To Oina, my wife, for her patience and forbearance during the writing of this book. The phenomena of pain belong to that borderland between the body and soul about which it is so delightful to speculate from the comfort of an armchair, but which offers such formidable obstacles to scientific inquiry. J. H. Kellgren (1948) Extracts from reviews of the first edition: ‘…I warmly recommend this book to anyone who wants to learn more about this often neglected area of common musculoskeletal pain conditions…’ Journal of the Royal College of Physicians of London ‘This is a book that should belong to physicians, neurologists, rheumatologists and teachers of medical students…’ Pain Endorsements of the new edition: ‘Peter Baldry is one of the most respected practitioners of Medical Acupuncture in the UK. This new edition is yet another first-class book, which adeptly combines the theory and practice of treatment of trigger points for musculoskeletal pain. An eminently readable and informative text; this is a tour du forceand an essential acquisition for those practitioners who want a clear practical guide for the treatment of musculoskeletal pain using trigger point treatment and the scientific understanding that underpins the treatment.’ Jacqueline Filshie, Consultant in Anaesthesia and Pain Management, Royal Marsden Hospital, London and Surrey; Secretary of the British Medical Acupuncture Society ‘In this fine comprehensive book, Dr Baldry removes much of the mystique from acupuncture as a technique for musculoskeletal pain relief. Using a fully scientific integration of Eastern and Western knowledge, coupled with the relevant literature on clinical effectiveness of acupuncture, he provides an ideal, evidence-based text for the practitioner. From the beginner to the expert, anyone with an interest in the nature of muscle pain, its pathophysiology and treatment will be informed by this book: the entry-level therapist will gain a better understanding based on sound scientific evidence, while the experienced clinician will be rewarded with a well-written guide to what is significant in everyday clinical practice. Clinicians of several medical specialties (neurologists, orthopaedic surgeons, general practitioners, pain specialists, physiatrists) and other practitioners (acupuncturists, physiotherapists, nurses, occupational therapists) will find this book an indispensable reference in their daily work. For those who wish to implement acupuncture in the clinic, this textbook is an invaluable resource for responsible practice. In total, this book offers an innovative approach to the diagnosis, understanding and treatment of myofascial trigger point pain using acupuncture that integrates all current concepts of neurophysiology and neuroanatomy principles. Dr Peter Baldry is to be congratulated for conceptualizing, editing and writing such a truly valuable asset for every clinical practice.’ Dr George Georgoudis, Research Physiotherapist, University of Manchester, UK; Lecturer, Technological Educational Institute of Athens, Department of Physiotherapy, Greece; “Tzanio” General Hospital of Pireaus, Greece For Elsevier Ltd Commissionning Editor:Karen Morley Project Development Manager:Kerry McGechie Project Manager:Derek Robertson To Oina, my wife, for her patience and forbearance during the writing of this book. The phenomena of pain belong to that borderland between the body and soul about which it is so delightful to speculate from the comfort of an armchair, but which offers such formidable obstacles to scientific inquiry. J. H. Kellgren (1948) Extracts from reviews of the first edition: ‘…I warmly recommend this book to anyone who wants to learn more about this often neglected area of common musculoskeletal pain conditions…’ Journal of the Royal College of Physicians of London ‘This is a book that should belong to physicians, neurologists, rheumatologists and teachers of medical students…’ Pain Endorsements of the new edition: ‘Peter Baldry is one of the most respected practitioners of Medical Acupuncture in the UK. This new edition is yet another first-class book, which adeptly combines the theory and practice of treatment of trigger points for musculoskeletal pain. An eminently readable and informative text; this is a tour du forceand an essential acquisition for those practitioners who want a clear practical guide for the treatment of musculoskeletal pain using trigger point treatment and the scientific understanding that underpins the treatment.’ Jacqueline Filshie, Consultant in Anaesthesia and Pain Management, Royal Marsden Hospital, London and Surrey; Secretary of the British Medical Acupuncture Society ‘In this fine comprehensive book, Dr Baldry removes much of the mystique from acupuncture as a technique for musculoskeletal pain relief. Using a fully scientific integration of Eastern and Western knowledge, coupled with the relevant literature on clinical effectiveness of acupuncture, he provides an ideal, evidence-based text for the practitioner. From the beginner to the expert, anyone with an interest in the nature of muscle pain, its pathophysiology and treatment will be informed by this book: the entry-level therapist will gain a better understanding based on sound scientific evidence, while the experienced clinician will be rewarded with a well-written guide to what is significant in everyday clinical practice. Clinicians of several medical specialties (neurologists, orthopaedic surgeons, general practitioners, pain specialists, physiatrists) and other practitioners (acupuncturists, physiotherapists, nurses, occupational therapists) will find this book an indispensable reference in their daily work. For those who wish to implement acupuncture in the clinic, this textbook is an invaluable resource for responsible practice. In total, this book offers an innovative approach to the diagnosis, understanding and treatment of myofascial trigger point pain using acupuncture that integrates all current concepts of neurophysiology and neuroanatomy principles. Dr Peter Baldry is to be congratulated for conceptualizing, editing and writing such a truly valuable asset for every clinical practice.’ Dr George Georgoudis, Research Physiotherapist, University of Manchester, UK; Lecturer, Technological Educational Institute of Athens, Department of Physiotherapy, Greece; “Tzanio” General Hospital of Pireaus, Greece For Elsevier Ltd Commissionning Editor:Karen Morley Project Development Manager:Kerry McGechie Project Manager:Derek Robertson Distributed in the United States of America by Redwing Book Company, 44 Linden Street, Brookline, MA02146. © Longman Group UK Limited 1993 © Harcourt Brace and Company Limited 1998 © Harcourt Publishers Limited 2000 © Elsevier Ltd 2005 No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without either the prior permission of the publishers or a licence permitting restricted copying in the United Kingdom issued by the Copyright Licensing Agency, 90 Tottenham Court Road, London W1T 4LP. Permissions may be sought directly from Elsevier’s Health Sciences Rights Department in Philadelphia, USA: phone: ((cid:2)1) 215 238 7869, fax: ((cid:2)1) 215 238 2239, e-mail: [email protected]. You may also complete your request on-line via the Elsevier homepage (http://www.elsevier.com), by selecting ‘Customer Support’ and then ‘Obtaining Permissions’. First edition 1989 Second edition 1993 Third edition 2005 Translated into Japanese 1995 Translated into German 1996 ISBN 0 443 06644 2 British Library Cataloguing in Publication Data Acatalogue record for this book is available from the British Library. Library of Congress Cataloging-in-Publication Data Acatalog record for this book is available from the Library of Congress Note Knowledge and best practice in this field are constantly changing. As new research and experience broaden our knowledge, changes in practice, treatment and drug therapy may become necessary or appropriate. Readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of the practitioner, relying on their own experience and knowledge of the patient, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the author assumes any liability for any injury and/or damage. The Publisher The Publisher’s policy is to use paper manufactured from sustainable forests Printed in China Prelims.qxd 13*10*04 14:30 Page vii vii Foreword Quod est ante pedes nemo spectat: coeli Scrutantur evaluation of acupuncture. The results of properly plagas. (What is before one’s feet no one looks at; controlled experiments and trials demonstrating they gaze at the regions of heaven.) the efficacy of acupuncture are slowly but surely Ennius, quoted by Cicero, De Divinat., 2, 13. accumulating and Dr Baldry discusses these criti- cally and points the way to the further rigorous This is an important and valuable book that studies that are urgently needed. The third part of needed to be written. Musculoskeletal or myofas- the book gives a detailed and splendidly practical cial pain is an all too common and extraordinarily account of the many different forms of muscu- neglected subject of medicine; it is barely men- loskeletal pain and the way that these can be treated tioned in many textbooks of medicine. In reality it with acupuncture. is a ubiquitous condition that causes a great deal Even for the reader who does not intend to use of pain and suffering and one which, unfortu- acupuncture, this book still serves a most valuable nately, either slips by unrecognized or is passed purpose by drawing attention to the very large off as trivial or untreatable. In this book Dr Peter number of common musculoskeletal pain condi- Baldry has shown how musculoskeletal pain can tions that are all too commonly overlooked. Apar- be simply and effectively treated by acupuncture. ticularly helpful feature of Dr Baldry’s book is the But this book is much more than that because it is rich admixture of case histories of his own really three books in one. patients, from which the medical reader can learn The first part presents an interesting historical the correct way to diagnose and subsequently to background to Chinese acupuncture and its spread treat these painful conditions. to the outside world, particularly to the West. The There seems little doubt that, through unfamil- second part deals with the principles of trigger iarity with this condition, much time and effort are point acupuncture wherein, over the course of six often expended unnecessarily both by the medical chapters, the reader is presented with a detailed profession and by patients seeking the cause and and critical account of the evidence for and the treatment of pain problems that are, in fact, mus- nature of trigger points and the way in which acu- culoskeletal in origin. Dr Baldry has performed a puncture can be used to deactivate them. Dr Baldry most valuable service in writing this eminently spares no effort to provide the reader with an up-to- readable book and I wish it the very considerable date and accurate account of the neurophysiology success that it richly deserves. of pain and the possible ways in which acupunc- ture can be used to control it. He also grasps the dif- John W. Thompson ficult and important nettle concerning the scientific Prelims.qxd 13*10*04 14:30 Page ix ix Preface The aims of this book point and fibromyalgia syndromes since the 2nd edition of this book was published, that in this edi- It is because traditional Chinese acupuncture is per- tion four chapters in Part 2 (Principles of Trigger force inextricably bound up with archaic concepts Point Acupuncture) have had to be replaced by concerning the structure and function of the body entirely new ones. In addition to these changes that most members of the medical profession in the most of the other chapters in Part 2 and Part Western world view it with suspicion and scepti- 3 (The Practical Application of Trigger Point cism and assign it, together with various other Acupuncture) have had to be extensively revised. seemingly esoteric forms of therapy, to what is It is hoped that as a result of reading this book called alternative or complementary medicine. many more anaesthetists, rheumatologists, ortho- Moreover, it is evident that attempts during the past paedic specialists, general physicians, general prac- 40 years to place Chinese acupuncture on a more titioners and physiotherapists than at present may rational and scientific basis have done little to dispel not only be led to search for trigger points in their this attitude. routine clinical investigation of pain,but may also My reason for writing this book is to bring to the be persuaded to include dry needling at these attention of doctors and physiotherapists a 20th- points in their therapeutic armamentarium. century-evolved scientific approach to acupunc- ture for the relief of pain emanating from trigger Case histories points in the myofascial pain syndrome and from tender and trigger points in the fibromyalgia syn- I offer no apology for having included case histor- drome, and to take acupuncture (so far as the alle- ies in this book. They are, of course, by their very viation of nociceptive pain of this type is concerned) nature essentially anecdotal and certainly no infer- out of the category of alternative or complementry ence is meant to be drawn from them concerning medicine by describing a method of employing it the effectiveness of trigger point acupuncture, for that has been developed as a result of observations any conclusions about that can only come from made by physicians during recent years and is clinical trials. The sole purpose of including these now fast becoming incorporated within the frame- vignettes is to provide illustrations from everyday work of present-day orthodox medical practice. clinical practice that serve to highlight certain It is because there have been so many advances important principles underlying the diagnosis and in our knowledge concerning the pathophysiology, management of various painful musculoskeletal diagnosis and treatment of the myofascial trigger disorders. Prelims.qxd 13*10*04 14:30 Page xi xi Acknowledgements My very sincere thanks are due to Professor John 15.17, 15.23*, 16.8, 16.9, 16.10, 18.1*, 18.6, 18.7*, Thompson for the meticulous manner in which he 18.9*, 18.11*, 20.1, 20.2, 20.5*, 20.6. The illustrations read the manuscript of this book and then gave me from Gray’s Anatomymarked with an asterisk orig- much valuable advice and constructive criticism inally appeared in Quain’s Anatomy11th edition. besides kindly writing a foreword. Finally, I have to thank the following: I wish to express my gratitude to Dr Alexander Dr J. H. Kellgren and the editor of Clinical Science Macdonald for it was he who, some years ago, first for permission to publish Figures 4.1 and 4.2; drew my attention to the aetiological importance Dr Kellgren and the editor of the British Medical of trigger points in the pathogenesis of mus- Journal for permission to publish Figure 4.3; culoskeletal pain and introduced me to trigger Dr Howard Fields and McGraw Hill, New York for point acupuncture as a method of alleviating it. permission to reproduce Figures 6.1, 6.2, 6.3 and I thank Dr Felix Mann for having initially brought 7.3 from Pain1987; Dr David Bowsher and the edi- to my notice the close relationship between trigger tor of Acupuncture in Medicine – The Journal of the points and traditional Chinese acupuncture points. British Medical Acupuncture Society for permission I wish to say how indebted I am to the late to reproduce Figures 6.5 and 9.1; Dr David Simons Drs Janet Travell and Dr David Simons for the and Haworth Press for permission to reproduce very considerable contribution they made to Figure 7.2; Dr Alexander Macdonald and George my knowledge of specific patterns of myofascial Allen & Unwin, London for permission to repro- trigger point pain referral. It has largely been from duce Figures 7.4 and 7.5 from Acupuncture – from studying their descriptions and illustrations Ancient Art to Modern Medicine 1982; Mr R. J. of these patterns in various publications referred D’Souza for providing me with Figure 7.6; to later in this book that I am now able to recog- Professor Yunus and Lea & Febiger, Philadelphia nize them in my own patients. for permission to reproduce Figure 7.7; Dr J. Park I also wish to say how very grateful I am to and the editor of Acupuncture in Medicine for per- Dr David Bowsher, for it has been from him in parti- mission to reproduce Figure 11.1; Dr David Simons cular that I have learnt so much about what is and Churchill Livingstone, Edinburgh for permis- currentlyknown concerning the mechanisms respon- sion to reproduce Figure 16.6 from Textbook of sible for the pain-relieving effect of acupuncture. Pain (Wall P., Melzack R., eds) 2nd edition 1989; I have to thank Professors Peter Williams and Professor R. W. Porter and Churchill Livingstone, Roger Warwick, the editors of Gray’s Anatomy Edinburgh for permission to reproduce Figures (36th edition 1980) and its publishers Churchill 17.2 and 17.3 from The Lumbar Spine and Back Pain Livingstone for giving me permission to repro- (Jason M. I. V., ed) 3rd edition 1987. duce Figures 12.1, 12.5, 12.9, 12.14, 13.12, 15.1, 15.2, P.E.B. ([email protected]) Prelims.qxd 13*10*04 14:30 Page xiii xiii Introduction to the third edition For reasons to be explained later in this book, the needle) for the purpose of stimulating peripheral early 1970s saw the dawn of an era when people in nerve endings, achieves its pain-relieving effect the Western world began taking an increasing inter- by virtue of its ability to evoke activity in pain- estin the ancient oriental mode of therapy known modulating mechanisms present in the peripheral as acupuncture, with lay practitioners of it leading and central nervous systems. the public to believe that it has such wide ranging In the light of this discovery and a number of healing properties as to be an effective alternative others the public in general and the medical pro- to orthodox medicine in the treatment of a large fession in particular have had to revise their atti- number of diseases. tudes towards acupuncture. There is clearly no justification for such extra- Furthermore, when the House of Lords select vagant claims and it has to be said that, at the onset committee in science and technology (2000) took a of this era, the medical profession in Europe and close look at various types of treatment at present America viewed this form of therapy with consid- included within the ambit of complementary/ erable suspicion and continued to do so for so long alternative medicine, it divided them into three as explanations as to how it might work remained groups and placed acupuncture in the one con- inextricably bound up with abstruse concepts for- taining therapeutic procedures deemed to be the mulated by the Chinese 3000 years previously. most organized and regulated. This reluctance to believe in these long-established The committee, in addition, considered that the but somewhat esoteric hypotheses was, of course, research bases of these procedures are of suffi- because they had been conceived at a time when ciently high standards to allow them to be used ideas concerning the structure and function of the within the UK’s National Health Service. body together with those concerning the nature of Prior to the publication of this report the British disease belonged more to the realms of fantasy than Medical Acupuncture Society (1997) had published fact, and for this reason it was difficult to reconcile a discussion paper entitled ‘Acupuncture’s Place them with the principles upon which the present- Within Mainstream Medicine’. In this it was stated: day Western system of medical practice is based. ‘…Medical acupuncture practice depends on During the latter part of the 20th century, how- three important principles: an orthodox Western ever, there has been a considerable increase in diagnosis needs to be made for every patient; knowledge concerning the neurophysiology of acupuncture should be integrated with conven- pain and because of this there is now a scientific tional medicine; and it must be appreciated that explanation for acupuncture’s ability to alleviate the traditional Chinese view of acupuncture is being pain. It has become apparent that this technique, replaced in many areas by an approach based on which involves the use of dry needles (acus(Latin), modern physiology and neuroanatomy. …’ Prelims.qxd 13*10*04 14:30 Page xiv xiv INTRODUCTION TO THE THIRD EDITION In accordance with the above, in 2000 The Royal devised a method of practising it principally for College of Physicians of London set up a subcom- the relief of musculoskeletal pain that may be con- mittee to assist with the present task of bringing sidered to be a forerunner of the somewhat more acupuncture and a strictly selected number of other sophisticated one developed in recent years and hitherto somewhat pejoratively called complemen- described in this book. It is also pointed out that, tary or alternative therapeutic procedures within although physicians who advocated the use of the framework of orthodox medical practice. acupuncture in the Western world during the last Lewith et al (2003), moreover, during the course century wrote enthusiastically about it, it was never of discussing the current status of certain thera- widely practised by their contemporaries, mainly peutic procedures in the Journal of the Royal College it would seem because at that time there was no of Physicians of London, including acupuncture, made satisfactory explanation as to the manner in which the following two apposite comments concerning it might work. the latter: (1) ‘needling trigger points is particu- In Part 2 attention is drawn to fundamental lab- larly effective in the treatment of pain’; (2) oratory investigations into the phenomenon of ‘acupuncture is currently used in at least 84% of referred pain from musculoskeletal structures car- pain clinics in the UK…’ ried out by J. H. Kellgren at University College Apaucity of suitably funded research has been Hospital, London, in the late 1930s. In addition it the principle hindrance to getting certain therapeut- is explained how these investigations prompted ic procedures including acupuncture integrated many physicians during the 1940s, in particular within the fabric of conventional medical practice. the late Janet Travell in America, to study the clin- This has prompted Lesley Rees, Director of Edu- ical manifestations of this particular type of pain, cation at the Royal College of Physicians of London and how, as a result of this, she came to recognize and Andrew Weil, Professor of Medicine at the Uni- the importance of what she termed trigger points versity of Arizona (Rees & Weil 2001), to emphasize as being the source of pain in many commonly the need for the NHS research and development occurring musculoskeletal disorders. directorate and the Medical Research Council to It is also shown how once it had been discover- now help correct this unfortunate state of affairs. ed that it is possible to alleviate such pain by The purpose of this book is to discuss the scien- injecting trigger points with a local anaesthetic or tific aspects of acupuncture in general and trigger with one or other of a variety of different irritant point acupuncture in particular and to show how substances, it was found that this could be accom- this latter type of therapy can readily be used by plished even more simply, as well as more safely doctors and physiotherapists in the treatment of and equally effectively, by means of the carrying the myofascial pain and fibromyalgia syndromes. out of needle-evoked nerve stimulation at trigger For those trained in the Western system of medi- point sites. cine there are obvious advantages in using this Part 2 also contains a brief account of advances particular method rather than the traditional in knowledge concerning the neurophysiology of Chinese one, but clearly these advantages cannot pain during the 1960s and 1970s and describes the be fully appreciated without knowing something various pain-modulating mechanisms now consid- about the latter. This book is, therefore, divided into ered to be brought into action when acupuncture is three parts with Part 1 containing a brief account carried out. In addition, it includes a discussion of of traditional Chinese acupuncture. It also gives some of the difficulties so far encountered in scien- reasons as to why doctors in Europe on first learn- tifically evaluating the pain-relieving efficacy of this ing about this type of treatment in the 17th century particular type of therapy and in determining its rejected it, and describes how certain 19th-century place relative to other forms of treatment in the alle- European and American doctors, having put on viation of musculoskeletal pain. one side what they considered to be unacceptable Part 3 is devoted to the practical applications of Chinese concepts concerning this mode of therapy, trigger point acupuncture. Prelims.qxd 13*10*04 14:30 Page xv Introduction to the third edition xv References British Medical Acupuncture Society 1997 Acupuncture’s Lewith G T, Breen A, Filshie J, Fisher Pet al 2003 place within mainstream medicine. Acupuncture in Complementary medicine: evidence base, competence to Medicine 15(2): 104–107 practice and regulation. Clinical Medicine (Journal of the House of Lords Select Committee on Science and Royal College of Physicians of London) 3(3): 235–240 Technology 2000 6th report, Session 1999–2000. Rees L, Weil A2001 Integrated medicine. British Medical Complementary and alternative medicine. Stationary Journal 322: 119–120 Office, London Chap-01.qxd 11*10*04 10:11 Page 3 3 1 Chapter Traditional Chinese acupuncture The Chinese first carried out acupuncture, that CHAPTER CONTENTS seemingly strange practice whereby needles are inserted into people for therapeutic purposes, at Ancient Chinese concepts concerning the least 3000 years ago. News of this, however, did not practice of acupuncture and moxibustion reach the Western world until about 300 years ago when European medical officers employed by the Dutch East Indies Trading Company in and around Java saw it being used there by the Japanese, and when at about the same time Jesuit missionaries came across it whilst endeavouring to convert the Chinese to Christianity. From their writings it is clear that both these groups found the concepts upon which the Chinese based their curious practice difficult to comprehend, due to the fact that these appeared to be completely at variance with what Europeans by that time had come to know about the anatomy and physiology of the human body. And it has been this inability to reconcile the theoretical concepts put forward by the Chinese in support of acupuncture with those upon which modern scientific medicine is based that has for so long been the cause of such little interest being taken in it in the Western world. During the past 30 years, however, attitudes towards acupuncture in the West have been changing since research into the mechanisms of pain has provided a certain amount of insight as to how possibly it achieves its effect on pain. These, as might be expected, are entirely different from those origi- nally put forward by the Chinese. The prime purpose of this book is to describe a recently developed method of practising acupunc- ture in which dry needles are inserted into the tis- sues overlying what have come to be known as