Document 236242

Objectives
Intra-Muscular Manual Therapy:
Dry Needling
An Overview of this Unique Modality
1. Discern the differences between acupuncture & dry needling as
alternative medical treatments.
2. Who can use it & Where can it be used? How do you Bill for it?
1. Correctly identify the necessary guidelines and training to
performing dry needling as a physical therapist.
3. Understand the different theories and mechanisms behind the use
of dry needling.
1. Understand the current evidence in order to apply dry needling in
clinical practice.
What is it?
∗ Dry Needling (Intramuscular Manual Therapy) is a technique using
the insertion of a solid filament needle, without medication, into or
through the skin to treat various impairments including, but not
limited to: scarring, myofascial pain, motor recruitment and muscle
firing problems.
∗ Goals for treatment vary from pain relief, increased extensibility of
tissue, to the improvement of neuromuscular firing patterns.
∗ (FSBPT 2013)
∗ “intramuscular manual therapy, trigger point dry needling, or
intramuscular needling”
∗ 2011: advocated using dry needling as the term of choice. (FSBPT)
Why are they often confused?
∗ Dry needling is presently performed by physical therapists and chiropractors
using the same solid, filiform needles as acupuncturists.
∗ They look very similar to the consumer and are often mis-labeled when reported
to peers.
∗ PT’s:
∗ Do not and cannot claim to practice acupuncture
∗ Do not use acupuncture traditional Chinese medicine theories, meridian acupoints and
terminology
∗ Do not use acupuncture diagnosis like tongue and pulse
∗ do not use dry needling to address things such as fertility, smoking cessation, allergies,
depression or other non-neuro-musculoskeletal conditions
∗ Overall, an important distinction is that acupuncture is an
entire discipline and profession where as dry needling is
merely one technique which should be available to any
professional with the appropriate background and training.
∗ (FSBPT,2013)
What it is NOT:
Acupuncture
∗ "Acupuncture" means a form of primary health care,
based on traditional Chinese medical concepts and
modern oriental medical techniques
∗ Employs acupuncture diagnosis and treatment, as well
as adjunctive therapies and diagnostic techniques, for
the promotion, maintenance, and restoration of health
and the prevention of disease.
∗ Treat blockages existing within the body that can be
restored by properly placing needles along energy
channels called meridians.
∗ Most schools take about 3-4 years
∗ Master's degree in acupuncture or Oriental medicine
Who Can Perform it?
∗ FSBPT 2012: States that allow dry needling are only allowing it to be performed
by licensed physical therapists and not the support personnel.
∗ Is specifically controlled by the state practice act related to one’s profession
∗ There are currently no consistent profession-wide standards/competencies
defined for the performance of dry needling.
∗ Each state has defined what the requirements will be in that state.
∗ As Texas has no official position: no requirements are available at this time
∗ KinetaCore requires a minimum of one year of experience treating patients while
licensed.
∗ Accepted: Physical Therapists, Medical Doctors, Doctors of Osteopathy, Physician
Assistants, Doctors of Chiropractic or Nurse Practitioners.
∗ Not Accepted: Athletic Trainers, Acupuncturists, Massage Therapists,
Occupational Therapists.
APTA Position Statement:
Jan 2012 - 14
AMERICAN ACADEMY OF ORTHOPAEDIC MANUAL PHYSICAL THERAPISTS
(AAOMPT)
∗ “Dry
Needling is an invasive technique used by physical therapists
(where allowed by state law) to treat myofascial pain that uses a dry
needle, without medication or injection, which is inserted into areas of
the muscle known as trigger points.”
Dry Needling: (10/17/09)
∗ “Preliminary research supports that dry needling improves pain control,
reduces muscle tension, normalizes biochemical and electrical dysfunction of
motor endplates, and facilitates an accelerated return to active rehabilitation.”
POSITION: It is the Position of the AAOMPT Executive Committee that dry
needling is within the scope of physical therapist practice.
∗ As of March 2014, the APTA Board of Directors has now formally listed dry
needling within the scope of practice.
∗ “Physical therapy, which is limited to the care and services provided by or
under the direction and supervision of a physical therapist, includes:
Alleviating impairment and functional limitation by designing, implementing,
and modifying therapeutic interventions that include, but are not limited to:
∗ dry needling”
SUPPORT STATEMENT:
∗ “Dry needling is a neurophysiological evidence-based treatment technique that
requires effective manual assessment of the neuromuscular system. Physical
therapists are well trained to utilize dry needling in conjunction with manual
physical therapy interventions. Research supports that dry needling improves
pain control, reduces muscle tension, normalizes biochemical and electrical
dysfunction of motor endplates, and facilitates an accelerated return to active
rehabilitation.”
USA- Dry Needling -
Billing
∗ The quick answer for this is YES, we can bill for Dry Needling.
∗ However, payment is dependent on your specific insurance
contracts and on the state in which you practice.
∗ Billing insurance
∗ Fee for Service
∗ Must include in the POC
∗h
August 12, 2011- overturned previous policy that it was not within scope
Texas does not have an official position and is legally not allowed to offer advisory
opinions; however, the board has made no determination that dry needling is outside
the scope of practice for PTs
∗ Notify Physician if they are unfamiliar
∗ The APTA recently published remarks about the inappropriate
use of the CPT’s NMR/Manual for Dry Needling
APTA Public Policy, Practice, and Professional Affairs Unit
2014
∗ “Practitioners who seek to bill any third party payer should first check the
payer’s coverage policy to determine if dry needling is a covered service and
if the policy specifies which code is used to report the service.
∗ Absent a specific payer policy, the use of CPT code 97140 for the performance
of dry needling should not be utilized.
∗ Currently, there is no CPT code that describes dry needling nor do any of the
existing CPT codes include dry needling techniques in clinical vignettes
utilized by AMA in their process to establish relative value units.
∗ CPT specifically states to select the procedure or service that accurately
identifies the service performed.
∗ Do not select a CPT code that merely approximates the service provided.
∗ If no such specific code exists, then report the service using the appropriate
unlisted physical medicine/rehabilitation service or procedure code 97799”
Definition and Technique
Second:
How Do They Form?
What are Trigger Points
Inflammatory
mediators
Neuropeptides
Reduced pH
∗ The cause is usually multi-factorial:
∗ Overworking or overstressing muscles with activity
∗ Poor Posture leading to chronic elongation
∗ Muscular maladaptation or misuse related to firing
patterns
∗ Direct Trauma or reflexive protection after an injury
∗ Blood supply is restricted due to the holding state which
leads to accumulation of metabolic waste (notably
hydrogen ions) which further the acidic environment and
increase nociceptive sensory input.
Catecholamines
∗ EMG studies have shown the MTrP is “kind of like buzzing
with uncontrolled electrical activity” which causes the
muscle to feel tight and can restrict motion.
Cytokines
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Third:
Is It Right for You?
∗ FDN (Functional Dry Needling) can be used for a variety of
musculoskeletal pathologies:
∗
∗
∗
∗
∗
∗
∗
∗
Neck/Back/Shoulder MTrP pain
Headaches
Tennis/Golfer’s Elbow
Hip/Buttock/Leg or “Sciatica” MTrp Pain
Jaw or TMJ pain
Whiplash
Carpal Tunnel
Etc.
What’s the Process?
Insertion of needle
∗ Active TrP = Painful
∗ Normal muscle = painless
Technique: as described by Dommerholt
1.
2.
3.
4.
5.
Palpate an active trigger point
Cleaning the area via
Place a solid filament sterile needle into the trigger point
Withdraw the needle from the muscle but not from the skin.
Change direction of the needle and bring it back into the same area to get more and more twitch
responses
1.
The muscle will ‘grasp’ the needle in what can be described as a cramping sensation
6. Elicit twitch responses until they are no longer present.
Gunn IMS Pain Clinic, Research, Education http://www.istop.org
Proposed Response
Does It Hurt?
∗ Local:
∗ CGRP (calcitonin gene-related peptide) release
∗ This promotes vasodilation and formation of new blood vessels
∗ Segmental:
∗ Stimulation of small myelinated nerves = Enkephalin
∗ Pain blocking and modulating peptide
∗ Systemic:
∗ Beta-Endorphin released
∗ Analgesic effect
∗ FDN responses can be extremely varied and individual
∗ Typically will not feel the needle enter the skin
∗ Various Responses Include:
∗
∗
∗
∗
∗
∗
“Pressure” over the area
“Cramping” sensation
“Good Pain”
Surprising type discomfort
Sweating or dizziness or Nausea
Bruising and Soreness
How Long Does it Take to Work &
What Should I do Afterward?
∗ Typically, a positive response takes ~ 0-2 days
∗ This can be longer in chronic conditions
∗ It make take multiple sessions to achieve a cumulative effect
Take Home Message
∗ “Remember that trigger points are rarely an isolated
phenomenon, and the key to successful long-term outcomes of
any treatment regime is addressing the precipitating and
predisposing factors for each particular person.”
∗ After the first session:
∗ Expect to feel sore (Like a hard workout or long run) in that area
∗ Icing and topical ointments can help with the soreness
∗ Stretching is OK, avoid strenuous activity
∗ After subsequent sessions:
∗ Expect less soreness and faster improvement of symptoms.
∗ Can and Should begin to complete activity or exercises same day
Huguenin 2004
Dry Needling – The Evidence
Cummings et al., 2001 - Needling Therapies in the
Management of Myofasial Trigger Point Pain: A
Systematic Review
The Evidence
∗Reviewed 23 studies
∗ Included if some form of needling therapy was used to treat
muscular trigger points
∗ Concluded that direct needling of myofascial TP is an effective
treatment
∗Karakurum et al., 2001 - The dry needle technique:
intramuscular stimulation in tension type headache
∗ Dry needling (vs. placebo needling) resulted in significant
improvement in pain and neck range of motion in patients with
tension headaches
Dry Needling Systematic Review
Dry Needling – The Evidence
Tekin et al., 2012 – The effect of dry needling in the treatment
of myofascial pain syndrome: a randomized double-blinded
placebo-controlled trial.
Kietrys, et al
∗Compared DN vs. sham DN (placebo)
∗ Double-blinded, randomized-controlled – outpatient clinic
∗Concluded that dry needling treatment is effective in treating MPS and
improving the quality of life
JOSPT, 2014
12 studies
∗ Cochrane Review (Furlan, 2005)
∗ LBP (Acupuncture and DN)
∗ 35 RCTs
∗ Conclusions
∗ Acupuncture and DN may be
useful adjuncts for chronic lowback pain.
24
Upper quarter
dysfunction
Recommende
d DN for
immediate
and shortterm decrease
in Pain
References
Questions
Muscle Trigger Point
Biochemistry
∗ Shah, 2008
∗ 9 Subjects
∗ UT Active, latent, normal
∗ Method
∗ Microdialysis needle
analysis
∗ Results
∗ Analyt concentrations
were high in active MTPs
compared to latent MTPs
and normals
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Energy Crisis Theory
1. APTA. Physical therapists & the performance of dry needling. www.apta.org/StateIssues/DryNeedling/ResourcePaper/. 2012.
2. Cotchett MP, Landorf KB, Munteanu SE. Effectiveness of dry needling and injections of myofascial trigger points associated with plantar
heel pain: A systematic review. J Foot Ankle Res . 2010;3:18.
3. Cummings, T.M., White, A.R. Needling therapies in the management of myofascial trigger point pain: a systematic review. Arch Phys
Med Rehabil: 2001. 82; 986-992.
4. Dommerholt J. Dry needling in orthopaedic physical therapy practice. Orthopedic Practice. 2004.16: 11- 16.
5. Dommerholt J, Mayoral O, and Gröbli C, Trigger point dry needling. J Manual Manipulative Ther. 2006. 14;4: E70-E87.
6. Ferrie, B.W. Treating the trigger. Advance for PT and Rehab Med. 2008. 19:6: 26.
7. Garvey, T.A., Marks, M.R., Wiesel, S.W. A prospective, randomized, double blind evaluation of trigger point therapy for lower back pain.
Spine. 1989. 14; 962–964.
8. Gunn IMS Pain Clinic, Research, Education. http://www.istop.org. 2007
9. History of Dry Needling. http://www.dryneedlingcourses.com/history.html. 2009
10. Huguenin, L.K. Myofascial trigger points: the current evidence. Phys Ther in Sport: 2004.5; 2-12.
11. Karakurum, B., Karaalin, O., Coskun, O., Dora, B., Ucler, S., Inan, L. The dry needle technique: intramuscular stimulation in tension type
headache. Cephalalgia. 2001. 21; 813–817.
12. Lucas KR, Polus BI, Rich PS. Latent myofascial trigger points: Their effect on muscle activation and movement efficiency. J Bodywork
Mov Ther 2004.8:160-166.
13. Simons DG, Travell JG, Simons LS. Travell and Simons’ Myo- fascial Pain and Dysfunction: The Trigger Point Manual. Vol 1. 2nd ed.
Baltimore, MD: Williams & Wilkins, 1999.
14. Simons DG, Hong C-Z, Simons LS. Endplate potentials are common to midfiber myofascial trigger points. Am J Phys Med Rehabil.
2002.8;212-222.
15. Tough EA, White AR, Cummings TM, Richards SH, Campbell JL. Acupuncture and dry needling in the management of myofascial trigger
point pain: A systematic review and meta-analysis of randomized controlled trials. Eur J Pain. 2009;13(1):3-10.
Motor End Plate Hypothesis
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