Trigger Point Dry NeedlingRobert Whittaker, SPT

History

Acupuncture has been practiced for more than 2000 years

1942 - Dr. Janet Travell published method of injections into trigger points & introduced the term myofascial trigger points (MTrP)

1979 - Dr. Karel Lewit concluded the effect of injections were caused by the mechanical stimulation from the needle alone.

1989 - Maryland became the first jurisdiction to allow intramuscular therapy

Trigger Point Dry Needling (TDN)

Trigger point – the presence of exquisite tenderness at a nodule in a palpable taut band of muscleAble to produce referred pain, either spontaneously or

on digital compressionActive – actively refers pain either locally or to another

location (refer along nerve pathways) Latent – one that exists but doesn’t yet refer pain

actively but may do so when pressure/strain is appliedKey – one that has pain referral pattern along a nerve

pathway that activates a latent MTrP Satellite – one which is activated by a key MTrP

What causes them?8

Chronic overload/repetition of muscles with poor mechanics

Acute overload (ie slipping/lifting/MVA)

In poorly conditioned muscles

Prolonged positions (posture)

Treatment Contract–relax–passive/contract-relax-active stretch done

repeatedly until the muscle lengthens Trigger point release – apply direct equal pressure over MTrP 8-20

sec until pain absent, repeat 3-4x if not resolved, gentle stretch/STM after

Spray & stretch Injection or Trigger Point Dry Needling (TDN)

Use of a fine filament needle to deactivate a MTrP within a taut muscle band

TDN6,7

Goal of TDN: desensitize supersensitive structures & restore motion & function Release shortened muscle, remove source of irritation, promotes healing

through local inflammation, decreases spontaneous electrical activity (SEA) at TP site

Mechanism of TDN Disrupts a dysfunctional motor endplate Needling results in a local twitch response (LTR) – alters muscle fiber

length as well as having an inhibitory effect on antagonistic muscle, may also utilize excessive Ach which previously was triggering increased firing of localized fibers

Chemical effects – Reduction immediately following an LTR of bradykinin, substance P, & CGRP which were present in trigger points, hypoxic MTrP causing an acidic environment which can lead to swelling, distorted nerve ending & muscle pain

Neurophysiological effects – stimulates afferent sensory A-delta nerve fibers for as long as 72 hours post TDN, may activate the inhibitory dorsal horn interneurons which may release opioid medicated pain suppression along with increasing overall BF

TDN

Treats Chronic pain, athletic population w/ specific reoccurring

injuries, elderly population, weekend warriors, anyone w/ pain & dysfunction

Contraindications masses/tumors, use of blood thinners, active infection,

hematomas

Complications allergic reactions, vasodepressive syncope, hematoma,

nerve/vascular injury, trauma to brainstem/spinal cord, increased spasm & pain of the muscle injected, penetration of visceral organ (lung 15%/bowel/kidney), infection, muscle edema

Performing TDN

Technique Position NOT SEATED, prepare skin with alcohol, apply

gloves, identify taut band first & palpate nodule Needle placed perpendicular to skin, needle angled

toward TP, can apply micro current/TENS, hemostasis is achieved by post-needling compression

May feel sore immediately after tx (lasts 24-48 hours feels like intense workout), common to have bruising (shoulder, base of neck, head/face, arms/legs)

Pt. may feel tired, sweaty, light headed, nauseous, emotional, or “out of it” (autonomic response) which can last for 1-2 hours

TDN

Failure Diagnostic error,

incomplete management of perpetuating factors, TP missed or inadequately treated, pain zone needled but not primary TP, irrelevant TP was needled, inadequate post needling care

Emergency Difficulty breathing, chest

pain, feeling light headed, having difficulty breathing, other concerning symptoms

After Needling

Stretch!

Increase water intake, hot bath/tub, work out/stretch, massage area, tylenol/ibuprofen/motrin

Reoccurrence?

Can be completed in same tissue once very 5-7 days

Meta-analysis of TDN on UQ3

12 RCTs selected Sham/placebo & use of other pain reducing injections (ie

lidocaine) compared to TDN

Conclusion Dry needling recommended compared to sham/placebo for

decreasing pain immediately after treatment & at 4 weeks for UQ myofascial pain syndrome (MPS)

When LTR elicited in studies comparing other tx, no significant differences

Total Effect Size (CI)

Immediate 4 weeks

TDN v Sham

1.06 (0.05, 2.06) 1.07 (-0.21, 2.35)

TDN v Other

-0.64 (-1.21, -0.06)

-0.07 (-1.39, 1.26)

TDN on TKA RCT5

40 subjects assigned to TND & sham group PT applied TDN to identified MTrP

while pt. anesthetized before start of surgery

Measured VAS, prevalence of MPS, & WOMAC at 1, 3, & 6 month follow up

Results Variation rate of pain higher in T

group, -54.5 (56.6) vs -30.5 (63.2) (p=0.048) at 1 month

MPS 30% difference in T compared to 11% S, but not statistically different (p=0.06)

WOMAC worse in T group through whole study*

TDN better than placebo, results different at 1 month

ResultsBaseline

1 mo 3 mo 6 mo

T VAS

56.8 (22.3)

23.8 (24.9)

20.6 (21.5)

23.5 (22.5)

S VAS

50.4 (16.8)

32.3 (25.7)

25.3 (20)

20.9 (18.6)

T MPS

80% 50% 50% 59%

S MPS

70% 59% 53% 64%

Rabbits & Pain/Inflammation/Hypoxia2

80 rabbits in 1D/1Dsham and 5D/5Dsham group TNF-α, substance P, COX-2 pain

from periphery to CNS β-endorphin can suppress

neurons from releasing substance P

Hypoxia responsive proteins – VEGF, iNOS, HIF-1α

Results Short term – 1D produces short

term analgesic effect, no lasting effect,

Long term – 5D increased proteins for capillary formation, excessive muscle damage from overload (muscle fibrosis?) β-endorphin predominate in later

phases of inflammation

Posture Effects on TDN using Shear-Wave Elastography4

7 female subjects w/ palpable MTrPs TDN to upper trapezius

muscle Ultrasound SWE allows for

quantification of soft tissue stiffness

Results Pre/post 29.5% reduction

(p<.01) Posture 21% reduction

(p<.05) Shear Modulus significantly

reduced in prone vs. sitting

Shear Modulus (kPA)

Sitting Prone

Before

After Before

After

Mean

13.56 9.11 10.23 7.67

Effects of TDN on Trapezius O2/BF1

N = 20 R upper trapezius received

TDN A distant R point & 2

symmetrical points on L side measured using O2C (SaO2) & laser Doppler flowmetry (BF)

Results BF increased 164% on R

immediately, 72% higher as compared to baseline at 15 min

SaO2 increased 17% on R immediately

No changes in regions distal to needle site

Training

www.kinetacore.com & www.myopainseminars.com Level 1 - 3 day course of lecture, demonstration &

large amount of hands on laboratory work Must be licensed as PT, DC, DO, MD, PA, or nurse

practitioner with a minimum of 1 year practicing Hip, lumbar spine, thigh, c-spine, shoulder, UE/LE

Level 2 – advanced hip/lumbar/UE/LE/c-spine, TMJ/face, t-spine, Completion of L1 & 200 logged TDN tx sessions or

complete of Functional Therapeutics: Application for Dry Needling & 100 logged sessions

Pelvic floor

Montana Practice Act

The Montana Board of Physical Therapy has determined that trigger point dry needling is within the scope of practice for physical therapists. The board has formed a committee to begin the process of setting rules for trigger point dry needling which met for the first time June 30, 2011 & their work continues presently.

Training guidelines – currently drafting (July 2013)

Mountain View PT, Great Northern PT, Professional Therapy Associates

Not within practice act: Idaho, New York, Hawaii, Florida, California, & Pennsylvania. KS/SD?

Billing

Check the payer’s coverage policy

Absent of specific payer policy, the use of CPT code 97140 for the performance of TND should not be utilized97140 – STM, joint mobilization, manipulation,

manual tractionNo code specifically for dry needling If no code exists, report the service using the

appropriate unlisted physical medicine/rehabilitation service or procedure code 97799

ABN for Medicare patients

http://www.apta.org/StateIssues/DryNeedling/

References

1. Cagnie B, Barbe T, De Ridder E, Van Oosterwijck J, Cools A, Danneels L. The influence of dry needling of the trapezius muscle on muscle blood flow and oxygenation. J Manipulative Physiol Ther. 2012;35(9):685-691. doi: 10.1016/j.jmpt.2012.10.005 [doi].

2. Hsieh YL, Yang SA, Yang CC, Chou LW. Dry needling at myofascial trigger spots of rabbit skeletal muscles modulates the biochemicals associated with pain, inflammation, and hypoxia. Evid Based Complement Alternat Med. 2012;2012:342165. doi: 10.1155/2012/342165 [doi].

3. Kietrys DM, Palombaro KM, Azzaretto E, et al. Effectiveness of dry needling for upper-quarter myofascial pain: A systematic review and meta-analysis. J Orthop Sports Phys Ther. 2013;43(9):620-634. doi: 10.2519/jospt.2013.4668 [doi].

4. Maher RM, Hayes DM, Shinohara M. Quantification of dry needling and posture effects on myofascial trigger points using ultrasound shear-wave elastography. Arch Phys Med Rehabil. 2013;94(11):2146-2150. doi: 10.1016/j.apmr.2013.04.021 [doi].

5. Mayoral O, Salvat I, Martin MT, et al. Efficacy of myofascial trigger point dry needling in the prevention of pain after total knee arthroplasty: A randomized, double-blinded, placebo-controlled trial. Evid Based Complement Alternat Med. 2013;2013:694941. doi: 10.1155/2013/694941 [doi].

6. Baldry P. Management of myofascial trigger point pain. Acupunct Med. 2002;20(1):2-10.

7. Shah JP, Danoff JV, Desai MJ, et al. Biochemicals associated with pain and inflammation are elevated in sites near to and remote from active myofascial trigger points. Arch Phys Med Rehabil. 2008;89(1):16-23. doi: 10.1016/j.apmr.2007.10.018 [doi].

8. Kisner C, Colby LA. Therapeutic exercise: Foundations and techniques. F a Davis Company; 2007.