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Points of Clarification

Delineating the distinction between acupuncture and dry needling for trigger-point pain

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Vol. 23 • Issue 21 • Page 29

Trigger Point Pain

Myofascial trigger-point pain is a prevalent condition facing therapists who treat chronic pain cases. Myofascial trigger-point therapy has become widely used by many healthcare providers for a variety of musculoskeletal problems.

Several studies demonstrate a high prevalence of pain due to myofascial trigger points. One researcher suggests that prevalence of pain originating from myofascial trigger points in a general pain practice can reach the level of 85 percent. The recognition of the myofascial pain phenomenon by the medical community as one of the key pain generators has led to the development and expansion of a variety of myofascial therapy interventions.

Two instrument-assisted means of treating chronic pain conditions are acupuncture and trigger-point dry needling. Unfortunately, many therapists confuse the terms acupuncture and dry needling, or use the terms interchangeably. However, a clear and definitive distinction exists between the two modalities, and a distinction must be made to avoid confusion.

Dry Needling

Trigger-point dry needling is one of many treatment methods for myofascial trigger points and it is not proprietary to one specific profession. Trigger-point dry needling is practiced around the world by physicians, physical therapists, acupuncturists, chiropractors, osteopaths, dentists, nurses and many other properly trained healthcare providers who specialize in the treatment of myofascial trigger points.

Dry needling is the insertion and repetitive manipulation of a fine, flexible, filamentous needle within a myofascial trigger-point area that produces repetitive local twitch responses and leads to inactivation of the trigger point or a decrease of the trigger-point activity. Preliminary research supports that dry needling improves pain control, reduces muscle tension, normalizes biochemical and electrical dysfunction of motor endplates, and facilitates an accelerated return to active rehabilitation.

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It's unfortunate that a number of acupuncture practitioners and some of their associations try to equate dry needling with acupuncture, and to make dry needling proprietary to acupuncturists. Some do this by using a modified definition of acupuncture points, which defines an acupuncture point the same as a myofascial trigger point. This creates confusion regarding appropriateness of treatment, which may have negative consequences on consumers deciding on the most appropriate provider for their condition.

Belgrade supports that "tender points are acupuncture points and can be often chosen for therapy."1-3 Belgrade uses one of the major criteria used to define a trigger point to also define an acupuncture point. Issues become even more confusing when one considers that trigger-point dry needling,4-6 one of the major treatments for myofascial trigger points, is performed with an acupuncture needle.

Acupuncture

Acupuncture is a traditional system of Chinese medicine that has been practiced for more than 2000 years.7 The Florida State Code defines acupuncture as follows: "Acupuncture" means a form of primary health care, based on traditional Chinese medical concepts and modern oriental medical techniques, that employs acupuncture diagnosis and treatment, as well as adjunctive therapies and diagnostic techniques, for the promotion, maintenance and restoration of health and the prevention of disease. Acupuncture shall include, but not be limited to, the insertion of acupuncture needles and the application of moxibustion to specific areas of the human body and the use of electroacupuncture, Qi gong, Oriental massage, herbal therapy, dietary guidelines and other adjunctive therapies as defined by board rule.

In some manner, the ancient Chinese became aware of certain sensitive skin areas (sensitive points) when a body organ, muscle or function was impaired. They also observed that these sensitive skin areas were the same or similar in all people who suffered from the same impairment. Moreover, the sensitive areas varied consistently according to the organ or muscle function deviating from the norm. It was at this point that some of the relationships among various internal organs or muscles and their functions were observed and established.7-9

Acupuncture was introduced to the West in the 17th century by Jesuit missionaries sent to Peking. In the 1940s, French sinologist and diplomat Soulie de Morant published his voluminous writings on acupuncture.8

Acupuncture was first introduced in the United States in the late 1960s. Since then, Western licensed acupuncturists use acupuncture primarily for the treatment of various conditions such as gastrointestinal problems, gynecological conditions, infertility, musculoskeletal problems, immunological conditions, smoking cessation and many others.

Melzack et al found a 71-percent correlation between trigger points and acupuncture points for the treatment of pain.10 Melzack's contention was that trigger points and acupuncture points may have the same neural mechanism. However, new discoveries clearly demonstrate that the trigger-point phenomena originate in the vicinity of dysfunctional endplates,11-12 and this puts an end to the previous claim by Melzack. In a subsequent article, Melzack defines acupuncture and trigger-point dry needling as two distinctively different approaches.13

Recognizing the Distinction

Despite some similarities in terms of location between acupuncture points and trigger points, the objective clinician and researcher must recognize the distinct differences. These differences define acupuncture points and trigger points as two completely different clinical entities with possible overlaps.5-14

There are foundational and pathophysiological differences between trigger points and acupuncture points. Classical acupuncture points are identified as precise points along meridians defined by ancient Chinese documents.9 An exception to that are extrameridian and "achi" points. Conversely, myofascial trigger points may be found anywhere within a muscle belly, and there is evidence that their pathophysiological mechanism resides in dysfunctional endplates.12,15

Trigger-point dry needling is a very effective clinical intervention for the treatment of myofascial pain syndrome. While this intervention uses a thin filamentous stainless steel needle, the same as an acupuncture needle, it is distinctly different from acupuncture both in the rationale and its means of application.5-14It is important to understand that these two approaches are very different and require different training for their clinical application.

Trigger-point dry needling is not proprietary to one specific profession, but can be practiced by properly trained healthcare providers. Scientific merit requires that we are clear in our distinction between these two separate treatment approaches.

References are available at www.advanceweb.com/pt under the Resources tab.

Dimitrios Kostopoulos graduated from the New York College of Traditional Chinese Medicine and UHSA School of Medicine. He can be reached at dimi@handsonpt.org. Konstantine Rizopoulos is a graduate of Evidence in Motion's DPT program. He can be reached at kostas@handsonpt.org They are founders of Hands-On Seminars (www.handsonseminars.com) and Hands-On Care Physical Therapy in New York.

Therapist, Heal Thyself

The concept for a soft-tissue therapy device evolved over the past 25 years treating patients with every condition from carpal tunnel syndrome to low-back pain to plantar fasciitis and more.

About seven years ago, I found myself in the middle of battling carpel tunnel syndrome and osteoarthritis in both of my hands, wrists and forearms from the years of practicing soft-tissue therapy without using any professional quality instruments.

I searched for a tool that could facilitate my manual therapy techniques and that would ultimately help me get better results for my patients. Finding none, I knew I had to create something myself that would help me continue practicing all of those soft-tissue therapy techniques while simultaneously protecting and rehabilitating myself.

The bene?ts of the soft-tissue therapy tool are numerous for both the patient and the therapist. Every millimeter is designed to be in contact with the human body either as a treatment surface, handle/grip or both.

The device is very capable at implementing a wide variety of orthopedic and manual soft-tissue therapy treatments, techniques and conditions. These include but are not limited to IT band syndrome, rotator cuff injuries, nerve entrapment, osteoarthritis, psoas release, TMJ, tennis elbow and carpel tunnel syndrome. Clinicians can implement almost any soft-tissue therapy technique regardless of whether it is traditionally applied with a tool or with just the hands. The soft-tissue therapy tool enables clinicians to seamlessly integrate a wide variety of both hand and instrument therapies and techniques with stellar results and ease of use.

Self treatment is another designed strength of the soft-tissue therapy tool. A user can easily and effectively treat more than 90 percent of their own body, from the trapezius and teres muscles to the glutes, piriformis, calves, feet, hands, elbows, hips and knees. I was able to treat my carpel tunnel condition successfully with the prototypes I had created of the device.

For therapists with limited treatment time, the tool can make a signi?cant impact in as little as a minute or two. It is especially good for isolated pressure points, cross-friction ?ber and myofascial release techniques.

This tool is extremely efficient because of the increased leverage and mass that add a tremendous value to the practitioner. They will only need a fraction of the force that they would normally apply to implement the treatment. It is much easier to guide the weight than it is to create the force.

The ability to "feel" the tissues is greatly enhanced when utilizing this instrument, much like a needle on a record player as it picks up the vibrations of the music. Treatment with the device is a very stable, comfortable and balanced experience for the therapist. One of the central design elements was to free up the therapist's ?ngers during the treatments so they could be used in conjunction with the instrument to stay in full patient contact.

Now, clinicians have twice as much feedback since both the instrument and their ?ngers are actively involved in the treatment. The key thing here is that the instrument by design absorbs all of the treatment force through the palm of the hand and not the ?ngers. Therapists should see the soft-tissue therapy tool do the treatment and let it work for them. 

 Michael Conchard is an exercise physiologist and the president of Soft Tissue Therapy Tools in Indianapolis.


 

Trigger point dry needling is certainly within the PT profession scope of practice with extra training of course. A profession should engage itself in training in any intervention that is appropriate for their respective field to allow them to provide services that are best for the patient. I highly doubt there is another profession more qualified to provide dry needling than PT with extra training, and we're constantly exposed to patient's who could benefit from it. There is no legitimate reason for it not to be in a PT's scope of practice.

November 25, 2012



It is my sincere advise for you to read more in the area of Trigger Point Dry Needling and then you will understand that Physical Therapists are amongst the most qualified professionals to treat such conditions. Dry Needling is not exclusive to any one profession and at the same time you as a professional should make a choice if you want to learn and apply such technique to your patients or not.
More and more states permit PTs in performing dry needling which is an effective and safe technique.

Dimitrios Kostopoulos,  PT, DPT, MD, PhD, DSC, ECS,  Hands-On SeminarsNovember 19, 2012
Astoria,, NY



I don't think this is a good idea to promote "trigger point dry needling". Physical therapy treatment is a non-invasive therapy. If we integrate dry needling therapy into our scope of practice, we will face the legal issue of our profession. Dry needling trigger point treatment is an invasive treatment that is beyond our scope of practice. I really want to use whatever effective treatment method I can get to help my patients, but any profession has its boundary. I don’t care what the healthcare providers around world can practice this and that, which we can’t practice in United States, because we have to follow the scope of practice of each profession. I know the acupuncturists in China use so called ”needle knife” to treat tendonitis, rotate cuff syndrome, frozen shoulder, etc. with amazing results. Will we integrate this procedure in our practice, if we, as physical therapists, are “properly trained”? In physical therapy school, we all learned joint manipulation and mobilization, including spine. We are properly trained those technique. Can we treat patients as Chiropractors? Can we use same billing codes as Chiropractors use to claim our service? If we can claim a lot of treatments or procedures that are not proprietary to one specific profession after we get “properly trained”. Why do we need to obtain a profession license to practice?
My point is we, as physical therapists, should develop our own effective treatment methods to better serve our patients instead of integrating other treatments that are not within our scope of practice into our practice.


Jing Shan,  Physical TherapistNovember 09, 2012
Bayside, NY




     

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