper
limbs. Often, the entire spine has to
be treated.
Not infrequently, a tight neck is
secondary to the chin-up, head
forward posture. Check to see if the
neck is hyperextended at C2-3-4,
where there will be a deeply recessed
spinous process.
\
Position of patient
Prone, with a shallow pillow to
support the chest and allow the neck
to flex.
Alternate position
Sitting, with neck flexed and forehead
supported on a table. Because of the
possibility of a vasovagal reaction,
the sitting position should not be
used until the patient has had
previous treatments and has shown
good tolerance to needling.
Trapezius
Semispinalis
capitis
Longissimus
capitis
56 Intramuscular stimulation in practice
Needle trapezius from posterior aspect muscles through the splenius capitis at
about v" Y<, and 1 inch from the
midline at C5 and, if necessary, at C4
and C6. Then reach deeper to treat
the multifidi and rotatores muscles.
When paraspinal muscles at
consecutive segmental levels are
needled, resistance to needle
w penetration can be substantially
",,-'"-j-'''r--,----j- Nerve
Z increased at the involved level(s) as
------"<:-T'i----- Artery
0- r-----;:-T--- V ein compared to the segmental levels
Il) ---;rr---- Lung above and below. The needle can
encounter spasm that seems bony
...I
hard, and penetration cannot attain
<t Important: Careful ly grip and isolate the trapezius the depth reached at other levels.
U muscles, and needle from posterior aspect to avoid
Penetration is only possible after
piercing the l u n g .
> repeated "pecking" and the
ex: application of some force. This dense,
w fibrotic tissue is an important clinical
U finding as it is not revealed by
radiological, CAT, or MRI techniques.
Recheck the range of flexion,
which should be improved.
and much more supple neck. Identify Also palpate and treat the dorsal
and treat residual taut and tender spine, if necessary-the spinalis
muscle bands. thoracis and semispinalis. It is often
necessary to explore with a needle,
inserting it to reach the spine, but
The "Whiplash " syndrome
keeping the needle to within one
This syndrome, more often than not, finger's breadth from the midline.
affects the entire spine. Palpate the Search especially for tenderness at
w entire spine (with patient prone and 06, 8 to 010, and on both sides of any
Z using the palm of the hand) for tender, prominent spinous processes.
prominent and tender spinous Palpate and treat, if necessary, the
processes that indicate the level(s) longissimus, iliocostalis, multifidi and
of injury. All muscles supplied by quadratus lumborum muscles in the
..I
cervical nerves in the neck and upper lumbar back. The gluteus medius is
oct:
limb should be examined and nearly always tender. Check
u
palpated, especially the trapezius, Trendelenberg's test.
> splenius capitis and cervicis, longissimus
a: capitis and cervicis, and semispinalis H eadaches
w capitis muscles.
Almost all headaches are referred
u On the painful side, the levator
from the cervical spine. The three
scapulae is frequently shortened (see
most common types of headache are
Shoulder, p. 63) and the "Hammer
muscle contraction (or tension)
lock" test is positive (see p. 62). Treat
headaches, migraine, and cluster
the neck as described above.
headaches. There is no laboratory or
Check for range of motion.
X-ray test that will diagnose these.
Forward flexion is usually limited,
The diagnosis is suggested by a
especially by shortening of semi
history that is typical of one of them,
spinalis capitis. Measure by using
and there is usually no need for
"number of fingerbreadths" between
investigation. Treatment may be
chin and chest. Lateral rotation is
started when there are no abnorma
usually limited by shortening in the
lities on clinical examination, and its
ipsilateral upper trapezius and the
progress can be gauged by observing
contralateral splenius capitis and
the response to treatment. However,
cervicis. If pain is worse on one side
there are seven danger signals that
of the neck, there is usually a
suggest the possibility of serious
compensatory scoliosis in the dorsal
disease:
back on the other side to keep the
head vertical, and another on the failure of the headache to conform
ipsilateral side in the lumbar back. readily to an innocuous pattern
Treat taut sides to realign back to onset of headache in childhood or
normal. Also examine and treat any middle age (45-50)
tender muscles in the upper limbs, recent onset and progressive course
usually the muscles of the shoulder other neurological or general
and at the lateral aspect of the elbow. symptoms
As anxiety is a frequent companion to the patient "looks sick" or "isn't
the syndrome, examine the "stress right"
muscles" (see Treatment in anxiety abnormal physical signs
states). meningeal irritation.
Regional examination and specific treatment 59
Shou lder C
."
EXAMINATION ."
m
Identify bony landmarks
Clavicle r
Anterior aspect: clavicle, acromion, Acromion
humerus (lesser tuberosity, inter Coracoid J:
tubercular groove), coracoid process, H umerus OJ
acromioclavicular joint.
Posterior aspect: the spinous
process of TI , scapula (superior and (I)
Palpate muscles
Palpate the muscles for tender points
and spasm. Examination should
include:
Superficial
Trapezius: the medial third of the
superior nuchal line, external
occipital protuberance, ligamentum
nuchae, and spinous processes of
C7-T12 to the lateral third of clavicle,
acromion, spine of scapula, and base
of scapular spine.
a: Trapezius Latissimus dorsi: from the spines
w of the lower six thoracic vertebrae,
C lumbar fascia, outer lip of iliac crest,
...I
lower three or four ribs, and by an
::J
occasional slip from the inferior angle
0
of the scapula to the bottom of the
J: bicipital groove of the humerus in
I/)
front of the teres major. As it turns
around the lower border of the teres
a:I major, it forms the posterior fold of
:E the axilla.
...I
Deep
a: Levator scapulae: from the posterior
w tubercles of the transverse processes
a. of the upper cervical vertebrae to the
a. medial border of the scapula between
::J the superior angle and spine of the
scapula.
Rhomboid minor: from the
ligamentum nuchae and spine of C7
to the medial border of the scapula
opposite the spine of the scapula.
Rhomboid major: from the spines
of the upper five thoracic vertebrae to
the vertebral border of the scapula
below the rhomboid minor.
reached) .
TREATMENT
Treatment o f the shoulder always
64 Intramuscular stimulation in practice
J
previous one (B).
\ A restricted glenohumoral
range
Compare one side to the other:
normal range is approximately 70-90
degrees. Restricted range is usually
caused by shortening of the
infraspinatus, teres minor, and
latissimus dorsi muscles. Abduct the
arm to 90 degrees to stretch and treat
the above muscles.
i
When there is pain in the first 30
I
degrees of abduction, treat the rotator
\
cuff muscles: supraspinatus, infra
to increase abduction-treat
a:I
infraspinatus, teres minor and major.
I: Common to increase forward elevation-all
flexor
..J origin the above muscles, and also the
subscapularis.
a::
to improve internal rotation
w
Q. posteriorly-the pectoralis major
Q. and minor, and anterior deltoid
:J muscles.
Anatomical relations
The radial and ulnar arteries run
down the forearm on each side, with
their accompanying nerves lying
nearer the margin: the radial nerve
70 Intramuscular stimulation in practice
:t
IX: T REATMENT
<C
w Treatment o f the arm always
IX: includes the paraspinal muscles of
o the neck.
u.
o
Z To treat pain and tenderness
<C
over the lateral epicondylar
region
Pain and tenderness over the lateral
o epicondylar region upon wrist
a:J
extension (e.g. "tennis elbow" or
...I
lateral epicondylitis) is a common
W
condition that responds well to IMS
of the extensor muscles on the back
1 . Degeneration (spondylosis) in the of the forearm: the brachioradialis,
neck causes neuropathy. especially the extensor carpi radialis
longus, extensor carpi radialis brevis,
...I
extensor digitorum, extensor carpi
ulnaris, extensor digiti minimi, and
anconeus, but sometimes all tender
muscles in the region, for example
the triceps and supinator, must be
2. Neuropathy causes spasm and needled . To access the supinator
shortening of the wrist extensors. muscle, the arm must be in a
supinated position.
r
EXAMINAT I O N
Treatment o f the wrist and hand
always includes treatment to the
cervical spine on both sides.
Needle site
TREATMENT
Trigger fingers
A sudden snapping may occur
..J
during flexion and re-extension of a
finger or thumb. Palpation usually
reveals tender nodules on the flexor
tendon within, or proximal to, the
synovial sheath. In early cases, the
condition responds to treatment of
the flexor digitorum muscles in the
forearm and the direct needling of the
nodules and surrounding soft tissues.
Rheumatoid arthritis
This frequently involves the joints of
the hand and wrist, affecting the C
distal and proximal interphalangeal "CI
and metacarpophalangeal joints. "CI
m
For pain in the joints of the fingers:
"
in the forearm, treat muscles that
extend (extensor digitorum, extensor r
indicis, and extensor digiti minimi) and
J:
flex (flexor digitorum superficialis and
CXI
profundus) the fingers.
In the hand, needle the dorsal
interossei muscles with a fine liz to
I -inch long needle.
"
With patient's fist clenched, apply
firm digital pressure to the muscles VI
between the metacarpals: needle the Angle insertions -4
to pierce both
most tender areas, about 1 liz inch heads
proximal to the heads of the meta
Z
carpals where the Matchstick test
C
usually yields the deepest indenta
tion. Angle the insertions medially I:
and laterally to pierce both heads.
In the initial stages, when the Z
disease affects soft tissues and before C
structural disintegration occurs, relief
of pain and swelling can be provided
by releasing the shortened muscles
that act on these joints. Release
relieves stress on tendons and the
friction in their sheaths. Treatment
repeated at weekly intervals during condition with fibrosis occurring in
an acute episode can alleviate the the palmar fascia. The fibrosis
condition and minimize any ultimately progresses to fibrous
structural disintegration until the bands that cause the fingers to
episode has passed. These comments contract. Although the flexor tendons
also apply to rheumatoid arthritis are not intrinsically involved,
affecting other joints in the body. needling their shortened muscles,
especially the palmaris longus and any
nodular lesions in the palmar fascia,
Dupuytren's contracture
can gradually provide worthwhile
Dupuytren's contracture is a painless contracture release in early cases.
THIS PAGE INTENTIONALLY
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Regional examination and specific treatment 75
Back
Dorsal back
EXAM I N ATION
Check curvatures of the vertebral
column. All thoracic vertebrae
articulate with ribs; the spinous o
trapezius
latissimus dorsi
levator scapulae
rhomboid major
Trapezius
-iitIh:\
rhomboid minor.
TREATM ENT
The intrinsic back muscles (see
Lumbar back) can be needled at
segmental levels about Y, inch from
the midline. Treatment can also
relieve visceral symptoms .
..J
<C
Radiculopathy and segmental
\I)
a:
autonomic reflexes
o The actions of the sympathetic and
Q parasympathetic systems are
generally mutually antagonistic. The
sympathetic system helps maintain a
7
rami to all spinal . ','
nerves C1 ' ./ ,,1'1
"
, .
White communi-
Cardiac and J !
/ .:
cating rami C5 , pulmonar y plex uses
_
,.
;:
a '
a aa.
- .-.-...-....- ,." ,..
" , ,
Intermedio- __ ._ a.
a
:-
_:::.-
I atera I II o I umn
_-
;
: ,:
------;.
" ,. .. - Stomach
" ., ,_
, ., Celiac " : -- c
T4 .:
,
, Great plex us
o
.
T5
-L_------::-- splanchnic ,-
nerve / ::v
T6 (I)
_ki'N'1'-'
T7
T8 r-
T9
Spinal cord
.,
" ,
S5
Preganglionic fibers --
Postganglionic fibers - - - - .
Sympathetic division of the autonomic nervous system (left half). CG-celiac ganglion; SMG-superior
mesenteric ganglion; IMG-inferior mesenteric ganglion. (From de Groot and Chusid 1 991 Correlative
Neuroanatomy, 2 1 st edn. With permission from Appleton and Lange, Norwalk, Connecticut, USA)
78 Intramuscular stimulation in practice
I}-""=?J-J---- capitis
Lon gissimus
Ill::
<
1:
::J
....
U I
I l i ocostal is
<
thoracis
Superficial layer
This consists of the splenius capitis and
cervicis.
Intermediate layer
The erector spinae (sacrospinalis) is the
largest muscular mass of the back.
It runs vertically from the pelvis to
the skull in three columns-the
iliocostalis, the longissimus, and the
spinalis:
The iHocostalis is a three-part
muscle. The iliocostalis lumborum
originates from the iliac crest and
inserts into the inferior 6 ribs; the
iliocostalis thoracis arises from the
inferior 6 ribs to insert into the angles
of the superior 6 ribs; the iliocostalis
cervicis ascends from the 3-6 ribs and
inserts into the transverse processes
of the C6-C4 vertebrae.
The longissimus muscle originates
from the iliac crest. It is also in three
parts. The longissimus thoracis inserts
into the tips of the transverse
processes of all the thoracic vertebrae
and into the lower 1 0 ribs between
their tubercles and angles; the
longissimus cervicis inserts into the
posterior tubercles of the transverse
processes of C2-C6; the longissimus
capitis inserts into the mastoid
process of the temporal bone.
The spinalis muscle is also in three
parts: spinalis thoracis, spinalis cervicis,
and spinalis capitis. It arises from the
spinous processes in the dorsolumbar
regions and inserts into the spinous
processes in the upper thoracic region.
82 Intramuscular stimulation in practice
Deep layer
This consists of the transversospinal
muscles: the semispinalis, the multi
fidus, and the rotatores. This group of
obliquely-disposed short muscles
runs from the transverse processes
to the spinous processes of most
vertebrae, hence, "transversospinal" .
The semispinalis muscle, as its
name indicates, originates from
about half the upper spine (TlO and
up) to insert into the thoracic spinous
processes (semispinalis thoracis), the
cervical spinous processes (semi
spinalis cervicis), and the occipital
bone (semispinalis capitis). The semi
spinalis capitis forms the largest
muscle mass in the neck.
The multifidus ("many-cleaved")
muscle is divided into many bundles
that occupy the groove on each side
of the spinous processes. These
extend the entire length of the spine,
but are more substantial in the
lower half. The bundles arise from
the sacrum and the mammillary
processes of L5 to Tl2, the transverse
processes of the thoracic vertebrae,
and the articular processes of cervical
vertebrae. They ascend over 2-5
vertebrae and insert into the spinous
processes.
The rotatores are short muscles
that arise from the transverse process
of one vertebra and insert into the
base of the spinous process of the
vertebra above.
T REATMENT
Position of patient
Position the patient prone, using a
shallow pillow to support the abdo
men, thus straightening the lumbar
curvature. Allow the arms to hang
down freely on the sides of the couch,
thus pulling the scapulae laterally.
Regional examination and specific treatment 83
Choice of needle
The minimum length is 2 inches. In
the low back and buttock, a 3-inch
needle is generally required to
penetrate thicker muscles. Since
many muscles require treatment, the
use of a plunger-type needle holder
is often more convenient than
individual needles. If individual
needles are preferred, a number of
them (e.g. eight) may be inserted into
selected muscles and left for several
minutes (sometimes up to 20 minutes)
until muscle shortening is released.
The needles are then withdrawn and,
if desired, reinserted into other
muscles.
Procedure
Treatment of the lumbar back usually
includes the intrinsic muscles of the
back, the buttocks, and part of the
posterior abdominal wall (quadratus
84 Intramuscular stimulation in practice
The "super-contracture"
When paraspinal muscles at conse-
cutive segmental levels are needled, ERECTOR
resistance to needle penetration SPINAE: Iliocostalis Longissimus
may be substantially increased at the
involved level(s) when compared to
the segments above and below.
Occasionally, the needle
encounters a contracture that seems
bony-hard and cannot be penetrated
to the depth reached at other levels.
Penetration, then, may only be pos
sible by applying some considerable
force, and after repeated "pecking".
Finally, when the needle enters
the dense, fibrotic contracture, the
patient experiences the intense
cramp described previously. This
gradually diminishes as the needle
grasp is liberated. The dense, fibrotic
contracture is an important and
crucial clinical finding which is
invisible to radiological, CAT, or
MRI techniques and may be
labelled as the "invisible lesion".
However, the hard contracture is
but a consequence of Cannon's law.
Cannon described four types of
increased sensitivity:
Buttock r
o
EXAMINAT I O N
m
Identify landmarks "
Surface markings
The superior gluteal nerve: the
junction of the upper and middle
third of a line between the posterior
superior iliac spine and the top of the
greater trochanter is the point where
the superior gluteal nerve and vessels
Piriformis
leave the pelvis. The piriformis muscle
is immediately inferior to these. The
sciatic nerve passes from under the
cover of the gluteus maximus about Quadratus
midway between the ischial femoris
tuberosity and the greater trochanter.
The sciatic nerve leaves the pelvis
with the internal pudendal vessels
and the pudendal nerve below the
point of emergence of the superior
gluteal nerve, separated by the width o The gluteus medius is tender in most back and leg
of the piriformis muscle. conditions and requires treatment.
88 Intramuscular stimulation in practice
TREAT M E N T
Treatment o f the buttock always
includes treatment to both sides of
the back.
Position of patient
Place the patient in the supplementary
position, lying on one side with the
u upper hip flexed. (The ischial tubero
o sity is covered by the gluteus maximus
l when the hip is extended, but is
I palpable when the hip is flexed.)
:::) Palpate and needle the tender
a:l bands in the gluteus maximus muscle
(the small area on the outer surface
of the ilium between the posterior
gluteal line and iliac crest, back of the
sacrum and sacrotuberous ligament
..J to the iliotibial tract of the fascia lata
a:
and gluteal tuberosity above the linea
w aspera).
Needle the gluteus medius muscle
(the outer surface of the ilium
o
between the iliac crest and middle
..J
gluteal line to the lateral surface of
the greater trochanter along a line
downward and forward at about
2 inches from the iliac crest).
Then, needle these muscles as they
insert into the greater trochanter and
iliotibial tract.
When the gluteal muscles are
relaxed, the quadratus femoris, gluteus
medius, and gemelli muscles can be
palpated. Needle these muscles at
about 2 inches from the greater
trochanter.
The gluteus minimus muscle (the
outer surface of the ilium between
middle and inferior gluteal lines to
the impression on anterior part of the
greater trochanter) can be needled
through the medius.
The sciatic nerve runs deep to the
gluteus maximus muscle, midway
between the greater trochanter and
ischial tuberosity. In IMS, when no
Regional examination and specific treatment 89
EXAMINATION
Three large muscles make up the
hamstrings: the semimembranosus,
semitendinosus, and biceps femoris.
HAMSTR I N G S : They have a common origin from the
:r:
ischial tuberosity deep to the gluteus
Biceps femoris ---;-
maximus, and run to the proximal
:r: Semitendinosus ---+--tI- ends of tibia and fibula.
I- Biceps femoris: long head from the
Semimembranosus medial part of the ischial tuberosity
a::
with the semitendinosus; short head
o
from the linea aspera to the head of
a:: the fibula.
w Semitendinosus: from the medial
I part of the ischial tuberosity to the
III medial surface of the tibia below the
o knee joint.
c.. Semimembranosus: from the
lateral part of the ischial tuberosity to
the posterior surface of the medial
condyle of the tibia deep to the
medial ligament of the knee joint.
These muscles extend the hip and
a:: flex the knee, and are therefore
w examined and treated when there is
pain in either of these joints.
o
oJ TREATMENT
Treatment o f the hamstrings always
includes the intrinsic muscles of the
back. Likewise, lumbar spondylosis
may manifest as pain in the
hamstrings. In low back pain, tender
hamstrings are always treated. To
demonstrate the muscles, the knee
is flexed at 90 degrees against
resistance. Needle the tender
mid portion of each muscle; but
further needle insertions along the
length of the muscles may be
necessary to produce full relaxation.
Regional examination and specific treatment 91
Surface markings
The femoral artery begins at a point
midway between the anterior
superior iliac spine and the pubic
symphysis. Draw a line from that
point to the adductor tubercle; the
proximal two thirds of that line
represents the femoral artery. The
continuC'tion is the popliteal artery: a
line down the center of the popliteal
fossa to the level of the tubercle of the
tibia. Anterior tibial artery: a point
midway between the tubercle of the
tibia and the head of the fibula to
midway between the two malleoli.
Dorsalis pedis artery: a line
continued to the proximal part of the
first intermetatarsal space.
Avoid the femoral triangle which
contains the femoral vessels and the
femoral nerve, bounded laterally by
the sartorius, and medially by the
medial margin of the adductor
longus; its floor is formed by the
iliopsoas, pectineus, and adductor longus.
M uscles
Pectineus: from the pectineal line of
the pubis and the surface in front of it
to a line from the lesser trochanter to
the linea aspera.
Gracilis: from the outer surface
of the inferior pubic ramus to the
medial side of the upper end of the
tibia.
92 Intramuscular stimulation i n practice
a: Knee pain
w
... Knee pain is commonly causd by
shortening in muscles that activate
Z
the joint. These muscles are
""
innervated by segmental nerves from
the lumbar spine; therefore,
examination and treatment of the
knee always includes the back, where
L2-3, 3-4 and 4-5 are usually found
...I
to be involved.
a:
w Knee flexors
Two on the lateral side:
o Biceps femoris (long head from the
...I medial part of the ischial tuberosity,
short head from the linea aspera to
the head of the fibula).
Popliteus (lateral condyle of the
femur to the tibia above the soleal
line).
Four on the medial side (pes
anserinus):
Sartorius (the anterior superior
iliac spine and outer edge of the iliac
Regional examination and specific treatment 9S
crest for 2 inches to the medial side of Treating the pes anserinus, the tendinous expansion a n d
the upper end of the tibia). attac hment o f the sartorius, gracilis, and semitendinosus.
Patellofemoral pain
o
...I
u. T REATMENT
0 Peroneus
longus "Sh i n splints"
:!:
::J This is a lay term for a painful
III
a: condition of the anterior compartment
0 of the leg which occurs following
C vigorous or lengthy exercise. This
overuse condition can occur when
C ankle dorsiflexors, the tibialis anterior
Z
(and extensor hallucis longus and
<2:
Peroneus brevis), and sometimes the ankle
'" brevis evertors (peroneus longus and
w brevis), shorten in the anterior crural
..I
compartment and reduce blood flow
to the muscles, i.e. "anterior shin
a:I splints" . Chronic overuse may lead
:!: to microtraumata and scar tissue
..I formation. When plantar flexors
the tibialis posterior, flexor hallucis
a:
w longus, and flexor digitorum longus
(see Calf, p. 99)-are painful, the
condition is sometimes known as
0
..I "posterior shin splints" .
Calf r
o
EXAMI NATION
m
Treatment o f calf pain always
"
includes an examination of the
low back, as pain in the calf is a r
Flexor
dig itorum
T REATM ENT
..J longus
Pain in the back of the knee may
a:: result from shortening in the
w popliteus muscle.
Pain in the lateral side of the leg
o It--r-- Tibialis above the lateral malleolus. Calf pain
posterior
..J nearly always includes pain and
tenderness in the peroneus longus
and brevis.
Pain in the medial side of the leg
above the medial malleolus. Calf pain
Flexor is often associated with pain and
hallucis tenderness in the flexor digitorum
longus
longus.
Tenosynovitis
Shortening of the tendons of the
tibialis anterior, tibialis posterior,
extensor digitorum longus, or peroneal
muscles may cause pain similar to De
Quervain's tenosynovitis at the wrist.
Release of the involved shortened
muscles relieves the condition.
Achilles tendonitis
Release the soleus and gastrocnemii
muscles. When pain is bilateral, treat
one side at a time only as soreness
from needling can cause limping.
Treatment of any condition in the
lower limb requires muscles on both
Regional examination and specific treatment 101
Soleus
TREATMENT r-
0
Arches of the foot
m
The integrity of the arches of the
;:tI
foot, particularly the medial arch, is
Flexor
maintained by the action of the tibialis r-
hallucis
posterior, flexor hallucis longus, and longus --+r-A
flexor digitorum longus muscles
'"
through the bracing action of their Tibialis
tendons. These muscles must be posterior Peroneus
examined and treated in the calf longus ."
Hallux valgus
Shortening of the extensor hallucis
longus and extensor hallucis brevis
muscles can cause lateral deviation
of the big toe, and produce medial
deviation of the head of the first
metatarsal. A bunion can form at the
medial aspect of the metatarso
phalangeal joint. In the early stage,
before severe arthritic damage to the
joint occurs, the condition responds
to needling of these muscles, and
alignment of the toe can return to
normal after a few treatments.
1 02 Intramuscular stimulation in practice
Hallux rigidus
Degenerative joint disease may occur
Angle i nsertions in the first metatarso-phalangeal
to pierce both joint, causing pain, tenderness, and
heads stiffness (often bilateral). Early cases
respond to needling of the first dorsal
interossei muscle. The Matchstick test
usually yields deep indentations.
Using a I-inch long needle, pierce the
muscle between the first and second
II..
metatarsals at the most tender areas
(about 1 Y2 inches proximal to the
heads of the metatarsals). The flexor
hallucis longus and brevis and extensor
hallucis longus muscles may also
require treatment.
a::
w Pain in the sole
This may result from:
o Shortening of the extensor hallucis
.J
longus and extensor digitorum longus
muscles which dorsiflex the toes, thus
angulating the metatarso-phalangeal
joint and exposing the tenc.er under
side of the heads of metatarsals and
plantar nerves to pressure on
-H.---i-""-- Extensor walking.
hallucis Metatarsalgia. Pain in the
longus metatarsal region may arise from
weakness of the intrinsic muscles.
Palpate for tenderness in the flexor
-;--irbn- Extenso r digiti minimi, abductor digiti minimi,
hallucis flexor digitorum brevis, flexor
brevis hallucis brevis, abductor hallucis, and
adductor hallucis muscles. Also check
the flexor hallucis longus and flexor
digitorum longus muscles in the calf.
Plantar (Morton's) neuralgia. An
interdigital plantar neuroma may
subsequently develop in the inter
digital nerves, commonly between
the third and fourth toes, causing
pain, numbness, tingling, aching,
and burning in the distal forefoot.
Treatment is to the above extensor
muscles. The long flexors and
Regional examination and specific treatment 1 03
Supplementary
information
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Musculoskeletal pain of spondylotic origin 107
Muscle shortening
Secondary pain from tissue
Muscle shortening from increased
degradation
muscle tone (possibly associated with
abnormal spinal reflexes or super Muscle shortening mechanically
sensitive peripheral mechanisms) stresses ligaments, tendons, cartilage,
nearly always accompanies neuro and bone. When stress occurs in
pathic musculoskeletal pain structures that have collagen already
syndromes. Shortening can cause weakened as a consequence of
pain by compressing intramuscular neuropathy, the overload can produce
nociceptors that may have become degeneration and secondary pain, for
overly sensitive and prone to example, tendonitis, epicondylitis,
abnormal impulse generation. spondylosis, discogenic disease, and
I I0 Supplementary information
stimulation reaches the affected part 1797, this current was later measured
indirectly. It is the reflex response in by Dubois-Reymond in 1860 to be
efferent fibers to the affected approximately a microampere. Recent
structure that stimulates the measurementsll using a vibrating
therapeutic target. probe (which can measure steady
Thus, physical therapies can extracellular currents as small as
provide relief while the nerve heals 0.1 microamperes/cm2) showed a
(usually within days or, at the most, freshly amputated finger-tip to
weeks). Unfortunately, external forms generate 500 microampere/ cm2
of reflex stimulation are short-lived Stimulation by needling can reach
and cannot furnish long-lasting deep muscles (especially lumbar
benefit: when therapy is paraspinal muscles) which are
discontinued, its stimulus ceases. otherwise inaccessible, and its effect
Therefore, when pain persists, can persist for days, until the
treatment with a more effective miniature wounds heaP Pain relief
physical modality is indicated. and muscle relaxation in one region
We have found that muscle can spread to the entire segment,
shortening is an inherent component suggesting a reflex mechanism
of persistent musculoskeletal pain, involving spinal modulatory systems.
and its release is central to treatment. Sympathetic hyperactivity also
Where simpler measures fail to responds to reflex stimulation, and
release muscle shortening, an the relaxation of smooth muscle can
injection technique generally spread to the entire segment releasing
succeeds. Local anesthetics are vasospasm7 and lympho-constriction.
commonly employed, but normal
physiological saline has also been
Removal of the cause of
used with good results.22 The benefit
nerve irritation
of injection methods is partly derived
from the local inflammation created In spondylosis, efferent flow of
by the needle regardless of the impulses is most commonly impeded
substance injected: thus, dry needle at the spine where shortened para
stimulation, without injected spinal muscles cO!l1press the nerve.
substances, is also effective.13,22 To break this vicious circle, these
One of the body's responses to muscles nearly always require
inflammation is the generation of needling.
injury potentials. The insertion of a
needle into a muscle generates
Promotion of healing
bursts of electrical discharges with
amplitudes as high as 2 mV. These When muscle shortening is associated
are greatly prolonged in neuropathy with extensive fibrosis, another
(> 300 ms), and are further therapeutic mechanism-the
augmented by manipulation of the healing process-may be involved.
needle. These discharges can cause a Treatment of extensively fibrotic
shortened muscle to visibly fasci contractures necessitates more exten
culate and relax instantly or within sive needling. The progressive nature
minutes.9 Injured tissue also yields of symptomatic relief, substantiated
current, known as the "current of by the gradual amelioration of
injury".8 First described by Galvani in objective clinical findings, suggests
I 12 Supplementary information
REFERENCES
1. Asbury A K, Fields H L 1984 Pain due to 16. McCain G 1983 Fibromyositis. Clinical
peripheral nerve damage: an hypothesis. Review 38: 197-207
Neurology (Cleveland) 34: 1587-1590 17. Ochoa J L, Torebjork E, Marchettini P,
2. Axelsson J, Thesleff S 1959 A study of Sivak M 1985 Mechanisms of neuropathic
supersensitivity in denervated mammalian pain: cumulative observations, new
skeletal muscles. Journal of Physiology experiments, and further speculation. In:
147: 178-193 Fields H L, Dubner R, Cervero F (eds)
3. Bradley W G 1974 Disorders of peripheral Advances in pain research and therapy,
nerves. Blackwell Scientific Publications, vol 9. Raven Press, New York
Oxford 18. Purves D 1976 Long term regulation in the
4. Cannon W B, Rosenblueth A 1949 The vertebrate peripheral nervous system.
supersensitivity of denervated structures, a International review of physiology.
law of denervation. MacMillan, New York Neurophysiology II, vol 10. University
5. Culp W J, Ochoa J 1982 Abnormal nerves Park Press, Baltimore, pp 125-162
and muscles as impulse generators. Oxford 19. Ross R, Vogel A 1978 The platelet-derived
University Press, New York growth factor. Cell 14: 203-210
6. Dyck P J, Lambert E H, O'Brien P C 1976 20. Sharpless S K 1975 Supersensitivity-like
Pain in peripheral neuropathy related to phenomena in the central nervous system.
rate and kind of fiber degeneration. Federation Proceedings, vol 34, no 10,
Neurology 26:4671 September 1990-1997
7. Ernest M, Lee M H M 1985 Sympathetic 21. Simons D G, Travell J 1981 Letter to editor
vasomotor changes induced by manual re: myofascial trigger points, a possible
and electrical acupuncture of the Hoku explanation. Pain 10: 106-109
Point visualized by thermography. Pain 22. Sola A E 1984 Treatment of myofascial pain
21: 25-34 syndrome. In: Benedetti C, Chapman C R,
8. Galv'lni A 1953 Commentary on electricity: Morrica G (eds) Advances in pain research
translated by Robert Montraville Green. and therapy, vol 7. Raven Press, New York,
Elizabeth Licht Publishing, Cambridge pp 467-485
9. Gunn C C 1978 Transcutaneous neural 23. Thesleff S, Sellin L C 1980 Denervation
stimulation, acupuncture and the current supersensitivity. TINS August: 122-126
of injury. American Journal of 24. Thomas P K 1984 Symptomatology and
Acupuncture 6; 3:191-196 differential diagnosis of peripheral
10. Howe J F, Loeser J D, Calvin W H 1977 neuropathy: clinical features and
Mechanosensitivity of dorsal root ganglia differential diagnosis. In: Dyck P J,
and chronically injured axons: a Thomas P K, Lambert E H, Bunge R
physiological basis for the radicular pain (eds) Peripheral neuropathy, vol II. W B
of nerve root compression. Pain 3: 24-41 Saunders, Philadelphia, pp 1169-1190
11. Jaffe L F 1985 Extracellular current 25. Wall P D 1979 On the relation of injury to
measurements with a vibrating probe. pain, the John J Bonica Lecture. Pain
TINS December: 517-521 6:253-264
12. Klein L, Dawson M H, Heiple K G 1977 26. Wall P D 1979 Changes in damaged
Turnover of collagen in the adult rat after nerve and their sensory consequences.
denervation. Journal of Bone and Joint In: Bonica J J, Liebeskind J C, Albe-Fessard
Surgery 59A:1065-1067 D G (eds) Advances in pain research and
13. Lewit K 1979 The needle effect in the relief therapy, vol 3. Raven Press, New York,
of myofascial pain. Pain 6: 83-90 pp 39-50
14. Loeser J D, Howe J F 1980 Deafferentation 27. Wall P D, Devor J 1983 Sensory afferent
and neuronal injury. In: Lockard J S, Ward impulses originate from dorsal root
A A (eds) Epilepsy: a window to brain ganglia as well as from the periphery in
mechanisms. Raven Press, New York, normal and nerve injured rats. Pain
pp 123-135 17:pp 321-339
15. Lomo T 1976 The role of activity in the 28. Willison R G 1982 Spontaneous discharges
control of membrane and contractile in motor nerve fibers. In: Culp W J, Ochoa
properties of skeletal muscle. In: Thesleff J (eds) Abnormal nerves and muscles
S (ed) Motor innervation of muscle. impulse generators. Oxford University
Academic Press, New York, pp 289-315 Press, New York
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Table I. Shortened muscles in common syndromes 1 15
Capsulitis, shoulder; "frozen shoulder" all muscles acting on the shoulder, including
trapezius, levator scapulae, rhomboidei,
pectoralis major, supra- & infraspinati, teres
major & minor, subscapularis, deltoid
Headaches:
frontal upper trapezius, sternomastoid,
occipitofrontalis
temporal temporalis, upper trapezius
vertex splenius capitis, cervicis
oCcipital suboccipital muscles
Intervertebral disc (early stages) muscles acting across the disc space, e.g.
rotatores, multifidi, semispinalis
I 16 Supplementary information
UPPER EXTREMITY
Trapezius XI C3 C4
Levator scapulae C3 C4
Latissimus dorsi C6 C7 C8
Pectoralis major C6 C7 C8 TI
Serratus anterior C5 C6 C7 C8
Pectornlis minor C8 TI
Deltoid C4 CS C6 C7
Coracobrachialis C5 C6 C7 C8
Biceps brachii CS C6
Teres major CS C6 C7
Triceps brachii C6 C7 C8
Supraspinatus C4 CS C6
Infraspinatus C4 CS C6
Teres minor C4 CS C6 C7
Brachialis CS C6
Brachioradialis CS C6
Pronator quadratus C6 C7 C8 TI
Palmaris longus C6 C7 C8 TI
Supinator C5 C6 C7
Extensor carpi C5 C6 C7 C8
Palmaris longus C6 C7 C8 TI
Abductor pollicis C6 C7 C8 TI
Opponens pollicis C6 C7 C8 TI
Adductor pollicis C8 TI
LOWER EXTREMITY
Pectineus L2 Ll L4
Adductor brevis L2 Ll L4 LS
Sartorius L2 Ll L4
Adductor longus L2 Ll L4
Adductor magnus L2 Ll L4 LS
Gluteus maximus L4 LS SI S2 S3
Semimembranosus L4 LS SI S2 S3
Semitendinosus LS SI
Biceps femoris L4 LS SI S2 S3
Gluteus medius L4 LS SI S2
Gracilis L2 Ll L4 LS
Gluteus minimus L4 LS SI
Quadratus femoris L4 LS SI
Piriformis SI S2 S3
Gastrocnemius, soleus L4 LS SI S2 S3
Tibialis posterior L4 LS 51 S2
Tibialis anterior L4 LS 51 52
Sources of supplies
Although the author uses the follow The AcuMedic needles are pre
ing suppliers, you are encouraged to sterilized and supplied in plastic
develop your own sources. Your local tubes; by cutting both ends of the
medical acupuncture society may plastic tube a tubular guide is
be able to offer suggestions or formed. Needles are available in:
recommendations.
50 mm, dia. 0.30 and 0.35 (2 inches)
Japanese needle plungers. I use -most often used length.
Showa #6 fr om: 30 mm, dia. 0.25 (1 inch)
15 mm, dia. 0.25 (Y2 inch)
Nikka Industries Ltd.
611 Powell Street Note: the thickness of their handles
V ancouver, BC can be inconsistent; when they are too
Canada V6A IH2 small, the needles tend to fall out of
Telephone: 001604 251-2466 the Showa plunger. These needles are
Fax: 001604 251-7226 also available from Nikka Industries
Ltd.
This plunger is made of cruome
plated brass. Although somewhat
ITO ESS disposable needles are
costly, it is durable and can last for
available from:
years. The plunger requires cleaning
and autoclaving (in paper purpose Electro-T herapeutic Devices Inc
use envelopes) after each use. You 570 Hood Road, Suite 14
will need several plungers; the exact Markham
number depends on how many Ontario
patients you treat per working session Canada L3R 4G7
(I have 30 plungers). Make sure that Telephone: 001 416 494-7997/001
you are not given a much cheaper 905 475-8344
plunger made of aluminium. 1 find Toll Free (only in Canada): (800)
they cannot accept a 2-inch needle, 268-3834
and the plungers do not last for long. Fax: 001 905 475-5143
acupuncture needles for manual (I use the 1-inch needle for the face,
stimulation (with glass tubes). hand, elbow and neck. The 3-inch
IMPORTANT: these needles, with needle is useful for heavier patients,
glass tube guides, are used for but it is also generally necessary for
manual stimulation. They are not all patients for the buttock.)
intended for, and do not fit, the
Showa #6 plunger. TENS units
Most of the above suppliers also offer
AAA Acupuncture Inc TENS units. I find the Pointer Plus
PO Box 44-45 an inexpensive, hand-held acupunc
Taipei ture point-locator-easy to use to
Taiwan stimulate the inserted needle instead
R.O.c. of twirling it. I also recommend the
Telephone: 00-886-2-725 1042 unit to patients for transcutaneous
Fax: 00-886-2-725 2203 stimulation at home. The point
finder, powered by a 9 volt battery,
These needles are also available
can also provide galvanic stimulation:
from Nikka Industries Ltd. Needle
lengths available: Output intensity 0-22 rnA
Frequency of 10 Hz
#2610 1 inch output continuous
#2612 1;1, inch Pulse width 240/Js
.
#2614 2 inch Waveshape biphasic square
#2616 2Yz inch pulse with
#2618 3 inch negative spike
Suggested reading 123
Suggested reading
Trapezius TZ
Levator scapulae LS
Deltoid D
Coracobrachialis CoBr
Biceps brachii Bi
Triceps brachii TR
Supraspinatus SS
Infraspinatus IS
Brachialis Brac
Brachioradialis BrRad
Supinator Supin
Flexor pollicis longus & brevis Fix pol ing & brev
Pectineus Pect
Sartorius Sart
Semimembranosus Semimemb
Semitendinosus Semitend
Gracilis Grac
Piriformis Piri
Gastrocnemius Gastroc
Soleus Sol
Tibialis anterior TA
pend ices
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List of appendices 1 29
List of appendices
Appendix 6 Dry needling of muscle motor points for chronic low-back pain.
A randomized clinical trial with long-term follow-up. Spine
5(3): 279-291,1980 (abstract) (With permission from J. B.
Lippincott Company) 151
The author and publishers have made every effort to trace the copyright holders for borrowed material.
If they have inadvertently overlooked any, they will be pleased to make the necessary arrangements at
the first opportunity.
THIS PAGE INTENTIONALLY
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Appendix 1 13 1
Appendix I.
Neuropathic pain: a new theory for chronic pain of intrinsic origin
C. C. Gunn MA MB BChir
Annals of the Royal College of Physicians and Surgeons of Canada
Appendix 2.
"Prespondylosis" and some pain syndromes following denervation
supersensitivity
C. c. Gunn MA MB BChir
Spine (From the Clinical Research Unit, Rehabilitation Clinic, Workers' Compensation Board of British Columbia, Richmond,
British Columbia, Canada.
Presented in part at the 47th Annual Meeting of the Royal College of Physicians and Surgeons of Canada, January 27,1978.)
STIMULUS
Fig. 1 Information flow in the nervous system. Receptors transmit information to the central nervous
system via primary afferent fibers which synapse onto either motoneurons or interneurons. The latter
may activate other interneurons, either in the cord or in the brain. Following complex patterns of
interaction among these cells, information is fed to motoneurons and effector cells.
pathologic reactions.2 This may be either and may contribute to c hronic pain. For
attenuation of the caliber of axons or example, whereas acute structural
primary damage to myelin, but is usually deformation of a healthy nerve is not
a combination of both. Variable degrees painful or only briefly so (e.g. peroneal
of damage with variable degrees of nerve palsy!! or radial nerve "Saturday
reversibility may be present, ranging night" palsy), such is not the case in an
from neurapraxia to axonotmesis and unhealthy nerve. It has recently been
neurotmesis.32,36 Peripheral neuropathy shown that when and if pain develops
may occur at various sites, but the spinal in a peripheral nerve, it is primarily
root within the spinal canal and inter associated with the acute breakdown of
vertebral foramina, and even after it myelinated fibers (either Wallerian or
emerges, is especially prone to damage.2 ,42 axonal degeneration) superimposed on
This may follow acute trauma, but more the pre-existence of c hronic nerve fiber
usually it is the long-term sequela of degeneration .1O Pain is probably not
spondylosis which causes simultaneous caused simply by the different pro
damage to the nerve roots (radiculopathy) portions of large to small fibers remaining
and cord (myelopathy).42 Spondylosis after nerve degeneration as anticipated by
(which refers to the structural disintegra the gate theory, but by the acute upon
tion and morphologic alterations in the c hronic or recent abnormal rate of break
intervertebral disc and pathoanatomic down of myelinated fibers (whatever
changes in surrounding structures) has its primary cause may be).10 Animal
been acknowledged as a clinical entity experiments have furthermore shown
only for some 20 years,42 although even that an acute mechanical injury to a
today the significance of the silent, pain healthy dorsal nerve root does not
free, but not necessarily morbidity-free, produce a sustained discharge unless
prespondylotic phase is still not widely there has been pre-existing minor c hronic
recognized. "Prespondylosis" may be injury to the nerve.39 Clinically, it is also
"symptomless", its symptoms and signs common knowledge that in asymptomatic
unsuspected, because pain may not be a subjects the mere appearance of degen
feature. Pain occurs only when and if the erative changes in spinal roentgenograms
degenerative changes impinge upon local is not of much clinical significance, but
pain-sensitive structures to produce local in these persons, disability after injury
pain, or upon pain fibers of the nerve root will tend to be prolonged and signs of
to produce the transmitted pain of radiculopathy more commonly found.13,14
"radiculitis", a clinical term commonly It would therefore appear that for pain to
used to describe the discomfort or pain persist after trauma, a prerequisite is the
radiating along the peripheral nerve. existence of c hronic nerve irritation.
However, constant attrition of the
peripheral nerve can attenuate fibers
DENERVATION
other than those of pain (which are small
SUPERSENSITIVITY AND
and less liable to mechanically caused
MYALGIC HYPERALGESIA
ischemia),43 producing insidious neuro
pathy, the effects of which are projected Myalgic hyperalgesia, or excessive
onto the dermatomal, myotomal, and tenderness to digital pressure, is not a
sclerotomal target structures supplied by normal feature of muscle because their
the segmental nerve. Dysfunction may be mechanosensitive nociceptors are located
motor, sensory, trophic, or autonomic,12 deep within the muscle bulk and have
but since pain fibers are not necessarily high thresholds. (Muscle Ao fibers are
involved, there are no "symptoms" and mechanosensitive, have high thresholds,
both patient and physician may be and respond to strong localized pressure
oblivious to the condition. "Prespondy but not to stretch or ischemia. Muscle C
losis" nonetheless has its implications fibers also have high mechanical
138 Appendices
also overstimulate the essential feedback the efferent nerve, in addition to its usual
mechanism by which skeletal muscle and effects, causes depolarization of the
resting muscle tonus are controlled. The somatic sensory nerve at the point of
afferent discharge of the spindle via the artificial synapse. This depolarization is
dorsal root on the motoneurons of the then propagated orthodromically along
same muscle is excitatory. the afferent sensory nerve and when
added to normal sensory impulses causes
abnormally high sensory discharge which
DENERVATION SUPER
is felt as pain . In addition, depolarization
SENSITIVITY AND NEURALGIC
at the artificial synapse is said to propa
HYPERPATHIA
gate antidromically along the somatic
The extreme example of causalgia is afferent, leading to the release of certain
discussed first, as its manifold manifesta substances5 that decrease the threshold
tions represent all aspects of peripheral at the sensory nerve ending and further
neuralgic hyperpathia. The term increase the impulses reaching central
"causalgia" is derived from the Greek areas.
kausis, "burning", and algos, "pain", to Livingston's25 theory of the "vicious
describe the most striking feature of the cycle of reflexes" postulated that there is
condition, which is persistent, severe, and chronic irritation of a peripheral sensory
burning pain in an affected extremity, nerve leading to increased afferent
usually as the result of a partial injury to a impulses and resulting in abnormal
nerve (commonly, the median, ulnar, and activity in an "internuncial pool" of
sciatic nerves).9,26,35 In addition to the pain neurons in the lateral and anterior horns
there is invariably autonomic dysfunction of the spinal cord, The concept of
and trophic changes in skin and! or bones denervation supersensitivity supports
in the involved part. Causalgic pain has Livingston's theory, because peripheral
been categorized as "major causalgia" receptors, afferent neurons, internuncial
and a less painful variant referred to as pools, and autonomic ganglia may
"minor causalgia" or "posttraumatic become hypersensitive or hyperreactive.
reflex sympathetic dystrophy". Typically, Furthermore, autonomic neurons may
causalgic pain appears within a week generate spontaneous autogenic
following a nerve injury (when denerva potentials similar to muscle fibrillations
tion supersensitivity has had time to (see above). However, the increased
develop), but its onset may be delayed receptivity of denervated autonomic
by as much as 3 months. The severe, neurons to a variety of foreign synapses
burning pain may be explained by and peripheral nociceptors to released
hypersensitivity of receptors and small algogenic substances5 also supports the
diameter afferen t fibers (AI) and C) in theory of artificial synapses proposed by
cutaneous and other tissues. The auto Doupe and co-workers. It is also signi
nomic dysfunction and trophic changes ficant that c hanges at spinal and other
may likewise be the result of super central synapses may occur (see above)
sensitivity at lateral horn cells, autonomic with facilitation of noxious input.
ganglia, and receptors around blood In recent years the well-known gate
vessels; thus, a sympathetic nerve block theory of Melzack and WaIFS has been
and! or sympathectomy provides relief applied to causalgia (and to many other
in a proportion of patients. pain syndromes). It is suggested that cells
Doupe and co-workers9 have suggested in the substantia gelatinosa of the dorsal
that traum a causes the formation of horn of the spinal cord act as a "gate
"artificial synapses" (ephapses) between control system", modifying the trans
sympathetic efferents and somatic sensory mission of afferent sensory impulses.
afferent nerves. According to this theory, This theory em phasizes a pattern of
a sympathetic impulse traveling down impulses rather than single impulses
140 Appendices
with a "selection process" to explain the In this restatement, Wall stated that fiber
intricacies of sensory experience. The gate diameter alone is not enough or is even
theory contends that impulses from large completely irrelevant to explain pain in
myelinated fibers inhibit or "close the the neuropathies when pathologic
gate", whereas tonic background peripheral fibers have unusual impulse
impulses transmitted along smaller fibers generation and conduction properties.
(which include afferent sympathetic However, the original proposal that trans
fibers) "open the gate" to facilitate mission of information about injury from
transmission . The theory also proposes a the periphery to the first central cells is
descending control system originating in under control (influenced by peripheral
the brain that modulates the excitability afferents and by descending impulses),
of afferent conduction . The "gate theory", still holds. In denervation supersensitiv
published in 1 965, was written before the ity, as mentioned above, facilitation of
present explosion of information about noxious input may occur at the "gate"
the anatomic state of nerves in the in the dorsal horn from a reduction of
peripheral neuropathies. Wall and presynaptic inhibition through inter
Melzack were influenced, in particular, neurons. This facilitation may also occur
by a study on postherpetic neuralgia in at autonomic ganglia where interneurons
which it was shown that intercostal have been described.
nerve biopsy specimens had a preferential Because the peripheral nerve responds
loss of large myelinated fibers, and with only a limited repertoire to the many
N oordenbos29 had generalized from this and varied causes of neuropathy/ it is to
observation to propose that pain was a be expected that other forms of neuro
consequence of a loss of inhibition pathy and neuralgic hyperpathia
normally provided by the large fibers. It (whatever their primary cause) will have
is now known that loss of large fibers is many common features. For example, in
not necessarily followed by pain.lO In diabetic neuropathy,3 the unremitting
many conditions (e.g. Friedreich's ataxia) pain, characteristic cutaneous hyper
there may be a large-fiber deficit without sensitivity, burning sensations,
pain. Wall, now realizing that any attempt paresthesias, and autonomic symptoms
to correlate the remaining fiber diameter are certainly not specific for diabetes.
spectrum with pain is no longer possible, Histologic findings in nerve biopsy
has restated the gate control theory of specimens have indicated that the
pain recentlyto: diabetic lesions are predominantly in
the small fibers, with nerve sprouting (a
1. Information about the presence of injury
feature of denervation supersensitivity)
is transmitted to the central nervous system by
the likely cause of the pain .
peripheral nerves. Certain small-diameter
fibers (AI) and C) respond only to injury while
others with lower thresholds increase their DISCUSSION
discharge frequency if the stimulus reaches
noxious levels. An enigma in the past, and today a source
2. Cells in the spinal cord or fifth nerve of great interest to neurobiologists, the
nucleus that are excited by these injury signals importance of denervation supersensi
are also facilitated or inhibited by other tivity with regard to pain has not been
peripheral nerve fibers that carry information appreciated. The implications of
about innocuous events. Cannon's Law of denervation are
3. Descending control systems originating
probably far more embracing than the
in the brain modulate the excitability of the
few conditions briefly discussed here. It
cells that transmit information about injury.
Therefore the brain receives messages about is possible that many other forms of pain,
injury by way of a gate-controlled system that is e.g. trigeminal or postherpetic (neuralgic)
influenced by (1) injury signals,(2) other types and even chronic low back pain, are a
of afferent impulse, and (3) descending control. post-denervation supersensitivity
Appendix 2 14 1
phenomenon rather than the result of blood vessel tone of virtually all tissues
noxious stimuli. Thus, pain may be the and cause secondary pain by structural
central perception of (1) an afferent disintegration. Following denervation,
barrage from noxious stimuli or (2) the the total collagen in soft and skeletal
abnormal input into the central nervous tissues is reduced. Replacement collagen
system from ordinarily non-noxious also has fewer cross-links and is markedly
stimuli rendered excessive through overly weaker than normal mature collagenY
sensitive receptors (or a variable combina Because collagen provides the strength of
tion of both). Consider, therefore, the ligaments, tendons, cartilage, and bone,
chronic "low back" patient whose dis this may contribute to many degenerative
comfort.still persists following resolution conditions in the weight-bearing (spinal
of the acute phase. Though not crippled and intervertebral disc) and activity
or even in distress, he is unable to cope stressed parts of the body (tendinitis, cuff
with any but light activities. Such a tears, epicondylitis, ruptured tendons,
patient may not be subjected to noxious and so forth). These secondary condi
stimuli (nociception) but may be " hyper tions, presently dignified by various
algesic" in that ordinarily non-noxious terms to imply specific clinical entities,
stimuli, e.g. prolonged standing, sitting, are probably only the ultimate sequelae
or walking, can cause symptoms. "Pain" of neuropathy. Degenerative disc disease
as a scientific term should preferably itself may not be a primary condition.
be discarded and a distinction made The structural integrity, strength, and
between "nociception" and " hyper reparative capacity of these somatic
algesia", because different approaches are tissues are such that the constant wear of
required in their management. A source normal usage is probably adequately
of nociception should be eliminated- compensated for, unless their trophic
an unstable fracture or spondylolisthesis capability is depressed, as in chronic
stabilized, the unrelenting spatial com neuropathy. Thus, in a young person the
promise of an impinging disc or carpal supraspinatus tendon does not rupture
tunnel relieved, or the inflammatory and but avulses from its bony insertion, and
algogenic agents of trauma soothed. In the intervertebral disc (now thought to be
hyperalgesia, any contributory factors the prime causative factor in spondylosis)
from spinal spondylosis should be is so strong that following violence to the
alleviated (traction, support, mobilization, vertebral column, the bones always give
or even surgery) and the hypersensitive way first. The disc is particularly vulner
structures desensitized. Lom026 has shown able to altered vascular tone, being almost
in animal experiments that denervation avascular and dependent largely upon
supersensitivity (as assayed by the sensi diffusion through adjacent spongy bone
tivity of muscle extrajunctional membrane for nutrition. It is food for thought that in
to acetylcholine) may be reduced or all our recent studies,12-15 early and subtle
abolished by electrical stimulation. The signs of peripheral neuropathy were
analgesic effect of transcutaneous neural found in a significant number of young
stimulation may thus depend in part on (under 30 years), apparently normal, and
the reduction of supersensitivity as on asymptomatic subjects. Prespondylosis, a
the neurohumoral inhibitory effects of term introduced here to describe the early
the spinal and brainstem antinociceptor effects of spondylotic attrition on the
systems. Continuous stimulation was peripheral nerve, is generally painless,
found most effective, and it has been though not necessarily devoid of
suggested that the efficacy of needle acu morbidity. It and its frequent companion,
puncture for hyperalgesia may be due in radiculopathy, would therefore seem to be
part to stimulation by the current of injury. IS fertile areas for further study in order to
Supersensitivity in autonomic pathways understand better the genesis of pain and
can furthermore lead to the increased "degenerative" conditions.
142 Appendices
REFERENCES
Appendix 3.
Tenderness at motor points: a diagnostic and prognostic
aid for low bacl< injury
C. c. Gunn MA MB BChir and W. E. Milbrandt MD
Journal of Bone and Joint Surgery (From the Workers' Compensation Board, Rehabilitation Clinic, Vancouver)
Appendix 4.
Tennis elbow and the cervical spine
C. C. Gunn MA MB BChir and W. E. Milbrandt MD
CanadIan MedIcal Association Journal (From the Workers' Compensation Board, Rehabilitation Clinic, Vancouver)
Appendix S.
Tenderness at motor points: an aid in the diagnosis of pain in the
shoulder referred from the cervical spine
C. C. Gunn MA MB BChir and W. E. Milbrandt MD
Journal of the American Osteopathic Association
Appendix 6.
Dry needling of muscle motor points for chronic low back pain.
A randomized clinical trial with long-term follow-up
C. C. Gunn MA MB BChir, W. E. Milbrandt MD, A. S. Little MD and K. E. Mason
BSe MSe
Spine (From the Workers' Compensation Board, Rehabilitation Clinic, Vancouver)
Fifty-six male patients who had chronic assessed at the time of discharge, 1 2
low back pain of at least 12 weeks' weeks after discharge, and a t the time of
duration' (average duration, 28.6 weeks) writing (average, 27.3 weeks). The group
and who had failed to respond to that had been treated with needling was
traditional medical or surgical therapy found to be clearly and significantly
were entered into a randomized clinical better than the control group (P > 0.005,
trial to compare the relative efficacies of N 53) with regard to status at discharge,
=
the Clinic's standard therapy regimen status at 12 weeks' follow-up, and status
with and without dry needling at muscle at final follow-up. At final follow-up, 1 8
motor points. Before entering the trial, all o f the 2 9 study subjects had returned to
patients had wldergone without improve their original or equivalent jobs and 1 0
ment eight weeks of the Clinic's standard had returned to lighter employment. In
therapy regimen of physiotherapy, the control group, only four had returned
remedial exercises, and occupational to their original work and 14 to lighter
therapy. The 29 study subjects and 27 employment; nine were still disabled.
control patients then continued with this The results seem to justify the procedure
regimen, but the study subjects also in chronic low back patients in whom
received needling at muscle motor points myofascial pain (the majority) rather than
once or twice a week (average number skeletal irritation is the dominant
of treatments, 7.9). All patients were disabling feature.
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LEFT BLANK
Appendix 7 153
Appendix 7.
Male-pattern hair loss-a supraorbital nerve entrapment syndrome?
C. c. Gunn MA MB BChir and Mathew H. M. Lee MD MPH FACP
International Journal of Acupuncture and Electro-therapeutic Research
The cause of male-pattern hair loss in any part of the body in both men and
remains obscure. It is noted to occur in women. It seems therefore that scalp hair
the geographic distribution of the supra loss, more common in the male, occurs
'
orbitaI and sometimes the great occipital because higher levels of testosterone
nerves. It is suggested that these nerves create a situation in which scalp nerves
are susceptible to entrapment and sub become vulnerable to neuropathy.
sequent neuropathy since signs of the Testosterone greatly increases muscle
latter precede and accompany hair loss. and skeletal bulk, thickens skin and
Male-pattern alopecia is uncommon in reduces subcutaneous fat, most especially
women, yet neuropathy and deprivation in the head. These factors may well cause
of the trophic factor can lead to hair loss increased tension to scalp nerves.
Supraorbital nerve
) \
I S4 Appendices
Auriculotemporal n.
"
lambdoid suture
Appendix 8.
'Fibromyalgia'-"What have we created?"
C. c. Gunn MA MB BChir
Pain
Appendix 9.
Questions commonly asked by patients
I wish he would explain his explanation sensitive; they tend to magnify ordinary
BYRON : DEDICATION TO DON JUAN inputs and change them into painful
sensations. Supersensitivity usually
occurs when there is some irritation to the
Q: I have been in many clinics to treat my nerve roots that come from your spinal
aching back and legs. I have had many cord. Probably your nerves were already
medical investigations including X-rays. I weakened (through wear and tear, or
have tried physiotherapy, manipulations, aging), and it took only a minor accident
and pills without any lasting relief. My to trigger them into supersensitivity.
doctors tell me they have found nothing
wrong. But why are my "aches and Q: How can my supersensitive nerves
pains" still with me and so difficult to be treated?
treat? Is surgery necessary?
A: Supersensitivity cannot be operated
A: Pain is not one entity but three. Type on and "cut away", but it can be desensi
One is well known and easily understood. tized. "Pain killers" and other pills only
There is an obvious painful cause from mask pain briefly. What your nerves need
injury. Think of a burn on the skin, or a is energy to heal themselves. That is why
cut from a knife. Type Two pain is the we instinctively massage a painful part to
pain of inflammation, such as a sprained provide mechanical energy and to revital
ankle when there is obvious swelling, ize it. Heat-or thermal energy-is
redness and the ankle is hot to touch. another commonly used form of treatment.
These two types of pain and their In fact, all effective treatments for Type
treatment are well understood by the Three pain are different forms of energy.
medical profession.
Since an obvious cause of pain from Q: But I've tried massage and heat. They
injury or inflammation has not been only give me temporary relief. Why?
found, it is very likely that there is no
A: All types of local treatment have their
actual source of pain. This is not unusual;
limitations. They cannot penetrate deeply
the pain you feel is caused by abnormal
into the body and the duration of their
and excessive sensitivity of your body's
energy input is temporary. For instance,
nervous system. This is medically known
the energy of a massage does not last
as "supersensitivity" . Unfortunately,
much longer than the massage itself. That
supersensitivity has received little
is why I prefer to use a needle treatment
attention in medical circles. Since there is
that is a modification of traditional
no pain source, surgery will not help and
acupuncture. A needle causes a minute
is definitely not indicated.
local injury, and the injury does two
important things. Firstly, the injury
Q: If my pain is Type Three, what makes
generates electrical energy (as proven by
my nerves supersensitive?
Galvani over 300 years ago), and muscle
A: The basic problem is that the nerves spasm is released. The injury also releases
going to your painful area are unwell. fresh blood into the painful site and blood
Doctors call it neuropathy. Unwell nerves platelets have a healing effect. The
behave abnormally-they are too needle's main purpose is not to block
158 Appendices
pain (although it does this too), but to A: Many doctors perform traditional
stimulate the body to heal itself. It's as acupuncture by inserting needles into
close to a "cure" as you can get. locations according to acupuncture
"maps". They are not seeking the
Q: I've heard of acupuncture and that it epicenter of the painful muscle. Some
can help pain. How is Intramuscular times they may add electrical stimulation
Stimulation different? to the inserted needles. This type of
acupuncture is not so painful-but the
A: Acupuncture is an ancient philosophy
results may not be as good as IMS.
and its diagnosis and practice in Tradi
tional Chinese or Oriental Medicine are
Q: How long will the benefit last?
not based on modern science. What was
a great approach 4000 years ago can be A: The effects of IMS are cumulative.
improved with today's medical Each needle injury stimulates a certain
knowledge. Intramuscular Stimulation or amount of healing, until eventually, the
IMS relies on neurology and a Western condition is healed and the pain dis
understanding of anatomy for diagnosis appears. Blood also brings a healing
and treatment. factor, known as the platelet derived
growth factor, to injured tissues. IMS is
Q: I've always been nervous about like pruning a plant: you produce small
needles. Is it painful? injuries to stimulate new growth to
replace injured tissues. But once healing
A: The acupuncture needle is very fine
has occurred, you are back to where you
much finer than the hollow needle used
were before the pain occurred.
to inject medicine or to take a blood
sample. You may not even feel its Q: How often are treatments necessary?
penetration through the skin, or if you do,
it's only a mild and momentary prick. If A: Treatments are usually once a week
your muscle is normal, the needle inside because time is needed between
you is painless. However, if your muscle treatments for the body to heal itself.
is supersensitive and in spasm, and if the Also, stimulation for healing remains
needle is correctly placed, you'll feel a for several days, lasting for as long as the
peculiar sensation-like a charleyhorse injuries caused by the needle are present.
or muscle cramp. This is a distinctive type Treatment can be spaced out to two
of discomfort, caused by the muscle weeks.
grasping the needle. Patients soon learn
Q: How many treatments will I need?
to recognize and welcome it. They call it a
"good" or positive pain because it quickly A: The number of treatments depends on
disappears and is followed by a wonder several factors: your general health, the
ful feeling of relief and relaxation. The duration and extent of your condition,
needle may still be in you, but because how much scar tissue there is-previous
the muscle is no longer tight, you don't surgery is bad news-and how quickly
feel it anymore. Therefore, the needle your body can heal. The rate of healing
itself is painless. What has happened is also depends on the condition of your
that the needle has caused your abnormal nerves; young people usually heal
muscle spasm to be intensified briefly, quicker, but older is not necessarily
and then released. It is important that you slower. If the pain is of recent origin, one
experience this peculiar sensation in order treatment may be all that is necessary. In
to have relief. my published study of patients with low
back pain, the average number of
Q: But some of my friends tell me they treatments required was 8.2.
have had painless acupuncture and have
not felt these sensations. Q: Does IMS always succeed?
Appendix 9 159