The 2-Needle Technique
By Alejandro Elorriaga Claraco, MD
The "2-needle technique," a relatively unknown
acupuncture method for the treatment of chronic musculoskeletal pain,
is useful for trigger point inactivation in muscles, ligaments, and/or
periosteum. Indications, procedure, treatment precautions, and the role
of trigger point inactivation in the treatment of chronic musculoskeletal
pain is discussed.
Musculoskeletal Pain, Chronic Pain, Trigger Point, Acupuncture Point,
Electro-Acupuncture, Dispersion Technique
Chronic and recurrent pain of musculoskeletal origin is a prevalent
problem.1 Several theories have been offered to explain the possible
pathophysiology of chronic musculoskeletal pain. One widely accepted
theory postulates that pain occurs as a result of increased neurological
activity from trigger points that develop in different tissues (e.g.,
muscle, fascia, periosteum) in response to sustained mechanical overload
associated with metabolic and histological factors still poorly understood.2
Another theory links chronic musculoskeletal pain with the development
of radiculopathy and neuropathy secondary to spondylosis.3 Whatever
the common mechanisms involved, in practice, many of these chronic conditions
share a clinical feature: the presence of discrete foci of neurological
hyperactivity that appear to be the source of most of the pain. Effective
therapeutic interventions used for the treatment of chronic musculoskeletal
pain and dysfunction include several forms of "wet" and "dry"
needling: trigger point injection,2 intramuscular stimulation,3 osteopuncture,4
In the acupuncture tradition, different schools have developed different
approaches to the treatment of musculoskeletal pain. All approaches,
however, have acknowledged the need of treating "tender spots"
(Ah Shi points, Kori) to achieve a successful outcome. Contemporary
practitioners usually include 1 or more of these points in their therapeutic
regimen for the treatment of musculoskeletal pain.3-6
Also in the acupuncture tradition, another lesser known needling technique
for the treatment of tender spots is the 2-needle technique, which consists
of the insertion of 2 acupuncture needles, close on the skin surface,
aiming toward the same tender spot deeper into the tissues. This technique
is used to treat chronic musculoskeletal pain by deactivating foci of
neurological hyperactivity located in muscle, tendon, ligament, joint
capsule, periosteum, or in any of the interfaces between these tissues.7
The author has found the 2-needle technique to be useful in the treatment
of chronic myofascial pain (e.g., myofascial trigger points at levator
scapulae, upper trapezius, or gluteus medius), chronic low back pain
(e.g., periosteal trigger points on lumbar vertebrae, sacrum, or ilium),
chronic neck pain and headaches (e.g., deep trigger points in the suboccipital
muscles), chronic articular problems (e.g., capsular trigger points
on osteoarthritic hips, knees, and small joints), and to address the
axial component of many chronic pain problems in the limbs (e.g., myofascial
trigger points in the upper thoracic deep paravertebral musculature
in cases of lateral epicondylar pain).
Mechanism of Action
The mechanism of action of local acupuncture techniques such as osteopuncture,4
surface energetics,5 and intramuscular stimulation3 remains conjectural.
Speculations about possible mechanisms of action of the 2-needle technique
include relief of local pressure by bursting collections of inflammatory
tissue encapsulated in anti-inflammatory tissue, something akin to a
dental abscess, and inactivation of foci of sympathetic hyperactivity,
especially on the paravertebral muscles, which may be causing persistent
neurological facilitation on the peripheral territories supplied by
that spinal segment.
Materials and Methods
The equipment consists of acupuncture needles, 0.20 to 0.25 mm in diameter
and 10 to 120 mm in length, and an acupuncture electrostimulator able
to deliver impulses at a frequency range of 2 to 10 Hz. Although no
controlled studies of 2-needle acupuncture have been published, it appears
that the type of wave delivered by the electrostimulator does not affect
the outcome. The most important factor for a successful clinical outcome
appears to be the precise identification of the point(s) to be needled.
Point selection involves identifying the source of neurological hyperactivity
responsible for most of the pain in a particular region. Often, this
focus is close to the painful area (e.g., at the levator scapulae insertion
in some cases of neck pain), but sometimes may be quite distant (e.g.,
T2-T4 paravertebral musculature in some cases of lateral epicondylar
The points to be needled are located using appropriate examination and
palpation techniques. Knowledge of referred pain patterns, autonomic
and segmental innervation, and periosteal and capsular distribution
of tender points is mandatory.2 The most effective points will be those
exquisitely tender on palpation that also give referred pain or trigger
autonomic phenomena when compressed.
For chronic upper limb problems (e.g., lateral epicondylar pain), the
author palpates for tender points in the cervical and upper thoracic
paravertebral musculature. For chronic lower extremity problems, the
lower thoracic and lumbosacral levels are palpated. Often, trigger points
may be situated deep in the paravertebral gutter and be difficult to
detect. One recommendation is to assist the palpating hand by compressing
the tissues simultaneously with the other hand; another recommendation
is to palpate the back with the patient lying prone or in the lateral
recumbent position, relaxed and comfortably positioned.
Foci of abnormal hyperactivity are situated at different depths depending
on the tissue and the anatomical region. To help with precision, the
author recommends keeping the tissues compressed during insertion until
the target is reached, and then releasing the tissue slowly while the
needle is held in place with the insertion hand. When using the technique,
trying to visualize the different layers of tissues as the needle passes
through helps to keep the target in sight. In addition, proprioceptive
information from the patient is constantly received by the noninsertion
hand, which is compressing the tissues during the whole process.
Once the needles are in place, they can be left untouched for the whole
length of the treatment, be thrust once or several times during the
treatment, or be connected to an acupuncture electrostimulator at a
low frequency (2-8 Hz) that is strong but comfortable for the patient.
The author typically uses electrostimulation in the upper and lower
back and limbs, but prefers to use it sparingly in the neck area to
avoid autonomic overstimulation. When using electrical stimulation with
this technique over muscular trigger points, sometimes muscle contraction
will be elicited. If this contraction is not uncomfortable for the patient,
it should be allowed to happen; the treatment appears to be more effective
when muscle contraction is elicited.
When using the 2-needle technique, occasionally a needle shock reaction
may occur, most frequently when treating the neck area, particularly
in the sitting position. Foci of neurological hyperactivity are very
active autonomically (sympathetic hyperactivity), and sometimes, stimulation
of those areas, even during examination, may trigger pain with concomitant
autonomic phenomena such as hypotensive reaction, nausea, malaise, dizziness,
or cold sweat. The author recommends limiting the number of points treated
with this technique to 4 or fewer per session, and not to repeat treatment
exactly in the same area for a few days, until the full effect of the
first treatment occurs.
The duration of treatment is determined by physician experience, by
asking the patient whether the local pain has diminished, and by observing
local changes in the skin and/or general signs of autonomic overstimulation.
Occasionally, an unpleasant reaction during the treatment session or
the following day may occur. Thus, it is advisable to start with short
treatments (a few minutes), and at the following session, use feedback
from the patient to adjust treatment duration. The recommended stimulation
time for this technique is from 2 to 3 minutes to 10 to 15 minutes maximum.
The number of treatments needed in a given area will range from a few
in an isolated episode of musculoskeletal pain in an otherwise healthy
patient, to regular repetition in patients with chronic pain. The success
rate of inactivating trigger points using this technique is higher than
with any other dry needling approach, though no formal studies can validate
this opinion. The author believes that this technique is more effective
when used in the context of an overall energy movement through the acupuncture
Usually, some immediate pain relief is evident following 2-needle acupuncture.
Improvements of 15% to 20% or more on a pain visual analog scale are
considered very good. In general, further improvement follows within
a few days. Occasionally, the effects of this technique are immediate;
however, most of the time, several days and repeated treatments are
necessary to see full pain relief. If a satisfactory response is not
achieved within a few treatments, a more careful selection of the point
is imperative. Generally, for a completely successful outcome, the point
to be treated has to be the one that reproduces the referred pain, or
be a paravertebral point located on the relevant somatic or autonomic
segmental levels associated with the painful area.
There are several styles and schools of acupuncture, different types
of needles, and various techniques of insertion into the human body.
However, when treating musculoskeletal pain and dysfunction, what appears
to have the greatest impact in the treatment outcome is the practitioner's
ability to find and needle the most tender points, whether or not they
coincide with classic acupuncture points. As in classic acupuncture
points, tender points seem to be effective stimulation sites located
in different tissues of the musculoskeletal system.6 The 2-needle technique
demonstrates how needling these effective stimulation sites can produce
a significant change in cases of chronic musculoskeletal pain. Other
examples of effective use of tender-point needling are reported in the
English literature,3-6 and some current reports have been published
in acupuncture journals about the strong therapeutic effect of deep
needling of a single acupuncture point.8-10
The 2-needle technique, when used regularly, helps refine the practitioner's
ability to find the ultimate origin of musculoskeletal pain and to develop
a precise proprioceptive touch. However, more is not always better,
and inserting 3 needles instead of 2 into the same spot is of no benefit,
usually causing more irritation at the trigger point instead of deactivating
1. Culliton PD. Current utilization of acupuncture by United
States patients. In: Program and abstracts of the NIH Consensus Development
Conference on Acupuncture; November 3-5, 1997; Bethesda, Md.
2. Travell JG, Simons DG. Travell & Simons' Myofascial Pain
and Dysfunction: The Trigger Point Manual. Vol 1. Baltimore, Md: Williams
& Wilkins; 1983.
3. Gunn CC, Wall PD. The Gunn Approach to the Treatment of Chronic
Pain: Intramuscular Stimulation for Myofascial Pain of Radiculopathic
Origin. 2nd ed. Singapore: Churchill Livingstone; 1996.
4. Helms J. Acupuncture Energetics: A Clinical Approach for Physicians.
Berkeley, Calif: Medical Acupuncture Publishers; 1995.
5. Seem M. A New American Acupuncture: Acupuncture Osteopathy:
The Myofascial Release of the Bodymind's Holding Patterns. Boulder,
Colo: Blue Poppy Press; 1995.
6. Wong J, Cheng R. The Science of Acupuncture Therapy. 2nd rev
ed. Hong Kong: Kola Mayland Co; 1987.
7. Langrick R. The Needle Game. Altona, Manitoba: Friesens Printers;
8. Wang S, et al. Chronic headache treated by one point multi-needle
acupuncture: a report of 60 cases. Int J Clin Acupuncture. 1994;5:451-453.
9. Dong Z. Treating vascular migraine with deep acupuncture at
Fengchi: a report of 240 cases. Int J Clin Acupuncture. 1994;5:455-458..
10. Hou A. Treatment of migraine by needling Yifeng. Int J Clin
Dr Alejandro Elorriaga Claraco is a Research Fellow in Anaesthesiology
and formerly, a Clinical Fellow in Sports Medicine. He is chief lecturer
and course coordinator of the McMaster CME course, "Medical Acupuncture
for the Treatment of Pain," at McMaster University, Hamilton, Ontario.
Dr Claraco's specialty is Sports Medicine (Spain), and he is a Clinical
Preceptor and Lecturer for the UCLA Medical Acupuncture for Physicians
McMaster University, Dept of Anaesthesia
Health Sciences Centre
1200 Main St W
Hamilton, Ontario, Canada L8N 3Z5
Phone: (O)905-521-2100, #75175, (H)905-572-9510