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To the Point NewsIn our quarterly newsletter, you will find information about physical therapy, various pain conditions, and the different treatment techniques employed at Bethesda Physiocare. In this issue, you may learn how trigger point dry needling differs from traditional acupuncture.

In another article, we will have a closer look at why so few physical therapists have specialized in the treatment of persons with chronic pain conditions.

Contact us at 30�.656.56�3

Physical therapists at Bethesda Physiocare use trigger point dry needling (TrP-DN) in the treatment of many of their patients.

Dry Needling or Acupuncture?

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Sometimes patients, referring doctors and even state boards of physical therapy wonder whether TrP-DN is a form of traditional acupuncture. While there are simi-

larities between the two treatment approaches, there are probably many more differences. Physical therapists are legally allowed to practice dry needling in many countries, including Canada, Spain, South Africa, the Netherlands, Ireland, Australia, Switzerland, the UK, etc. In the US, state boards of physical therapy in eight states have determimed that TrP-DN

falls within the scope of physical therapy practice. States where physical therapists can practice TrP-DN are New Hampshire, Maryland, Virginia, South

Carolina, Georgia, New Mexico, Kentucky, and Colorado. In other states, such as New York, Hawaii, California, and Tennessee physical therapists are not allowed to

use dry needling. Most other state boards have not considered the issue. In some states the physical therapy statutes are quite confusing. For example, according to the Florida statutes, physical therapists are allowed to practice acupuncture “when no penetration of the skin occurs.”

The practice of traditional acupuncture has its roots in ancient China and is based on a presumed flow of energy through acupuncture meridians. The objective of

acupuncture is to restore the energy balance in the meridians which is seen as a prerequisite to restore a person’s health. Acupuncturists insert thin needles in specific points throughout the body. Acupuncture has been

recognized by the World Health Organization and is practiced around the world. In the US,

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Trigger Point Dry Needling

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the training of an acupuncturist requires completion of a master’s degree from an accredited school of acupuncture.

TP-DN requires the completion of an accredited post-graduate continuing education program. In the US, Myopain Seminars directed by Jan Dommerholt and Dr. Robert Gerwin, is the premier company to study TP-DN. In Canada, many physical therapists have completed the training program from Dr. Chan Gunn, also known as “intramuscular stimulation”. Dr. Gunn is one of the early pioneers of TP-DN. Although many patients assume that dry needling originated from traditional acupuncture, Dr. Gunn based his thinking on Western medicine and neurology. Another pioneer of dry needling is Dr. Karel Lewit from the Czech Republic, who was strongly influenced by Dr. Janet Travell and her focus on myofascial trigger points. In TrP-DN, we use the same needles as acupuncturists even though the technique is very different. The objective if TrP-DN is to elicit so-called local twitch responses, which require the needle to be placed directly into myofascial trigger points.

Referred Pain and MeridiansWhile a few researches have suggested that acupuncture points overlap with myofascial trigger points, it remains difficult to compare an ancient metaphysical concept with a more modern neurophysiologic scientific concept. There are several scientific studies that support both dry needling and acupuncture, although the mechanisms of each remain somewhat elusive.

It is interesting to see the similarities between the well-described referred pain patterns of myofascial trigger points and the course of acupuncture meridians. However, from a physical therapy perspective the objective of TP-DN has nothing to do with the control of presumed energy flows. Three recent studies confirmed that acupuncture does not have unique effects on the central nervous system or on pain and pain modulation, which implies that the discussion whether TrP-DN is a form of acupuncture becomes irrelevant. In these studies, there were no significant differences between acupuncture and sham acupuncture.

In summary, physical therapists practicing TrP-DN do not practice traditional Chinese acupuncture. More research on the differences and similarities is needed. .

“If pain is a puzzle, we should not throw away any pieces of the jigsaw, because we are obsessed with a preconceived single solution.” Patrick Wall

2006 OPTP AwardDid you know that a recent article by Jan Dommerholt, Carel Bron and Jo Franssen was awarded with the 2006 OPTP Award for Excellence in a Published Review of the Literature? The article, “Myofascial Trigger Points; an evidence-informed Review”, was published in the Journal of Manual and Manipulative Therapy.

Jo Franssen, PT practicing “dry needling” in Dublin

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Trigger Point Dry Needling

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Traditional Chinese acupuncture

PerspectiveMany patients at Bethesda Physiocare have been seen by other physical therapists, chiropractors, acupuncturists, and usually several medical doctors. Yet, some patients continue to suffer from pain and are not able to work, play tennis, or go to the movies or a concert.

The prevalence of chronic pain is estimated to range from 10% to over 50%. Chronic pain diagnoses may include complex regional pain syndrome, fibromyalgia, whiplash-associated pain, orofacial pain, migraines or other headaches, low back pain, etc. Most persons suffering from chronic pain conditions consult with a physical therapist. Physical therapy has been described as one of the pillars of pain management programs.

Physical therapists are not always prepared to offer patients with chronic pain the best evidence-based interventions. A recent study showed that as many as 96% of orthopedic physical therapists would prefer not to work with persons with chronic pain! The orthopedic section of the American Physical Therapy Association has a Pain Management Special Interest Group, but at last count, the group had less than 400 members nationwide. Physical therapists are poorly represented at international pain management associations. For example, the American Academy of Pain Management has fewer than 100 physical therapy members.

The American Physical Therapy Association has published the Guide to Physical Therapy Practice, but the publication offers limited guidance in determining the best physical therapy approach. The Guide does not recognize chronic pain as a specific disease, diagnosis, or musculoskeletal

pattern. To top it off, very few university physical therapy programs include courses in chronic pain management or even in the neurophysiologic mechanisms of persistent pain. It should then come as no surprise that many physical therapists lack knowledge of pain management and may not be all that interested in working with persons with chronic pain conditions.

Fortunately, there is a growing number of physical therapists with advanced knowledge of pain management principles. Physical therapists at Bethesda Physiocare have specialized in chronic pain physical therapy. After a thorough examination and the formulation of a physical therapy diagnosis, chronic pain physical therapy consists of two distinct, but overlapping phases. During the first phase, the emphasis is on reduction of pain. Physical therapists may use manual trigger point therapy, dry needling, deep muscle massage therapy, or other soft tissue and joint mobilization techniques. In addition, patients will be educated about their pain problem, the

Marwan Khayat, PTMarwan Khayat completed his Bachelor’s degree in physical therapy at Tel-Aviv University in Israel. In addition, he completed a one-year program of continuing medical education in the field of Sports Medicine at the Sackler School of Medicine in Tel Aviv University. Mr. Khayat has attended several courses in the field of sports medicine back in Israel and in the United States. He has completed the Myopain Seminars course program and is certified in Trigger Point Dry Needling.

Mr. Khayat has attended several courses in the field of craniomandibular and facial pain/dysfunction taught by Dr. Mariano Rocabado. He spends much of his time researching the field of temporomandibular joint (TMJ) rehabilitation and is dedicated to exploring new avenues of collaboration between physical therapists and dentists. He is a Certified Kinesio Taping Practitioner. He is a member of the Kinesio Taping Association, the American Physical Therapy Association, the International Myopain Society, and the American Academy of Orthopedic Manual Physical Therapy.

Outside the office, he is an assistant soccer coach and a dedicated practitioner in the art of Kempo Karate. Marwan resides with his wife in Washington, DC.

“Anyone who lives a sedentary life and does not exercise, even if he eats good foods and takes care of himself according to proper medical principles, all his days will be painful ones and his strength shall wane.” Maimonides, 1199 AD

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Directions to Bethesda PhysiocareFrom the North (Maryland and West (Virginia): Take I-495 to Exit 36, Rte �87 (Old Georgetown Rd) south. Turn right to Del Ray Avenue and an immediate left to park in the garage underneath the building.

From the South (DC): Drive north on Wisconsin Avenue. Take a left at Rte �87 (Old Georgetown Rd). Bethesda Physiocare is on the left after Cordell Avenue. Make a left at Del Rey Avenue and an immediate left to park in the garage underneath the building.

By Metro: Take the Red Line to the Bethesda station. Walk north on Old Georgetown Road for about three blocks, or take the “Bethesda 8 Shuttle” (free) from the Metro station, which can drop you off across the street from the building at 7830 Old Georgetown Road.

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role of the central and peripheral nervous system, and the importance of improved posture and early conditioning exercises. Chronic pain conditions rarely are associated with persistent tissue damage. In other words, “the issues are not in the tissues”.

During the second phase of physical therapy, the focus shifts to further improving physical function and reducing disability and suffering. It is important to learn self-pacing skills and set achievable goals. Goals should include physical goals (exercise, walking), functional goals (work, recreation), and social goals (visit friends, go to a concert).

Physical therapists can play an integral role in assisting persons with chronic pain to return to a meaningful life. Hopefully, knowledge from the pain sciences will become part of the standard curriculum of physical therapy schools to better prepare future physical therapists to become more effective pain management specialists.

“The onset of low back pain has not created a new problem. It has merely made more urgent the necessity of solving an existing one.”

modified from Albert Einstein (1879-1955)

7830 Old Georgetown Road, Suite C-�5Bethesda, MD 208�4 -2440

30�.656.56�3info@bethesdaphysiocare.comwww.bethesdaphysiocare.com

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Soft Tissue Mobilization