Most people have heard of acupuncture and understandably assume that if a treatment involves a needle, it must be acupuncture. This is akin to saying that everybody who uses a knife must be a surgeon. Our task here is thus to look in depth at all the ways that needles are used, so that you better understand what the differences are and thus eliminate the confusion surrounding this type of treatment. By doing so, it will also hopefully help you gain confidence to try this form of treatment in the future and help you seek out the best type of practitioner for your problem.
Historically, the use of the needle for treatment started in the east, most probably in China, many thousands of years ago. Thus, there have been thousands of years to refine and improve the understanding of acupuncture in Chinese Medicine, the latter being a complete medical system which looks at the whole body. It regards illness as the body being out of balance and thus seeks to identify why it is out of balance and then treats to redress this.
What Is Acupuncture?
Today’s acupuncture uses very thin needles, much thinner than a hypodermic needle. These are inserted in the body at prescribed Chinese points which have a known therapeutic effect, or directly into an area of muscle spasm or pain. The needles are generally inserted and then left for anything up to 30 minutes.
Electro-acupuncture was originally developed for use as analgesia in surgery. However, the benefits of electro–acupuncture were soon recognised for the control and treatment of pain. Research is still ongoing to better understand the best settings to use and the technology is thus continuously evolving.
The equipment we use in house allows us to vary the settings to help you in the best way possible. It is understood that the use of different frequencies can stimulate the release of natural opioid pain killers in the body and that by using dual frequencies, both the intensity and longevity of the pain control can be varied.
A benefit of using needles with this type of electrical signal is that the pain relief can be applied at deep levels, within the muscles that are causing the pain.
Western acupuncture as taught today is a small subset of Chinese acupuncture, combining needling to local areas of pain or spasm, ‘Ah Shi’ points, sometimes called trigger points, plus some use of Chinese points, but without reference to Chinese theory.
Needles are used in the same way as Chinese medicine and the types of needle are the same. The focus in western acupuncture is to link the treatment to western medical principles, which requires ‘evidence based’ justification. This is discussed below in the Acupuncture in the NHS section.
Chinese Medicine is a complete standalone medical system and is totally different to western medicine. By teaching and using Chinese acupuncture points, western acupuncture in effect has a foot in both camps.
Intra Muscular Stimulation – GunnIMS
The majority of acupuncture needling is performed at relatively shallow depths in the body. As explained above, the needles are inserted and left static until removed.
GunnIMS is completely different.
Professor Chan Gunn, a medically qualified Doctor, discovered GunnIMS by accident while carrying out tests in a laboratory in Vancouver, Canada. He found that patients were in pain, quite often long term, or chronic, pain, because of muscles being in spasm. In addition these muscles were not responding properly to the signals from the brain to expand and contract. He found that by inserting needles into these non-responding muscles, those same muscles could be made to release and start behaving normally. To effectively release a muscle he found that multiple insertions were needed, using the needle more as a microsurgical tool rather than a simple insertion device.
Eventually GunnIMS evolved to using an external device, called a plunger, which allowed the therapist to rapidly and easily retarget the needle to achieve the required result.
GunnIMS is fundamentally different to acupuncture
The results in treating muscle pain are far superior. It utilises western anatomical knowledge and makes no reference to Chinese Medicine. It generally requires much deeper needling and directly targets and micro surgically treats muscles in spasm. The training is thus totally different and only those practitioners trained through the Institute for the Study and Treatment of Pain (ISTOP), based in Vancouver, are qualified to provide GunnIMS. Nicky Snazell is one of only 3 practitioners in the UK to have reached the highest level of training and was awarded the first honorary membership of ISTOP in the world for her dedication to the use of GunnIMS.
Nothing Is Wrong
A major strength of GunnIMS is that it is unsurpassed in diagnosing and treating muscle spasm. Both MRI and X-ray cannot ‘see’ muscle spasm, it is totally invisible to these scans. Thus many patients who may have been in long term pain and given a scan, only to be told ‘nothing is wrong’ will now understand why.
Dry needling refers to the use of a non-hypodermic needle. Acupuncture needles are solid, they cannot inject a drug. Thus they provide a dry and not wet treatment.
Hypodermic needles, which are used to inject drugs, are relatively much thicker and more painful to insert. This is perhaps why so many of us grow up with needle phobias.
It may at first seem that both acupuncture and dry needling are the same. After all they are both dry techniques. But there the similarities end. Whereas acupuncture is a traditional method developed thousands of years ago, dry needling is relatively new, only having been adopted in the last few decades.
Dry needling is primarily used to treat tight muscles, or trigger points, to ease muscular pain. In some cases the needles are inserted and left for a number of minutes. In some cases the needles are moved up and down to increase the effect.
The term Dry Needling is tending to replace GunnIMS as the teaching of dry needling is much more widespread. In many cases there is an overlap with GunnIMS. However, GunnIMS specifies that only Medical Doctors and Physiotherapists (in countries with the highest standards) are qualified to be trained, it also requires intensive training and passing exams. Dry needling courses can be attended by less qualified therapists and can involve little more than a weekends training.
Does Needling Hurt?
Our skin has a lot of nerves to sense touch, hot and cold, pressure and pain. However, once a needle has gone beyond the immediate outer layer, there are very few pain sensors.
A skilled practitioner understands this and will penetrate the skin very quickly, so that you would feel nothing more than a small prick. (no pun intended)
TCM will aim to penetrate to the layer of fascia where the patient gets a very definite sensation which is almost totally painless. Thus the majority of TCM and those western practitioners who use TCM points, will be almost totally painless.
The next level of needling is dry needling into tight muscles, or trigger points. This can cause pain, usually only slight and short lived.
Again, an experienced practitioner can use skills and technology to largely alleviate the pain response. Firstly, by using a therapeutic laser, which will generally penetrate up to 30mm into the body and greatly help to relax muscle spasm. In fact ‘Laser puncture’ refers to the use of a laser over TCM points, and can be helpful in treating patients without needles.
The second and more powerful technique to minimise a pain response is by first acupuncturing specific points which are known to minimise pain signals reaching the brain and others that will put the patient into a relaxed meditative state. This is no different to the same procedures used in China and now used in the USA for pain control in surgery.
A healthy, normal muscle has very limited ability to even realise a needle has penetrated it and in this situation a patient is unlikely to be aware at all. At times muscles will go into severe spasm and fail to respond to normal expand and contract commands from the brain. A very common example is low back pain and sciatica.
If you feel that acupuncture or GunnIMS could help you then please call us on 01889 881488 to book now.
Our staff capabilities are at the highest standard available in the UK.
The Pain Relief Clinic is pleased to announce Consultant Physiotherapist, Nicky Snazell, has won a top award and national recognition for ‘Excellence in Patient Service’ at a Gala Dinner, held by The Acupuncture Association for Chartered Physiotherapists, (AACP). The prestigious awards dinner was held on Friday 13th May at the Hilton Hotel in Coventry as part of the AACP Annual Conference. The awards were held to recognise individuals who were honoured for their achievements and the contributions they have made.
Nicky Snazell, Clinical Director of The Pain Relief Clinics was honoured at The AACP Awards evening. Nicky was selected from more than 6000 physiotherapists in both NHS and private practice from across the UK to win the first ever ‘Excellence in Patient Service’ Award. Nicky was recognised for her incredible achievements and for making a significant contribution to the practice of acupuncture having successfully treated thousands of patients throughout her career spanning nearly thirty years.
The AACP celebrated Nicky’s patient-focused approach, holistic understanding and treatment of patients and excellence in practice. Nicky was said to be an inspirational leader in her field and having made a significant contribution to the practice of acupuncture in the UK. Collecting the award Nicky said,
“Winning this award inspires me to continue my work driving holistic physiotherapy practice forward. I believe it is every health practitioner’s duty to study and share with enthusiasm the secrets of good health. We should work in the wellness industry with preventative health advice and not just the illness industry”
Nicky’s drive to learn and discover better methods to treat pain was ignited by her frustration as a child watching her mother suffer years of terrible back pain. Despite Nicky’s mother seeing numerous professionals nothing ever really helped.
A qualified biologist, physiotherapist, spinal pain specialist and author; Nicky’s career has taken to her to China, Korea, Canada and many European countries, where she has been privileged to work alongside many pioneers in their field. Nicky is one of the few people in the world to have achieved the highest level of qualification and the first practitioner in the world to be awarded a fellowship from the Institute for the Study and Treatment of Pain.
It’s this work Nicky continues at her two clinics in Stafford and Harrogate.
Welcome back to the series of articles about physiotherapy and tennis elbow (also known as lateral epicondylitis, lateral epicondylosis and lateral epicondylalgia). So far we have covered who is affected by tennis elbow, the anatomy of the elbow and which muscles or tendons are most likely to be injured. This article will try to give an overview of a huge subject: the physiology of tendons and why they get injured, now this is a massive topic in physiotherapy and has been the subject of huge amounts of research (and in fact our knowledge on this topic is still developing) so I will only be touching the surface.
Firstly we need to look at what tendons actually are and why they might get injured in tennis elbow. Simply put a tendon is a piece of connective tissue that joins muscle to bone and is comprised of well organised mostly one directional collagen fibres (Wang et al 2003). Unlike muscles tendons can not contract themselves and are relatively inelastic (with a much lower proportion of elastin – only about 1-2% Jozsa & Kannus 1997). So basically muscles do the contraction and force generation but tendons, because they connect to the bones and are relatively inelastic, transfer that force over to the bones and move our joints. A key fact about tendons is that they generally will have a much lower blood supply than muscles and in turn have a lower metabolic rate which affects their ability to heal and makes an injury to a tendon much slower to recover and heal properly (Abate et al 2009). Furthermore the point at which muscle turns into tendon (the musculo-tendinous junction) is the point which is most often injured and is subject to large mechanical forces (Abate et al 2009).
Okay – how does this affect tennis elbow? Well, as we found out in the last article, extensor carpi radialis brevis (ECRB) is the most commonly injured muscle in tennis elbow and this muscle is most commonly injured at either the musculo-tendinous junction or at the lateral epicondyle (bony bit of the elbow) where the common extensor tendon inserts into the bone. Therefore understanding tendons and how they react and function is key to understanding tennis elbow.
The common extensor tendon as shown above is the continuation of all the extensors of the wrist and fingers and therefore any time you extend your wrist or your fingers to pick anything up it is put under stress. So it isn’t really a surprise that if you do too much of anything like picking things up then this tendon may get irritated and sore and that your physiotherapist will be able to find fairly easily a very sore spot on the lateral epicondyle of your elbow.
Next blog post will look in more detail at the physiology of what happens when the tendon gets injured in tennis elbow and hopefully manage to summarise and simplify decades of research on tendinopathies.
Abate M., Gravare-Silbernagel K., Siljeholm C., Di Iorio A., De Amicis D., Salini V., Werner S., Paganelli R. (2009) Pathogenesis of tendinopathies: inflammation or degeneration? Arthritis Research and Therapy 11 (3): 235
Jozsa, L., and Kannus, P., Human Tendons: Anatomy, Physiology, and Pathology. Human Kinetics: Champaign, IL, 1997
Wang J., Jia F., Yang G., Yang S., Campbell B., Stone D., Woo S., (2003) Cyclic Mechanical Stretching of Human Tendon Fibroblasts Increases the Production of Prostaglandin E2 and Levels of Cyclooxygenase Expression: A Novel In Vitro Model Study Connective Tissue Research 44: 128 – 133
Welcome back to the new series of articles about physiotherapy and common injuries and pathologies seen by physiotherapists. Last time we took a brief look at one of the most common musculo-skeletal conditions that a physiotherapist will encounter – tennis elbow (also known as lateral epicondylitis, lateral epicondylosis and lateral epicondylalgia). This article will now look at the anatomy of the elbow and the muscles connected to it in detail so that we can have a good idea of what is hurting or being injured in tennis elbow and can maybe start to have an idea of what causes it.
The elbow is an amazing piece of biomechanical design and is comprised of 3 bones – the humerus which is the upper arm bone and two bones in the forearm called the radius and ulna. The radius runs from the elbow to the thumb and the ulna starts at the bony prominence on the back of your elbow (olecranon process) and runs down to the wrist. To make it easy to remember which bone is which, when I was a student I used to repeat “the ulna is underneath the radius”. Simple I know but effective nonetheless when you are a physio student desperately trying to cram in your anatomical knowledge.
Now as we are looking at tennis elbow we are not going to look or worry too much about the actual elbow joint itself except to say that it has two ways of movement – flexion and extension (basically straightening and bending) and pronation and supination (pronation is rotating the hand palm down and supination palm up). It may seem strange that in a condition called tennis elbow we will be ignoring the elbow joint itself but hopefully the reason why will become clear soon.
The key part of the elbow in tennis elbow that we really need to examine is the lateral epicondyle – this is the point where all of the wrist extensors and finger extensors start from and is the point at which pain is felt in tennis elbow, it is also called the common extensor origin (for reasons which will become apparent soon) and is the site of attachment for the common extensor tendon. Pain here is the cardinal sign for tennis elbow that all physiotherapists look for.
Running from the lateral epicondyle and the common extensor origin are all of the muscles that extend the wrist and the fingers – extensor carpi radialis brevis, extensor carpi ulnaris, extensor digitorum, extensor indicis and extensor digiti minimi. Two other muscles have attachments at the lateral epicondyle – supinator and anconeus. All of these muscles merge together here to form what is known as the common extensor tendon which then attaches to the lateral epicondyle. So it is fairly obvious that this common extensor origin is an important point in wrist and finger extension and may well be a likely site of injury that physiotherapists will need to examine.
Before moving on it is worth considering the actions of a couple of these muscles in more detail extensor carpi radialis brevis and extensor carpi ulnaris have an important synergistic role in stabilising the wrist – they both act at the same time in concert with their flexor brothers (flexor carpi ulnaris and flexor carpi radialis) to prevent side to side movement at the wrist (ulnar and radial deviation). The two extensors also act together at the same time you grip an object to hold the wrist in extension a bit and prevent the finger flexors from flexing the wrist. In fact studies have shown that extensor carpi radialis brevis is the tendon most commonly injured in tennis elbow and the most common point that it is injured at is the common extensor tendon.
So hopefully from the above brief anatomy lesson we can now see that any extension or even flexion of the wrist is going to put a large amount of stress through the common extensor tendon and in turn if this tendon receives any injury we are likely to feel pain at the lateral epicondyle – which is where patients with tennis elbow will normally describe to their physiotherapist that they feel pain when they pick things up.
The next article will look at the physiology and some of the reasons why tendons get injured and why tennis elbow can often become chronic and last for a long time.