Cupping&

Dry NeedlingSarah GuarinoIthaca College

Cupping

What is Cupping?"Cupping is a form of alternative medicine in which cups are placed on the skin to create suction. The pressure in the cup is reduced by use of heat or suctioning out the air so the skin and superficial layers are drawn out and held in the cup.”

• Ancient Chinese practice.• A Handbook of Prescriptions for Emergencies.• Taoist Herbalist: Ge Hong (281-341 A.D.)• Animal horns

• Hippocrates • Father of modern medicine.

Benefits

• Mobilizes blood flow to promote healing.

• Promotes detoxification.

• Invigorates Qi.

• Regulates aspects of the autonomic NS.

• Deep relaxation of muscle fascia.

Indications

• Incontinence• OA• Nerve Pain• Hyper/hypo tension• LBP• Facial Paralysis• Sciatica• Shingles• GI disorders

• Asthma• Weight loss• Respiratory Diseases• Pain syndromes• Headaches• Gynecological Disorders• Common Colds• Insomnia • Acne

Contraindications

• Skin that is inflamed• High fever• Convulsions• Cramping• Easy bleeding• Pathological level of low platelets

• Abdominal area or low back area during pregnancy• Should not glide over boney prominences• Best use is over fleshy areas

TechniqueVarious types of Cupping involving different levels of suction, heat and duration.• Dry Cupping• Wet Cupping• Medicinal bleeding

• Needle Cupping• Acupuncture • Dry needling

• Gliding• Massage cupping

*Cupping is the inverse of massage- cupping draws the skin upwards (massage pushes the muscles downward) which causes a relaxing and relieving sensation.

*Moxibustion therapy

• Wet cupping- Muslim world. • Mild suction using cups, left for 3 minutes then remove

and make a small skin incision using a cupping scalpel.

• Gliding- oil used to decrease friction (sometimes medical oils with herbs)

• Moxibustion- moxa made from dried mugwort. • Use with acupuncture or burned on pts skin. • Warm meridian points to promote flow of Qi. • Pain control. • RCT found that moxibustion alone and with acupuncture

may be effective in changing breech presentation of babies by affecting the placental release of estrogen and prostaglandins which leads to uterine contractions that change the babies positioning.

Steps1. Flammable substance is placed in a cup and set on fire.2. As the fire burns out, the cup is places upside down on the

patients skin3. The air inside the cup is cooling which causes the vacuuming

effect.4. This causes the skin to rise and redden as blood vessels expand.5. Generally left on the skin

for 5-20 minutes.

*Plastic cups used with suction pump vs. glass cups with fire*Plastic cups are not suitable for gliding cupping. They have more control over the amount of suction and are easier to use.

Qi"A circulating life force or energy whose existence and properties are the basis of much Chinese philosophy and medicine."

• 5 Elements• Cyclic• Create • Destroy

• Sickness due to imbalance of elements• Overproduction• Underproduction

• Associated with symptoms or traits • Complementary forces not opposing • Everything is composed of both Yin & Yang (ex: shadow)• Health and longevity

Yin & Yang

Yin• Dark, cool, wet• Earth to heaven• Female• Solid organs• Negative force• Outward movement• Towards periphery• Internal energy

Yang• Light, warm, dry• Heaven to Earth• Male• Hollow organs• Positive force• Inward movement• Towards center• Physical body

Meridians• Yin & Yang determine meridians• Associated with body parts/ organs• Manipulating meridians has effect on body functions associated with that meridian• Qi flows through meridians• Used to balance the 5 elements

Case Study 1Method:• LBP in pregnant women• 50 women in control (no cupping) 50 women in cupping group• 15 to 20 min. up to 4 consecutive times• VAS scale 0-10

Results:• Baseline 7.8• Immediately: 3.7• 24 hours: 2.5• 2 weeks: 1.4

• ANOVA: Significant difference in pain due to intervention

Case Study 2“Medicinal cupping therapy in 30 patients with fibromyalgia: a case series observation”

• 30 patients with Fibromyalgia at an outpatient hospital in Beijing, China

• Patients diagnosed according to criteria set by the American College of Rheumatology (1990)

• Bamboo cup boiled in herbal liquor for 5 minutes applied to Ashi points (defined as a tender point) for 10 minutes 1x daily for 15 days.

• Pain assessed on a 10 point VAS.

Time Pain (VAS) Number of Tender Points

Baseline 2.63 13.5

5 days 2.22 12.57

10 days 1.78 11.2

15 days 1.36 9.33

• 29 patients completed a 2 week follow-up:• Reduction in pain (1.31) and in the number of tender

points (9.07) was sustained • No serious adverse effects.• Conclusion:• Medicinal cupping therapy was associated with a

reduction in fibromyalgia symptoms for both pain ratings and number of tender points.

Case Study 3“Effects of wet-cupping on BP in hypertensive patients: a randomized controlled trial”

• 2 clinical groups (40 subjects each)• Intervention group: wet cupping & conventional hypertension treatment

• 3 cupping sessions performed every other day• Control group: conventional hypertension treatment

• Mean systolic and diastolic BP measured using a validated automatic sphygmomanometer• Follow up period was 8 weeks

• •

• Results:• Wet cupping provided an immediate reduction of systolic BP.• 4 week follow up: mean systolic BP was 8.4 mmHg less in the

intervention group compared to control group.• 8 week follow up: no significant differences • No serious side effects

• Conclusion:• Wet cupping is effective for reducing systolic BP in hypertensive

patients for up to 4 weeks with no serious side effects and should be considered as a complementary hypertensive treatment.

• •

Case Study 4“Management of knee osteoarthritis with cupping therapy”

• RCT• Cupping performed on days 0-6, 9-11 and 14• 15 day span

• Significant and better results in the overall management of knee OA• Pain, edema, stiffness and disability

• Comparable with acetaminophen 650 mg 3x a day orally in terms of analgesia, anti-inflammatory and resolution of edema with minimal and temporary side effects like ecchymosis and blister formation.• Control drug has greater side effects on the GI tract.

Dry Needling

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.

Dry Needling

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

Goals of Dry NeedlingTo release/inactivate the trigger point and relieve pain.

Diagnostic Evidence• Latent trigger points are shown to increase EMG activity at

rest and during movement and can alter motor control.• Trigger points are related to pain, inflammation and misfiring of

intercellular signaling. • Needling is shown to reduce trigger point sensitivity and

spontaneous electrical activity therefore affecting the pain threshold associated with trigger points.

• Trigger point diagnostic essential criteria:• Taut band of muscle• Spot tenderness of a nodule in a taut band• Patient complaint of pain with pressure applied to the nodule.

• Identify active trigger point• Painful limit to full stretch ROM

Types of DN• Pistoning- rhythmic & multidirectional passes into tissue. May

see LTR; used with trigger point model.• Local twitch response (LTR)- muscle spindle and reflex arc at

the segmental level of innervation. Needle inserted into point of tenderness.• Superficial- reduce or eliminate post-tx soreness.• Trigger point- LTR; causing local or widespread myofascial pain.

Most researched model.• Neurofunctional- leaving needles in mm, sensory or motor

effects (motor point).• Perineurial- all needling impacts nervous system.• Tendon or ligament- VAS improvements (achilles, shouler).• Estim- easier twitch response elicited. Decrease soreness.

Common Impairments• Acute/chronic

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 muscle extensibility

Adverse Events• Practiced for over 20 years by PTs.• Most common side effects include post-needling soreness

and minor hematomas. • FSBPT’s (Federation of state boards of PT) ELDD

(Examination, licensure and disciplinary database) 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.

• *Pneumothorax: the abnormal presence of air between the lung and the wall of the chest (pleural cavity), resulting in collapse of the lung

APTA• Recognizes dry needling as being part of the Physical

Therapist professional scope of practice.

2012 = 27 states

• 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 is 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.

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.”

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.

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.

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-Stim through needle ~$20/ pair.

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.

*Taught at most international universities

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

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 $550http://www.gemtinfo.com.au

Various Seminars: ~55 hrs. of online/ home study + 3 day theoretical and practical examinations. ~$1295http://dryneedlingcourse.com/schedule-and-registration

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

Inclusion: dx of knee OA and scheduled for TKA, + presence of active or latent myofascial trigger points in at least 1 of the muscles involved in the examination protocolExclusion any other condition that causes myofascial or neuropathic pain in LE. Ex: fibromyalgia.

• Treatment 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

treatment.

• Treatment Group 2: Sham, no treatment given for myofascial trigger points.

• Purpose: Is dry needling of myofascial trigger point effective in the prevention of pain post-TKA?

• Conclusion: Group 1 experienced reduced pain in 1st 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.

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 treatment, shoulder ROM limited in all cases in ABD and IR due to pain.

• Treatment Group 1: Dry needling to myofascial trigger points, STM to shoulder, Cryo post-training, exercises and stretching as needed.• 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.

Results:• Pain decreased to 3/10 or less

-3 with outcome, 1 without• Full pain-free ROM post-treatment into shoulder ABD

-3 with outcome, 1 without• Full pain-free ROM post-treatment 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.

Considerations• There is no way to blind subjects or therapists.• How long do benefits last?• How many treatment sessions per muscle?• Patient reported outcome measurements.• Diagnostic imaging is gold standard.

• Minimal adverse events reported.• Are eastern medicinal techniques under utilized?

• Insurance coverage.• Skepticism• Meridian lines• Qi• Balance of 5 elements