dry needling & headache management
TRANSCRIPT
Concussion Rehabilitation:Dry Needling & Headache Management
Michelle Ninemire, PT, DPT & Jocelyn Shaal, PT, DPT
Nebraska Brain Injury Conference 2020Omaha, Nebraska
CHI Health Immanuel Rehabilitation
Objectives1. Review proposed mechanisms and effects of trigger point dry
needling. 2. Recognize subjective and objective findings indicating appropriate
referral for dry needling. 3. Understand precautions and contraindications related to dry needling
technique. 4. Identify key muscle groups and associated referral patterns possibly
contributing to headaches. 5. Discuss state laws and limitations related to dry needling.
What is Dry Needling?
Invasive, skilled therapeutic intervention completed by physical therapists and other healthcare providers in which a
thin needle is used to penetrate the skin and stimulate muscular, connective, and neural tissue(s) to reduce pain and
address movement impairments.- American Physical Therapy Association
What is a myofascial trigger point?
● A hyperirritable spot in a tight band of muscle that is painful on compression, stretch, or contraction.
● Muscle overload/overuse causes the muscle to misfire and inadequately respond
● Characterized by local twitch response, spontaneous electrical activity, and biochemical changes
● Provokes weakness, imbalances, pain, restricted motion, and/or spasms causing revolving pain cycle
How does Dry Needling work?● Promotes relaxation of the muscle● Restores muscle’s ability to lengthen
and shorten by releasing the trigger point
● Alters chemical environment to decrease sensitivity and restore normal muscle function
● Increases blood flow and oxygenation to local area of pain for healing
● Attracts nutrients and flushes away acidic chemicals
Dry Needling + Concussion
Concussion review● Type of traumatic brain injury caused by a bump, blow, or jolt
to the head or by a hit to the body that causes the head and brain to move rapidly back and forth○ Sudden movement causes the brain to bounce or twist in the skull○ Causes stretching and damage to brain cells ○ Typically categorized under “mild traumatic brain injury”
Concussion vs. WhiplashA concussion is due to
acceleration or deceleration of the brain, while whiplash
is due to acceleration or deceleration of the neck.
Similarities:● Physical symptoms: headaches,
soreness, aching, dizziness● Cognitive symptoms: confusion
and difficulty concentrating● Behavioral symptoms: fatigue,
irritability, and anxiety
Headache Classifications
Basic Categories of Headaches
Primary Secondary
No underlying origin
Migraine Cluster
Result of other source(ie: inflammation, head/neck injury)
Vascular disorder CervicogenicTension “Brain Freeze”
Cervicogenic Headache
● Meaning “stemming from the neck”● Caused by injury to the neck, shoulders, or scapular regions● Includes a headache accompanied by neck pain
• Typically unilateral • Occasionally involve unilateral upper extremity pain
● Presents with:• Reduced cervical range of motion• Aggravation by movement or sustained neck positions• Palpable trigger points or tenderness in the neck or shoulder regions
• Reproduces or refers pain to familiar locations
Referred Pain + Referral Patterns
What is referred pain?
• “Secondary” pain• Pain that’s perceived at a location other
than the site of the painful origin • Area and size can be variable and can
spread in any/all directions• Descriptors: deep, diffuse, burning, tight,
or difficult to locate• Cause: network of interconnecting
sensory nerves that supply more than one area
Muscle Referral pattern
Upper Trapezius
Muscle Referral pattern
Sternocleidomastoid
Muscle Referral pattern
Splenius capitis + cervicis
Capitis
Cervicis
Muscle Referral pattern
Semispinalis capitis
Muscle Referral pattern
Oblique capitis inferior
Muscle Referral pattern
Cervical mutlifidi
Dry Needling Demonstration
What should I expect after completing Dry Needling?● Post-treatment soreness
○ Common 1-2 days following dry needling technique○ Utilize strategies to reduce severity of soreness by:
■ Using heat or ice on the affected area■ Gently massaging the area■ Stretching the muscle or muscle group as directed by your physical
therapist■ Staying hydrated■ Staying active and utilize body part for regular, daily activities■ Take prescription or over-the-counter medications as recommended by
your physician
● Possible Bruising
When should I avoid Dry Needling?• Needle phobia• Communication or language barriers
Information to discuss with your Physical Therapist:• Abnormal bleeding tendency • Compromised immune system • Vascular disease/Lymphedema• Pregnancy
• Age• Allergies• Medications• Diabetes
How do I know if I’m a candidate for Dry Needling?● Have you had an injury that causes pain?● Has this injury caused a restriction in range of motion or
flexibility?● Is your injured body part tender to the touch?● Can you feel a “knot” in any of the painful areas of your body?● Are you open to other forms of therapy including exercise,
manual treatments, and modalities?
If you answered yes to some or most of these questions, you may be an appropriate candidate for Dry Needling.
Frequently Asked Questions
Is Dry Needling the same as Acupuncture?
Dry Needling Traditional Acupuncture
Origin (Place & Time) Czechoslovakia ~1980 China ~3000 years ago
Basis Western medicine Eastern medicine
Needle insertion Soft tissues Meridian lines
Type of technique Pistoning, static, electrical stimulation
Typically left for a duration
Used for treatments of:
• Neuromuscular conditions• Relieving pain• Improving range of motion
Wide variety of conditions:• Internal ailments• Depression• Nausea• Migraine• Vomiting
Is Dry Needling an Injection?Dry Needling Wet Needling (Trigger Point Injection)
Meaning Without medication Local injection
Type of needle Thin, monofilament Hollow-bore
Cost $45-$85 (MD Save) $358-$591 (MD Save)
Other Information
-- Local anesthetic can reduce post-injection painOccasional use of ultrasound guidance
Is Dry Needling safe?● Yes. Physical therapists are experts in human anatomy and
kinesiology● Technique is learned following completion of accredited
physical therapy educational program and after obtaining licensure in practicing state
Is there anything I should avoid after Dry Needling?
● No. Patients are recommended to continue their typical daily routine following completion of dry needling, including but not limited to:○ Grocery shopping or running errands ○ Child care○ Exercise routine or recreational activities ○ Community interests: volunteer activities, clubs, social groups○ Other hobbies and interests
Are the needles reused or recycled?
● No. Each needle is discarded after use, consistent with medically approved standards and practices.
Billing + State Regulations
State Laws + Regulations
State of Nebraska:• Within scope of PT
practice• Must complete in-
service training prior to implementing the technique into practice
Citations
Citations
1. Dommerholt, J., Fernandez-de-las-Penas, C. 2013. Trigger Point Dry Needling: an evidence and clinical-based approach. Elsevier Health Sciences.
2. Matharu M. Cluster headache. BMJ clinical evidence. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907610/. Published February 9, 2010.
3. International Headache Society. The international Classification of Headache Disorders 3rd edition. https://ichd-3.org/. Published 2019.
4. Chowdhury D. Tension type headache. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3444224/. Published August 15, 2012.
5. Kaljić, E., Trtak, N., Avdić, D., Bojičić, S., Katana, B., & Pecar, M. (2018). The role of a dry needling technique in pain reduction. Journal of Health Sciences, 8(3), 128-139.
6. Dommerholt J. (2011). Dry needling - peripheral and central considerations. The Journal of manual & manipulative therapy, 19(4), 223–227.
7. Dunning, J., Butts, R., Mourad, F., Young, I., Flannagan, S., & Perreault, T. (2014). Dry needling: a literature review with implications for clinical practice guidelines. Physical therapy reviews : PTR, 19(4), 252–265.
8. Gildir, S., Tüzün, E. H., Eroğlu, G., & Eker, L. (2019). A randomized trial of trigger point dry needling versus sham needling for chronic tension-type headache. Medicine, 98(8), e14520.
9. Abbaszadeh-Amirdehi, M., Ansari, N. N., Naghdi, S., Olyaei, G., & Nourbakhsh, M. R. (2013). The neurophysiological effects of dry needling in patients with upper trapezius myofascial trigger points: study protocol of a controlled clinical trial. BMJ open, 3(5), e002825.
10. Page P. (2011). Cervicogenic headaches: an evidence-led approach to clinical management. International journal of sports physical therapy, 6(3), 254–266.
11. Myran, Rigmor & Hagen, Knut & Svebak, Sven & Nygaard, Oystein & Zwart, John-Anker. (2011). Headache and musculoskeletal complaints among subjects with self reported whiplash injury. The HUNT-2 study. BMC musculoskeletal disorders. 12. 129. 10.1186/1471-2474-12-129.
Michelle Ninemire, PT, [email protected]
If you have any questions, feel free to contact us via e-mail.
Jocelyn Shaal, PT, [email protected]
Thank you!