Sharp relief
Monday April 9, 2012
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(Photo courtesy of Jan Dommerholt, PT)
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Popular in Europe and Canada for years, dry needling is catching on in many parts of the U.S. as a physical therapy modality to help relieve muscle pain and dysfunction.
"I’ve seen incredible results from needling," said Steve Cuddy, MPT, PRC, a physical therapist in private practice in Austin, Texas. "When other things don’t work, the needles work."
"The specificity is so unique," said Jan Dommerholt, PT, DPT, MPS, DAAPM, president and owner of Bethesda (Md.) Physiocare and Myopain Seminars. "That little needle can get right to the spot to the few muscle fibers that are contracted."
Cuddy said PTs may use two different dry needling models: a trigger-point and a systemic approach that taps into the body’s ability to heal chronic pain. He uses trigger-point needling with patients experiencing hypertonic muscles that will not shut off after manual therapies, and the systemic method to alter the autonomic nervous system and interfere with the chronic cycle of pain.
"Every dry-needling modality works, and we cannot say which is superior," said Yun-tao Ma, PhD, founder of the American Dry Needling Institute in Boulder, Colo. Ma said dry needling is a dynamic technique, supported by research, with new information continuing to contribute to a greater understanding of its value.
Useful for acute and chronic conditions, dry needling is not a standalone treatment approach but an adjunct to other soft-tissue techniques, said Herbert L. Silver, PT, DSc, MBA, president of Velocity Spine and Sports Physical Therapy in Atlanta, an adjunct professor at Mercer University, and a member of the board of directors of the American Dry Needling Institute. He said dry needling may produce a response more quickly than massage, for instance.
Dommerholt said he finds patients with an acute injury respond more quickly than those with chronic pain.
David Pasion, PT, MPT, facility manager for Emory Physical Therapy-Spine, part of the Emory Orthopaedics & Spine Center in Atlanta, said dry needling is helpful in addressing muscles he cannot reach effectively with manual techniques, such as deep gluteal muscles, which can refer pain down the leg. "With solid filament needles, we can get in and directly affect the muscle," he said.
History and theory
Although dry needling incorporates solid filament needles, it differs from the ancient Eastern practice of acupuncture in that acupuncture is a discipline, while dry needling is a technique. "This is a Western-medical approach to the use of needles," Cuddy said.
Janet G. Travell, MD, a White House physician to Pres. John F. Kennedy, coined the term dry needing in the 1940s, independent of acupuncture, Silver said. While performing trigger-point injections, she found patients experienced relief long before the local anesthetic had a chance to take effect. Travell and David Simons, MD, pioneered and wrote about trigger-point dry needling.
The first Western article describing the needle effect was published in the journal Pain in 1979. The author, K. Lewit, found 86.8% of patients obtained immediate analgesia without hypesthesia, and concluded, "the effectiveness of treatment was related to the intensity of pain produced at the trigger zone."
In the 1970s, Chan Gunn, MD, PhD, developed the Intramuscular Stimulation system for chronic myofascial pain by treating the underlying neuropathic conditions that cause pain. He conducted a randomized clinical trial using needling for chronic low-back pain and published the findings in 1980 in the journal Spine.
Gunn and colleagues enrolled 56 male patients with chronic low-back pain for at least 12 weeks who had failed to respond to traditional therapy, including an eight-week physical and occupational therapy regimen. All enrolled participants continued with the regimen, while 29 also received dry needing at muscle motor points one or two times per week for an average of 7.9 visits. At time of discharge, 12 weeks later and on final followup at an average of 27.3 weeks later, those patients in the needling group were significantly better than the controls, with 18 in the needling group returning to their original jobs and 10 returning to lighter duties, while four of the controls returned to their regular jobs and 14 to lighter duty. Nine of the controls remained disabled.
"This is starting to appeal to physical therapists now as we understand the physiology of trigger points and what a needle does to a trigger point," Silver said. "It becomes a logical intervention."
Trigger-point dry needling
A trigger point is an acidic and hypoxic area in the muscle, Silver said. The elevated acidity causes calcium to remain bound to the myosin molecule. The needle mechanically stretches the trigger point, and it releases nitric oxide, a powerful vasodilator on the capillaries and the lymphatic vessels, reducing the acidity and trigger point, he said. That release restores blood flow, oxygen and normal pH to the tissue, and the body reabsorbs the biochemicals that have built up there.
Jay Shah, MD, a senior staff physiatrist at the Rehabilitation Medicine Department at the National Institutes of Health in Bethesda, researched trigger points and uncovered the biochemical response, which he described in a 2008 article in the Journal of Bodywork and Movement Therapies. "He found the inflammatory agents were eliminated following the local twitch response," Pasion said. "That local twitch response releases the muscle and allows it to reset."
In trigger-point dry needing, a sterile, disposable needle is inserted and removed. "I insert it right into the muscle tissue, looking for the local twitch," said Capt. Shaun O’Laughlin, PT, DPT, OCS, a physical therapist at the Munson Army Health Center at Fort Leavenworth, Kan. "I move it around in the muscle, looking to get it to fire, and remove it."
Dommerholt, who has taught dry needling since 1997, said repositioning continues until twitches stop. "The patient feels better immediately," Dommerholt said. "The needling does not hurt, but the twitch response, you can feel. Most people do not like it. It’s like an electric shock with a little cramping. With some people, it’s painful. In others, it’s not."
The soreness may last a day or so. Some bleeding or bruising may occur, he said.
O’Laughlin said he uses dry needling for headaches and other muscle pain. The number of treatments is patient specific, depending on chronicity, the condition and the cause. The main risk is a pneumothorax if working in the thoracic area. O’Laughlin said PTs use caution if working in that region, but overall needling is considered a safe treatment method.
"Physical therapists’ knowledge of anatomy allows them to do this safely," Silver said, adding patient tolerance also is a concern.
Integrative dry needling
"Anytime you have an area of pain that has gone on for any length of time, even as short as a few days, you will get chemical and neurochemical changes in the nervous system that are hypersensitizing that painful condition, peripherally and in the brain," Cuddy said. "This is another modality that [interferes with that pain cycle]."
Ma teaches the Integrative Dry Needling System for soft-tissue dysfunction or pain. He said clinical results occur even if the needle is not placed in the trigger point. "This needle makes a lesion inside the soft tissue, and this lesion activates the healing of the tissue locally and the healing of the body systemically," Ma said.
With an integrative systemic approach, the needle stays in for as long as 30 minutes, said Ma, and the procedure can cause some discomfort.
Controversy exists
Several physical therapy licensing boards have recognized dry needling as part of a PT’s scope of practice. Most medical liability coverage will not cover a PT unless the state board has approved PTs performing dry needling. Some states require a specific amount of training.
O’Laughlin encouraged fellow PTs to research their states’ practice acts before seeking additional training and ensuring any course being considered covers everything their states require. Information about the status of dry needling in each state is available at Myopainseminars.com.
Several entities offer dry-needling programs, and physical therapy schools are beginning to introduce students to the technique. Cuddy expects most states will approve it eventually, because it is a useful modality for physical therapists. •
Debra Wood is a freelance writer.
"I’ve seen incredible results from needling," said Steve Cuddy, MPT, PRC, a physical therapist in private practice in Austin, Texas. "When other things don’t work, the needles work."
"The specificity is so unique," said Jan Dommerholt, PT, DPT, MPS, DAAPM, president and owner of Bethesda (Md.) Physiocare and Myopain Seminars. "That little needle can get right to the spot to the few muscle fibers that are contracted."
Cuddy said PTs may use two different dry needling models: a trigger-point and a systemic approach that taps into the body’s ability to heal chronic pain. He uses trigger-point needling with patients experiencing hypertonic muscles that will not shut off after manual therapies, and the systemic method to alter the autonomic nervous system and interfere with the chronic cycle of pain.
"Every dry-needling modality works, and we cannot say which is superior," said Yun-tao Ma, PhD, founder of the American Dry Needling Institute in Boulder, Colo. Ma said dry needling is a dynamic technique, supported by research, with new information continuing to contribute to a greater understanding of its value.
Useful for acute and chronic conditions, dry needling is not a standalone treatment approach but an adjunct to other soft-tissue techniques, said Herbert L. Silver, PT, DSc, MBA, president of Velocity Spine and Sports Physical Therapy in Atlanta, an adjunct professor at Mercer University, and a member of the board of directors of the American Dry Needling Institute. He said dry needling may produce a response more quickly than massage, for instance.
Dommerholt said he finds patients with an acute injury respond more quickly than those with chronic pain.
David Pasion, PT, MPT, facility manager for Emory Physical Therapy-Spine, part of the Emory Orthopaedics & Spine Center in Atlanta, said dry needling is helpful in addressing muscles he cannot reach effectively with manual techniques, such as deep gluteal muscles, which can refer pain down the leg. "With solid filament needles, we can get in and directly affect the muscle," he said.
History and theory
Although dry needling incorporates solid filament needles, it differs from the ancient Eastern practice of acupuncture in that acupuncture is a discipline, while dry needling is a technique. "This is a Western-medical approach to the use of needles," Cuddy said.
Janet G. Travell, MD, a White House physician to Pres. John F. Kennedy, coined the term dry needing in the 1940s, independent of acupuncture, Silver said. While performing trigger-point injections, she found patients experienced relief long before the local anesthetic had a chance to take effect. Travell and David Simons, MD, pioneered and wrote about trigger-point dry needling.
The first Western article describing the needle effect was published in the journal Pain in 1979. The author, K. Lewit, found 86.8% of patients obtained immediate analgesia without hypesthesia, and concluded, "the effectiveness of treatment was related to the intensity of pain produced at the trigger zone."
In the 1970s, Chan Gunn, MD, PhD, developed the Intramuscular Stimulation system for chronic myofascial pain by treating the underlying neuropathic conditions that cause pain. He conducted a randomized clinical trial using needling for chronic low-back pain and published the findings in 1980 in the journal Spine.
Gunn and colleagues enrolled 56 male patients with chronic low-back pain for at least 12 weeks who had failed to respond to traditional therapy, including an eight-week physical and occupational therapy regimen. All enrolled participants continued with the regimen, while 29 also received dry needing at muscle motor points one or two times per week for an average of 7.9 visits. At time of discharge, 12 weeks later and on final followup at an average of 27.3 weeks later, those patients in the needling group were significantly better than the controls, with 18 in the needling group returning to their original jobs and 10 returning to lighter duties, while four of the controls returned to their regular jobs and 14 to lighter duty. Nine of the controls remained disabled.
"This is starting to appeal to physical therapists now as we understand the physiology of trigger points and what a needle does to a trigger point," Silver said. "It becomes a logical intervention."
Trigger-point dry needling
A trigger point is an acidic and hypoxic area in the muscle, Silver said. The elevated acidity causes calcium to remain bound to the myosin molecule. The needle mechanically stretches the trigger point, and it releases nitric oxide, a powerful vasodilator on the capillaries and the lymphatic vessels, reducing the acidity and trigger point, he said. That release restores blood flow, oxygen and normal pH to the tissue, and the body reabsorbs the biochemicals that have built up there.
Jay Shah, MD, a senior staff physiatrist at the Rehabilitation Medicine Department at the National Institutes of Health in Bethesda, researched trigger points and uncovered the biochemical response, which he described in a 2008 article in the Journal of Bodywork and Movement Therapies. "He found the inflammatory agents were eliminated following the local twitch response," Pasion said. "That local twitch response releases the muscle and allows it to reset."
In trigger-point dry needing, a sterile, disposable needle is inserted and removed. "I insert it right into the muscle tissue, looking for the local twitch," said Capt. Shaun O’Laughlin, PT, DPT, OCS, a physical therapist at the Munson Army Health Center at Fort Leavenworth, Kan. "I move it around in the muscle, looking to get it to fire, and remove it."
Dommerholt, who has taught dry needling since 1997, said repositioning continues until twitches stop. "The patient feels better immediately," Dommerholt said. "The needling does not hurt, but the twitch response, you can feel. Most people do not like it. It’s like an electric shock with a little cramping. With some people, it’s painful. In others, it’s not."
The soreness may last a day or so. Some bleeding or bruising may occur, he said.
O’Laughlin said he uses dry needling for headaches and other muscle pain. The number of treatments is patient specific, depending on chronicity, the condition and the cause. The main risk is a pneumothorax if working in the thoracic area. O’Laughlin said PTs use caution if working in that region, but overall needling is considered a safe treatment method.
"Physical therapists’ knowledge of anatomy allows them to do this safely," Silver said, adding patient tolerance also is a concern.
Integrative dry needling
"Anytime you have an area of pain that has gone on for any length of time, even as short as a few days, you will get chemical and neurochemical changes in the nervous system that are hypersensitizing that painful condition, peripherally and in the brain," Cuddy said. "This is another modality that [interferes with that pain cycle]."
Ma teaches the Integrative Dry Needling System for soft-tissue dysfunction or pain. He said clinical results occur even if the needle is not placed in the trigger point. "This needle makes a lesion inside the soft tissue, and this lesion activates the healing of the tissue locally and the healing of the body systemically," Ma said.
With an integrative systemic approach, the needle stays in for as long as 30 minutes, said Ma, and the procedure can cause some discomfort.
Controversy exists
Several physical therapy licensing boards have recognized dry needling as part of a PT’s scope of practice. Most medical liability coverage will not cover a PT unless the state board has approved PTs performing dry needling. Some states require a specific amount of training.
O’Laughlin encouraged fellow PTs to research their states’ practice acts before seeking additional training and ensuring any course being considered covers everything their states require. Information about the status of dry needling in each state is available at Myopainseminars.com.
Several entities offer dry-needling programs, and physical therapy schools are beginning to introduce students to the technique. Cuddy expects most states will approve it eventually, because it is a useful modality for physical therapists. •
Debra Wood is a freelance writer.
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Monday April 9, 2012