2. Definition
History
Dry Needling vs. Acupuncture
Application
Scope of Practice
Billing
Questions?
3. APTA (2012):
“Dry needling is a skilled intervention provided by
physical therapists that uses a thin filiform needle to
penetrate the skin and stimulate underlying
myofascial trigger points, muscular tissues, and
connective tissues for the management of
neuromuscular pain and movement impairments.
4. Acupuncture" refers to a form of health care, based
on a theory of energetic physiology that describes
and explains the interrelationship of the body
organs or functions with an associated acupuncture
point or combination of points located on
"channels" or "meridians".
6. Western Philosophy
Dry Needling
History
Behavior of symptoms
Pain patterns
Objective evaluation
Functional testing
Traditional Chinese
Medicine
Acupuncture
Meridians of the body
Tongue:
▪ color
▪ hydration
Pulse diagnosis
▪ Rate
▪ Quality
▪ Tooth indentations
8. 1816 - Balfour: thickenings which were painful to the
touch
1930 - Kellgren: referred pain patterns
1940 - Karl Lewit:The Needle Effect
1952 -Travell: myofascial trigger points
1966 -Travell & Mennell: founded the North
American Academy of Manipulative Medicine
9. 1983 – Simons and
Travell:Trigger Point
Manual
1996: Chan Gunn –
Intramuscular
stimulation for pain of
radicular origin
2000’s: PT’s perform
Dry Needling
11. Hyperirritable spot in a taut band of skeletal muscle
fibers.
Active: pain in response to movement, stretch or
compression,
Latent: pain or discomfort in response to
compression only
13. Excessive acetylcholine (ACh) release in the
neuromuscular junction at the motor endplates
Abnormal endplate potential
The development of a taut band
EMG: Amplitude changes of SEA; Endplate noise
14. Sustained sarcomere contractures
Local ischemia and hypoxia.
Vasoactive and algogenic substances are released
Sensitize peripheral nociceptors
15.
16. Sensitize dorsal horn neurons and supraspinal
structures
Hyperalgesia: increased sensitivity to pain
Allodynia: pain due to a stimulus which does not
normally provoke pain
Referred pain
17. Local twitch response (LTR).
Involuntary spinal reflex
localized contraction of affected muscle fibers
that are being dry needled.
DN is most effective when these LTRs are elicited.
18. 1st:
insertion of a needle at the endplate region
reduce available ACh stores
leading to a lesser SEA.
2nd:
LTR causes alterations in the length and tension of
the muscle fibers
stimulates mechanoreceptors
19. Axon reflex caused by LTR
Release of vasoactive substance, such as CGRP and
SP
Leads to
vasodilatation in small vessels
Increased blood flow
No agreement on remote effects
20. No lasting effects after 1 session, more lasting
effects after 5 sessions
Release of endogenous opioids
Pain Gate control
Activate the serotonergic and noradrenergic
descending inhibitory system
Placebo?
21. Local lymphedema
Severe hyperalgesia or allodynia
First trimester of pregnancy
Allergic to certain metals in the needle
22. Needle phobia
Cognitive impairment
Local Skin lesions
Local infections
Vascular disease
23. Practice consistent with the OSHA Blood Borne
Pathogens standard: wear gloves!
Explanation of the procedure to the patient
Sharp needle container, alcohol swabs
24. Decreased pain and muscle tension
Improved range of motion
Improved muscle strength
Improved function
25.
26.
27. Palpate the target muscle for a taut band
Identify a hyperirritable spot within the taut band
confirmingTrPs to be treated.
Clean the area with alcohol swab
28. Solid filament needle
Rounded tip of needle
In a guide tube with rounded edges
Diameter x Length: p.e. (0.30) x 60mm
29.
30. The fili-form needle in its tube is fixed with the non-
needling hand against the suspected area by using a
pincer grip or flat palpation
With the needling hand, the needle is gently
loosened from the tube.
The top of the needle is tapped or flicked allowing
the needle to penetrate the skin.
31.
32. With deep DN, the needle is guided toward the
TrP until resistance is felt and a LTR is elicited.
The needle is then focused in this area or other
neighboring areas by drawing the needle back
toward the subcutaneous tissue without taking
it out of the skin, and then redirecting the needle
toward the remainingTrPs.
33. Withdraw the needle completely from the skin
Apply pressure directly to the skin over the needle
insertion site to prevent possible swelling or post
needling soreness.
The muscle is then palpated again to reassess for
taut bands andTrPs. Further needling can be
performed for the same muscle or for other
clinically relevant musculature within the same
treatment session.
34. A minimum of 2 needles is required per
channel,
Multiple channels can be used
simultaneously.
The best results are reached when the
needles are placed within the dermatomes
corresponding to the region of dysfunction.
40. Little level of evidence supporting the
efficacy and effectiveness
Lack of precision
High level of bias
41. Controlled Clinical trial, N=30
Each trigger point will be repeatedly needled
for 1–2 min until the pain is resolved.
Outcome:VAS, DASH, PPT
’significant difference’
No long term effect, intervention therapist
and data collector are the same
42. 4 RCT’s compared DN to Lidocaine
1 RCT compared DN to placebo
Not significant clinical outcome,
Patterns favoring lidocaine immediately after
treatment
Patterns favoring dry needling at three to six
months.
43. RCT, single blinded, N=84
1 tx per week for 6 weeks
VAS, FHSQ
Both groups showed statistical significant
decrease after 6 weeks
44. RCT, N=17
Single session or waiting list
Data collected 10 min post and 1 weeks post
Decrease in pain greater than MDC:
pain,
pressure pain threshold,
cervical range of motion
45. “Physical therapists shall not perform any
procedure or function which they are by
virtue of education and training not
competent to perform”
Not part of entry-level physical therapy
education
46. Since 2006 increased support from state
boards for dry needling
Variance in regulatory affairs from state to
state
Refer to practice act within the state,APTA,
AAOMPT, FSBPT
47. AAOMPT:
Executive Committee
Dry needling is within
the scope of physical
therapist practice.
48. APTA:
no official positions on
intramuscular manual
therapy
internal staff task force is
looking further in to the
need for a policy.
APTA recognizes that PTs
are performing dry
needling and that PTs who
do it should have
additional education and
be competent to do so.
49. FSBPT:
Although the FSBPT
Model Practice Act does
not specifically mention
intramuscular manual
therapy there is nothing
to specifically exclude
the technique.
50. Federation of State Boards Resource Paper
2010
“It is clear that no single profession owns any
procedure or intervention. Overlap among
professions is expected and necessary for access
to high quality care”
51. Many differences between different
therapists and clinics
CPT code set by
American Medical Association
Current ProceduralTerminology Editorial Panel
Provides a uniform language for medical
services
52. CPT 97140: ManualTherapy should not be
included: (soft tissue mobilization, joint
mobilization, manipulation by a physician,
initial area, and each additional area, and
manual traction.)
Currently no CPT code that describes Dry
Needling
Recommended:CPT 97799: Unlisted physical
medicine/rehabilitation service or procedure
54. 1) Cagnie, B.,V. Dewitte, et al. "Physiologic effects of dry needling." Current Pain
& Headache Reports 17(8): 348-348
2)APTA (2012). "PhysicalTherapy andThe Performance of Dry Needling: An
Educational Resource Paper." APTA Department of Practice;APTA Department
of Government Affairs.
3)APTA (2013). "Description of Dry Needling in Clinical Practice: A Resource
Paper Educational " Public Policy, Practice, and Professional Affairs Unit.
4) Brady, S., J. McEvoy, et al. (2014). "Adverse events following trigger point dry
needling: a prospective survey of chartered physiotherapists." Journal of Manual
& ManipulativeTherapy (Maney Publishing) 22(3): 134-140
55. 5) Clewley, D.,T.W. Flynn, et al. (2014). "Trigger Point Dry Needling as an Adjunct
Treatment for a PatientWith Adhesive Capsulitis of the Shoulder." Journal of
Orthopaedic & Sports PhysicalTherapy 44(2): 92-101
6) Cotchett, M. P., S. E. Munteanu, et al. (2013). "Effectiveness ofTrigger Point
Dry Needling for Plantar Heel Pain: A Randomized ControlledTrial." Physical
Therapy 94(8): 1083-1094.
7) Kinetacore, Functional Dry Needling Level I
8) Ziaeifar, M., A. M. Arab, et al. (2013). "The effect of dry needling on pain,
pressure pain threshold and disability in patients with a myofascial trigger point
in the upper trapezius muscle." Journal of Bodywork & MovementTherapies
18(2): 298-305
56. 9) Joshua Ong, B. a., Leica S. Claydon, PhD, PG CertTertTeach, BSc (2012). "The
effect of dry needling for myofascial trigger points in the neck and shoulders: A
systematic review and meta-analysis.“ Journal of Bodywork & Movement
Therapies (2014) 18, 390 - 398.
10) Short-Term Changes in Neck Pain,Widespread Pressure Pain Sensitivity, and
Cervical Range of Motion After the Application ofTrigger Point Dry Needling in
PatientsWith Acute Mechanical Neck Pain: A Randomized ClinicalTrial: María J.
Mejuto-Vázquez, PT, Jaime Salom-Moreno, PT, PhD Ricardo Ortega-Santiago,
PT, PhD SebastiánTruyols-Domínguez, PT, PhD, César Fernández-de-las-Peñas,
PT, PhD
11) APTA (2014). “Official Statement – Billing of Dry Needling by Physical
Therapists" Public Policy, Practice, and ProfessionalAffairs Unit.