Monday, December 7, 2015

Muscles of Mastication

Muscles of Mastication (Chewing) and Their Relationship to TMJ Disorder, Headaches, and Sinus Pain

There are three muscles of mastication (chewing) which can be involved with a host of symptoms. Most notably, these muscles are often involved with TMJ disorder (also referred to as temporomandibular joint disorder, or TMD), but also can be a strong contributing factor to headaches, tooth pain and sensitivity, and sinus pain. In the case of tooth pain and sinus pain, painful trigger points in these muscles can often go undiagnosed and can lead to unnecessary dental or sinus surgery, as the muscles are rarely considered with pain in the teeth or sinuses. In the majority of the cases of dysfunction, patients present with a head forward posture (discussed in a previous blog post) and this should be addressed for long term relief of pain associated with these muscles.

Acupuncture/Traditional Chinese Medicine is one of the best treatments for a host of problems that derive from dysfunction in one or several of these muscles. It can directly target the site of pain and dysfunction while also examining why these muscles are dysfunctional. Beyond that, it can add a different perspective for problems that cause a host of problems for patients.

Fig. 1: The Masseter muscle and commonly used acupuncture points
used to treat pain and dysfunction with this muscle.
The masseter muscle is one of these muscles of the jaw.  The masseter consists of a superficial and deep layer. Both can be palpated (pressed) directly and both are easily accessible with an acupuncture needle (Fig. 1). Trigger points frequently form in this muscle, and they can refer to the teeth (causing pain that is mistaken for problems with the teeth), the eye (contributing to headaches), the ear (contributing to tinnitus or ear ringing).

Fig 2: Masseter Trigger Points with their pain referral patterns. Image from Travell and Simons'
Myofascial Pain and Dysfunction: The Trigger Point Manual. The red indicates where pain is felt
when hypersensitive nodules or trigger points develop in this muscle.
Fig. 3: Lateral and Medial Pterygoids. Image from
Netter's Atlas of Anatomy
The pterygoids are also jaw muscles and consist of the medial and the lateral pterygoids. These muscles cannot directly be pressed except from inside the mouth. Occasionally I release these muscles by putting on surgical gloves and accessing them in just this way. They can also be reached with an acupuncture needle which, due to its thinness, can reach places that a hand cannot. In this case, the needle does not need to access these muscles through the mouth to reach them but can be inserted on the outside and advanced through spaces between two bones to reach painful trigger points (Fig. 3).

The medial pterygoid refers pain deep to the ear and to the throat. This can interfere with swallowing and contribute to soreness in the throat. This muscle also has an interesting relationship to a muscle called the tensor veli palatini, which, when you yawn or open your mouth, pulls the eustachian tube open and allows drainage and pressure normalization of the middle ear. Tightness of the medial pterygoid can block this function and can be a major contributor to ear stuffiness (barohypoacusis) and can contribute to otitis media.
Fig. 4: Lateral pterygoid TrP referral pattern.
Image from Travell and Simons' Myofascial
Pain and Dysfunction: The Trigger Point Manual

The lateral pterygoids refer pain deep into the maxillary sinus and to the TMJ. Pain in this muscle is frequently a contributing factor to sinus pain and/or TMJ dysfunction.

The final muscle involved with chewing is the temporalis muscle which, as the name implies, is in the temple region. Like the masseter, this muscle can be directly pressed and easily accessed with an acupuncture needle. This muscle frequently contributes to headaches.

Fig 5: Temporalis TrP referral pattern. Image from Travell and Simons' Myofascial
Pain and Dysfunction: The Trigger Point Manual 

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Friday, December 4, 2015

Two Blogs

Splitting My Blog Into Two Blogs to Allow for Specialized Focus

Starting in the Fall of 2015 I committed myself to regular blog posting. I had two primary things in mind for this. First, I wanted to provide educational information for my patients and the public. Second, I wanted to provide educational material for practitioners of Traditional Chinese Medicine, especially those interested in working more with sports injuries and orthopedic conditions.

For the first goal, I wanted to provide information that would help educate the public, primarily related to my area of expertise which is sports injuries and orthopedic conditions. And, I wanted to give some insight into how acupuncture, manual therapy, herbal medicine and other things practiced as part of Traditional Chinese Medicine can help prevent, improve and manage these conditions.

For the second goal, that of writing for professionals, my plan was to take material from lectures I have given in Manhattan and San Diego with the Sports Medicine Acupuncture Certification program run by AcuSport. This material is on the sinew channels, secondary channels in the meridian system described in Chinese medicine, and is derived from work I have been doing first as a Structural Integration practitioner and then as an Acupuncture Physician. The blog posts are the first step in a process that will lead to a book. The steps for me include producing lecture notes, writing blog posts, refining much of this information for published articles, and then further refining this for a published book.

Since these two goals are somewhat hard to synchronize in a blog, I have made the decision to have two separate blogs. One will be for patients and the public, which will remain here. The second will be oriented toward professionals and will explore the sinew channels in much more anatomical detail. This will be found at These two blogs will be linked by tabs at the top of each blog so that those interested in both can move back and forth between them.

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Wednesday, December 2, 2015

Head Forward Posture

The Head Forward Posture and Health Ramifications

One of the most common postural disparities I see is a head-forward posture. In The Physiology of Joints, Volume III, French surgeon and anatomist Adalbert I. Kapandji states that for every inch the head goes forward it gains an additional ten pounds of weight in terms of strain on the posterior neck and upper back muscles. The average weight of the head is about 4.5-5 kg (10-11 pounds) and, in a balanced posture, it is supported evenly amid the muscles of the neck. With a head-forward posture, this balanced support is disrupted, and the posterior neck and upper back muscles then become increasingly more overloaded (and painful) with every additional degree of head-forward posture. With the head an inch forward (neutral is considered as consisting of the ear aligning over the acromion process which is the highest point of the shoulder) this means that the posterior neck and upper back muscles have to support about 20 pounds of weight all day. At 2 inches forward, this becomes about 30 pounds. With Americans spending more and more time behind the wheel, in front of computer screens, glued to cell phones and tablets, and performing other activities which lend themselves to this already common posture, it is not surprising that we frequently see so many problems attributed to this posture.

The following are common complaints that involve a head-forward posture:

Generalized neck pain and shoulder pain caused from muscle overuse: As stated above, for every inch the head moves forward, it gains an additional 10 pounds of weight in terms of strain on the posterior neck and upper back muscles. What this means is that the muscles of the posterior cervical spine are working overtime, day in and day out, and for a prolonged time. It is just a matter of time before they start to cry out for some attention and that usually comes in the form of aches and pain. Specifically, the upper trapezius, levator scapula, and splenius cervicis are frequent muscular contributors to neck discomfort; they not only produce pain, but reduce range of motion and can contribute to stiffness, including stiffness which makes it difficult to turn the neck. Generally, restriction in the upper trapezius manifests in reduced range of motion and discomfort towards the end of the range of motion when looking in the opposite direction, while restriction in the levator scapula often causes pain when looking to the same direction. However, sometimes all three of these muscles can become spasmed, making it very difficult to turn the neck in any direction without considerable pain.

And it is not just the muscles which are involved with neck pain from a head-forward posture. The strain in the posterior neck from the additional load signals fibroblasts to produce more extracellular matrix to support this area. Fibroblasts are specialized cells that produce the building blocks of fibrous connective tissue, such as collagen fibers and a sticky, syrupy substance called proteoglycans (a protein-carbohydrate based molecular structure). Prolonged strain (such as years of bracing against the extra weight of having the head forward) stimulates production of this extra material which can be easily felt as dense, ropy, fibrous bands in the upper back and neck region. It is the body’s attempt to add more support to a region that has additional demands placed on it. Local massage, acupuncture, or other treatments applied directly to the painful tissue may temporarily help make this dense, stagnant tissue feel better, but the posture as a whole needs to be addressed if there is to be any hope of long-lasting relief.

Cervical facet joint referral patterns.
Image from: Osteoarthritis of the Spine:
The Facet Joints, Gellhorn, A.C. et al
Nature Reviews Rheumatology 9, April 2013
Facet joint syndrome: This involves a degeneration of the vertebral facet joints, which is usually secondary to degeneration of the intervertebral discs. Cervical disc degeneration is usually exaggerated whenever there is long term hypomobility (limited movement) of cervical spine. While the outer part of the intervertebral disc has a blood supply, the inner part does not and requires nutrition and fluids via diffusion from the outside. So, with any limited movement patterns that persist for a long time, the discs suffer. As one of my tai chi instructor states, “Motion is Lotion,” and this is definitely true for the spine. In addition to the discs, the synovial, freely moveable (at least they should be) joints of the spine can become degenerative and lead to pain, which can affect the neck but can also refer to the head and, even more commonly, between the shoulder blades. This is a commonly overlooked source of pain and patients with a head-forward posture are much more predisposed to it.

Facets joints are the synovial joints between adjacent vertebrae. They can become degenerative and painful with osteoarthritis of the spine. In a head forward posture, the upper cervical facets are often in a closed position while the lower facets are in an open unstable position. Both situations can aggravate the joints and lead to referred pain. This image is from Kapandji's Physiology of Joints.

Splenius capitis (close to GB-20) and splenius cervicis
(at extrapoint Bailao) TrP referral patterns.
Image from Travell and Simons' Myofascial Pain and
Dyfunction: A Trigger Point Manual.
Tension headaches: With cervical (neck) flexion and capital (head) extension, the posterior cervical muscles are in a shortened position, especially the muscles referred to as the suboccipitals. These four deep upper cervical muscles are very common causes of referred pain into the head, contributing to tension headaches. With the movement of the head forward, the eyes would be looking toward the ground if not for these muscles tightening to lift the head, placing the occiput into an extended position relative to the top of the cervical spine. Other muscles, such as the upper trapezius, splenius capitis, splenius cervicis, and sternocleidomastoid (SCM) are also negatively impacted and common contributors to tension headaches.

Nerve impingements and entrapments: Since disc health is affected by head-forward posture, it can play a role in spinal nerve impingement. In addition, thoracic outlet syndrome (another type of entrapment of neural structures) is often seen with a head-forward posture. Both of these can radiate pain into the upper extremities and be causes of pain in the arms, elbows, forearms or hands.

Thoracic outlet syndrome involves an entrapment of the brachial plexus, which is the bundle of nerves that exit from the neck and travel to the arms. The brachial plexus can be entrapped as it travels between the anterior and middle scalene muscles (two anterior neck muscles which are shortened in a forward-head posture), between the clavicle and ribcage, and between the pectoralis minor muscle and the ribcage. The head-forward posture is often a contributing factor to all of these, especially as the entire shoulder girdle is involved (more on this in the next post).

Jaw tension: a head-forward posture places the mandible (lower jaw bone) in a position which stresses and tightens the muscles of the jaw. The position of the head places anterior neck muscles such as the suprahyoids and infrahyoids in an overstretched position. These muscles attach to the mandible and pull down on the lower jaw bone. The muscles of mastication (chewing), such as the masseter, reflexively tighten to hold the jaw close. They then develop trigger points which put pressure on the temporomandibular joint (TMJ).

Shoulder and other problems: Part 2 of this post will discuss the relationship of the balance of the cervical spine to the shoulder girdle. Because these are so intimately tied to each other, shoulder dysfunction such as supraspinatus tendinopathy, bicipital tenosynovitis, infraspinatus and subscapularis myostrain, and other conditions are often made worse by the strain of a head-forward posture. As we explore the sinew channel relationship described in Chinese medicine, this neck-shoulder girdle relationship will become even more apparent.

Image from Startle as a Paradigm
for Malposture, by Pierce, F. et al
Perceptual and Motor Skills, 1964
A) Patient standing upright
B) Door closes loudly and startles patient. Notice the shortening along the front of the body
In addition to shoulder dysfunction, head-forward posture can contribute to other problems elsewhere in the body. This could become a very complex analysis, so I will not give a complete list. However, I will mention some interesting research that explored hamstring flexibility in relation to the suboccipital muscles (which extend the joint between the occiput and top of the cervical spine). This research measured hamstring flexibility and then split the subjects into two groups. Members of one group performed hamstring stretches; members of the other performed stretching to the suboccipital muscles. Surprisingly, the group that received stretching for the suboccipitals alone had a greater increase in hamstring flexibility (13%) than the group receiving hamstring stretches alone (9%). The reason likely has to do with the high concentration of muscle spindles present in the suboccipital muscles and, due to this, the fact that they have such a strong influence on tone throughout the musculature of the back, especially at the hip joint. Consider what happens when someone is startled, and the typical startle response observed. The firing of the suboccipitals might be reflexively tied to the firing of the hamstrings which assists in extending the hip joint. This, along with the shortening in the front of the body, would effectively protect the vulnerable organs.

For acupuncturists, it is worth reexamining the Urinary Bladder sinew channel and noting that it does bind to the occiput, and, therefore would include the suboccipital muscles. Looking for a head-forward posture and addressing shortened suboccipitals would be a worthwhile strategy, not only when treating local dysfunction, but with any strain pattern affecting the Urinary Bladder sinew channel. Addressing this pattern would help focus the selection of effective points to treat according to the principle of “selecting points above to treat below.”

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The Four Pillars of Chinese Medicine

Acupuncture is Just One Pillar of Traditional Chinese Medicine

Traditional Chinese Medicine (TCM) is a comprehensive medical system from China. While many people are aware of acupuncture, TCM actually incorporates four major avenues or treatment. These are known as “the four pillars” of TCM, and they are: acupuncture; Chinese herbal medicine and dietary therapy; Tuina, which incorporates medical massage and manipulation; and exercise and movement therapy. Your trained Doctor of Oriental Medicine will evaluate your case and prescribe one or several of these treatments depending on what is needed.

Acupuncture involves the use of very thin, single-use, sterilized needles inserted in various locations to regulate body processes. In the West, acupuncture is most often used for pain relief, for which it is very effective. But this is not the full scope of comprehensive acupuncture treatment; it is actually appropriate in a wide range of illnesses.

Chinese herbal medicine is based on a vast array of medicinal formulas, which are therapeutically balanced combinations of herbs used to treat patterns of medical disharmony. TCM looks for clinical signs and symptoms of these patterns and then prescribe specific herbal medicinal formulas to treat these patterns. TCM pattern differentiation and treatment with herbal Medicinals can offer a safe and effective natural treatment for illness or can complement your treatment prescribed by your Western MD, in some cases possibly enabling your Western pharmaceutical prescription to be reduced or helping deal with side effects.

In addition to the prescription of herbal Medicinals, dietary recommendations can also be used as part of the treatment. This can include general assistance with weight loss or maintenance, or specific food choices and preparations designed to help you manage an existing condition.

Tuina is a Chinese system of clinical massage and joint mobilization. Tuina is derived from two words; tui meaning to “to push” and na meaning “to lift and squeeze”. Tuina uses light, moderate, or deep pressure to mobilize the body’s structures and joints and restore normal movement. It is primarily used for musculoskeletal conditions, but it can also be employed for other condition such as respiratory or digestive problems. Generally, Tiuna focuses on particular regions such as the neck, back, legs, etc., and resembles more clinical styles of Western deep tissue massage therapy. Click here to see a previous post about Tiuna.

Finally, Therapeutic Exercises are often prescribed in China to help treat illness and to maintain and improve health. In particular, tai chi (Taiji) and qigong are therapeutic forms of exercise that improve flexibility, circulation and general wellbeing.

When looking for a practitioner of Traditional Chinese Medicine, it is important to understand that many practitioners focus mostly on one or maybe two of these ‘pillars’ listed above, usually based on a practitioner’s specialization. Practitioners focusing on internal medicine might use herbs more extensively while those treating musculoskeletal pain might be inclined to use Tiuna more. In my clinical practice, I specialize in the treatment of sports injuries and orthopedic pain conditions. So, I primarily focus on acupuncture, Tiuna, and corrective exercises to facilitate rehabilitation from injury, and to correct muscle imbalances that contribute to pain conditions. When I prescribe herbal medicine, it is usually a formula (balanced combinations of herbs) to help with the particular pain or injury. Such herbal formulas may help with trauma; they may address how the body deals with inflammation, or they may regulate the nervous system to reduce over-contraction and tightness in the muscles. The herbs basically support the treatment, while the acupuncture, Tiuna and therapeutic exercise prescription specifically target the region of pain and return normal movement to the body.

Another practitioner who specializes in internal medicine might rely much more on herbs, and their acupuncture treatment might be more supplemental. It is important for patients to know what to look for when seeking a practitioner, as not all have equal training and not all have experience that will make them effective in treating all medical problems.

Most TCM practitioners do use these four pillars, but there is no need to be dogmatic about using only techniques that originated in historical China. If a modern or Western-developed treatment protocol is appropriate and compatible with TCM principles, it can be integrated into a Four Pillars-based treatment plan. For instance, to reduce inflammation, I might prescribe a classical herbal formula, but I might also prescribe fish oil supplementation. Also, I frequently use manual massage techniques and mobilization of joints, but much of my training comes from Western bodywork systems such as myofascial release and structural integration (I am certified in both of these via the CORE Institute). On an even deeper level, my acupuncture treatments rely heavily on Western anatomy and Sports Medicine principles. These techniques are taught in AcuSport Seminar Series and the Sports Medicine Acupuncture Certification Program, on whose faculty I serve. My point is that as Chinese medicine becomes more global, it can include insight from many other viewpoints, especially Western medicine, but the heart of the medicine will continue to focus on these four basic pillars of treatment which are designed to return the body to a balanced state of health.

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Myofascial Release

What is Myofacial Release?

Myofascial release is a deep-tissue work whose focus is to relieve pain, resolve structural dysfunction, and improve function, mobility, and posture. “Myofascia” refers to the combined anatomical system of muscles (“myo”) and fascia. Fascia is a continuous web of connective tissue found throughout the entire body, It surrounds every muscle, nerve, blood vessel, and organ, and holds all these structures together, giving them their shape, offering support and interconnecting the body as a whole.

Myofascial release has its roots in Connective Tissue Massage (Bindegewebsmassage) which was developed by Elizabeth Dicke who lived in Germany in the 1920s and 1930s. This work consisted of light strokes whose theoretical purpose was to improve circulation in subcutaneous connective tissue, resulting in reflex action to other parts of the body, including visceral organs.
Hands doing myofascial release massage to a back.
Myofascial Release to the Lower Ribcage

The term “myofascial release” was coined by Robert Ward, DO, (Doctor of Osteopathy) in the 1960s. John Barnes, PT, (Physical Therapist) adopted the term as designation for his method of freeing fascial restriction, and this is a popular form of myofascial therapy practiced today.

Another important figure in the development of myofascial therapies, and someone whose work more directly influences my own, was Ida Rolf, PhD who taught in the 1960s and 1970s. Dr. Rolf developed a ten-session series of work that she called Structural Integration and that later was trademarked as RolfingTM. Dr. Rolf was very influenced by osteopathic manipulation; through her ten-session series, she sought to re-establish vertical alignment in the body by manipulating fascial layers. I studied this work in 2002-2003 at the CORETM Institute with George Kousaleos and, upon certification, I continued my education, studying with Certified Advanced Rolfer Liz Gaggini and also studying with KMI/Anatomy Trains faculty (Tom Myers, James Earls, and Simone Lindner).

Simone Lindner, while still maintaining a busy teaching schedule with KMI, is currently serving on our faculty in the Sports Medicine Acupuncture Certification Program, where she teaches Anatomy Trains principles in the Fascial Release for Myofascial Meridians (FRMM) course. This has been an extremely rewarding experience, as I teach in the Anatomy, Palpation and Cadaver Lab in a two-day course prior to the FRMM course, where I lecture on the sinew channels discussed in the Chinese meridian system. These have much crossover with the anatomy discussed in the anatomy trains system.

After my class, Simone then teaches fascial release techniques to work with these lines to restore structural balance. I assist with this class and occasionally help relate this information into TCM language more familiar to acupuncturists. This has been a tremendous amount of fun and a very educational experience for me personally, as well as for class participants. Matt Callison (the director of SMAC) and I then follow up and review some of these techniques in the Assessment and Treatment class, which usually takes place about a month later. In this class we teach assessment of injuries and conditions and using the assessment results to build treatment protocols, primarily geared around acupuncture, but also prominently featuring myofascial release techniques.

Much of this work, in addition to work from other Structural Integration practitioners (my original teacher, George Kousaleos, and a current influence of mine, Advance Rolfer Til Luchau) has made its way into a course I am teaching at East West College of Natural Medicine. I teach many classes there, including Anatomy and Physiology, Orthopedic Evaluation, and Acupoint Anatomy, but more and more I have been teaching myofascial release techniques as part of the Tuina curriculum. The goal is to make this work accessible to acupuncture physicians in training so that they can improve the therapeutic outcome of their treatments and more deeply understand the sinew channels and how they relate to global strain patterns. To see more on this, visit my past blog post Teaching and Tuina.

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Sports Medicine Acupuncture®

Teaching Sports Medicine Acupuncture®

Since 2013, I have been on the faculty of the Sports Medicine Acupuncture Certification Program, teaching first on location in Manhattan, NYC and currently in San Diego, CA. It is a great honor and experience to teach with this program, as it is the most in-depth and extensive program of its kind in the country. I have the opportunity to work closely with probably the most knowledgeable person in the field of acupuncture and sports medicine, Matt Callison.

Acupuncture Needles Sports Medicine Acupuncture® integrates Traditional Chinese Medicine principles with Western sports medicine. Practitioners are extensively trained in the following:
  • Evaluation of injuries and orthopedic disorders to find the cause of pain and dysfunction. Based on these findings, treatment plans are then devised, which include acupuncture, myofascial release (a type of clinical deep tissue massage), and corrective exercises.
  • Postural assessment to understand the global imbalances that can lead to, and/or prevent proper healing of, orthopedic disorders and sports injuries.
  • Anatomy in great detail, including cadaver dissections. This allows for a comprehensive three-dimensional understanding of anatomy relevant to needle techniques, manual therapy techniques, and assessment of injuries.
  • Relating the acupuncture channels discussed in Traditional Chinese Medicine to anatomical structures, especially continuous myofascial planes (myo-muscle, fascia-connective tissue).

Sports Medicine Acupuncture Certification is taught in four modules: 1) the spine; 2) head, neck and upper extremities; 3) low back and hip; and 4) lower extremities. Each module focuses on sports injuries, repetitive use injuries and orthopedic disorders in these regions. This program is designed to provide the most advanced training available in the assessment and treatment of these injuries.

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Dry Needling and Acupuncture

Is Acupunture Dry Needling?

I often get asked if I do dry needling. Many acupuncturists become defensive when asked this, and there is currently some contention in the fields of acupuncture and physical therapy, as PTs either have it in their scope of practice to do dry needling (in some states) or are trying to get it added to their scope (in other states, such as Florida). Many acupuncturists feel that dry needling is just another name for acupuncture and that PTs are trying to add acupuncture to their scope.

So, what is dry needling and why is there any controversy? First off, I want to state that this blog post is not intended to state any profession opinion or get into the politics. Instead, I am going to discuss the technique, goals, and give a brief history of dry needling.

Dry needling as a technique and name grew out of work primarily from Dr. Janet Travell, MD. Dr. Travell, along with her colleague, Dr. David Simons, MD wrote a very influential two-volume book in the field of pain management called Myofascial Pain and Dysfunction: The Trigger Point Manual. In this book, they discussed trigger points (TrPs) which are defined as hypersensitive spots found in taut bands of muscle (click to read more about TrPs). When palpating muscles that are dysfunctional, there are notable taut bands. Following these taut bands, physicians might find a hypersensitive nodule, often in the belly of the muscle along these taut bands. Pressing these yields hypersensitivity and often a characteristic referral pattern is noted, many times quite a distance from the location of the TrP. These two volume books gave a detailed description of the palpation, signs and symptoms, and pain referral zones of these TrPs for each muscle in the body.

In addition to clinical information regarding locating and diagnosing these TrPs, these books also discussed treatment. Many protocols were discussed, but TrP injections were primary treatments outlined in these books. It became increasingly understood that the mechanism that was at play with TrP injections was the mechanical stimulation from the needle. Most often what was injected were substances such as lidocaine which served the purpose of reducing sensation as a relatively thick hypodermic needle probed into a hypersensitive TrP. Dr. Travell did discuss dry needling, differentiating between using a hypodermic needle to inject a substance versus using a hypodermic needle without injecting a substance (which was, therefore, 'dry needling'). Over time, especially as acupuncture was becoming more popular in America, other practitioners determined that the use of a thinner solid filiform acupuncture needle could serve the same purpose.

Actually, in the history of acupuncture in China these same techniques were discussed, and the Chinese referred to these hypersensitive nodules as Ashi points. Ashi means something along the lines of ‘That’s it’. Imagine a physician palpating for the source of a patient’s pain and the patient proclaims ‘Ashi’. The needle technique involves with needling Ashi points is extremely similar to those described in TrP injection and dry needling circles. Notably this involves locating the hypersensitive nodule, inserting a needle, bringing the needle back to the subcutaneous layer and redirecting the needle. Imagine a needle pointing to numbers on a clock and, from the same point, the needle touches 12, 1, 2, 3, etc. This describes the lifting and thrusting technique discussed in the classics of Chinese medicine. When doing these techniques, there is a characteristic muscle twitch or fasciculation that is achieved as the TrP is being deactivated.

This technique can be extremely effective in reducing pain associated with TrPs which is a very common source of pain. Increasingly, TrPs are being understood to be a major contributor to pain. Needling TrPs with an acupuncture needle is one of the most effective tools to treat these. I feel that acupuncturists are best suited to treat TrPs, as we have the greatest amount of training with needle technique, and we have the greatest ability to incorporate this technique into a balanced acupuncture session. However, while all acupuncturists have had some training on needling sensitive points, those who have undergone more continuous training with emphasis on a detailed understanding of anatomy and palpation are going to yield the greatest results. While not all acupuncturists have this understanding, there is growing movement within acupuncture circles to incorporate a more detailed understanding of Western anatomy and utilizing a more integrative approach to treating patients.

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