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 At the muscle belly, the needle was partially withdrawn and re-angled using a fanning technique to target 3-4 unique points within a narrow cone-shaped area.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) .