The trigger point techniques I and II and the inter-muscular mobilization IV include a strong manual pressure. This is why Trigger Point therapy is often uncomfortable or somewhat painful.
It's important to follow the principle that the pain should be tolerable for the patient and, if possible, reported as "good pain". The more accurately the trigger point is treated, the less pressure has to be applied. Relevant contraindications have to be excluded and patients should be informed about the possible side effects. The trigger point compression technique technique I may be combined with simultaneous passive or active change in muscle length in order to optimize the effect.
The fascia technique III should be painless. The decision to treat a certain trigger point with Dry Needling , Manual Trigger Point Therapy or a combination of the two techniques, is made by the therapist and the patient. We also provide valuable knowledge on these topics in our courses. The David G. The first phase of their study failed to establish a high degree of agreement between therapists when palpating MTrPs for tenderness, taut bands, referred pain, local twitch response, or reproduction of pain.
The features of a trigger point were reviewed during this training in order to be certain that the physicians were interpreting their findings similarly. Njoo and Van der Does 31 reported a kappa of 0. The authors noted good reliability for referred pain and the jump sign. Modern trigger point dry needling has its origins in the work of Karel Lewit of Czechoslovakia. To some, trigger point dry needling may appear synonymous with Traditional Chinese Acupuncture TCA ; nonetheless, the two are uniquely different.
Therefore, if an acupuncturist detects any abnormal flow or quality of Qi about a meridian, he or she would needle the respective acupoint, theoretically normalizing the flow of Qi in the body. While there are several philosophies of practice that differ between acupuncture institutes, all TCA is based on the Daoist concept of yin and yang.
Several authors have noted that the scientific basis regarding pain neurophysiology and the mechanisms employed with dry needling supports its use. The second model is called the spinal segmental sensitization model, and was developed by Andrew Fischer.
Fischer 51 contends that use of the needle and infiltration of a local anesthetic is optimal for achieving long term relief of muscle pain and normalization of tenderness. These differences include, but are not limited to: 1 the use of injection needles by Fischer vs. Gunn who minimizes their importance; and 3 the integration of new research into Fischer's model vs.
Gunn's which has not been developed much beyond its inception in The last, and most frequently utilized model for dry needling, is the trigger point model. The trigger point model advocates that inactivation of the MTrPs via dry needling is the fastest and most effective means to reduce pain, as compared to other conventional interventions. It is this model of trigger point dry needling that the remainder of this commentary will address.
Compliments of Bachrach Studios. Used with permission from Virginia Street, daughter of Dr. Janet Travell. Proper DN technique begins with identifying the appropriate patients, and eliminating those in whom it may lead to adverse affects. DN should not be administered in the following patient scenarios: 1 a patient with needle phobia; 2 an unwilling patient; 3 a patient who is unable or unwilling to give consent; 4 a patient with a history of abnormal reaction to needling or injection; 5 in a medical emergency; 6 a patient who is on anticoagulant therapy, or who has thrombocytopenia; and 7 into an area or limb with lymphoedema.
Additional relative contraindications include an altered psychological status, anatomic considerations extreme caution must be taken over the pleura and lungs, blood vessels, nerves, organs, joints, prosthetic implants, implantable electrical devices, etc. An ideal candidate for DN should possess the following qualities: 1 a physical therapy diagnosis that will reasonably improve with DN; 2 the ability to understand what is being done and why; 3 the ability to effectively communicate his or her own response to treatment; 4 the ability to lie still during treatment; and 5 the ability to provide informed consent according to clinical guidelines.
This comes after discussion regarding the indication and aim of the treatment, a brief explanation of how the intervention works, and an open discussion concerning the risks involved. Treatment is commenced with the patient positioned in a relaxed posture suitable to expose the muscles being treated.
Positions may include supine, prone, or sidelying, and pillows and bolsters may be utilized to help with patient positioning. Completion of DN in a seated position is not recommended given the risk of syncope. Ideally, the practitioner would be able to view the patient's face, so as to receive regular feedback during the intervention, though treating the patient in prone is acceptable. According to the work of several authors, routine disinfection of visibly clean skin before needling is not necessary.
A pincer grip technique is employed to gently lift the skin. Additionally, flat palpation can be utilized to take up the slack of the skin. A high quality, sterile, disposable, solid filament needle is inserted directly through the skin, or using a guide tube that is then removed Figure 3.
Once the needle has penetrated the skin and is inserted into the muscle, techniques vary: the practitioner may utilize a slow, steady, lancing or pistoning motion in and out of the muscle termed dynamic needling , he or she may leave the needle in situ termed static needling , or the needle may be rotated several revolutions in order to draw the fascia or soft tissues. If a static technique is utilized, it can be augmented by intramuscular electrical stimulation IES as well.
Contraindications include, but are not limited to: 1 a patient who is not comfortable or phobic to electrical stimulation or needling; 2 2 it is not recommended to connect needles across the spinal column; 56 3 patients with implanted electrical devices; 56 4 in the vicinity of the mid or low back, pelvis or abdomen during pregnancy; 2 5 in the vicinity of the carotid sinus or near the recurrent laryngeal nerve; 40 and 6 in an area of sensory denervation.
Whichever techniques are employed, the intensity of the treatment must suit the tolerance of the patient, and their pathologic presentation.
It is important to note that gauge and length of needles vary Figure 4. The 0. Smaller gauge needles are utilized for smaller tissues, including a. Please note that these are simply guidelines, and not standards; choosing the gauge and length of needles should be left to the discretion of the treating practitioner. The effectiveness of DN is largely dependent upon the skill of the therapist, and his or her own ability to accurately palpate MTrPs. This kinesthetic awareness helps assist in better localization of needling, and improved outcomes.
Several authors have noted that a trained clinician should be able to perceive the end of the needle, the pathway or trajectory the needle takes inside the patient's body and be able to decipher between skin, subcutaneous tissue, and the anterior and posterior lamina of the aponeurosis of the rectus abdominis, for example. Practitioners often inquire as to how many muscles should be treated in one session.
As young practitioners will learn, every muscle will respond uniquely different to DN. For example, the medial gastrocnemius often becomes tonic and dysfunctional in young athletes. Obtaining more than one or two twitch responses of this muscle will undoubtedly cause excessive post needling soreness; hence, this muscle is often the only muscle needled in a session.
Occasionally the practitioner will be unable to elicit a twitch response, commonly occurring when treating deep musculature eg. If a twitch response is not elicited in a more superficial muscle, it is advised that the practitioner utilize more dynamic needling techniques, including twirling of the needle, or repeated lancing motions. If the twitch is still not elicited, then the needle should be withdrawn and second attempt made.
It is opinion of the author that if the twitch is not elicited after the second needle is inserted, the practitioner may not have correctly palpated the trigger point, the needle did not engage the palpated trigger point, or the trigger point will require IES in order to engage it.
Another frequent question relates to how many trigger point sessions should be utilized with patients. In order to answer this, it is imperative that the practitioner sees dry needling within the larger picture of an entire plan of care.
In subsequent visits not the same day the DN was performed , strengthening of the once inhibited or painful muscle groups can then be initiated. Rarely will the author needle an individual fitting these parameters for more than six sessions, although the remainder of the rehabilitation program may still be in progress. Despite the proven efficacy of DN when treating myofascial pain, utilization of the procedure must be balanced by the inherent risk that comes with employing the technique; this is especially true given the fact that the skin is violated.
While a paucity of research currently exists describing the risk of infection with dry needling, extensive data has been reported on infections and acupuncture. Considering that both techniques employ dermal penetration with a solid filament to varying depths within the body for therapeutic indications, it appears reasonable to correlate the data.
In a review of the literature, Peuker and Gronemeyer 65 noted ten cases of injuries to the spinal cord or spinal nerve roots. In four cases, fragmented needles were responsible for the lesions, whereas six were caused from direct injury. The authors also describe several cases of arachnoiditis and subarachnoid hemorrhage as well. There have been rare and isolated cases of serious bacterial skin infection associated with acupuncture, which have even led to death.
The incidence of infectious diseases with acupuncture has decreased dramatically since the 's. The risk of infection continues to decrease with the optimization of sharps containers, latex gloves, and universal precautions, including regular hand washing.
Serious adverse effects of dry needling are very rare. Rarely do patients think twice about taking one of these medications. However, data suggests that patients are significantly more likely to have a serious adverse effect, or even die, after taking one of these medications, as compared to receiving trigger point dry needling.
Therefore, while there is a risk to any physical therapy intervention, the risk associated with DN is minute in the hands of a skilled practitioner. Considering the invasive nature of DN, it is very difficult to execute a double blinded, randomized, controlled clinical trial. A Cochrane review investigated the effects of DN in the treatment of myofascial pain syndrome in the lumbar spine. Several systematic reviews have also been published related to needling therapies for the management of myofascial trigger point pain.
They noted that nearly all the studies revealed that the beneficial effect of the intervention was independent of the injectable substance. A second systematic review was performed by Teasdale 10 and focused on DN in athletes.
Teasdale 10 investigated four comparisons: 1 DN vs. She concluded that DN in athletes was more beneficial than sham acupuncture or no treatment, and that no safety problems were reported.
However, when comparing dry needling to standard acupuncture, Teasdale 10 found a statistically significant benefit to dry needling, and noted that dry needling has been shown to reduce pain, increase quality of life, and increase range of motion beyond that produced with standard acupuncture. The authors noted that the source of patients pain was not controlled in any of the studies, that sample sizes were small thus increasing the risk of making a Type II error , and that there was poor consistency between specific parameters of intervention eg.
Several case series have also been documented demonstrating the benefits of DN. They concluded that dry needling followed by active stretching is more effective than stretching alone in reducing the sensitivity to pressure of MTrPs. In summary, dry needling research is still in its infancy. However, there is mounting evidence that the procedure can be effective at decreasing pain, improving range of motion, reducing the sensitivity of MTrPs, and ultimately improving quality of life.
As of March , State Boards regulating the practice of physical therapy in 32 jurisdictions have determined that DN does indeed fall within a physical therapists scope of practice. It reduces or restores impairments of movements, of function, and body structures.
Which leads to improved activity and participation. Dry needling can significantly reduce your pain and restore function. It will make it possible for you to increase your activity level and get back to your normal routine.
A Trigger Point in the muscles or fascia tissues lead to myofascial pain causing an entire muscle to be painful, tight, weak, and more easily fatigued. The cause is multi-factorial. Trigger Points can be either the cause or a contributing factor of a wide variety of painful conditions that you have.
Dry needling involves a thin filiform needle that penetrates the skin and stimulates underlying myofascial trigger points and muscular and connective tissues. The needle allows a physical therapist to target tissues that are not manually palpable.
Physical therapists wear gloves and appropriate personal protective equipment PPE when dry needling, consistent with Standard Precautions, Guide to Infection Prevention for Outpatient Settings. The sterile needles are disposed of in a medical sharps collector.
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