Abstract Nonspecific lower back pain affects a major part of the population at a certain point of their life. The intensity of pain can be debilitating and it causes a significant burden on society. Trigger point dry needling is a method of alleviating such pain by the introduction of needles into trigger points in muscles. A growing body of evidence supports its use in myofascial pain and specifically lower back pain. Submarine Medicine is a unique field due to the special characteristics and the environment of the submarine. It poses challenges that are not always seen by primary care physicians. Here, we present a case of a 40-yr-old senior submarine officer who complained of pain in his lower back and pelvis before departing on a mission. The pain persisted in spite of treatment with nonsteroidal anti-inflammatory drugs and he was then treated by the submarine’s physician with trigger point dry needling. The officer showed rapid improvement following this treatment, both regarding pain and the range of motion. Introduction Lower back pain (LBP) is a common complaint with widespread detrimental effects on function and quality of life.1 Over 85% of LBP patients present with nonspecific low back pain.2,3 Numerous studies have shown that maintaining a steady posture without mobilization increases the incidence of lower back pain,4,5 both in civilians and in military personnel. It has also been shown that postures maintained in certain army conditions increase the biomechanical stress on the spine.6 Myofascial pain is defined as pain originating from trigger points in the muscle and its fascia. About one-third of the patients presenting to primary care with pain are found to have myofascial pain as its cause.7 A trigger point (TrPt) is defined as a hyperirritable spot within a taut band of a skeletal muscle that is painful on palpation or muscle contraction and usually presents with a typical referred pain pattern distant from the spot. Very often, there are palpable nodules within the muscle with the size ranging from 2 to 10mm.8 “Dry needling” (DN) is a technique that helps to release trigger points by the introduction of needles into these points.9 This method has been shown to alleviate myofascial pain.10 Dry needling has been found to be effective in the treatment of lower back pain,11,12 including radiating pain.13 Medicine in a submarine has unique attributes and the nature of the submarine environment will influence the decisions of the medical officer.14 There may be long journeys to distant locations, communication with headquarters may be limited, as will be the ability to evacuate patients. One can only bring a certain amount of medical equipment and drugs and the treatment has to be done in a small space. A submarine physician has to be independent, capable of good and quick decision making, as well as creative sometimes. The physician’s ability to contain medical situations at sea may have significant tactical importance. TrPt DN has been implemented in the military.15,16 It has even been offered as a tool that could be used by medics in special operation units.17 To our knowledge, there is no description of TrPt DN during a submarine operation. We present here a case of severe debilitating myofascial pain treated by the medical officer during a submarine military mission with excellent results (Table I). A summary of the clinical course from initial presentation and following treatment with trigger point dry needling (TpDN) is presented in Table I. Table I. Clinical Outcomes 24 h Before Departure Second Day Off Shore 3 h Post-Needling 4 d Post-treatment Week After Treatment Pain (on a scale of 0–10) 8 8 3–4 0 0 Range of motion Limited Limited Minimal limitation Normal Normal Medical treatment Nonsteroidal anti-inflammatory drugs TpDN: paracetamol and orphenadrin Paracetamol and orphenadrin None None 24 h Before Departure Second Day Off Shore 3 h Post-Needling 4 d Post-treatment Week After Treatment Pain (on a scale of 0–10) 8 8 3–4 0 0 Range of motion Limited Limited Minimal limitation Normal Normal Medical treatment Nonsteroidal anti-inflammatory drugs TpDN: paracetamol and orphenadrin Paracetamol and orphenadrin None None Table I. Clinical Outcomes 24 h Before Departure Second Day Off Shore 3 h Post-Needling 4 d Post-treatment Week After Treatment Pain (on a scale of 0–10) 8 8 3–4 0 0 Range of motion Limited Limited Minimal limitation Normal Normal Medical treatment Nonsteroidal anti-inflammatory drugs TpDN: paracetamol and orphenadrin Paracetamol and orphenadrin None None 24 h Before Departure Second Day Off Shore 3 h Post-Needling 4 d Post-treatment Week After Treatment Pain (on a scale of 0–10) 8 8 3–4 0 0 Range of motion Limited Limited Minimal limitation Normal Normal Medical treatment Nonsteroidal anti-inflammatory drugs TpDN: paracetamol and orphenadrin Paracetamol and orphenadrin None None Case Presentation A 40-yr-old male senior officer in an Israeli navy submarine, without significant medical history, presented at the shore-based clinic 24 h before departing on a mission with pain in his lower back, mainly on the left, and his left pelvis. His movement was partially limited because of pain. When asked about his pain intensity, he described it as 8 out of 10. The pain was not preceded by trauma, strenuous physical activity, or a long period of being seated, and he had no similar pain in the past. He did not suffer from urinary incontinence. On examination, he had normal motor function and tactile sensation in both lower limbs, normal and symmetrical patellar and achilles tendon reflexes and negative “Straight Leg Raise” tests bilaterally. He did, however, suffer from paravertebral tenderness on the left of his lumbar vertebrae, with no tenderness directly over the vertebrae. As there were no red flags, no imaging was done and intramuscular injection of 75 mg diclofenac was administered, followed by 400 mg etodolac per dose, three times a day. Two days later, on the second day at sea, he presented to the submarine physician with debilitating pain, claiming no improvement in spite of the medication that had been prescribed by the physician that had previously helped him. He was unable to function normally and was bedridden. He described the intensity of pain as 8 out of 10, the same as before the current medical treatment. On examination aboard the submarine, he had significant tenderness with a palpable taut band on the erector spinae muscles and a palpable trigger point on his left gluteus maximus. Dry needling was performed to the erector spinae muscles and the left gluteus. The procedure was done using solid filament needles (0.3 × 60 mm for the erector spinae and 0.3 × 100 mm for the gluteus). The needle was inserted and partially withdrawn from the treated muscle, in order to produce twitch response. Due to potential post-needling soreness, the timing of treatment was postponed for several hours, to a time that was tactically convenient, and a combination pill of 500 mg paracetamol and 30 mg orphenadrin was prescribed, replacing etodolac. His job on the submarine did not allow any activity limitations; also local cooling or heating was not available. Three hours post-needling, his pain improved to a level of 3–4 out of 10, with minimal limitation to his range of movement. A follow-up 4 d after the treatment showed complete resolution of the pain, no limitation in the range of motion, and no symptoms at all, making no further medical treatment necessary. One week post-treatment, he was still symptom-free and kept normal function. Discussion Lower back pain, especially among key crew members, can seriously affect a submarine’s ability to complete its mission. A submariner’s clear mind and quick responses can be critical both to completion of the mission and to the submarine’s safety. The working environment in submarines, although mostly sedentary, can require long durations of standing and crouching. Part of the routine work in a submarine includes long periods of sitting down or standing up in a specific posture and this can result in a higher incidence of lower back pain. For example, while using a periscope, one may have to stand for long periods of time, while bending or even crouching, which can increase the biomechanical stress. In the case presented above, the submarine’s physician was a primary care military general practitioner. He had completed a 20-hour long practical course on dry needling. This course is an official course of the Israeli Musculoskeletal Society under the auspices of the Israel Medical Association.18 He had experience using the technique both at the base clinic and at sea. This case shows the tactical benefit of treatment with dry needling – improvement of the fitness of a significant crew member, quickly and during the course of the journey. The main challenge of this medical case was giving the best possible care that the submarine medical doctor could provide by himself, without the possibility for referral and very limited ability to consult. TrP DN is a common procedure in physiotherapy clinics and is also done by a growing number of primary care physicians. It requires very little equipment and can therefore be easily carried out in austere environments, in a similar way that it is done in the shore clinic. Acupuncture is another treatment using needling, shown to reduce patients’ lower back pain and improve their function.11 In our opinion, TrP DN has the advantage of a shorter training period, enabling the easy incorporation into military medical officer training. The use of dry needling has, in fact, been recently implemented among doctors of the Israeli navy submarine flotilla. Even though the personal experience of the current Israeli submarine doctors is very good, further investigation is needed regarding the use of dry needling by primary care physicians in austere environments. Funding Article submission fee was paid by Rambam Health Care Campus, Haifa. References 1 Hoy D, March L, Brooks P, et al. : The global burden of low back pain: estimates from the Global Burden of Disease 2010 study. Ann Rheum Dis 2014; 73( 6): 968– 74. doi:10.1136/annrheumdis-2013-204428. Google Scholar CrossRef Search ADS PubMed 2 van Tulder MW, Assendelft WJ, Koes BW, Bouter LM: Spinal radiographic findings and nonspecific low back pain. A systematic review of observational studies. Spine (Phila Pa 1976) 1997; 22( 4): 427– 34. Google Scholar CrossRef Search ADS PubMed 3 Chou R, Qaseem A, Snow V, et al. : Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med 2007; 147( 7): 478– 91. Google Scholar CrossRef Search ADS PubMed 4 Lis AM, Black KM, Korn H, Nordin M: Association between sitting and occupational LBP. Eur Spine J 2007; 16( 2): 283– 98. doi:10.1007/s00586-006-0143-7. Google Scholar CrossRef Search ADS PubMed 5 Pelham TW, White H, Holt LE, Lee SW: The etiology of low back pain in military helicopter aviators: prevention and treatment. Work 2005; 24( 2): 101– 10. Google Scholar PubMed 6 Berry DB, Rodriguez-Soto AE, Su J, et al. : Lumbar spine postures in marines during simulated operational positions. J Orthop Res 2017; 35( 10): 2145– 53. doi:10.1002/jor.23510. Google Scholar CrossRef Search ADS PubMed 7 Skootsky SA, Jaeger B, Oye RK: Prevalence of myofascial pain in general internal medicine practice. West J Med 1989; 151( 2): 157– 60. http://www.ncbi.nlm.nih.gov/pubmed/2788962%5Cnhttp://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC1026905. Google Scholar PubMed 8 Simons DG, Travell JG: Myofascial Pain and Dys-Function: The Trigger Point Manual. Vol 1, Upper Half of Body , ed 3, Baltimore, MD, Williams & Wilkins, 1999. 9 Lewit K: The needle effect in the relief of myofascial pain. Pain 1979; 6: 83– 90. Google Scholar CrossRef Search ADS PubMed 10 Tekin L, Akarsu S, Durmuş O, Çakar E, Dinçer Ü, Kiralp MZ: The effect of dry needling in the treatment of myofascial pain syndrome: A randomized double-blinded placebo-controlled trial. Clin Rheumatol 2013; 32( 3): 309– 15. doi:10.1007/s10067-012-2112-3. Google Scholar CrossRef Search ADS PubMed 11 Furlan AD, van Tulder MW, Cherkin D, et al. : Acupuncture and dry-needling for low back pain. Cochrane Database Syst Rev 2005; ( 1): CD001351. doi:10.1002/14651858.CD001351.pub2. 12 Liu L, Huang Q-M, Liu Q-G, et al. : Evidence for dry needling in the management of myofascial trigger points associated with low back pain: a systematic review and meta-analysis. Arch Phys Med Rehabil 2018; 99( 1): 144– 55.e2. doi:10.1016/j.apmr.2017.06.008. Google Scholar CrossRef Search ADS PubMed 13 Mahmoudzadeh A, Rezaeian Z, Karimi A, Dommerholt J: The effect of dry needling on the radiating pain in subjects with discogenic low-back pain: a randomized control trial. J Res Med Sci 2016; 21( 1): 86. doi:10.4103/1735-1995.192502. Google Scholar CrossRef Search ADS PubMed 14 Hornez E, Gellie G, Entine F, et al. : Is there still a benefit to operate appendiceal abscess on board French nuclear submarines? Mil Med 2009; 174( 8): 874– 7. Google Scholar CrossRef Search ADS PubMed 15 Guthrie RM, Chorba R: Physical therapy treatment of chronic neck pain a discussion and case study: using dry needling and battlefield acupuncture. J Spec Oper Med 2016; 16( 1): 1– 5. Google Scholar PubMed 16 Rock JM, Rainey CE: Treatment of nonspecific thoracic spine pain with trigger point dry needling and intramuscular electrical stimulation: a case series. Int J Sports Phys Ther 2014; 9( 5): 699– 711. Google Scholar PubMed 17 Cavett T, Solarczyk J: Trigger-point dry needling for the SOF Medic. J Spec Oper Med , 16( 4): 33– 9. PubMed 18 Ratmansky M, Minerbi A, Kalichman L, et al. : Position statement of the Israeli Society for Musculoskeletal Medicine on Intramuscular Stimulation for Myofascial Pain Syndrome – a Delphi process. Pain Pract 2017; 17( 4): 438– 46. doi:10.1111/papr.12491. Google Scholar CrossRef Search ADS PubMed Author notes The views expressed are solely those of the authors and do not reflect the official policy or position of the Israeli Army, Israeli Navy, Israeli Air Force, the Israeli Ministry of Defense, or the Israeli Government. © Association of Military Surgeons of the United States 2018. All rights reserved. For permissions, please e-mail: firstname.lastname@example.org. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)
Military Medicine – Oxford University Press
Published: Apr 4, 2018
It’s your single place to instantly
discover and read the research
that matters to you.
Enjoy affordable access to
over 18 million articles from more than
15,000 peer-reviewed journals.
All for just $49/month
Query the DeepDyve database, plus search all of PubMed and Google Scholar seamlessly
Save any article or search result from DeepDyve, PubMed, and Google Scholar... all in one place.
Get unlimited, online access to over 18 million full-text articles from more than 15,000 scientific journals.
Read from thousands of the leading scholarly journals from SpringerNature, Elsevier, Wiley-Blackwell, Oxford University Press and more.
All the latest content is available, no embargo periods.
“Hi guys, I cannot tell you how much I love this resource. Incredible. I really believe you've hit the nail on the head with this site in regards to solving the research-purchase issue.”Daniel C.
“Whoa! It’s like Spotify but for academic articles.”@Phil_Robichaud
“I must say, @deepdyve is a fabulous solution to the independent researcher's problem of #access to #information.”@deepthiw
“My last article couldn't be possible without the platform @deepdyve that makes journal papers cheaper.”@JoseServera