Interventions
Cervical and thoracic mobilization was performed at the initial visit
and the patient was provided a home exercise
program.70 At the second visit, 1-week following
initial evaluation, DN was performed and was directed to the levator
scapulae muscle belly one thumb width medial and cephalad to the
superior angle of the scapula and to the distal teno-osseous attachment,
bilaterally. The patient was placed in a prone position with his arm
internally rotated behind the back and a rolled towel placed under the
anterior shoulder to further expose the superior angle of the scapula. A
pincer grip was used to bracket the superior angle of the scapula as
well as draw the tissue superiorly, thus avoiding proximity to the
ribcage and underlying lungs. Seiren needles (0.30 mm diameter x 50 mm
length) were inserted obliquely from lateral-to-medial,
superior-to-inferior and posterior-to-anterior through the upper
trapezius and into the levator scapulae muscle belly, one thumb width
medial and cephalad to the superior angle of the scapula (Figure
1 ). At the muscle belly, the needle was partially withdrawn and
re-angled using a fanning technique to target 3-4 unique points within a
narrow cone-shaped area. The observation or lack thereof for local
twitch responses during DN did not appear to correlate with a subjective
change of symptoms, consistent with a recent literature review that
concluded that local twitch responses during DN are not necessary for
analgesia.71
Periosteal pecking at the distal enthesis of the left and right levator
scapulae was also performed at the junction between the root of the
spine of the scapula and the superior angle of the scapula, bilaterally
(Figure 1 ). The superior angle was marked superiorly by the
left index finger and medially by the third (long) finger to ensure the
needle did not migrate superiorly or medially and miss the scapula. The
patient reported reproduction of headache symptoms during unidirectional
winding of the needle targeting the distal MTrPs and enthesis of the
levator scapulae muscle, bilaterally. The technique of winding or
twisting needles enhances the physiological effects of dry needling, by
increasing local tissue stimulation, activating mechanoreceptors and
subsequently amplifying the transmission of sensory signals to the
central nervous system.72 This heightened sensory
input has been linked to the release of neurotransmitters, including
endorphins and serotonin, which are crucial for pain modulation and
regulation.73 Interstitial adenosine, one of the
body’s natural anti-inflammatory mechanisms, has been shown to remain
elevated for 30 minutes post needle insertion, if the needle is inserted
and unidirectionally rotated.74
All interventions performed during each session along with prescribed
home exercise program can be found in (Table 2) .