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Dry Needling for TMJ pain

Adam Kimberly PT,DPT,OCS

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Goals

• Review history of dry needling• Discuss trigger point theory• Learn about myofascial referrals for jaw pain• Utilize current knowledge of dry needling to expand treatment

options for jaw pain case study

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• This lecture is just and part of a 2.5 day hybrid course focused on dry needling for TMJ and upper cervical spine• Focus on headaches, trigger point treatment and theory• No prior needling experience required• Ask questions

OPTIMAL DRY NEEDLING SOLUTIONSWITH

IAOM-US 866-426-6101

www.iaom-us.com

DRY NEEDLING FOR TMJ AND CERVICAL SPINE

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Origins of Dry Needling• Dry needling originates from trigger

point injection research• M Kelly in 1941: Injections of local

anesthetics were not superior to saline for treating myofascial pain

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Travell and Simons

• Physician and medical researcher

• Helped to map trigger points and their referral patterns

• Can cause sensory, motor and autonomic disorders

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Karl Lewit 1979: The Needle Effect

“In comparing techniques for therapeutic local anesthesia for pain spots, it appears that the common denominator was puncture by the

needle and not the anesthetic employed.” Dry needling resulted in analgesia without hyperesthesia in 86.8% of

cases

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Trigger Points• Hyperirritable nodule within a taut band of

skeletal muscle• Active

• Painful at rest and with activity (spontaneous)

• Latent• Only painful when palpated

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Trigger Points• Can form from overwork, overuse, overstrain,

dehydration, mineral deficiencies • As a result of trauma, OA, whiplash, systemic disease,

metabolic disorders (Bajaj. et al 2001)• Associated with increased ACh, ACh Receptor sites,

decreased ACh-esterase, increased substance P and CGRP

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Trigger Points•Taut Band•Tender Nodule within the taut band•Reproduction of patient’s pain upon palpation•Painful limit to full stretch range of motion•Muscle weakness as a result of muscle inhibition

or lack or power (inner and outer ranges)

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What are we working with?

•Single use/Disposable

• Sterilized

• Filiform

•Blister packed with guide tube

• Stainless steel shaft

•Plastic, copper or steel handle

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Deep Dry Needling vs

Superficial Dry needling

• Pain relief by A Delta fiber firing• Use for fascial remodeling• Use when DDN not desirable or

possible• Use when anatomy dictates

• Pain relief by resolving MTrP’sthrough LTR’s, secondary healing.• Improve mms function by

restoring length and strength

Superficial Deep

SDN in conjunction with DDN to increase pain relief; avoid excessive tissue damage, remodeling

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Superficial Dry Needling• Pre and Postsynaptic inhibition at spinal cord level

• Corresponds to dermatome where needle placed

• Pin prick confirms A delta activation– OMAS

• OMAS – opioid mediated analgesic system

• Successful with nociogenic pain

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Cytoskeletal Remodeling

• Helen Langevin• Mechanically induced .• Fibroblast spreading and

lamellipodia formation in 30 mins• Response spread over cms• 2 rotations max effect

Fox JR, Gray W, Koptiuch C, Badger GJ, Langevin HM. Anisotropic tissue motion induced by acupuncture needling along intermuscular connective tissue planes. J Altern Complement Med. 2014 Apr;20(4):290-4. doi: 10.1089/acm.2013.0397. Epub 2014 Mar 4. PMID: 24593827; PMCID: PMC3995146.

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Superficial Dry Needling Technique• Use .30 x 13 to .30 x 30mm needles. Larger gauge needles work better for more

A delta stimulus, and for better wind of tissue• Insert 5-10mm (1/2 inch) into skin (McDonald et al 1983, Ann RCS England, &

Baldry 1993) or until you reach a fascial layer• Use as many needles as you need, but bear in mind the reactor type.• May repeat 7/7 (3/7 if acute)For pain relief• Twirl (unilat/bilat) until abolition of pin-prick sensation (usually 30-60 seconds).For fascial remodeling:• Wind in the same direction until is sticky and lifts when you lift the needle, and

leave for 15 -30 minutesFor increase in circulation:• i.e. persistent swelling, stagnant contusions – twirl and leave 15-30 minutes

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Periosteal Pecking

Technique:• Repeated tapping of periosteum with needle: 0.25x13 or 0.25 x25mm• Speed: 2-4 Hz• Duration: up to 10 secondsIndications:• Any Sclerotomal pain: Old # pain, OA, Attachments (ligament or

tendon)

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Deep Dry Needling

•Local Twitch Response •Palpated or visualized after strumming or needle

insertion•Needle until you exhaust the twitch or until patient

asks to stop•Associated with immediate drop in CGRP, Cytokines,

interleukins, Substance P, ACh, and increased ACh-esterase (Shah et al. 2005)

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Deep Dry Needling

Gold Standard – LTR • Evidence: Decreased Spontaneous Electrical Activity and

Acetylcholine at Myofascial Trigger Spots after Dry Needling Treatment: A Pilot Study

Enid Based Complement Alternat Med. 2017;2017:3938191. doi: 10.1155/2017/3938191. Epub 2017 May 16.Liu QG1, Liu L1, Huang QM1, Nguyen TT1, Ma YT1, Zhao JM1.

• Effectiveness of Different Deep Dry Needling Dosages in the Treatment of Patients With Cervical Myofascial Pain: A Pilot RCT.

Am J Phys Med Rehabil. 2017 Oct;96(10):726-733.

Fernández-Carnero J1, Gilarranz-de-Frutos L, León-Hernández JV, Pecos-Martin D, Alguacil-Diego I, Gallego-Izquierdo T, Martín-Pintado-Zugasti A.

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Take a breakAsk some questionsSee you in 10

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Myofascial Sources of jaw/head Pain• Temporalis• Masseter• Medial Pterygoid• Lateral Pterygoid• SCM• Upper trapezius• Digastric

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Myofascial pain/trigger points• Temporalis • Masseter

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• Massenteric nerve block vs Dry Needling vs trigger point injection for myofascial pain• All 3 groups improved with mouth opening• Dry needling and trigger point injections showed more improvement

in pain to palpation and function• Only needled masseter

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Masseter

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Myofascial pain/trigger points

• Medial pterygoid • Lateral pterygoid

Travell and Simons. Myofascial Pain and Dysfunction: The Trigger Point Manual

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• 2015 • Dry Needling group: DN to lateral pterygoid 1x/wk for 3 weeks• Control Group: Methocarbamol and paracetamol, 2 tablets every 6

hours for 3 weeks• Both saw pain reduction, but clinically significant with DN. DN also

had statistically significantly improved range into opening, deviation and protrusion

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Medial Pterygoid

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Lateral Pterygoid

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Sternocleidomastoid

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Upper Trapezius

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Talking about dry needling• Informed consent• Start with Education: benefits, what it is, what it isn’t, how it works• Then present risks/benefits clearly and with tact• Obtain written or verbal consent depending on your systems requirements• Needle will Pierce skin, rule out needle phobia and other red flags• Present alternatives to treatment• Possibility of transient symptoms of fatigue, euphoria, fainting or

aggression• Probability of treatment soreness• Need for patient compliance

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OK, we needled, now what?• Encourage mobility• Stretching, light massage, PNF,

active motion• Try to get the patient moving

every hour the day of procedure• Encourage hydration• Can return to training as soon as

desired, but may be sore. • Stay light for first day: yoga, light

cardio• Minimal use of NSAIDs

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What to expect the day after?

• The patient may be sore, let them know• Good chance to improve therapeutic alliance

• Return to normal home program as tolerated•Make yourself available•Utilize your gains in mobility to strengthen and improve

proprioception through larger range• Keep moving

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Questions/Review

• akimberlydpt@gmail.com

• Please join us in a full dry needling course

• Thank you for participating

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