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Ultrasound-guided Dry Needling

By May 18, 2018 No Comments

In the current climate where reduction of opiate use is at the forefront of medical and political policy, adjuvant pain management techniques are becoming increasingly relevant. An often-overlooked modality of treating both acute and chronic pain is dry needling of myofascial trigger points. A familiar procedure in the chronic pain world, it is now being explored in the realm of emergency medicine and the treatment of acute pain. Centers such as St. Joseph’s University Medical Center in Paterson, N.J. (featured in a recent NPR article) have employed dry needling as part of a comprehensive program to decrease narcotic prescription in their emergency department.

St. Joseph’s program incorporates regional blocks, pain procedures such as trigger point needling, lidocaine patches, and other non-opiate medications. ED patients are frequently sent home with ibuprofen, acetaminophen and instructions to use warm compresses in lieu of a narcotic prescription. It’s a dramatic shift in thinking on the part of both physicians and patients. Two years into the program, some ED physicians at St. Joseph’s may go an entire shift without prescribing any opiate medications.

Dry Needling

The literature supports the use of trigger point dry needling for short term relief of myofascial pain. In a recent meta-analysis, randomized controlled trials between the years 2000 and 2015 were reviewed. It found that dry needling of myofascial trigger points improved pain relief, range of motion and quality of life in the short term, however its long-term effectiveness is unclear. Of particular relevance to the opiate epidemic, evidence remains inconclusive both in the short and long term whether dry needling affects the amount of analgesic medications taken, disability and sleep.

One limitation found by the meta-analysis was the relative lack of standardized technique for dry needling utilized across studies. The concept itself is simple. Myofascial trigger points, or  “hyperirritable points in skeletal muscle that are associated with a hypersensitive palpable nodule in a taut band,” are targeted with a needle in an attempt to “break up” or deactivate the point. Typically, this is done under ultrasound guidance, and local anesthetic may or may not be injected afterwards to blunt the pain of the needling itself. Inexpensive, easy to learn, and associated with low risks, its lack of widespread application may be in part due to the poorly understood pathogenesis of myofascial trigger points and their associated pain syndromes.

Further studies are required to standardize procedures and elevate the level of methodological quality of randomized controlled trials to study whether dry needling of trigger points may be a useful tool in combating the opioid epidemic. As anesthesia providers, we are tasked with providing patients with analgesia, often with opiates as the default. While it may not be appropriate or desirable to completely eliminate narcotics from our practice, exploring alternative pain management for appropriate patients should be on our radar.

 

References

Espejo-Antúnez L, Tejeda JF, Albornoz-Cabello M, Rodríguez-Mansilla J, de la Cruz-Torres B, Ribeiro F, Silva AG. Dry needling in the management of myofascial trigger points: A systematic review of randomized controlled trials. Complement Ther Med. 2017 Aug;33:46-57. doi: 10.1016/j.ctim.2017.06.003. Epub 2017 Jun 15.

https://www.npr.org/sections/health-shots/2018/02/20/577139699/er-reduces-opioid-use-by-more-than-half-with-dry-needles-laughing-gas?utm_campaign=WW-2018-ENEWSLETTER-ENGLISH-APR&utm_medium=email&utm_source=Eloqua&elqTrackId=05c1c61320044363adefbca1650cb654&elq=53058ec0b6534c9bb517c690bcfcc4a0&elqaid=5373&elqat=1&elqCampaignId=9895