Validity of Dry Needling

This entry was written by Valerie Lanza SPT (Student from University of the Sciences in Pennsylvania)  based on a research paper by Dr. Leonid Kalichman, PT, PhD and Simon Vulfsons MD. Edited by David Kwon, DPT, CSCS.

Here is a link to the full article:

Dry Needling in the Management of Musculoskeletal Pain

Article Citation: Kalichman L, Vulfsons S. Dry Needling inthe Management of Musculoskeletal Pain. JABFM.2010;23(5):640-646.

Since my first day at Maven I have been intrigued by the application of dry needling. In school, I have learned other techniques to address pain, but was never introduced to the dry needling route. So naturally, I had to do a little more research to look into dry needling to try and understand the application and process better.

The article I found to further investigate dry needling was a clinical narrative review. A clinical narrative review is just a fancy way of saying it is a story written by a clinician to describe a clinical event or situation based on other research on that topic. The clinical review I found was conducted by Leonid Kalichman PT, PhD and Simon Vulfsons, MD. This study summarized the different methods of dry needling, and it’s effectiveness discussed in other studies.

Myofascial pain is pain that arises from the muscles or is related to the fascia and is commonly associated with myofascial trigger points. Fascia is a layer of fibrous connective tissue that surrounds muscles, groups of muscles, blood vessels, and nerves throughout the body. Fascia can help bind structures together as well as permit smoother movement over one another. Trigger points are highly localized, hyperirritable spots in a taut band of skeletal muscle fibers. When a muscle trigger point is stimulated, referred pain or a local twitch response can be elicited. Referred pain is when pain is perceived at a location other than the site of the painful stimulus. Muscle trigger point pain is a very common primary source of pain in the United States. For example, muscle trigger points were the primary source of pain in 74-96% of patients with musculoskeletal pain in an outpatient physical therapy setting. Also, 85% of 283 patients with chronic head and neck pain had active muscle trigger points. Many non-invasive methods like stretching, massage, heat, electric stimulation, and prescription medications have been used to address and alleviate chronic myofascial pain. However, no single application of the listed treatments has been proven to be 100% successful. Another way to treat myofascial pain is dry needling, a minimally invasive procedure where acupuncture needle is inserted directly into a muscle trigger point.

Dry Needling Methods: Dry needling was developed as a method to treat musculoskeletal disorders. In numerous studies prior to this article, it was found that dry needling was just as effective, if not more effective than injections like corticosteroid shots. The two most common concepts of dry needling are the radiculopathy and muscle trigger point models, radiculopathy referring to a condition in which more than one or more nerves do not work properly. Radiculopathy can result in pain, weakness, numbness, and/or difficulty to control specific muscles. The radiculopathy model is based on the idea that myofascial pain syndrome is always the result of peripheral neuropathy or radiculopathy. The muscle will shorten and therefore create pain and development of taut bands with muscle trigger points. An example of the radiculopathy dry needling model is if the back muscles were shortened, vertebral disc compression would occur, narrowing the discs between the vertebrae and narrow the tunnels where the nerves run through, creating a pressure that will ultimately results in a radiculopathy. According the muscle trigger point model of dry needling, the effect of the needle insertion is primarily caused by the mechanical stimulation of the muscle’s trigger point with the needle. Dry needling a muscle trigger point is most effective when a local twitch response at the site of stimulation is created. After the muscle finishes twitching, pain and dysfunction decrease dramatically.

Effectiveness of Dry Needling in the Management of Muscle Trigger Points: Many studies have looked at the effectiveness of dry needling for muscle trigger point management and have found that direct needling of muscle trigger points are an effective treatment to reduce pain compared to no intervention at all. A common area of interest for dry needling studies is in the low back since it is a very prevalent site for pain. From 35 studies that used dry needling as an intervention to address low back pain, all found dry needling to decrease pain and improve functionality of those who suffered from chronic low back pain. Not only were the positive effects noticed immediately at the end of the session, but at a short-term follow up of 8 weeks and a long-term follow up of 20 weeks. This supports that dry needling has positive long-term effects.

Deep vs. Superficial Needling: Initially, dry needling was done when the needle was inserted superficially to the tissue immediately overlying the muscle trigger point and was shown to have positive results, like a decrease in sensitivity, even for the treatment of trigger points in deeper muscles. Superficial dry needle insertion was seen as an easier procedure to carry out because there was less pain experienced compared to deep dry needling, minimal risk of damage to nerves, and blood vessels, as well as a lower incidence of soreness after treatment. Two studies recently looked at the effectiveness of superficial dry needling in combination with active stretching exercises, stretching exercises alone, or no treatment at all. After 6 weeks of the selected interventions for each group, the superficial dry needling and stretching group had significantly less pain compared to the stretching group and no intervention group.

Some studies have explored the idea of comparing superficial dry needling to deep dry needling. In a study that looked at anterior knee pain, pain measurements decreased significantly in both groups and remained low at both 3 and 6 months. In another study that compared superficial and deep dry needling for myofascial lumbar pain, there was no difference in decrease of pain between the groups at the end of the treatment, however, at a 3 month follow up, the deep dry needling group had significantly better pain that the superficial dry needling group. These studies show that not only is deep dry needling is just as effective as superficial dry needling, but also can have great long-term effects. This can be due to the fact that the pain receptors in the muscles are deep, and will respond better to the deep dry needling technique.

Conclusion: Overall, from this article, I found that the effectiveness of dry needling as a treatment option for myofascial pain and muscle trigger point pain has been confirmed to be successful in many studies prior to this article. Also, the deep dry needling method has been shown to be just as effective, if not more effective, than the superficial dry needling technique. The final suggestion from this article is the need for additional research to further evaluate the effectiveness of dry needling as well as dry needling techniques. So stay tuned! 

Ten Things You Need to Know About Trigger Point Dry Needling!

First of all if you do not know what Trigger Point Dry Needling is please refer this blog entry written by Dr. Yoo:

Dr. Yoo's Blog about Trigger point dry needling

• Dry needling (DN) is a skilled intervention used by physical therapists that uses a thin solid needle to penetrate the skin and stimulate underlying trigger points, muscular, and connective tissues to improve pain and increase mobility and helps to restore normal movement.

• The goal of dry needling treatment is to deactivate trigger points (knots) to facilitate the rehabilitation process of musculoskeletal dysfunction

• Physical therapists have been performing dry needling in the United States for the past 25+ years, according to the Federation of State Boards of Physical Therapy
• Physical Therapy and Rehabilitation is recognized as one of the 10 essential health benefits by law under the Affordable Care Act
• Dry needling is confirmed to be within PT scope in 25 states and Washington DC.
• In a November 2012 letter to APTA, CNA, an underwriting company of physical therapy professional liability insurance, reviewed their claims database specific to the issue of dry needling and reported that there are no trends relative to dry needling that would indicate this procedure presents a significant risk factor, nor does CNA foresee the practice of dry needling as having any immediate claim or rate impact
• There have been no patient safety complaints (or injuries) reported to the NJ State Board of Physical Therapy Examiners about physical therapists performing dry needling.
• A study published in 2010 in the Journal of the American Board of Family Medicine by an MD and a PhD concluded that “[Dry needlings] effectiveness has been confirmed in numerous studies and 2 comprehensive systematic reviews.  Dry needling can be used as part of complex treatment for chronic musculoskeletal pain…”
• Dry needling is only part of a comprehensive physical therapy program which includes neuromuscular, manual therapy, therapeutic exercises, postural correction, movement re-education, etc.
• Dry needling is strictly based on Western medicine principles and research and has nothing to do with Eastern medicine and acupuncture. 

New Parent Injuries: Dequervain's Tendinosis

New Parent Injuries: Dequervain's Tendinosis

My son is now 9 months old and standing in his crib. He also likes to stand in his playpen, next to the couch, by the kitchen table, and any other surface that hold his weight (did I mention he was a chunker?). With all this standing, he requires me to pick him up from his standing position which inevitably places my wrist twisted in some start awkward position. This constant lifting can cause something called Dequervain's Tendinosis

Dequervain’s Tendinosis is a chronic irritation to the thumb tendons of the hand and wrist. This is caused by repetitively lifting babies and other objects with the thumb placed in the “thumbs up position” such as the picture below.

http://grhsonline.org/lifting-your-child-safely/

http://en.wikipedia.org/wiki/Anatomical_snuff_box#mediaviewer/File:Gray424.png

Cooking and cleaning repetitively also stresses the thumb tendons and will increase the amount of pain that you feel with other activities such as lifting your child. Obviously these activities are unavoidable as a new parent, thus it is necessary to modify these activities in the following ways: 
1. Attempt to not lift your child with your “thumbs up”.

2. Avoid lifting pots and pans with your hands in the “thumbs up” position.

3. Use baby carriers as much as possible

4. Possibly use hard wrist/thumb brace to take load of tendons. (see picture below). Although bulky, these brace remove much of the tension and pressure off those thumb tendons that are already irritated.

http://www.betterbraces.com/procare-comfortform-wrist-wabducted-thumb

5. Try PT and possible trigger point dry needling! (More info in coming blogs) TDN has been very effective in treating this condition for many of our patients. Call us for more info!

New Parent Injuries: Neck strain

When my daughter was first born she would not go to sleep without being held and rocked for 20mins to an hour (Yes, I was that guy). She would take about 30 mins to an hour to drink her bottle (yes, she was that baby). This inevitably led to many hours of me holding and looking down at my infuriatingly stubborn but adorable child. This caused me to have some very significant neck pain; my daughter literally became a pain in my neck (insert rim shot).

The cervical spine and the spine in general, is intended to be placed in a certain position for extended periods. This “ideal position” is what we can a neutral spine. This is where the head is supported and balanced on top of the neck. This allows the head to be supported by the underlying structure of the vertebrae. When this spine is taken out of this “ideal” position it relies on other structures to support the head. The muscles of the neck are not designed to be place in sustained flexion or extension (looking up or looking down) so when placed in these positions it causes undue stress and strain across the muscles of the neck.

http://en.wikipedia.org/wiki/Cervical_vertebrae#mediaviewer/File:Cervical_vertebrae_lateral2.png

To avoid strain to the neck it’s important to avoid sustained bending of the neck. It is easy for me to say this but let me give you a few techniques to avoid sustained neck flexion.

1.       Try to place the baby higher during feedings so you do not have to look down.

2.       Try feeding baby in a baby carrier.

3.       When carrying baby in carrier, ensure that baby weight is supported by your waist and not your shoulders.

4.       Try feeding baby in a bouncer or on a bed if they are not yet mobile.

Some stretching activities will help prevent injury.  Two of the most common muscles to be injured are the upper trapezius and the levator scapulae (Pictured below). Stretching the upper trapezius and the levator scapulae will help decrease the chances of sustaining a neck injury as well as help after injury.  

http://en.wikipedia.org/wiki/Levator_scapulae_muscle#mediaviewer/File:Levator_scapulae.png

Levator Scapulae Stretch:

http://www.humankinetics.com/excerpts/excerpts/levator-scapulae-stretch

Upper Trap Stretch: 

http://babyboomerfitnesschallenge.com/

The most effective way to prevent injury is to use common sense. Do not sit in sustained flexion for prolonged periods, do not fall asleep while holding the baby (this is more for the baby’s safety than yours), do not place neck in awkward positions for prolonged periods. Improving posture throughout the day is the most effective way to prevent injury but a more indepth discussion of this topic would be necessary.

If and when you get injured make sure you Ice, rest, stretch (do not over stretch), use anti-inflammatories (Advil) and do not perform painful activities. If after 2 weeks you still feel pain, call a PT!

New Parent Complaints : Carpal Tunnel Syndrome

I am in my late 20’s and this is the time in my life where most of my female friends are either pregnant or already have kids. One complaint I hear of more than any other, especially during pregnancy is of pain, numbness and weakness in the hands. Most of the time this condition is something called carpal tunnel syndrome (CTS). What is Carpal Tunnel Syndrome?

CTS is a condition where the nerve (Median Nerve) is pinched inside the wrist because of swelling of the finger flexor tendons. There are a few reasons why the finger flexors can become swollen such as; repetitive overuse, trauma, systemic swelling, diabetes, certain medication.  

http://en.wikipedia.org/wiki/Carpal_tunnel_syndrome#mediaviewer/File:Carpal_Tunnel_Syndrome.png

So what can be done about this condition? After birth most of the time this will resolve itself, however, it is possible that the condition could persist. If it does, these are some things you can do to help:

1. During pregnancy if you have gestational diabetes it important to discuss with your Doctor about how to properly control your blood sugar. High blood sugar could cause not only CTS but other systemic issues that will affect your life and your childs life.

2. Get enough exercise. Systemic swelling and edema are very common for those ladies that are sedentary. I am a male, so of course I do not understand what it is like to be 50lbs heavier than I was 3 months ago! That being said, mild forms of exercise are a good way to help the body reduce water retention and to help clear out systemic swelling.

3. Decreasing sugar and salt intake will also help the body to reduce swelling. Salt and sugar requires the body to retain water to maintain homeostasis (balance). The more sugar and salt you consume the more the body needs to retain water to balance out that excess minerals coming in.

4. If you are still working, try to use ergonomic keyboards and computer mouse. Have trained professional fit you with the proper workstation and try to stop working at least every 30mins.

5. Night splints are a good method to help relieve pressure off structures that are becoming impinged.

6. ICE - Icing the wrist could help reduce pain and decrease swelling in the short term.

7. This is the most impossible one for new moms…. Try to rest your wrist as much as possible and avoid using them for prolonged periods. Try to use breast feeding pillows, bolsters, towels, baby carries to avoid placing your hands in strange and unnatural positions to accommodate that new child.

8. Talk to a medical professional. Either a medical doctor or a physical therapist.

New Parent Complaints : Biceps Tendinitis

The other day I was lifting my chubby cheeked son and I felt a sharp pain in the front of my shoulder. This was the start of something that I feared. Biceps tendinitis! Like I discussed before, tendinitis is just inflammation of a tendon because of repetitive stress. How did this happen? Your bicep tendon is a very long tendon that can be felt at the front of the shoulder. This tendon attaches to your biceps whose main purpose is to bend the elbow. Because this tendon is so long and is attached to a very strong muscle it is very susceptible to injury. The common signs of biceps tendinitis is pain when touching the front of your shoulder, pain when lifting your arm, pain when stretching your arm back behind you. When lifting and carrying children, heavy car seats and diaper bags; its very common to place too much strain through the shoulder rather than through elbow. Obviously, it is impossible to avoid these activities so what can we do to decrease our risk of injury?

http://en.wikipedia.org/wiki/Biceps#mediaviewer/File:Gray411.png

How do we avoid this?

1. Try to use a baby carrier when hold your child for extended periods >10mins.

2. Pay attention to posture when lifting your child. Keeping your shoulders back keeps your shoulder in a better mechanical positions and decreases the amount of strain on your biceps tendon.

3. Keep your child close. As stated in our last post, keeping your child as close to you body as possible will also benefit your low back.

4. Do not lift with your shoulder but from the elbow.

How do we treat this?

1. ICE ICE BABY. Applying ice to the front of your shoulder before bed for 20mins will help to decrease inflammation and decrease overall pain.

2. Continue to avoid painful activities.

3. Strengthen your shoulder. This should be directed by a PT.

Common New-Parent Complaint: Low Back Pain

As a father of two small children—a 26-month-old daughter and a 6-month-old son—I’ve had my share of new-parent body pain (minus the actual giving birth part). Sometimes you get so used to being in pain from holding your kids all day that you’re actually surprised when your body isn’t lingering from soreness. One of the most common complaints I hear about (particularly from my wife) is low back pain.

Now, there are many different types and causes of low pack pain, and all of them have a specific mechanism in which they need to be treated. But overall, low back pain is usually an issue of two things: posture and repetitive stress.

When lifting your cute little heavy potato sack of a baby, it’s important to be mindful of your posture and to have your hips, knees and legs do most of the lifting (kind of like when you’re doing a squat or lunge). This means keeping your back aligned above your pelvis and not having it so rounded—and always engaging the “core”.

What’s this word “core” that I’m throwing out here? I tell my wife all the time to contract her core. Contrary to what she may think, your core is not just your belly or your abs. The core is actually a group of muscles that stabilize the spine and pelvis. These muscles contract together to prevent unnecessary movement of the spine during simple activities like picking up your child.

So how does one correctly contract the core? Most people end up just holding their breath or contracting their abs—wrong! This kind of contraction doesn’t really engage the entire core and won’t protect your spine the way it needs to. The proper way to assess whether you’re doing it the right way is to feel it with your fingers. Place your fingers just outside of your ab muscles—yes, we all have them, even though some people's may be hidden—and dig your fingers in around belly button level (see below for a visual reference). Keeping your fingers there, I tell my patients to pull their belly button in and up (kind of like when you're sucking in your stomach, but without holding your breath). 

If you are able to feel hardening or your fingers pushing back out a little bit, then you are contracting your core the right way.

Another way to prevent low back pain is to always keep your child as close to your body when picking him or her up. Unless your child’s just pooped himself up the back (in which case you may want to hold him away from your body), pick your child up in close body contact to reduce the amount of force on your back. Think about picking up a big sack of rice. You probably wouldn’t try picking it up with your arms held out, right? In similar fashion, when picking up your child, it’s important to be in proper position: shoulder kept back, core engaged, legs and shoulders aligned with your hips. And also make sure that your shoulders aren’t extended out too much in front of your body.

These basic steps—along with some nightly massages from the loving husband—can help in reducing your risk of injury and could even decrease the amount of pain you’re currently in. But of course we recommend that low back pain sufferers always consult with a physical therapist to discuss the best plan of care for your specific condition and needs.

New Parent Injuries : Tennis Elbow

I am a parent of two, one of which is about 4 months old. Not only is my son a newborn but he is a chubby one at that! The other day my wife comes to me and tells me that her elbow is really bothering her. As the good husband and PT I am, I took a look and it was very clear that she has what is called “Tennis Elbow”. Now my wife does not play tennis, but in my years as a therapist I have treated many new moms/dads with the same issue.  “Tennis Elbow” is layman’s terms for a condition call lateral epicondylitis or epicondylalgia.  This is a very long and non-interesting name for a specific condition that affects the wrist extensors (the muscles that enable you to extend your wrists). This condition received its name because it is very common among tennis players. This is due to the intense amount of repetitive eccentric torque placed on the wrist during a strong backhand. Now you may be asking, “Why are new mom’s and dad’s prone to this issue”? Well, as it turns out babies need a lot of care and attention in their first few years of life. This translates to a lot of long hours holding, rocking, feeding and carrying very heavy objects like an 45lb car seat! Not only are you required to lift these heavy things but usually it is required that you lift these things in narrow corridors such as a back seat of a car or a narrow garage.  All this leads to repetitive stress injuries to your wrist and elbows.

http://orthoinfo.aaos.org/topic.cfm?topic=a00068

What do we do to prevent this?

- Modify the way you are lifting and holding the baby. Hold the baby with palms up rather than palms down or palms towards your body.

- Use baby carriers that place the babies weight on your hips and shoulders rather than your elbow.

- Hold car seat in the crook of your elbow rather than hands. Also, attempt to use stroller as much as possible.

How do you treat this?
- Physical therapy, of course is an excellent option to relieve pain and to help prevent further injury. If you continually irritate this condition it could lead to a tear of the common extensor tendon pictured above. 

- RICE, No not glutenous kind. Rest, Ice, Compression, Elevation.

- Rest is not always an option but not doing things that cause pain will go miles to your recover. Basically every time you feel sharp pain in your elbow you are re-aggravating the injury.

- Ice is extremely useful to help decrease pain and inflammation.

- Compression helps to decreases stress across those common tendons in the elbow. A tennis elbow strap should help to improve pain during everyday activities.