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Following numerous treatments for chronic rotator cuff tendonitis-and years of not being able to lie on the injured side-a patient finally found relief from an unlikely source: acupuncture needles.
Anne Keil, PT, DPT, a physical therapist at the University of Colorado Hospital's Park Meadows clinic in Lonetree, CO, offered her patient trigger-point dry needling.
"After I did trigger-point dry needling into her rotator cuff musculature, she reported significant pain relief and was finally able to sleep on the injured side," Dr. Keil explained. "She was amazed by how much her pain improved."
Used primarily in the treatment of myofascial trigger points, dry needling is beginning to penetrate the U.S. physical therapy setting. Recent studies show that myofascial trigger points are commonly seen in acute and chronic pain conditions and in nearly all orthopedic conditions. PTs practice dry needling as part of their clinical practice and use the technique in combination with other physical therapy interventions.
How Does it Work?
Dry needling is a relatively easy technique with very few complications. "Thousands of PTs worldwide are doing this daily in their practices and there are no reports of significant complications," said Jan Dommerholt, PT, MPS, FAAPM. Dommerholt is a physical therapist and the president and owner of Bethesda Physiocare Inc. in Bethesda, MD.
There are three schools of dry needling, including the radiculopathy, myofascial trigger point and spinal segmental sensitization models. Another classification is based on the depth of the needle insertion and distinguishes superficial dry needling and deep dry needling.
Dry needling targets myofascial trigger points that may consist of multiple contraction knots and can be active or latent. According to Dommerholt, active myofascial trigger points can spontaneously trigger local pain or refer pain to more distant locations.
These trigger points cause muscle weakness and range-of-motion restrictions. Latent myofascial trigger points do not trigger local or referred pain without being stimulated but they may alter muscle activation patterns and contribute to limited range of motion.
Unique to myofascial trigger points, the local twitch response is an involuntary spinal cord reflex contraction of the muscle fibers in a taut band following palpation or needling of the band. "Local twitch responses can be elicited manually by snapping taut bands that harbor myofascial trigger points," Dommerholt said.
Dry needling a myofascial trigger point is most effective when a local twitch response is elicited. The local twitch response results in immediate reduction or elimination of pain. Once the pain is reduced, patients may begin stretching and strengthening programs.
Relief Supersedes Needles
"Many patients are worried about the technique and about needles in general," Dommerholt said. "But the vast majority of patients request dry needling once they have experienced its benefits."
Superficial dry needling is a painless procedure and there is no noxious mechanical or thermal stimulation. The needle does not typically reach the myofascial trigger point in superficial dry needling, so a local twitch response is not expected. However, the patient commonly experiences an immediate decrease in sensitivity following the needling procedure.
With deep dry needling, the needle is placed directly in myofascial trigger points to elicit local twitch responses. A local twitch response confirms that the needle was placed in a taut band, which is important when needling close to viscera or peripheral nerves.
Deep dry needling commonly triggers patients' referred pain patterns and therefore, the primary pain complaint. For example, deep needling of myofascial trigger points in the upper trapezius or sternocleidomastoid muscles may trigger a patient's migraine or tension headache.
In many instances, patients feel an immediate relaxation of tight and contractured muscle fibers with deep dry needling. However, needling does cause some temporary soreness, which is usually an aching and poorly localized pain sensation for one to two days.
According to Dr. Keil, dry needling elicits great results for chronic pain sufferers and those with tight muscle issues because the mechanical stimulation deactivates the trigger point in the muscle as well as some of the satellite trigger points. "How long I do the dry needling depends on what areas are affected," Dr. Keil said. "Once it elicits a referred pain pattern or twitch in the muscle, I can move on to another muscle."
In order to be able to practice dry needling, PTs need to demonstrate competence or have adequate training in the technique. Additionally, PTs can only practice the approach in a state where dry needling falls within the scope of PT practice.
"I initially sought training because I had suggested acupuncture for patients with continued pain who had hit a plateau and was curious what aspects were similar and different compared with acupuncture," Dr. Keil explained.
Dommerholt attended several workshops with Janet Travell, MD, who re-discovered trigger points and published articles about trigger points and referred pain. Dr. Travell pioneered the use of myofascial trigger point injections that eventually led to the development of dry needling. Dommerholt has also studied with others renowned in the field, including Robert Gerwin, MD, and Peter Baldry, MD.
Myths and Misconceptions
Other needling approaches, such as intramuscular stimulation or traditional Chinese acupuncture, do not specifically target myofascial trigger points and are based on different philosophical principles.
Traditional Chinese acupuncture is based on a series of meridians, or energy fields, running throughout the body and uses needles to work in conjunction with those energy fields. Dry needling, however, uses needles to interfere directly with the source of muscle contraction and dysfunction.
Before the development of dry needling, myofascial trigger points were treated primarily with injections. Recent studies show that dry needling is just as effective as injection therapy.
Many physicians advocate that a patient try dry needling before considering trigger point injections with a physician. The needles used for dry needling are typically more comfortable than the needles used by physicians for trigger point injections, as the acupuncture needles are thinner and have a different-shaped tip.
"A physician may do a trigger point injection to a muscle in the same or similar location that we do dry needling," Dr. Keil explained. "But what we do is typically more comfortable for the patient." There is generally less bleeding with dry needling as well.
Depending on the specific needs of the patient and dry needling technique used, good results may be achieved without the need for physician involvement. However, there are times when trigger point injections may be preferred over dry needling.
In those situations, a physician may perform trigger point injections with one of several different types of injectable solutions, including different types of local anesthetics, sterile saline and less commonly, steroids.
Dr. Keil screens potential candidates for medical conditions before providing dry needling therapy. A few of the red flags she looks for include infectious diseases, impaired immune systems and skin conditions in the area to be treated. She also will not treat patients who are taking blood-thinner medications without their physician's release.
How and when dry needling is used depends on the practice setting. In Dommerholt's practice, he applies dry needling as the first approach. "It is important to emphasize that dry needling does not replace other parts of PT practice," he said. "It gets patients out of pain much faster and as such facilitates movement corrections, posture corrections and joint range of motion."
Dr. Keil tends to rely on standard physical therapy treatments first and if the patient still has residual pain or chronic tightness, she will try dry needling. "I have seen some wonderful results," she said.
Rebecca Mayer is regional editor of ADVANCE and can be reached at rmayer@merion.com
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