dry needling

1. Dry Needling Sarah Guarino Ithaca College 2/12/15

2. What is Dry Needling? Skilled intervention used by PTs that uses a thin, solid filiform needle (without medication) to penetrate the skin and stimulate underlying myofascial trigger points, muscular, and connective tissue for the management of neuro-musculoskeletal pain and movement impairments.

3. Dry Needling

4. Terminology Dry needling, trigger point manual therapy, trigger point dry needling, intramuscular manual therapy. Trigger Point : a taut band of skeletal muscle located within a larger muscle group. - Usually tender to the touch and can refer pain.

5. Uses of Dry Needling Research Supports: Pain control. Reduces muscle tension. Normalizes biochemical and electrical dysfunction of motor endplates. Facilitates an accelerated return to active rehabilitation.

6. Common Impairments Acute/ c hronic tendonitis Overuse injuries Scarring & post-surgical pain Carpal tunnel Sciatic pain TMJ Myofascial pain Headaches & whiplash LBP Motor recruitment Neuromuscular firing problems Decrease spasm/ increase mm. extensibility

7. Goals of Dry Needling To release/inactivate the trigger point and relieve pain.

8. Adverse Events Practiced for over 20 years by PTs. Most common side effects include post-needling soreness and minor hematomas. FSBPT’s ELDD has 0 entries of harm caused by DN performed by PTs. Europe: 2 reports of pneumothoraces, 1 autonomic response, no other serious side effects. DN is under-utilized with no real danger/side effects involved in its practice by PTs.

9. APTA Recognizes dry needling as being part of the Physical Therapist professional scope of practice. 2012= 27 states

10. As of April 2014 states that include dry needling in PT scope of practice include but are not limited to Alabama, Arizona, Georgia, Kentucky, Maryland, Massachusetts, New Hampshire, North/South Carolina, Texas, Wisconsin . 9 State boards (Idaho, Kansas, New York, South Dakota, Hawaii ) have stated it i s not within PT scope of practice. Others :“ not-prohibited”, “no position”, “unresolved ” Countries that currently practice dry needling include Australia, Belgium, Canada, Chile, Denmark, Ireland, The Netherlands, New Zealand, Norway, South Africa, Spain and the United Kingdom.

11. Dry Needling in NJ As of October 23, 2012: “ The NJ State Board of Physical Therapy Examiners statutes and regulations do not prohibit the use of dry needling techniques or trigger point release by a physical therapist provided the physical therapist is trained and competent in the technique. Dry needling is not solely under the practice of acupuncture.” “ The NJ Acupuncture Examining Board considers dry needling by a NJ PT to be the unlicensed practice of acupuncture.”

12. Dry Needling VS. -Based on Western neuroanatomy and the scientific study of the musculoskeletal and nervous system. - Not curative . Acupuncture -Based on ancient Chinese medicine. -Uses Meridians/Channels, energetic physiology and energy flow patterns. -Can treat smoking termination, fertility, depression, allergies and other non-musculoskeletal conditions. -Promotion, maintenance and restoration of health and the prevention of disease. -3 yr. graduate program.

13. Billing/Reimbursement Medicare part A: Dry needling not covered. Medicare part B: Medically necessary services : Services or supplies that are needed to diagnose or treat your medical condition and that meet accepted standards of medical practice. Preventive services : Health care to prevent illness (ex: flu) or detect it at an early stage, when treatment is most likely to work best.

14. Cost to PT and patient For patients: $75-$100 per initial evaluation. $30-$60 per average treatment. Based on time. For PTs: #1 Brand: Lhasa Oms Inc. DBC Spring Acupuncture Needles ~$35-$ 50. Box of 1000 disposable needles. Various length/ thickness. Additional Features: Wires for E- S tim through needle ~$20/ pair.

15. Opportunities Not being taught in most entry level PT programs with the exception of Georgia State University, Mercer University, University of St. Augustine for Health Sciences and the Army PT program at Baylor.

16. THERAPY CONCEPTS COURSE Level 1: 3 day course $950 Theory and physiology of myofascial trigger points, history of dry needling, anatomy review and referral patterns. Cervical & lumbar spine, hip, LE, shoulder and forearm. 20 participants /course, min. 2 years experience. Level 2: 3 day course $950 Lecture, testing, demo & hands on lab sessions. Ant. Neck, head/face, thoracic spine, rib cage, hand, foot and other musculature. http://www.therapyconceptsinc.com/#!/physical-therapy-continuing- education

17. GLOBAL EDUCATION FOR MANUAL THERAPISTS Level 1: 3 days (27.5 contact hrs.) $950 Evaluation/ application of dry needling of neuromyofascial trigger points for basic musculature. Lecture, testing, demo, hands on lab sessions. Level 2: 2 days $550 Research based, specific Dx . Level 3: 2 days $550 http:// www.gemtinfo.com.au Various Seminars : ~55 hrs. of online/ home study + 3 day theoretical and practical examinations. ~$1295 http ://dryneedlingcourse.com/schedule-and- registration

18. Case Study 1 “Efficacy of myofascial trigger point dry needling in the prevention of pain after TKA.” Randomized, double-blind, placebo controlled. Population : >65 yr. old (mean age: 72) Acute care Subjects : 40 participants (29 F, 11 M) Involved knee: 60% R, 40% L 70% general anesthesia, 30% spinal anesthesia

19. Treatment Groups Group 1 : After anesthesia and before surgery. Myofascial trigger points located in TFL, hip add., H/S, quads, gastrocnemius, popliteal. Both active and latent trigger points marked. 20 insertions in each trigger point with consistent patient/ joint positions. Patients were unable to see their LE during Tx . Group 2 : Sham, no treatment given for myofascial trigger points.

20. Purpose : Is dry needling of myofascial trigger point effective in the prevention of pain post-TKA? Conclusion : Group 1 experienced reduced pain in 1 st month post-op compared to group 2, when pain is typically at its highest. Group 1 reached the same degree of pain reduction in month 1 as group 2 reached by month 6. Significantly reduced need for post-op analgesia for group 1. No difference in WOMAC, knee ROM or knee strength at any time post-op.

21. Case Study 2 “Management of shoulder injuries using dry needling in elite volleyball players.” Case report/ case study Population : 18-64 yr. old (mean age: 25, SD 2) Outpatient care 4 women on Great Britain national volleyball squad with complaints of anterior /anterolateral shoulder pain Subjects: 4- all female Right arm dominant Pain in shoulder ranging from 4/10 to 8/10 prior to tx , shoulder ROM limited in all cases in ABD and IR due to pain.

22. Treatment Group Group 1 : Dry needling to myofascial trigger points, STM to shoulder, Cryo post-training, exercises and stretching prn . 1 session of dry needling, 5-12 needles used and left inserted for 10 minutes . Purpose: To describe the ST benefits of dry needling on shoulder problems in 4 elite athletes, with replicable measures of functional pain scores on court and objective measurements of AROM.

23. Results: Pain decreased to 3/10 or less - 3 with outcome, 1 without Full pain-free ROM post- Tx into shoulder ABD -3 with outcome, 1 without Full pain-free ROM post- Tx into shoulder IR @ 90 ABD -2 with outcome, 2 without Conclusion: Supports use of trigger point dry needling in elite female athletes with ST pain relief and improved AROM in the management of acute shoulder injuries, during an intense competitive period.

24. Resources Adrian, Leslie. "FSBPT Dry Needling Resource Paper." Intramuscular Manual Therapy 4 (2013): 1-16. Pub-Med . Web. 28 Jan. 2015. Mayoral , Orlando, Isabel Salvat , María Teresa Martín, Stella Martín, Jesús Santiago, José Cotarelo , and Constantino Rodríguez. "Efficacy of Myofascial Trigger Point Dry Needling in the Prevention of Pain after Total Knee Arthroplasty : A Randomized, Double-Blinded, Placebo -Controlled Trial." Evidence-Based Complementary and Alternative Medicine 2013 (2013): 1-8. Pub-Med . Web. 1 Feb. 2015 . Osborne , N. J., and I. T. Gatt . "Management of Shoulder Injuries Using Dry Needling in Elite Volleyball Players." Acupuncture in Medicine 28.1 (2010): 42-45. Pub-Med . Web. 1 Feb. 2015 . "Physical Therapists & The Performance of Dry Needling." An Educational Resource Paper (2012): n. pag . APTA . Web. 28 Jan. 2015 .