Module Two Dry Needling PDF

In association with
Presents
Dry Needling
Module Two
2013
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© Optimal Dry Needling Solutions – United Kingdom, USA, Middle East and Europe - 2013 1
Dry Needling
Day Two
Having built up your needling confidence in Module One working in the

relatively safe areas of the buttock and calf – we bring you into the neck
and shoulder area, challenging your surface anatomy and palpation skills
as you work over the ribs and around the scapula, potential
pneumothorax sites when needling.
“A healthy upper quarter requires synchronous

distribution of normal mobility”
Tanya Bell-Jenje
We know that latent triggers, although not pain generating, will distort
M.A.P.S. (movement activation patterns) and our rotator cuff being a feed
forward local stabiliser can consequently have a profound effect on
shoulder function.
This second module will give you really useful techniques for the
treatment of headaches & shoulder pain and dysfunction.
Day Two - Index
Page
1. Trapezius 4
2. Levator Scapula 7
3. Posterior Cervical Needling 9
4. Splenius Capitis – Intermediate Layer 11
5. Splenius Cervicis – Intermediate Layer 12
6. Semispinalis Capitis & Cervicis 14
7. Cervical Multifidus 16
8. Longissimus Cervicis & Capitis 17
9. Infraspinatus 20
10. Supraspinatus 23
11. Teres Minor (‘Little Brother’) 26
12. Subscapularis 28
13. Latissimus Dorsi 31
14. Teres Major 34
15. Deltoid 36
16. References 39
17. Indemnity Form 41
18. Dry Needling Information 42
19. Consent for Dry Needling Treatment 43
20 Feedback 45
Drawings originally by Barbara Cummings for Travell and Simons book, ‘Myofascial Pain and
Dysfunction’.
Redrawn for this manual by Karen Korte, Darling, South Africa.
Trapezius
Normal Problem factors

Innervation Accessory n (motor)
C3-C4 posterior rami

(nociception and
Proprioception)
Function: Isometric Becomes hyperfacilitated when

scapula stability is poor
Upward rotation of Glenoid

Concentric fossa
Eccentric Controls downward rotation of

glenoid fossa
Common MTrP causes Postural dysfunction (AIG, Take care to stabilise scapula first
Upper Cross)
Stress
Starting position All: Contralateral SyLy, Check that neck is in enough upper
shoulders relaxed, 60 degrees F, and lower cervical flexion to facilitate
or arm extended for LFT palpation
UFT alternative: Supine, prone
Palpation landmarks Spine of Scapula, T12, Occiput
Possible Needle sizes UFT: 0.35x40mm, 0.35x50mm
Mid: 0.25x13mm-0.25x25mm
LFT: 0.30x25mm-0.30x40mm
Grip UFT: Lumbrical grip taking care Beware Pleura

to lift tissue cephalad and
posterior
Mid: Flat palpation with fingers

either side of target, intercostal
spaces Try to passively retract scapula and so
relax LFT
LFT: Modified pincer grip
Direction of insertion UFT: Into pincer grip
Mid: Inferomedial, along

direction of rib
Special precautions Beware pleura. Patient must be advised of additional risk of

pneumothorax injury and be advised what to do in case the symptoms
arise.
Trapezius Muscle
(referred pain patterns)
Trapezius Muscle (needle horizontally)
Levator Scapula

Innervation Dorsal scapula nerve C5 and C3
and C4
Function: Isometric Helps stabilize neutral scapula Becomes hyperfacilitated in abnormal

postures
Elevation of scapula
Concentric
Downward rotation of glenoid
fossa
Eccentric Controls upward rotation and

protraction of scapula
Common MTrP causes Postural dysfunction, scapular Take care to stabilise the scapula
instability before needling the overactive
compartments
Starting position Contralateral side lying (Belly) Check that Scapula is elevated and
or Ipsilateral side lying retracted
(Insertion)
Palpation landmarks Superior angle of scapula,

transverse processes C1-C4
Possible Needle sizes 0.3X40mm-0.35x50mm
0.30x25mm (insertion)
Grip Belly: Pincer grip using tips of

fingers or flat stretch between
lateral column of neck and
trapezius
Insertion onto scapula: Flat

palpation with finger either side
of long axis of origin
Direction of insertion Belly: towards your finger, or Dorsal Scapular artery lies deep to the
perpendicular insertion. Aim at the bone to avoid
unnecessary bruising
Insertion: towards
superomedial border of the
scapula
Special precautions Beware pleura. Patient must be advised of additional risk of

pneumothorax injury and be advised what to do in case the symptoms
arise.
Levator Scapula
Posterior Cervical Needling
http://www.imaios.com/en/e-Anatomy/Spine/Spine-diagrams
The Sub-occipital
triangle
The area between C2 and
the Occiput houses the
important vertebral artery,
and the risk of needling to
the actual spinal cord also
becomes high.
Do not needle deeply

in this region!!!!
http://virtualhumanembryo.lsuhsc.edu/hs2412/laboratory/New_Lab_Guide/back/suboccipitaltriangle.html
Occipital Attachments
Splenius Capitis Muscle
Splenius Capitis – Intermediate Layer

Innervation Posterior rami of middle cervical
spinal nerve
Function: Isometric Becomes dysfacilitated in the

presence of pain
Bilaterally: Extension of head and

Concentric neck
Unilaterally: ipsilateral lateral flexion

and rotation of head and neck to the
same side
Eccentric
Check rein contralateral lateral
flexion and rotation
Common MTrP causes Postural dysfunction, whiplash Poor core stability. Take care to assess
and treat deep neck flexors.
Starting position Prone or contralateral side lying Check that neck is in enough upper
and lower cervical flexion to facilitate
palpation
Palpation landmarks Spinous processes Ti-6, mastoid Take care to apply gel to skin in
process, superior nuchal line hairline
Possible Needle sizes 0.25x25mm if perpendicular or

0.30x30mm if inferomedial from C2
Grip Flat palpation approx. 1 cm away MTrP is typically more lateral than you
from spinous process – palpate for expect!
MTrP as you palpate upward and
outward, toward mastoid process.
Direction of insertion Towards the Lamina of the same level

if perpendicular approach or infero-
medial from junction C1/C2
Special precautions The neck is richly supplied with proprioceptive and ANS fibres. The patient
may easily become dizzy. The needles may need to be left in situ even after
LTR to achieve full relaxation. Somatoemotional release following needling
here is not uncommon. Onward referral to a good psychologist may be in
order.
Splenius Cervicis – Intermediate Layer
Innervation Posterior rami of middle
cervical spinal nerves
Function: Isometric Becomes dysfacilitated in the

presence of pain
Bilaterally: Extension of head

Concentric and neck
Unilaterally: ipsilateral lateral

flexion and rotation of head and
neck
Check rein contralateral lateral

Eccentric flexion and rotation
Common MTrP causes Postural dysfunction, Whiplash Poor core stability. Take care to assess
and treat deep neck flexors
palpation
Palpation landmarks Spinous processes C7-T3/4,
Tubercles of transverse
processes C1-3/4
Grip Flat palpation approx. 1 cm MTrP is typically found level C6/7,

away from spinous process – more lateral than you expect!
palpate for MTrP as you palpate
upward and outward, toward
transverse processes
Direction of insertion Towards the Lamina of the Beware inserting too deeply as this
same level (remember the places the deep cervical vessels at risk.
concept of a clock)
Special precautions The neck is richly supplied with proprioceptive and ANS fibres. The
patient may easily become dizzy. The needles may need to be left in
situ even after LTR to achieve full relaxation. Somatoemotional release
following needling here is not uncommon. Onward referral to a good
psychologist may be in order.
Splenius Cervicis (referred pain patterns)
Splenius Capitis Muscle and Splenius Cervicis
(inferomedial approach)
Semispinalis Capitis and Cervicis

Function: Isometric See Multifidus Becomes dysfacilitated in the

presence of pain
Bilaterally: Extension of head

Concentric and neck +
Unilaterally: slight contralateral

rotation
Check rein cervical flexion and

Eccentric
rotation
and treat deep neck flexors
palpation
Palpation landmarks Transverse processes C7-T7,

Occipital bone
Grip Flat palpation approx. 1 cm

away from spinous process
Direction of insertion Towards the Lamina of the Minimal ‘fishing’ in this area to
same level (remember the minimise risk to deep cervical vessels
patient may easily become dizzy. The needles may need to be left in
situ even after LTR to achieve full relaxation. Somatoemotional release
Do not needle deeply – TrP at C1/2 level as vertebral artery may be

penetrated
Semispinalis Capitis and Semispinalis Cervicis
(Referred pain patterns)
Cervical Multifidus

Innervation Posterior rami of middle cervical
spinal nerves
Function: Isometric Stabilises vertebral segments Becomes dysfacilitated in the presence

of pain
Concentric
Eccentric
and treat deep neck flexors.
palpation
Palpation landmarks Transverse processes C-T1,

Occipital bone

Direction of insertion Towards the Lamina of the Minimal ‘fishing’ in this area to
same level (remember the minimize risk to deep cervical vessels
patient may easily become dizzy. The needles may need to be left in situ
even after LTR to achieve full relaxation. Somatoemotional release
Longissimus Cervicis and Capitis

Function: Isometric
Extension of head and neck
Concentric Ipsilateral upper thoracic

flexion
Check rein cervical and thoracic

Eccentric
flexion
Common MTrP causes Postural dysfunction, whiplash, Poor core stability. Take care to assess
chronic emotional stress, and treat deep neck flexors
cervical collar use
palpation
Palpation landmarks Transverse processes and

articular processes of C2-C6,
Lamina T1-T5
Trigger point commonly C3

level
Capitis attaches to the posterior

border of the mastoid process
Possible Needle sizes 0.3X30mm in thorax
0.25x40mm in neck

Direction of insertion Towards the Lamina of the Beware pleura

same level (remember the
Inferomedial deep to splenius

cervicus
Special precautions The neck is richly supplied with proprioceptive and ANS
fibres. The patient may easily become dizzy. The needles
may need to be left in situ even after LTR to achieve full
relaxation. Somatoemotional release following needling
here is not uncommon. Onward referral to a good
o
Posterior Shoulder
Infraspinatus
Patients complaining of ‘shoulder joint pain’ will often have active
trigger points in the Infraspinatus muscle on the affected side. The
referral pain usually concentrates deeply in the anterior deltoid region,
shoulder joint and down the front and lateral aspect of the arm and
forearm. It may also refer pain to the cervical and suboccipital areas
resulting in headache.
Infraspinatus Muscle (referred pain patterns)
Anatomy
One of the rotator cuff muscles, lying on the posterior aspect of the scapula, partially
covered by deltoid and trapezius. Attaches to the posterior aspect of the greater
tubercle of the humerus.
 Action: Lateral rotation of the humerus and helps to keep the head of the
humerus in the glenoid cavity
 Origin: Infraspinous fossa of the scapula
 Insertion: Posterior to the insertion of supraspinatus on the greater tubercle of

the humerus
Positioning for Needling

 With the patient in Contralateral side lying, let the affected arm rest with the
elbow flexed on a pillow in front of the patient. Insert 0.25x25mm (0.30x30mm
in bigger patients) needles at a 45 angle over the trigger points, making sure
you are over the scapula. Be sure to obtain the LTR or at least a muscle ache.
Warning!
The scapula can be paper thin in some individuals, especially older, fragile
or osteoporotic patients. Some patients might also have a congenital hole
in the scapula. This can lead to accidental penetration of the lung lying
underneath. Take care to seek the muscle ache or the LTR, and not just go
as deep as you can.
Causes for Activating Trigger Points

 This is usually caused by repetitive overload of the muscle in actions of
stretching out backwards and up, or dragging something along for a prolonged
time. Infraspinatus is usually involved when patients are doing administrative
or computer work or are under stress at work or home.
Prevention and Care
 Avoid unnecessary back- and outward reaching. Stretching the muscle regularly
with the arm horizontally across the body, and with the hand behind the back,
will help prevent recurrence. When the muscle is badly affected, sleep on the
opposite side with the arm resting on a pillow in the front.
Associated Trigger Points

 Supraspinatus
 Teres minor
 Deltoid
 Biceps
 Pectoralis major
Supraspinatus
Active trigger points in this muscle often mimic deltoid pain. Pain is
usually referred down to the mid-deltoid region of the shoulder and can
extend further down the arm. Satellite MTrPs are often set up from this
muscle. The pain can also concentrate on the lateral epicondyle and
refer even further down to the wrist. Pain is also often found on the
anterolateral part of the shoulder joint.
Supraspinatus Muscle (referred pain patterns)
Anatomy
The Supraspinatus is located on the posterior aspect of the scapula, deep to trapezius.
It forms part of the rotator cuff muscles.
 Action: Assists in abduction and stabilises the shoulder joint

 Origin: Supraspinous fossa of scapula
 Insertion: Superior part of the greater tubercle of the humerus
Position for Needling
Patient is side lying on opposite side. The upper arm should be in mid-position on the
torso, with no rotation or winging of the scapula. Use 0.30x50mm or 0.30x60mm
length needles, the first needle between the clavicle and spine of the scapula, into the
lateral part of the body of the muscle. The second needle is inserted medially to the
first needle, but lateral to the medial border of the scapula. The pain over the
tendinous insertion on the head of the humerus can be needled with the patient in
side lying, and the needle directed at right angle toward the pain with a 0.30x25mm or
superficial 0.25x13mm length needle. Do not needle the actual tendon as it is relatively
hypovascular and does not respond to needling in the same way a muscle does.
Warning!
Take great care to accurately localise the triangle of landmarks of the
suprascapular fossa (acromion, spine of scapula and the crest of the upper
trapezius muscle). The apex of the lung can easily be penetrated if the
position of the scapula is not in neutral and special care should be taken
when treating a patient with scoliosis or any abnormality of the spine,
scapula or ribcage.

This can be activated by:
 Carrying heavy objects
 Working for a prolonged time above shoulder height with an outstretched arm
 Trying to stop a fall of a heavy object from above or carrying heavy objects with
the arm hanging at the side
 These trigger points are commonly active when patients participate in sporting
activities
Prevention and Care

Avoid any overload in the abducted position and in carrying. Regular stretching of the
muscle by putting the hand behind the back and combining it with extension will
maintain and increase mobility.
 Infraspinatus
 Trapezius
 Deltoid
 Latissimus dorsi
Teres Minor (‘Little Brother’)
Teres Minor is both anatomically and functionally the inferior part of the
Infraspinatus muscle, and mimics posterior deltoid pain. It is also
electromyographically identical in activity to Infraspinatus, but is
infrequently involved in trigger point problems.
Anatomy
Arises from the lateral border of the scapula immediately adjacent to the inferior
border of the Infraspinatus muscle, and from the aponeurosis which lies between the
Infraspinatus and the Teres Major muscles, and inserts onto the posterior aspect of the
greater tubercle of the humerus.
Function
A local stabiliser, it can also laterally rotate the humerus (same as Infraspinatus).
Teres Minor (referred pain patterns)
Referral Pattern
Refers locally to the posterior deltoid region. Local pain is the chief complaint, rather
than functional limitation. If the pain is chiefly anterior shoulder pain, the problem is
more likely to be the Infraspinatus itself rather than the little brother Teres Minor.
Causes of Activation
Common overuse, overstretch, overstrain, esp. overhead, and ++ fixation.
Needling Technique
 Side lying, affected shoulder uppermost, resting on pillows with a neutral
shoulder position
 The MTrP is located between the Teres Major and Infraspinatus muscles. Use a
pincer grip between middle and index finger. Angle into the pincer grip or
toward the lateral border of the scapula. Use a 0.3x30 or 0.3x40mm needle
depending on the patient size.
Subscapularis
Subscapularis is the key to understanding the problem of the ‘Frozen
Shoulder’, or rotator cuff syndrome. It develops as much force by itself,
as the other muscles of the cuff combined. Pain may be severe, both at
rest and with movement. Scapulohumeral rhythm disruption will always
result, but may also be a contributing factor. It generates severe pain
over the posterior shoulder, even at rest, and worsens with movement.
Anatomy
A fan-shaped muscle arising from most of the thoracic surface of the scapula, and runs
supero-laterally to attach to the lesser tubercle of the humeral head. It fills the
subscapular fossa.
Function
 Local stabiliser and local mobiliser of the shoulder
 Medial rotator of the shoulder
 Helps prevent excessive anterior displacement of the glenohumeral head
 Opposes pull of deltoid during elevation, thus keeping the glenohumeral head
centered (i.e. not impinging)
Subscapularis Muscle (referred pain patterns)
Referral Pattern
 Posterior shoulder
 A strap-like area over the ipsilateral wrist, dorsum more than volar surface
Causes of Activation
 Common overuse, overstretch, overstrain, esp. with high velocity throwing sports, and
trauma
 Shoulder replacements
 Usually overlooked in acromioplasty rehabilitation
 Dislocation and prolonged immobilisation may cause microtrauma to the muscle
Trigger Point Injection

For the muscle belly: Supine lying, with the arm abducted as far as possible given the
patient’s presenting ROM. Palpate the muscle bulk of the Teres Major and Latissimus
muscles. Palpate the chest wall. In the area between the two, aim your finger slightly
upward and palpate deeply into the armpit area. Flat palpate across the anterior face
of the scapula and locate the MTrPs. Localise the MTrP between two fingers and the
scapula. Needle, using a 0.35x75mm needle, and elicit a LTR of at least an ache.
For the Vertebral Border: This is an advanced technique, and not advocated on this
course. It is usually not necessary to needle this if you needle the belly effectively.
Beware of
Perforating the Chest wall!
The Brachial plexus, the Brachial artery and the Axillary vein are all anterior and
superior to the needling site!
Clinically relevant article:
Ingber RS. 2000. Shoulder Impingement in Tennis/Racquetball Players Treated with
Subscapularis Myofascial Treatments. Arch Phys Med Rehabil. 2000; 81:679-682
Abstract:
Conservative care of the athlete with shoulder impingement includes activity modification,
application of ice, nonsteroidal anti-inflammatory drugs, subacromial corticosteroid
injections, and physiotherapy. This case report describes the clinical treatment and outcome
of three patients with shoulder impingement syndrome who did not respond to traditional
treatment. Two of the three were previously referred for arthroscopic surgery. All three
were treated with subscapularis trigger point dry needling and therapeutic stretching. They
responded to treatment and had returned to painless function at follow-up two years later.
Key words: Myofascial pain syndromes; Shoulder impingement syndrome; Tendinitis;
Tennis; Rehabilitation.
Latissimus Dorsi
(Latin: “Widest of the Back”)
This muscle is often overlooked as a cause for mid-back pain. The pain
concentrates in the area of the inferior angle of the scapula and it may
radiate down the back of the shoulder into the medial arm and forearm.
Latissimus Dorsi (referred pain patterns)
Anatomy
This is a broad, flat muscle with a triangular shape located mostly in the lumbar area.
Superiorly it is covered by the trapezius. It forms part of the posterior wall of the axilla.
 Actions: arm extension, adduction and medial rotations. Depression of the

scapula.
 Origin: indirect attachment via the lumbodorsal fascia into the spinous
processes of the lower 6 thoracic vertebrae, the spinous processes of all the
lumbar vertebrae, the iliac crest, the lower 3 – 4 ribs and the inferior angle of
the scapula
 Insertion: the floor of the intertubercular grove of the humerus jointly with
teres major

 Although the muscle is quite large in its coverage, MTrPs are usually found in
the free border area and in the posterior axillary fold
 With the patient in supine, place the hand of the affected side under the head.
Pull the latissimus away from the ribcage and feel the trigger point
between your fingers, in a pincer grip. Use a bottom finger at an angle
perpendicular to the trigger. Be sure to check both deeply (scapula referral) and
superficially (arm referral). Use 0.3x40-50mm needle.
 Alternative needling position in prone with shoulder abduction, pull lats away
from chest wall and using a 0.30x30mm-0.35x50mm, needle into pincer-grip,
away from chest wall
Warning
The needle should not be directed medially as it can penetrate
the lung.
Causes for Activation of Trigger Points

 Sporting activities that involve power striking (Hammering, Swimming)
 Rowing or pulling, even relatively simple things like pulling out weeds
 General digging, use of pick/shovel/axe
 Unfit patients over-exercising in a gymnasium can easily suffer from the
involvement of this muscle. (New Year’s resolution syndrome!)
Prevention and care

 The patient should be advised when doing ‘Triceps Push Down’ exercise to keep
his upper arm vertical and his elbow beside the body. Sporting activities should
not allow for overload; regular stretching of the muscle should prevent
recurrence.
Associated trigger points

 Teres major
 Trapezius
 Serratus Posterior Superior
Latissimus Dorsi - referral patterns

(note the referral to the back of the
ring finger)
Anterior Shoulder
Teres Major
This muscle is seen as a twin to latissimus dorsi, with trigger points

usually present in both muscles simultaneously. The pain penetrates into
the posterior deltoid region.
Teres major (referred pain patterns)
Position for needling

 Side lying
Medial trigger point: with the patient in side lying position, arm in flexion,
adduction resting on a pillow, use a 0.3x25mm-0.35x50mm in bigger patients;
needle to penetrate the trigger obliquely over the inferior lateral border of the
scapula.
 Supine
Shoulder to 90o of abduction, elbow flexed and resting on either the therapist’s
shoulder, or a pillow. This helps to use active resisted tests. Pincer-grip the free
border of the muscle and needle with a 0.30x30mm-0.35x50mm needle.
Warning
Be sure to needle posterior to the scapula and not off from it,
to prevent penetration of the lung. Rather use a shorter needle
in fragile, osteoporotic patients and patients suffering from
emphysema.
Lateral trigger points can be needled with the patient in supine, arm
abducted to 90°.
This trigger point is found approximately 2,5cm below the armpit/axillamedial to the
trigger point in the latissimus dorsi. Grip the muscle with a pincer grip within the
axillary fold, use a 0.3x40mm (0.3x50mm in bigger patients), needle and penetrate the
trigger point directing the needle away from the ribcage. The needle should not be
directed medially as it can penetrate the lung. Make sure to keep the trigger point in
the pincer grip for accurate needling.

 Repetitive lifting of weights overhead, as in yard managers or storeroom
packers, people over-exercising in the gymnasium with weights, and heavy duty
truck drivers. Teres major should be treated as a latent trigger point after
shoulder surgery.
Prevention and care

 Adaptation to the work environment should be encouraged to prevent overuse.
Regular stretching of the muscle should prevent activation of the trigger points.
Deltoid
The pain from active trigger points in this muscle is usually in the
affected area of the muscle (i.e. no referral)
Anatomy
It is a thick, fleshy muscle forming the roundness of the shoulder
 Action: abduction of arm if all its fibres are contracted simultaneously; flexion
and internal rotation if only the anterior fibres are active; extension and
external rotation when only the posterior fibres are contracted
 Origin: anterior fibres on the lateral third of the clavicle; middle fibres on the
acromion and the posterior fibres on the lateral portion of the spine of the
scapula
 Insertion: deltoid tuberosity of the humerus
 Palpate the trigger point and penetrate it perpendicularly with a 0.3x40-50mm

needle, according to the size of the muscle
 Anterior trigger points: patient in supine position with the arm in abduction
 Middle area trigger points: patient in side-lying position with the arm in mid-
position
 Posterior trigger points: patient in side-lying position with the arm in adduction
Causes for Activation of Trigger Points
 Overload of the muscle can occur after deep-sea fishing, trying to stop a fall,
unaccustomed casting (as in fly fishing), a repetitive recoiling from using a
shotgun
 Common in rugby players
 Deltoid trigger points will usually be active when the associated trigger points
have been active for a long period. This is especially true of rotator cuff muscle
trigger points. Local injections can activate a trigger point in the middle portion
of deltoid.
Prevention and Care

 The patient should be taught to stretch the muscle regularly. He should be
advised to hold on to rails to prevent him from falling, not to overload the
muscle with repetitive actions and to pad the shoulder when shooting.

 Anterior trigger points active – pectoralis major, biceps and posterior deltoid
 Posterior trigger points active – triceps, latissimus dorsi, teres major,
supraspinatus and infraspinatus
Anterior Deltoid
Middle Deltoid
Posterior Deltoid
References and Recommended Reading
1. Baldry, P. 1992. Acupuncture, Trigger Points and Musculoskeletal Pain, Churchill and
Livingstone
2. Bowsher, D. 1998. Mechanisms of Acupuncture. Medical Acupuncture, Filsche &
White, Churchill Livingstone
3. Bruckner, P. & Kahn, D. 1993. Clinical Sports Medicine, McGraw Hill
4. Butler, D. 1991. Mobilisation of the Nervous System, Churchill Livingstone
5. Dommerholt.J & Huijbreghts. P. Myofascial Trigger Points. Jones & Bartlett . 2011
6. Filshie, J & White, A. 1998. Medical Acupuncture, Churchill Livingstone
7. Gerwin, R.D., Shannon, S., Hong, C-Z., Hubbard, D., Gevirtz, R. 1997. Interrater
reliability in myofascial trigger point examination. Pain 69:65-73
8. Gunn, C. 1989. Treating Myofascial Pain: Intramuscular Stimulation, University of
Washington
9. Hong C-Z, Hsueh T –C. 1996. Difference in pain relief after trigger point injections in
myofascial pain patients with and without fibromyalgia. Arch Phys Med Rehabil
77(11 ):1 161-1166.
10. Hong CZ. 1994. Lidocaine injection versus dry needling to myofascial trigger point.
The importance of the local twitch response. Arch Phys Med Rehabil 73:256-263
11. Hong, C-Z., Kuan, T-S., Chen, J-T., Chen, S-M. 1997. Referred Pain Elicited by
Palpation and by needling of Myofascial Trigger Points: A Comparison. Arch Phys
Med Rehabil 78:957-960
12. Hooshmand, H. 1993. Chronic Pain: Reflex Sympathetic Dystrophy, C.R.C. Press,
Tokyo
13. Melzack & Wall. The Challenge of Pain, Penguin
14. Jimbo S, Atsuta Y, Kobayashi T, Matsuno T. 2008. Effects of dry needling at tender
points for neck pain (katakori): near-infrared spectroscopy for monitoring
oxygenation of trapezius. Journal of Orthopaedic science, 13:101-106
15. National Commission for Certification of Acupuncturists (1989) Clean Needle
Technique for Acupuncturists
16. Oschman, J. 2002. Energy Medicine, The Scientific Basis. Churchill Livingstone.
17. Rachlin, Edward. 1994. Myofascial Pain and Fibromyalgia. Mosby Shah JP,
Phillips TM, Danoff JV, Gerber LH. An in vivo micro analytical technique for
measuring the local biochemical milieu of human skeletal muscle. J Appl Physiol
2005;99(5): 1977–1984 [Epub 2005 Jul 21].
18. JayP. Shah. 2008. Integrating Dry Needling with New Concepts of Myofascial Pain,
Muscle Physiology, and Sensitization. Chapter 5 of Contemporary Pain Medicine:
Integrative Pain Medicine: The Science and Practiceof Complementary and Alternative
Medicine in Pain Management Edited by: J. F. Audette and A. Bailey © Humana Press,
Totowa, NJShipton, E.A.. Pain: Acute and Chronic, Witwatersrand University Press
19. Simons, D. 1990. Muscular Pain Syndromes, Advances in Pain Research, Volume 1,
Raven Press.
20. Simons, David. 2001. Muscle Pain. Understanding its Nature, Diagnosis and
Treatment. Lippincott, Williams & Wilkins.
21. Travell, S. & Simons, D. 1983. Myofascial Pain and Dysfunction, Williams & Wilkins.
22. Whyte Ferguson L. & Gerwin R. Clinical Mastery in treatment of Myofascial pain.
Lippincott Williams & Wilkins. 2005
23. Webb, J. 1986. Pain Control via Dorso-lumbar Sympathetic flow,
Australian Journal of Physiotherapy 32(2).
24. Wells, J.C.D. & Woolf, C.J. 1991. Pain Mechanisms and Management, Volume
47(3). Churchill Livingstone.
25. Wheeler, A.H., Goolkasian, P., Gretz, S.S. 1997. A randomised double blind
prospective pilot study of Botulinum Toxin Injection for Refractory, Unilateral,
Cervicothoracic, Paraspinal Myofascial Pain Syndrome. Spine 23(15):1662-1664.
Indemnity Form
For Use on the Dry Needling Courses Only
1. I, ................................................................................................................. (the
undersigned) hereby give my consent to be dry needled by any of my co-participants
and the demonstrator in ways consistent with the content of the Optimal Dry
Needling Solutions course, in association with Club-Physio and The Dry Needling
Institute.
2. I have read and understood the document called “Dry Needling Information” and
have had sufficient opportunity to ask any questions that I want to.
3. I agree to expose the appropriate area of my body being needled, and to loosen or
remove such clothing as may be necessary for the technique to be performed
properly.
4. I indemnify Optimal Dry Needling Solutions and all of its lecturers and course
organisers against any claim which may arise from this course.
5. I acknowledge that I personally carry appropriate Malpractice insurance.
6. I freely participate in this course and am under no pressure to sign this document.
(Course Participant) (Date)
Dry Needling information
Your physiotherapist has offered to treat you using a technique called ‘Dry Needling’. This
information leaflet explains more about this technique.
Dry Needling is a very successful medical treatment which uses very thin needles without any
medication (a dry needle) to achieve its aim. Dry Needling is used to treat pain and dysfunction
caused by muscle problems, sinus trouble, headaches, and some nerve problems. It is not at all
the same as acupuncture. Acupuncture is part of Traditional Chinese Medicine, whereas dry
needling is a western medicine technique.
Dry Needling works by changing the way your body senses pain (neurological effects), and by
helping the body heal stubborn muscle spasm associated with trigger points (myofascial effects).
There are additional electrical and chemical changes associated with dry needling therapy which
assist in the healing process. It is important to see the needles as just one part of your overall
rehabilitative treatment. Dry needling is not a miracle cure – it is a normal part of physiotherapy. It
is vital that you do the exercises and follow the advice your therapist gives you in conjunction with
the needling for optimal recovery.
Your therapist has been specifically trained in the various needling techniques. The therapist will
choose a length and thickness of needle appropriate for your condition and your body size, and then
insert it through the skin at the appropriate place. You will feel a small pinprick. Depending on the
type of needle technique chosen by your therapist, you may also feel a muscle ache and a muscle
twitch. These are all normal and good sensations, and mean that you will experience good relief
from your symptoms.
In general, there is very little risk associated with this technique if performed properly by a trained
physiotherapist. You may have a little bruising around the needle site, much the same as you would
with any injection. On rare occasions, people may feel very happy, tearful, sweaty or cold. These
symptoms all fade quickly. Fainting may occur in a very small minority of people. There are no
lasting ill effects of these side effects.
If you are being treated in the shoulder, neck or chest area, there is an additional risk that involves
your lung. If the lung itself is punctured, you may develop a condition called a pneumothorax (air in
the space around the lung). This is a rare but serious problem, and you should go directly to a
hospital casualty department without panicking if it occurs. The symptoms of this event include
shortness of breath which gets worse, sudden sharp pain each time you breathe in, a bluish tinge to
your lips, and an inability to ‘catch your breath’. The treatment is very successful for this rare but
possible complication.
If you are happy to continue with the therapy as suggested by your therapist, and have asked any
questions that you may want to, then please sign the consent form attached to this page, and hand
it to your physiotherapist.
Please keep this information page for your own records.
©Optimal Dry Needling Solutions
Consent for Dry Needling Treatment
This document is to be read in conjunction with the information sheet titled
‘Dry Needling information’
1. I (full name), …………………………………………………………………………………. in my

capacity as:
Please circle which of the following two applies in your case:
The patient (if aged 18 or over),
Or
The parent or legal guardian, of
……………………………………………………………………………………………. (patient’s full name)
Who is my: Spouse / Child / Grandchild / Parent / Sibling / Foster Child / Ward
(please circle the appropriate term)
do hereby give my consent for the performance of dry needling therapy by the
physiotherapist named ............................................................................................. at

the physiotherapy practice. I understand that the therapist is appropriately
qualified and trained to perform the required therapy.
2. The areas of the body that I consent to have dry needled are:
3. I am satisfied that the technique has been fully explained to me, and that my
concerns have been addressed and that my questions have been answered to my
satisfaction. I have read the attached information sheet called “Dry Needling
information”, and am in a satisfactory position to weigh up the risks and limitations
of the technique as regards known side effects.
4. I understand that the technique is performed within a rehabilitative framework and
that I must follow instructions as given by the physiotherapist.
5. I understand that in the event of any litigation arising consequent to this
therapy, it can only be done within the jurisdiction of the Magistrate’s Court. The
applicant will be responsible for his own and the defendant’s legal costs.
7. I hereby indemnify the therapist and the practice against any liability arising from
unforeseen or unknown consequences.
Date: .................. Time: ................ Place: ...........................
Patient Guardian/Mandated person
Feedback Form
Your input is vital to improving courses.
Please make any additional comments that you think will be helpful.
Please rate each of the following topics from 1-5 with 1 being ‘poor’ and 5 being ‘excellent’
Topic Score Comments

Venue: Parking
Access
Comfort
Room
Food
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Lecturer
Lecturer’s Assistant
Manuals
Admin support
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High Point of course
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1. Would you recommend this course to your colleagues? Yes / No
2. What would you tell them?
3. Have all your questions been answered to your satisfaction? Yes / No
4. Do you have anything else to tell us that will help improve the course?
Thank you for your time, effort and

input.
We hope to see you again soon!
O D N S
© Optimal Dry Needling Solutions – United Kingdom, USA, Middle East and Europe - 2013
You are kindly asked not to video- or audio record any of the
lectures or practical sessions.
© Optimal Dry Needling Solutions – United Kingdom, USA, Middle East and Europe - 2013

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In association with

Having built up your needling confidence in Module One working in the

“A healthy upper quarter requires synchronous

Redrawn for this manual by Karen Korte, Darling, South Africa.

Normal Problem factors

C3-C4 posterior rami

Function: Isometric Becomes hyperfacilitated when

Upward rotation of Glenoid

Eccentric Controls downward rotation of

UFT alternative: Supine, prone

Palpation landmarks Spine of Scapula, T12, Occiput

Possible Needle sizes UFT: 0.35x40mm, 0.35x50mm

Grip UFT: Lumbrical grip taking care Beware Pleura

Mid: Flat palpation with fingers

Direction of insertion UFT: Into pincer grip

Mid: Inferomedial, along

Special precautions Beware pleura. Patient must be advised of additional risk of

Normal Problem factors

Function: Isometric Helps stabilize neutral scapula Becomes hyperfacilitated in abnormal

Eccentric Controls upward rotation and

Palpation landmarks Superior angle of scapula,

Possible Needle sizes 0.3X40mm-0.35x50mm

Grip Belly: Pincer grip using tips of

Insertion onto scapula: Flat

Special precautions Beware pleura. Patient must be advised of additional risk of

Do not needle deeply

Splenius Capitis Muscle

(referred pain patterns)

Normal Problem factors

Function: Isometric Becomes dysfacilitated in the

Bilaterally: Extension of head and

Unilaterally: ipsilateral lateral flexion

Possible Needle sizes 0.25x25mm if perpendicular or

Direction of insertion Towards the Lamina of the same level

Function: Isometric Becomes dysfacilitated in the

Bilaterally: Extension of head

Unilaterally: ipsilateral lateral

Check rein contralateral lateral

Palpation landmarks Spinous processes C7-T3/4,

Possible Needle sizes 0.25X30mm-0.35x50mm

Grip Flat palpation approx. 1 cm MTrP is typically found level C6/7,

Splenius Capitis Muscle and Splenius Cervicis

Normal Problem factors

Function: Isometric See Multifidus Becomes dysfacilitated in the

Bilaterally: Extension of head

Unilaterally: slight contralateral

Check rein cervical flexion and

Palpation landmarks Transverse processes C7-T7,

Possible Needle sizes 0.3X40mm-0.35x50mm

Grip Flat palpation approx. 1 cm

Do not needle deeply – TrP at C1/2 level as vertebral artery may be

(Referred pain patterns)

Normal Problem factors

Function: Isometric Stabilises vertebral segments Becomes dysfacilitated in the presence

Palpation landmarks Transverse processes C-T1,

Possible Needle sizes 0.3X40mm-0.35x50mm

Grip Flat palpation approx. 1 cm

Normal Problem factors