Your physiotherapeutic assessment reveals that your patient has a number of trigger points that are tender on palpation.
One of your go-to tools is dry needling but you hesitate because a) your patient can only tolerate so much needling per session and b) sometimes you have used dry needling in the past, but have not had the desired effects. I’ve learned the hard way that if you use dry needling on a hypertonic muscle that is not a primary source of dysfunction, but rather secondary to another dysfunction, you may irritate the patient if you’ve taken away their compensatory pattern. (For example, releasing a hypertonic right iliocostalis muscle at T9 may be helpful if this is a contributing factor to an intra-thoracic ring shift to the left at that level, but it may back-fire on you if the right iliocostalis is compensating for a ring shift to the right at another level.) A good ISM (Integrated Systems Model) evaluation can help you sort this out. (learnwithdianelee.com or ljlee.ca)
Another factor that may be contributing to trigger points is that of the fascial system. So how can we differentiate symptoms arising from increased neural drive vs fascial tension? Are they related to one another and if so, how?
One way to differentiate between these two disorders is via palpation. Palpation of a hypertonic muscle or trigger point frequently feels like “pepperoni stick in the middle of a salami.” On the other hand, palpation of a tight fascial line often feels like a “guitar string” that has too much tension (Diane Lee, personal communication).
Muscle release techniques that work exclusively on the reflexes (e.g., dry needling, Gunn intramuscular stimulation (IMS), positional counterstrain, shockwave therapy) are very effective for treating trigger points. If, however, these trigger points tend to recur despite attempts to normalize muscle balance, control, and strategy, then we must consider another influencing factor – fascia. Gautchi, in the seminal book called “Fascia: The Tensional Network of the Human Body” by Churchill Livingstone / Elsevier, states that muscular pathology in the form of myofascial trigger points (mTrPs) always has a fascial component and can be the cause of fascia dysfunction. Conversely, dysfunctional fascia can provoke or maintain dysfunctions of the muscles (mTrPs) (see Figure below).
Because of this interaction, an optimal treatment approach must include consideration of both trigger points and fascia. Muscle release techniques that work exclusively on the reflexes may indirectly decrease fascial pull. However, these techniques insufficiently affect the fascial aspect. Targeting the connective tissues using manual techniques is necessary in order to address the changed fascial structures. These manual techniques may be Rolfing-type techniques used by Structural Integrators. Physiotherapists may also incorporate techniques of Fascial Manipulation, as taught by the Steccos. I am, however, partial to my approach to treatment, called MSM (Mobilisation of the Myofascial System).
Clinically, I have found that if my evaluation reveals both fascial tension and trigger points, I tend to begin releasing the fascial tension first, using MSM techniques. I then follow up by dry needling whatever trigger points remain – they are generally fewer in number, so easier for the patient to tolerate.