intentionally breaking the skin
TRANSCRIPT
Intentionally Breaking the SkinA Dry Needling Approach to the
Lymphatic System
Alaina M. Newell, PT, DPT, WCS, CLT-LANAMelissa L. Buss, PT, DPT, WCS, CLT
Course Learning Objectives● To discuss the safety and application of dry needling in patients at-
risk or with lymphedema. ● To understand the physiology of the lymphatic system in relationship
to other body systems. ● To be able to apply dry needling techniques (with prior additional
training) within watershed territories of patients with compromised lymphatics from lymph node dissection and/or radiation.
● To be able to provide follow up corrective exercises to encourage neuromuscular gains following dry needling in patients at-risk or with lymphedema.
About Us - MelissaMelissa L. Buss, PT, DPT
Doctorate of Physical Therapy, University of Pittsburgh
Board Certified Women’s Health Clinical Specialist
Certified Lymphedema Therapist
BodyCentral Physical Therapy - Tucson, AZ
Dry Needling Training: Structure and Function Education
Connect with me: [email protected]
Conflict of Interest Disclosure:
Structure and Function Teaching Assistant
About Us - AlainaAlaina Newell PT, DPT
Doctorate of Physical Therapy, University of Pittsburgh
Board Certified Women’s Health Clinical Specialist
Lymphology Association of North America, Certified
Lymphedema Therapist
Oncology Rehab - Centennial, Colorado
Dry Needling Training: Kinetacore Functional Dry Needling
Level 1 and 2
Connect with me: [email protected]
Conflict of Interest Disclosure:
Alaina is a Clinical Instructor for PORi (Physiological Oncology
Rehabilitation Institute)
Who is in the audience?
Lymphedema
SpecialistDry Needling
Practitioner
Interested in
the title?
What are you afraid of?
Breaking Protocol
Needling
Lymphedema
Cancer Care
What is Dry Needling(DN)?● Thin monofilament needle
● Inserted through skin
● Goal: influence neurologic, myofascial
and skeletal systems
● “Western Medicine”
Wet Needling
● Hollow needle
● Goal: Delivery of treatment ○ Corticosteroids
○ Chemotherapy
Acupuncture
● Thin monofilament needle
● Inserted through skin
● Goal - correct imbalances of flow and
restore health along meridians of the
body
● “Eastern Medicine”
1
Dry Needling: Indications for Use
IMPROVE FUNCTION
● Pain Control
● Muscle Tension/Length
● Normalize motor endplates
● Biomechanics
Facilitate accelerated return to active rehabilitation2
Dry Needling: Physiology● Taut band
○ Disrupts motor endplate
○ Decreased ACh stores
○ Decrease spontaneous electrical activity
● Local Ischemia/Hypoxia○ Release of CGRP and NO -> Vasodilation
○ Increase in hypoxic responsive proteins
■ HIF-1alpha, iNOS, VEGF
■ Increase angiogenesis,
vasodilation, alter glucose
metabolism
● Peripheral and Central Sensitization
3
Dry Needling: Training/State practice
Map Key = Yes = No = Unsure =Silent
APTA 2017
Dry Needling: Standard PrecautionsPatient based:
● Significant cognitive impairment
● Unable to clearly communicate
● Must provide clear, direct
consent to treatment
○ Written: Initial treatment
○ Verbal: Follow-up treatment
● Needle aversion/phobia
● Severe hyperalgesia or allodynia
● Smoking
4
Dry Needling: Standard PrecautionsSafety based:
● Avoid local skin lesions
● Local or Systemic Infections
● Local lymphedema
● Metal allergies
● Abnormal bleeding tendency
● Compromised immune system
● First Trimester of Pregnancy
● Vascular disease
● Following surgical procedure, especially
opened capsular structures
Note: there is no evidence that DN would cause or
contribute to increased lymphedema, ie,
postmastectomy, and as such is not a
contraindication.
4
Dry Needling: Specific Precautions● Practitioner: Knowledge and skill
● Surgery/Radiation:
○ 12 weeks for local region
○ 6 weeks for distal sites
● Systemic disease:
○ Vascular disease
○ Diabetes
○ Autoimmune Disease
● Infection:
○ Acute infection
○ History: >3 lifetime integumentary
infections (ie. cellulitis),
● Cancer
○ Non-medically managed
● Bone Abnormalities:
○ metastatic disease, osteoporosis,
structural or surgical abnormalities
● Immunity: Unstable or low blood counts6
● Avoid tissue surrounding
○ implants, ports, stimulators, pumps,
pacers, wires, stents
5
Intentionally Breaking the Skin632 patients (760 at risk arms)
2009-2014
Prospective Study
Takeaway: Any Specific precautions going
forward are based upon decrease in infection
risk!
Correlation:
Increase in lymphedema risk
● Cellulitis
● Regional Lymph Node Radiation (RNLR)
● Axillary Lymph Node Dissection (ALND)
No increase risk in lymphedema
● Air travel
● Ipsilateral blood draws
● Injections
● Blood Pressure
5
We are not the first...Memorial Sloan-Kettering Cancer Center
November 2009- May 2011
33 Women with Breast Cancer Related
Lymphedema (BCRL)
● >2 cm difference
● 6+ months from dx
● Maintain current management
● 6+ months from last surgery
● Exclusions
Treatment
● 2x/week, 4 weeks, 30 minute sessions
● 14 points, 4 in affected limb
Takeaway: @ 6 month follow up
● No infection
● No exacerbations
7
Dosage of Dry Needling80 Rabbits
4 groups (20 in each)
1. 1 Treatment - Sham Operation
2. 1 Treatment - Dry Needling
3. 5 Treatments - Sham Operation
4. 5 Treatments - Dry Needling
10 in each group
● Immediate analysis (Short-term effects)
● 5 days delayed analysis (Long-term
effects)
Biochemicals Short Term Long Term
1X 5X 1X 5X
Substance P ↓ ↑ -- ↑
TNF- 𝛂 ↑ ↑ ↑ ↑
iNOS -- ↑ -- ↑
HIF-1𝛂 -- ↑ -- ↑
COX-2 -- ↑ -- ↑
VEGF -- ↑ -- ↑
8
Adverse Side Effects7,629 treatments
● Bleeding - 7.55%
● Bruising - 4.65%
● Pain during treatment - 3.01%
● Pain after treatment - 2.19%
● 2.2 million treatments
○ 8.6 % minor pain and bleeding
○ 2.2% required more treatment
Takeaway: Increased risk due to
thrombocytopenia in oncology population,
informs caution with treatment parameters
9, 10
*Integration of DN with Therapy Intervention30 participants
3 groups
1. Dry Needling only
2. Dry Needling + stretching
3. Stretching only
Treatment
● DN Technique: Pistoning x 1
● Stretching: 30”x 3, 2x/day, 4 days
Results:
● Immediate and ST improvement in
functional movement pattern for groups
1 and 2.
Takeaway: Dry Needling elicit more effective
change in functional movement than exercise
alone.
Limitation: Healthy subjects
11
Safe Needling Techniques - Cancer/Lymphedema● Needle application
○ Sterile
○ Single Use
○ Length -
● Clean treatment field○ Pre treatment
○ Post treatment
● Hand Hygiene○ Pre and Post treatment
● Personal Protective Equipment○ Gloves
● Needle Disposal○ Approved sharps container
12
Fluid Movement in BodyArteries (100%)
● Oxygenated blood
● Heart to body
Veins (90%)
● Deoxygenated blood
● Body to heart
Lymphatics (10%)
● Lymphatic Fluid
Lymphatic Vessel AnatomyWhere:
● Adjacent to Arteries and Veins
● Superficial and Deep structures
● Visceral and parietal
Large Lumen
Transport larger proteins
Larger gaps to allow proteins to be
transported
Functional Unit: Lymphangion
Lymphatic + Nervous Systems● Sensory input from affected
region
○ inform cognitive
awareness of body state
● Directs autonomic nervous
system for vessel
dilation/constriction
● Facilitates lymphatic pump
○ Intrinsic
○ Extrinsic
● Regulates immune function
Lymphatic + Myofascial SystemsIntrinsic (Lymphatic System)
● Along Pressure gradient
● One way valves
● Rapid/Phasic contraction of
lymphatic muscle
● Lymphangion in series
Extrinsic (Myofascial System)
● Cyclical Contraction of muscles
13
Lymphatic +Skeletal System● Joint mobility applies tension to
lymphatic - helps with lymphatic
pumping
● Posture
○ changes muscle length/ tension
● Joint ROM/mobility
○ contractile force to move
synovial fluid
○ Transported by lymphatics
● Synovial fluid drained via lymphatics
Lymphatic + Integumentary Systems
● Interstitial fluid drained
● Houses Lymphatic capillaries
● Provide infection barrier
Functional Physiology of the Lymphatic SystemTransport Capacity: Maximum volume
of lymphatic fluid that can be
transported.
Functional Capacity: Ability of body to
mobilize lymphatic fluid under current
circumstances
Lymphatic Load: Cells + Fluid in
interstitial spaces
Lymphedema: Lymphatic load above
functional capacity.
What changes lymphatic load?● Exercise
● Illness/Injury
● Stress
● Pressure changes (weather, air travel, scuba
diving)
● BMI
● Medications
What are symptoms of increased
lymphatic load? ● Heaviness
● Achiness
● Fullness
● Swelling
Before Cancer Treatment
After Cancer Treatment
Lymphedema
Our Treatment Goal
Our Method Assessment
Dry Needling
Manual Physiologic
Enhancement Techniques
(MPET)
Corrective Exercise
Retest
Assessment1. Review precautions
a. Change in status that will trigger change
in treatment
2. Symptom Reviewa. Based upon prior impairments and goals
3. Neurala. Functional Movement Patterns
4. Myofasciala. Active
b. Passive
1. Skeletala. Joint Mobility and ROM
2. Lymphatica. Fibrosis, Edema, Pitting, Cording, Girth,
Bioimpedance
3. Integumentarya. Integrity, Infection
Select Data to track
● Within treatment session
● Over Plan of Care
Dry Needling ApplicationDosage: FITT Principle
● Frequency○ 1x/week - 1x/month
● Intensity○ Length of Lesion
○ Number of lesions
○ Needle Manipulation
● Time○ <60 seconds up to 10 minutes
● Technique○ In Situ
○ Pistoning
○ Winding
○ E-Stim/NMES
Purpose: Improve body systems to support
functional capacity of lymphatic system
Manual Physiologic Enhancement Techniques (MPET)● Manual Lymphatic Drainage (MLD)
● Joint Mobilization
● TrP release
● Soft Tissue mobilization
● Myofascial release
● Visceral manipulation
● AAROM
● Manual Resisted Exercise
● Kinesiotaping
Purpose: Specifically address the tissues and
limitations that you addressed with dry
needling technique.
Examples:
● Increased ROM - Stretch, AAROM
● Muscle endurance with NMES - Manual
resistive exercise
● Joint Stiffness- Joint mobilization
● Increase lymphatic flow - MLD
Corrective ExerciseMovement based
Address tissue that was treated with previous
techniques
Prolong and Maintain gains achieved by DN
and MPETS
Transitions to Home Exercise Program
Purpose: Movement or exercise designed to
correct a specific dysfunction to restore
body’s physiological function
Examples:
● Reduce Neural Tension - Neural gliding
● Increase muscle activation -
strengthening or coordination
● Decrease muscle tension - stretching
● Decrease swelling - full range muscle
pumping
RetestBased upon impairment determined in
assessment
● Session
● Course of Care
Case Presentation: Upper Extremity - Stage 0Patient Information: Female 45y/o Stage IIB
Breast Cancer
Functional Limitation: Posture - shoulder
position
Assessment : Neurological, Muscular
Test: Shoulder ER, Neural Tension Test
Dry Needling
● F: 1x/3-4w weeks○ 3 treatments
● I : 4 needles (30-50mm)
● T: 5-30 second
● T: Piston, NMES (2Hz)
MPET: Scar mobilization, Myofascial release,
Joint mobilization to trunk, trigger point
release, scapular mobilizations, AAROM
Corrective Exercise: Nerve glides, scapular
stability, chest stretching
Retest: Shoulder Er
Case Presentation: Lower Extremity - Stage 1Patient Information: 72y/o Male with Stage I
Prostate Cancer
Treatment: Surgery
(prostatectomy+1xLND), Targeted Radiation;
<1 year ago
Functional Limitation: Running Tolerance
Assessment : Joint Range of Motion, Muscular
system
Test: Standing dorsiflexion
Dry Needling
● F: 1x/1-2 weeks○ 4 treatments over 6 weeks
● I: 2-5 needles (30-50mm)
● T: 5-30 seconds
● T: Piston, NMES (2Hz)
MPET: Joint mobilization, MLD, taping
Corrective Exercise: Standing dorsiflexion
with knee extension and flexion, heel/toe
walking
Retest: Ankle range of motion
(dorsiflexion)
Case Presentation: Trunk - Stage 1Patient Information: 56y/o Male with Stage II
Soft Tissue Carcinoma
Treatment: Surgery, Chemotherapy and
Radiation
Functional Limitation: Put socks on
Assessment: Integumentary, Neuromuscular
Test: Lunge
Dry Needling: Gluteals, Quadratus Lumborum
Scar
● F: 1-2x/week○ 8-12 weeks
● I : NMES: 4-6 needles (50-100mm)
Winding: 4-6 needles (60mm)
● T: 60sec (NMES); 5-10 min (Winding)
● T : NMES (2Hz), Winding
MPET: AAROM, Manual resistive exercise
Corrective Exercise: Squat,
Marching+rotation, Child’s pose, Side
bending, TRUNK ROTATION
Retest: Lunge
Case Presentation: Head and Neck - Stage 2Patient Information: Male, s/p Tongue Cancer
Treatment: Partial tongue resection,
chemotherapy, radiation
Functional Limitation: Swallow
Assessment: Integumentary - s/p radiation
Test: Cervical Spine ROM - Sagittal Plane
Dry Needling
● F: 1x/2-3 weeks
● I : 6 x 24 mm needle
● T: 5-6 minutes
● T: In situ
MPET: Joint mobilization, Scar mobilization,
Myofascial release
Corrective Exercise: Deep neck flexor
strengthening, Postural strengthening
Retest: Sagittal plane motion
Case Presentation: Upper Extremity - Stage 2 Patient Information: 67y/o Female with Stage
III Breast Cancer
Treatment: Surgery (including LN
Transfer, SAPL, DIEP), Chemotherapy,
Radiation, Hormonal Therapy; 7 years ago
Functional Limitation: Writing
Assessment: Lymphatics, Muscular System
Test: Grip Strength (R:23.3kg L 23.7kg)
Dry Needling
● F : 1x/week
● I : 2-6 needles
● T : 20-60 sec
● T : NMES
MPET: Joint Mobilization, Kinesiotape, MLD
Corrective Exercise: Lymphatic Pumping
(AROM)
Retest: Grip Strength R: 21.4kg (immediate
post) 24.8kg (5 days post)
Case Presentation: Lower Extremity - Stage 3Patient Information: 64y/o Female with
Primary lymphedema
Diagnosed at age 24
*Undergone all traditional Lymphedema Tx
Functional Limitation: Gait
Assessment: Integumentary, Joint ROM,
lymphatics
Test: Joint ROM - Knee flexion/Ankle
dorsiflexion (125 deg/10 deg)
Dry Needling
● F : 1x/2-4 weeks
● I : 4-6 needles (75-100mm)
● T: 2 minutes
● T: NMES (2Hz)
MPET : Joint mobilization, Kinesiotape, MLD
Corrective Exercise : Calf Stretch, Long step
gait
Retest: Knee/Ankle ROM (130 deg/15 deg)
Change: 5 deg
Protocol vs. Thought Process
● Encourage critical thinking
● Drive profession beyond
“technicians”
● Give parameters not protocols
● Safety first last and always
Limitations:
● Lipolymphedema
● Non-compliant patient
● Patient with sensitized systems
● High histamine/inflammatory
response
Our growth is our patient’s gain
Dry Needling is a useful adjunct to other treatments for patients with Cancer-related functional limitations
Q&A
Photo by Ian Schneider on Unsplash
Contact InformationAlaina Newell PT, DPT, WCS, CLT-LANA
Instagram: newell.alaina
Melissa Buss PT, DPT, WCS, CLT
References1. Dunning J, Butts R, Mourad F, Young I, Flannagan S, & Perreault T. Dry needling: a literature review with
implications for clinical practice guidelines. Physical therapy reviews.19(4), 252-265, 2014
2. American Academy of Orthopedic Manual Physical Therapist. Dry Needling. https://aaompt.org/Main/
About_Us/Position_Statements/Main/About_Us/Position_Statements.aspx?hkey=03f5a333-f28d-4715-b355-
cb25fa9bac2c Published October 17, 2009. Accessed September 16, 2018
3. Cagnie B, Dewitte V, Barbe T, Timmermans F, Delrue N, & Meeus M. Physiologic effects of dry needling.
Current pain and headache reports. 17(8), 348, 2013
4. American Physical Therapy Association. Description of Dry Needling In Clinical Practice: An Educational
Resource Paper. Published February 2013. Accessed September 15, 2018
5. Ferguson C, Swaroop M, et al, A. Impact of Ipsilateral Blood Draws, Injections, Blood Pressure
Measurements, and Air Travel on the Risk of Lymphedema for Patients Treated for Breast Cancer. Journal of Clinical
Oncology 34(7): 691-698, 2016
References6. Academy of Acute Care Physical Therapy – APTA Task Force on Lab Values. Laboratory Values
Interpretation Resource. https://c.ymcdn.com/sites/ acutept.site-ym.com/resource/resmgr/ docs/2017-Lab-Values-
Resource.pdf Published January 2017. Accessed September 16, 20187.
7. Cassileth BR, et al. Acupuncture in the treatment of upper‐limb lymphedema. Cancer. 119(13): 2455-
2461, 2013
8. Hsieh Y-L, Yang S-A, Yang C-C, Chou L-W. Dry Needling at Myofascial Trigger Spots of Rabbit Skeletal
Muscles Modulates the Biochemicals Associated with Pain, Inflammation, and Hypoxia. Evidence-Based
Complementary and Alternative Medicine. 1-12, 2012
9. Brady S, McEvoy J, Dommerholt J, Doody C. Adverse events following trigger point dry needling: a
prospective survey of chartered physiotherapists. The Journal of Manual & Manipulative Therapy. 22(3):134-140, 2014
10. Halle, JS & Halle, RJ. Pertinent dry needling considerations for minimizing adverse effects–part one.
International journal of sports physical therapy, 11(4): 651, 2016
11. Lake DA, Myers H, Aefsky B, & Butler R. Immediate and short term effect of dry needling and functional
movement: A randomized trial. International Journal of Sports Physical Therapy. 13(2), 2018
12. Bachmann S, Colla F, et al. Swiss Guidelines for safe Dry Needling. Dry Needling Verband Schweiz.
(1.7):1-21, 2014
13. Zawieja DC. Contractile physiology of lymphatics. Lymphatic research and biology, 7(2), 87-96, 2009