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Where do PT's stand on this issue?

Who will this help?

Clinical 1 In-Service Presentation

The Use of Dry Needling in Physical Therapy

  • Approximately ⅓ of patients who present with musculoskeletal pain meet the criteria for myofascial pain syndrome.

  • Trigger points are seen in 21% of patients in a general orthopedic clinic, 30% in a general medical clinic, and 85-93% of patients to present to a specialty pain clinic.

Ashley Dindial

Northeastern University

June 2014

  • In the state of Massachusetts:

“In the absence of specific statutory or regulatory prohibition, it is within the scope of practice for an OT/OTA/PT/PTA/AT to perform generally accepted professional activities for which they have been prepared by basic education, appropriate continuing education, training/experience, and for which they have demonstrated competence to perform safely and effectively. The OT/OTA/PT/PTA/AT must be prepared to accept responsibility & accountability.”

  • In a letter sent by the APTA president, he lists the reasons why Dry Needling should be considered part of PT’s scope of practice. This includes:
  • It is consistent with the manual therapies set forth in the Guide to PT Practice
  • PT’s are bound by their license to practice safely and efficiently
  • There are a number of states that already have accepted Dry Needling as part of their scope of practice, and they do not refer to this technique as “acupuncture”
  • The objectives and philosophies greatly differ between PT’s and acupuncturist’s use of this technique.

Does it work?

What will I learn today??

What is a trigger point?

  • Evidence has shown that Dry Needling has resulted in significant changes to pain intensity, pain pressure threshold, and disability outcome measures.
  • However, there was no significant difference between Dry Needling and manual techniques in reducing pain pressure thresholds and the outcome measures.
  • Other evidence suggests that there is nothing beyond a placebo effect with the use of modalities such as ultrasound.

  • More research needs to be done to examine the long-term effects of Dry Needling. Research right now only looks at immediate to 1 week post-treatment effects.
  • The process of Dry Needling
  • How Dry Needling affects the muscles
  • How to correctly identify a trigger point
  • Evidence of the efficacy of Dry Needling
  • The controversy surrounding PT's and Dry Needling
  • To classify a trigger point, the following criteria must be met:

1. a palpable taut band

2. an exquisite tender spot in the taut band

3. patient’s recognition of pain as ‘familiar’

4. pain on stretching the tissues

  • Trigger points can be caused by:
  • Trauma
  • Overuse
  • Mechanical overload
  • Postural faults
  • Physiological stress

  • Most common location for trigger points is in the upper trapezius muscle, which can result in altered scapulohumeral rhythm and shoulder dysfunction and disability.

What do the acupuncturists say?

  • Not within our scope of practice as PT’s in Massachusetts.
  • No professional standards contradicts licensing requirements for MA acupuncturists.
  • No required education for Dry Needling and the required time for PT’s is significantly less than acupuncturists.
  • Trigger points are considered a subset of acupuncture points by the World Health Organization.
  • The technique is basically a “re-packaging” of a type of acupuncture known as Ashi Point Needling.
  • Acupuncturists are better trained to provide this service safely and effectively, compared to PT’s.

How does Dry Needling work?

How can this help our patients?

Common locations for trigger points

What is Dry Needling?

  • Dry Needling works by stimulating the muscle fibers and connective tissue in order to inactivate the trigger point. The affected muscle is released from its shortened position, which in turn removes irritation and normalizes peripheral nerve sensitization.

  • While the trigger point is held with one hand, the other repeatedly moves the needle forward and backward until there are no more LTR’s.

“Dry needling is a skilled intervention used by physical therapists (where allowed by state law) that uses a thin filiform needle to penetrate the skin and stimulate underlying myofascial trigger points, muscular, and connective tissues for the management of neuromuscular pain and movement impairments”

  • As PT’s we all have encountered at least one patient who presents with some type of limitation due to trigger points.
  • Dry needling is another tool we can use to help restore motion, decrease pain, and reduce disability.
  • This technique does not have to work specifically with upper trap dysfunction, but can be used anywhere in the body where trigger points are present. Research has been done showing improvement in patients with adhesive capsulitis when using Dry Needling.

-APTA's Dry Needling Resource Paper

What's all the hype about?

Local Twitch Response (LTR)

Can I see how it's done?

  • Controversy surrounds PT’s ability to perform this technique.

  • Acupuncturists are in the process of trying to pass a bill though Massachusetts Senate and House of Representatives that would prohibit PT’s from being able to perform Dry Needling.

  • Currently Dry Needling by PT’s has been prohibited (and outside the scope of practice) in California, Utah, New York, Idaho, Hawaii and Florida due to the practice acts prohibiting the puncturing of the skin.

  • As of 2012, states that have accepted Dry Needling as part of PT’s scope of practice includes Alabama, Colorado, the District of Columbia, Georgia, Kentucky, Maryland, Mississippi, Montana, Louisiana, Nevada, New Hampshire, New Mexico, North Carolina, Ohio, Oregon, South Carolina, Tennessee, Texas, Virginia, Wisconsin, and Wyoming. (This list may have expanded since this time.)

Mechanisms of Action

  • “ involuntary spinal cord reflex contraction of the contracted muscle fibers in a taut band following palpation or needling of the taut band in”.

  • Unique characteristic of trigger points.

  • Microcirculation
  • needle increases blood flow to the stimulated area
  • Mechanical
  • needle provides mechanical stretch to the shortened muscle fibers, returning it to its resting length and decreasing the amount of overlap between the different muscle fibers
  • Neurophysiological
  • needle stimulates the A-delta nerve fibers acting on pain pathways to the brain, providing pain suppression and relief
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