The academic illustration of acupoints, Ahshi points and/or trigger points associated with the management of neuromusculoskeletal conditions is necessary to facilitate a working understanding across healthcare professions of the acupoint nomenclature that has been, and is being, used by medical physicians and physical therapists, in the main, in the methodology of randomized controlled trials that have investigated the effectiveness or neurophysiologic mechanisms of using solid monofilament needles (i.e. acupuncture needles!) in the treatment of a variety of Western (not East Asian or Oriental medicine diagnoses that involve tongue and pulse diagnosis and the theoretical movement of ‘qi’ or ‘energy’ along traditional Chinese meridians or channels) medical diagnoses including, but not limited to: knee osteoarthritis, plantar fasciitis, cervicogenic headaches, tension type headache, migraine, low back pain with or without radiculopathy, neck pain, internal shoulder impingement syndrome, temporomandibular disorder, lateral epicondylalgia, or carpal tunnel syndrome.
In addition, physical therapists, chiropractors, naturopathic physicians, nurse practitioners, oriental medicine practitioners, and medical doctors alike need to be able to critically appraise and interpret the Western or biomedical acupuncture and dry needling literature, that by enlarge has chosen to use the acupoint nomenclature system in order to communicate across professions where exactly the needles were placed in clinical trials—performed in the main by medical doctors and physical therapists—in order to investigate efficacy on pain and disability and the underlying neurophysiologic mechanisms in patients with Western medical or musculoskeletal diagnoses (e.g. knee osteoarthritis, not ‘bi’ syndrome as Oriental medicine practitioners would term it).
Notably, use of the nomenclature alone for point location and interpretation of existing randomized controlled trials that were conducted by medical doctors and physical therapists (our own profession!) has nothing to do with “regulating the flow and balance of energy to restore and maintain health”1—which is how traditional Chinese acupuncture or Oriental medicine is most commonly described in the United States.
DRY NEEDLING VERSUS TRADITIONAL CHINESE ACUPUNCTURE
There is a clear distinction between the Western scientific principles that underpin the use of dry needling by physical therapists for the diagnosis and treatment of neuromusculoskeletal conditions and the traditional Chinese, Oriental or East Asian medicine framework that governs the use of needles without injectate by ‘acupuncturists’ for the diagnosis and treatment of all 10 organ systems. According to the Federation of State Boards of Physical Therapy2 dry needling is a “skilled technique performed by a physical therapist using filiform needles to penetrate the skin and/or underlying tissues to affect change in body structures and functions for the evaluation and management of neuromusculoskeletal conditions, pain, movement impairments, and disability”.
Importantly, dry needling neither attempts to move energy or “qi” along meridians, nor does it rely on diagnoses from traditional Chinese acupuncture or Oriental medicine.3,4 Dry needling also relies on Western medical diagnoses such as chronic neck pain5,6-13, plantar fasciitis14,15,16, knee osteoarthritis17-30, and carpal tunnel syndrome,31-35 instead of traditional Chinese, Oriental or East Asian medicine36,37 diagnoses such as bi syndrome, qi , blood stagnation, and kidney yang deficiency.38, 39
ACUPOINTS & TRIGGER POINTS: VERY SIMILAR OR IDENTICAL LOCATIONS
The Chinese originally established a set of 349 acupoints between 259 and 282 AD, while trigger points were first described as “nodular tumors or thickenings” by Balfor40 in 1816 and “fibrosis” by Gowers41 in 1904. While Steindler is widely recognized as coining the term “trigger point” in 1940, Dr. Lewit, a medical physician and physiatrist from Czechoslovakia, published the first article on dry needling in 1979, noting that the needle insertion itself rather than the injectate appeared to be the cause of the analgesic response.42 Despite the unique developmental lineage of acupoints and trigger points, a number of journal articles have noted significant anatomical and clinical similarities between the phenomena.
In 1977, Melzack et al43 compared 48 known trigger points to acupoints for pain, giving a 100% anatomic correspondence and a 71% clinical correlation to pain patterns. While 48 trigger points is certainly less than the 255 myofascial trigger points documented by Travell and Simons,44 Dorsher et al45,46 provided a more comprehensive comparison of trigger points and acupoints, reporting 92% agreement for location and 79.5% agreement for pain referral patterns. Moreover, another recent study reported a 70% correlation between trigger points and classical acupoints.47
Following a 3-part analysis for the anatomical location, pain location and referred pain patterns of acupoints and trigger points, and using graphic software, Dorsher44,45 superimposed 255 of the most common myofascial trigger points from the Travell and Simons Trigger Point Manual43 with 361 classical acupoints. Dorsher concluded that 238 of the classical acupoints matched with the 255 myofascial trigger points, with 89, 107 and 32 acupoints falling within 1, 2 and 3 cm of myofascial trigger points, respectively.44,45 Dorsher then took the 238 corresponding anatomical points and cross-referenced their indications for pain with the Travell and Simons Trigger Point Manual43 and classical acupuncture texts. Dorsher found 221 of 238 points (93%) had myofascial trigger point pain indicators, 208 of 221 points (94%) had similar regional pain indicators, and 180 of 238 points (81%) had complete or near complete pain referral patterns.44,45
Notably, recent investigations by Western-based medical practitioners report a lack of robust evidence validating the clinical diagnostic criteria for trigger point identification and/or diagnosis. In a recent systematic review on the reliability of physical examination for the diagnosis of myofascial trigger points, Lucas et al48 concluded, “There is no accepted reference standard for the diagnosis of trigger points, and data on the reliability of physical examination for trigger points is conflicting.” Lew et al49 further reported that the inter-examiner agreement was only 21%, and Sciotti et al50 reported error rates of 3.3–6.6 cm among examiners attempting to identify the specific location of trigger points in the upper trapezius muscle.
In another recent literature review, Myburgh et al51 found poor inter-examiner reliability of manual palpation of trigger points in various muscle groups. Only ‘tenderness’ of the upper trapezius, not the actual location of the trigger point, was found to be moderately reliable. Therefore, high-quality evidence suggests that manual examination for the identification of the specific location of the ‘trigger point’ is not a valid51-53 or reliable48-51 process between-examiners—this is perhaps one reason why medical physicians and physical therapist researchers have chosen to use the acupoint nomenclature to more reliably identify the exact insertion location, angulation and depth of the needle placement, which is of course required when using standardized interventions or needling protocols in the confines of randomized controlled trials.
In a recent review paper on the similarities and differences between dry needling and acupuncture, Zhu et al54, a medical physician and licensed acupuncturist, recommended “collaboration and integration should be strengthened between dry needling practitioners who are not physicians and acupuncturists so that the patients can receive safe and high quality acupuncture treatment”. Consistent with the remarks of Zhu et al53, healthcare providers—i.e. physical therapists, chiropractors, nurse practitioners, naturopaths, osteopathic physicians and medical physicians—should possess a fundamental and working knowledge of the acupoint nomenclature so as to more reliably treat myofascial pain located throughout the body.
That is, without using the principles or theories of traditional Chinese acupuncture or Oriental medicine (i.e. movement of qi or energy along Chinese meridians to alter function of all 10 organ systems, use of tongue and pulse diagnosis, use of Oriental medicine diagnoses such as bi syndrome, kidney yang deficiency, blood stagnation etc.), physical therapists can achieve greater accuracy in needle placement (due to the poor inter-examiner reliability associated with localizing myofascial trigger points) by becoming familiar with the location of acupoints that correspond, in the main, to the very same ‘trigger point’ locations.41-47
‘ACUPUNCTURE’, ‘ACUPOINTS’ AND ‘DRY NEEDLING’: NOT EXCLUSIVELY OWNED BY ONE PROFESSION
Despite the difference in terminology, theoretical constructs, and philosophies, the actual procedure of inserting thin monofilament needles, as used in the practice of acupuncture, without the use of injectate is similar across professions.55 In fact, the most common term used to describe dry needling is ‘acupuncture’. Physiotherapists and/or medical physicians56-60,61 within both government administered national health services and mainstream university health systems,30, 56, 62-66 in the UK,18, 19, 23, 67, 68 Canada,56 USA and Germany30,62-66, 69 use the term ‘acupuncture’ to describe dry needling methodologies. The same is true of articles published in mainstream, highly respected journals, including the British Medical Journal,23, 29, 67, 68, 70 European Journal of Pain,6, 71 Archives of Physical Medicine & Rehabilitation,51, 72-75 Pain,27, 42, 76-78 Annals of Internal Medicine,20, 26, 79-81 Headache,82, 83 Rheumatology,8, 18, 24 Spine,56, 84-86 and Cochrane Database of Systematic Reviews85, 87. Even the Physical Therapy Journal88 sponsored by the APTA and the Journal of Orthopaedic and Sports Physical Therapy89 have used acupuncture and dry needling interchangeably in recent publications.
Likewise, a number of Western-based medical professions reference acupoints without claiming to alter energy flow or move “qi” along meridians. It is perhaps noteworthy that the dry needling protocol for knee osteoarthritis taught by the Dry Needling Institute and referenced by a Washington State East Asian Medicine provides a perfect example of the interdisciplinary use of acupoints. The protocol is a compilation of common sites of pain and discomfort in patients with knee osteoarthritis—i.e. muscles, musculotendinous junctions, teno-osseous insertions and connective tissue structures—that also have common acupoint names or labels that have been described in scholarly medical journal articles published predominantly by PhDs23, 26, 90-92 and MDs17, 18, 20, 21, 27-30, 62. Reference to acupoints can also be found throughout journal articles published by chiropractors93-96, osteopathic physicians97,98,99 and physical therapists.88,100
Importantly and of significance in this discussion, the use and labeling of acupoints have been a formal component of entry-level and post-graduate training of physical therapists for more than 40 years, as they help facilitate the identification of painful tissue101 and direct the placement of interferential current stimulation pads for electrotherapy in a variety of neuromusculoskeletal conditions.102 Consistent with this training, EMPI, one of the most well-known and respected medical device and supply companies in the United States, has provided physical therapists with products related to electrotherapy, and notably, they continue to publish booklets and operating manuals containing clinical guidelines on the placement of stimulation pads according to acupoints.103
According to the Revised Standards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA) by McPherson and colleagues104, 105, “acupuncture point descriptions based on anatomical locations and proportional ‘cun’ measurement systems have served as a blueprint for many Western translations.” In order to maximize methodological reproducibility, the authors further recommend, “specific point locations used in treatments where standardization should be described in terms of an accepted nomenclature (e.g. GB21) or in terms of anatomical location where there is no accepted name”.105 That is, studies that investigate acupuncture and/or dry needling interventions (i.e. insertion of needles without injectate for therapeutic purposes) should use acupoints or an “accepted nomenclature” so as to facilitate reproducibility by Western practitioners.
Given the limited number of studies presently available that has used the word or title ‘dry needling’, physical therapists should consider high-quality studies that have used needling without injectate to treat neuromusculoskeletal conditions, regardless of profession. Clearly, STRICTA standards require that healthcare researchers and clinicians alike are familiar with acupoint locations. The physical therapy profession must also be able to publish studies on dry needling treatments for neuromusculoskeletal conditions in accordance with STRICTA guidelines (i.e. with a methodology that is reproducible and in a language that consistent with that used by other professions). Given the exponential growth in the number of research articles that have been published on dry needling since 2000,53 familiarization of acupoints by the physical therapist has never been more important.
SCIENTIFIC EVIDENCE UNDERPINNING ACUPUNCTURE & DRY NEEDLING DEVELOPED BY PhDs, MDs & PTs
The biomedical scientific evidence supporting the peripheral and spinal mechanisms of acupuncture and/or dry needling mediated analgesia and tissue remodeling at acupoint locations was developed, in the main, by PhDs, medical physicians and physical therapists in Germany, England and the USA, not by Oriental medicine practitioners.1, 100
Through a series of high-quality and elegant studies, Langevin et al, an American medical physician, found that a greater pullout force is required to remove a needle from tissue when the needle is wound in one direction compared to when it is wound in both directions.106, 107 Moreover, there was a greater pullout force following uni- and bidirectional winding compared to needle insertion without manipulation.106, 107 By using Trichrome staining, Langevin further demonstrated that pullout force is due to the mechanical coupling of collagen fibers to the needle.106 The mechanical coupling directly pulls on collagen fibers, resulting in better alignment of collagen bundles, and stimulates cells via mechanotranduction.108
According to Wu et al,109 the mechanotransduction of connective tissue stimulates TRPv1 receptors on both neural and non-neural cells, resulting in intracellular calcium wave propagation (CWP). The intercellular CWP leads to alteration of C-fiber afferents and, subsequently, the release of glutamate from first order sensory afferents. According to Zhou et al the altered C-fiber excitation stimulates glycinergic interneurons in laminae-2 of the spinal cord to release glycine.110 When glycine receptors on postsynaptic dorsal horn neurons receive glycine, they attenuate pain transmission.110 The noxious stimulus-induced analgesia (NSIA) from dry needling also likely stimulates the nucleus accumbens, resulting in opioid release. The subsequent stimulation of μ and κ opioid receptors on interneurons in the dorsal horn results in the release of GABA and glycine, further inhibiting the transmission of pain information from sensory afferents to second order dorsal horn neurons.109, 111
Goldman et al112 also found that CWP causes the release of ATP via pannexin-1 hemi-channels, which catabolizes to adenosine. After needling ST36 for 30-minutes with needle rotation every 5 minutes to establish mechanotransduction, Takano et al reported a significant increase in interstitial adenosine113, which activates A1 adenosine receptors located on nerve endings114, afferent nerves115 and pre-synaptic DRG terminals116, resulting in anti-nociception. As G-protein coupled receptors, A1 receptor activation is thought to work by inhibiting adenylyl cyclase, attenuating Camp and phospholipase C.113 Since an increase in Camp is associated with chronic pain, the inhibition of adenylyl cyclase is noteworthy.113
Mechanotransduction mediated CWP further leads to rho-kinase-dependent, transient disassembly of polymerized actin and the subsequent decrease in fibroblast stress fibers117. Simply put, a reduction of fibroblast stress fibers changes the viscoelastic properties of the cells, allowing them to be more easily remodeled. Dry needling mediated mechanotransduction may therefore be able to help remodel painful tissue by dampening tissue tension via actin polymerization.117 A number of studies—by PhDs, MDs and/or PTs—have demonstrated the use of dry needling to reduce pain associated with scar42, 118 and fibrotic tissue119 further supporting this possibility.
Thus, the stimulation of TRPv1 receptors via tissue mechanotransduction may help explain the physiologic mechanism responsible for dry needling-mediated peripheral and spinal analgesia and tissue remodeling. Interestingly, Langevin et al120 used diagnostic imaging to determine that there was a higher concentration of connective tissue (i.e. collagen fibers) at acupoint versus non-acupoint locations. Given that mechanotransduction requires the physical attachment of connective tissue to the needle, it may be more therapeutic (i.e. lead to better clinical outcomes for reduced pain and disability) for clinicians to consider inserting needles at both acupoint and nonacupoint locations. Therefore, the neurophysiology underpinning Western-based pain science strongly suggests that it may be advantageous for physical therapists to become familiar with acupoint terminology and location.
ATTORNEY GENERAL OPINIONS
Dry needling and acupuncture dramatically differ in their origins, theoretical and scientific underpinnings; however, “dry needling and acupuncture overlap in terms of needling technique with solid filiform needles.”121 Notably, in response to an Attorney General Opinion request made by the Texas State Board of Acupuncture Examiners in 2016, the Attorney General of Texas opined, “it should not be assumed that the scope of practice of physical therapy and the scope of practice of acupuncture are mutually exclusive; that is, overlap between the scopes of practice of acupuncture and physical therapy may exist (recognizing that the scopes of practice of medicine and physical therapy overlap with regard to a procedure called needle electromyography).” [Texas Att’y Gen. Op. KP-0082 (2016)]
Moreover, at the request of the Chiropractic Examining Board, the Attorney General of Wisconsin concluded that “chiropractors do not have a monopoly on the application of therapeutic touch to the neck, back and joints”; furthermore, “even if nearly identical physical motions were performed by a chiropractor”, the “terms such as adjustment and manipulation have a variety of appropriate meanings to various healing disciplines”—that is, it is “the principles of physical therapy science” versus “chiropractic science” that separates the two disciplines, not the actual performance of the manipulation technique itself. [Wisconsin Att’y Gen. Op. OAG 1-01 (2001)].
In the words of Zhou and colleagues (2015), “Because of the close relationship between dry needling and acupuncture, collaboration rather than dispute between acupuncturists and other healthcare professionals should be encouraged with respect to education, research, and practice for the benefit of patients with musculoskeletal conditions who require needling therapy.”121
Just as familiarity by physical therapists with orthopaedic surgical procedures does not constitute the practice of medicine or surgery, familiarity with acupoint nomenclature and locations most certainly does not constitute the practice of traditional Chinese acupuncture or Oriental Medicine. Furthermore, a working knowledge of acupoint locations by physical therapists, chiropractors, osteopaths and medical physicians alike, has and will continue to facilitate interpretation of the existing ‘dry needling’ and ‘acupuncture’ literature, inter-professional communication, and most importantly, meaningful collaboration between professions on research design that maximizes methodological reproducibility for treatment standardization concerning the use of needles without injectate for the management of a variety of neuromusculoskeletal conditions.1, 100, 104, 105
Dr. James Dunning, DPT, MSc, OCS, FAAOMPT, Dip. Osteopractic, MMACP (UK), MAACP (UK)
Director, AAMT Fellowship in Orthopaedic Manual Physical Therapy
Member, Acupuncture Association of Chartered Physiotherapists (UK)
Member, Manipulation Association of Chartered Physiotherapists (UK)
Dr. Raymond Butts, DPT, PhD, MSc (NeuroSci), Dip. Osteopractic, MAACP (UK)
Senior Faculty, AAMT Fellowship in Orthopaedic Manual Physical Therapy
Member, Acupuncture Association of Chartered Physiotherapists (UK)
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