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Deep Dry Needling of the Arm and Hand Muscles 8

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Deep Dry Needling of the Arm and Hand Muscles 8 Deep dry needling of the arm and hand muscles 8 César Fernández-de-las-Peñas Javier González Iglesias Christian Gröbli Ricky Weissmann CHAPTER CONTENT conditions. Symptoms in the upper quadrant, including the neck, shoulder, arm, forearm, or Introduction . 107 hand not related to an acute trauma or underly- Clinical relevance of TrPs in arm ing systemic diseases, can be provoked by trigger and hand pain syndromes . 108 points (TrPs). In fact, there are several neck and Dry needling of the arm and hand muscles . 108 shoulder muscles with referred pain pattern being perceived throughout the upper extremity, e.g. Coracobrachialis muscle. 108 the scalenes, subclavius, pectoralis minor, supra- Biceps brachii muscle (short head) . 109 spinatus, infraspinatus, subscapularis, pectoralis Triceps brachii muscle (lower portion) . 109 major, latissimus dorsi, serratus posterior supe- Anconeus muscle . 110 rior and serratus anterior muscles ( Simons et al. Brachialis muscle . 110 1999 ). For instance, Qerama et al. (2009) dem- Brachioradialis muscle . 111 onstrated that 49% of individuals with normal electrophysiological findings in the median nerve, Supinator muscle . 111 but with symptoms mimicking carpal tunnel syn- Wrist and fi nger extensor muscles. 112 drome, presented with active TrPs in the infra- Pronator teres muscle . 113 spinatus muscle with paresthesia and referred Wrist and fi nger fl exor muscles . 113 pain to the arm and fingers. In the same study, Flexor pollicis longus, extensor pollicis patients with mild electrophysiological signs of longus, and abductor pollicis longus . 114 carpal tunnel syndrome exhibited a significantly Extensor indicis muscle . 115 higher occurrence of infraspinatus muscle TrPs in the symptomatic arm as compared with patients Adductor pollicis, opponens pollicis, with moderate to severe electrophysiological fl exor pollicis brevis, and abductor pollicis brevis muscles . 116 signs (33% vs 20%). Dry needling of these mus- cles has been covered in Chapters 6 (scalene) and Interosseous, lumbricals, and abductor digiti minimus muscles. 117 7 (shoulder). Additionally, TrP taut bands in the musculature of the upper quadrant can be related to neural or Introduction articular dysfunctions. For instance, since the bra- chial plexus runs anatomically between the ante- Arm pain syndromes constitute a complex entity rior and the medial scalene muscles, TrPs in the which can arise from a wide range of different scalene muscles may be related to entrapment of © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/B978-0-7020-4601-8.00008-6 PART TWO Clinical and evidence-informed approach of TrP dry needling the brachial plexus (Chen et al. 1998). Similarly, commonly referred to as pronator syndrome shortening of the scalene muscles induced by TrPs ( Lee & LaStayo 2004 ), tension induced by TrP taut bands may be related to first rib dysfunctions taut bands may be relevant for symptoms associ- ( Ferguson & Gerwin 2005 ), which means that cli- ated with median nerve compression ( Simons nicians should integrate TrP dry needling within the et al. 1999 ). Similarly, the median nerve can be overall clinical reasoning process and management. entrapped by TrPs in the flexor digitorum profun- In the current chapter we will cover deep dry nee- dus and superficialis muscles, whereas the ulnar dling of TrPs in the arm and hand muscles. nerve can be entrapped by TrPs in the flexor carpi ulnaris and flexor digitorum profundus ( Chaitow Clinical relevance of TrPs & Delany 2008 ). Therefore, clinicians should con- in arm and hand pain sider muscle-nerve interrelations into their daily practice even though no study has confirmed the syndromes clinical observations. Finally, TrPs within the intrinsic muscles of the There are several studies demonstrating the rel- hand, i.e., the interossei and lumbricals, can also be evance of TrPs in the etiology of different arm pain clinically relevant for unspecific wrist-hand pain. syndromes. The most accepted muscle pain syn- For instance, manual laborers or boxers who suf- drome in the arm is lateral epicondylalgia ( Slater fered a traumatic event over the wrist or the hand et al. 2003 ). Fernández-Carnero et al. (2007) found frequently develop TrPs in these muscles. There is that active TrPs in the extensor wrist musculature clinical evidence that TrP dry needling of the intrin- reproduced the pain symptoms in subjects with sic hand muscles, such as the dorsal interossei, is lateral epicondylalgia (65% extensor carpi radia- highly effective in these patients. TrPs in the thenar lis brevis, 55% extensor carpi radialis longus, 50% muscles are commonly seen in complaints of pre- brachioradialis, 25% extensor digitorum communis sumed arthritic changes in the joints of the thumb. muscle). In a subsequent study, Fernández-Carnero Dry needling of TrPs in the abductor pollicis bre- et al. (2008) reported that subjects with unilateral vis may relieve the pain associated with these joint lateral epicondylalgia also exhibited latent TrPs problems. Again, no scientific study has been pub- within the unaffected elbow (88% extensor carpi lished confirming these clinical observations. radialis brevis, 80% extensor carpi radialis longus), It is important for clinicians to combine scien- which may be related to the development of bilat- tific and clinical-based evidence as there is no sci- eral symptoms in this patient population. A recent entific evidence yet for several approaches that study found that active TrPs in the extensor carpi clinically are found to be effective. In this chap- radialis brevis were very prevalent (68% right side; ter we cover dry needling of TrPs in the arm and 57% left side) in women with fibromyalgia syn- hand musculature based on clinical and scientific drome ( Alonso-Blanco et al. 2011 ). These studies reasoning. support the role of TrPs in arm pain syndromes, although further studies are needed. Addition- Dry needling of the arm ally, when TrPs are present in the brachioradialis and hand muscles ( Mekhail et al. 1999 ) or extensor carpi radialis bre- vis muscle ( Clavert et al. 2009 ), entrapment of the radial nerve is feasible. Coracobrachialis muscle In clinical practice, an association between TrPs in the wrist flexor muscles and medial epicon- • Anatomy: The muscle originates from the cora- dylalgia is commonly seen, particularly in individu- coid process and inserts to the mid-portion of als with high muscular demands in the forearm, the humerus bone. i.e., climbers ( González-Iglesias et al. 2011 ), or • Function: It assists in flexion and adduction of with low-load but repetitive load, i.e., manual the arm at the glenohumeral joint. or office workers (Fernández-de-las-Peñas et al. • Innervation: Musculocutaneous nerve, via the 2012 ). Again, TrPs in the wrist flexor muscula- lateral cord from the C5 and C6 roots. It should ture can be also related to different nerve entrap- be noted that the musculocutaneous nerve ments. For instance, as the pronator teres muscle crosses the muscle belly of the coracobrachialis is a common place for median nerve entrapment, underneath the pectoralis major muscle. 108 Deep dry needling of the arm and hand muscles CHAPTER 8 Figure 8.1 • Dry needling of the coracobrachialis Figure 8.2 • Dry needling of the short head of the muscle. biceps brachii muscle. • Referred pain: It is projected over the anterior anatomically medial to the muscle belly of the aspect of the shoulder and also extends down biceps brachii ( Maeda et al. 2009). the back of the arm and dorsum of the forearm • Referred pain: It is projected mainly upward, over to the back of the hand. the muscle to the front of the shoulder (mimicking • Needling technique: The patient lies supine with symptoms of long head bicipital tendonitis) and lateral rotation at the shoulder. The muscle is the common tendon of the bicep brachii muscle. needled via flat palpation. The needle is inserted • Needling technique: The patient lies in supine. perpendicular to the skin from medial to lateral The muscle is needled via a pincer palpation. side toward the upper third of the humerus The needle is inserted perpendicular to the skin bone ( Figure 8.1 ). The muscle can also be nee- from medial to lateral side of the short head, and dled near the coracoid process just medial to the directed towards the practitioner’s finger (Figure tendon of the short head of the biceps brachii 8.2 ). Otherwise, the needle can be also inserted muscle. from lateral to medial side of the muscle. • Precautions: The neurovascular bundle, which • Precautions: The neurovascular bundle, which includes the median nerve, the musculocutaneous includes the median nerve, the musculocuta- nerve which passes through the muscle, the ulnar neous nerve, the ulnar nerve and the brachial nerve, and the brachial artery, is located dorsally artery, is located medially to the biceps brachii and medially to the muscle and must be avoided. muscle and must be avoided. Biceps brachii muscle Triceps brachii muscle (short head) (lower portion) • Anatomy: The long head of the muscle originates • Anatomy: The long head of the muscle origi- from the superior margin of the glenoid cavity, nates from the scapula inferior to the glenoid whereas the short head originates from the cora- fossa, the medial head originates from the coid process of the scapula. Both heads attach medial portion of the humerus and the lateral distally to the lesser tuberosity of the radius. head originates from the lateral side of the • Function: This muscle flexes the forearm at the humerus. All three heads insert to the olecranon elbow, assists flexion of the arm at the shoulder, process on the ulna via a common tendon. and assists supination of the forearm when the • Function: This muscle extends the forearm at the elbow is not fully extended. elbow (antagonist of biceps brachii). The long • Innervation: Musculocutaneous nerve, via head may extend the arm at the shoulder joint. the lateral cord from the C5 and C6 roots. It • Innervation: Radial nerve, via the posterior cord of should be noted that the median nerve runs the brachial plexus from spinal roots C7 and C8.
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