Dr. David Fishkin DC, MPH...1. Trigger point/tender point characteristics 2. Parameters of size, number and distribution 3. Active, passive and latent trigger/tender points 4. DifferentialDiagnoses

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Dr. David Fishkin DC, MPHPracticing for over 30 years, lives in Maryland

Obtained his Doctor of Chiropractic from the New York Chiropractic College.

Obtained his Masters in Public Health at the George Washington University School of Public Health and Health Services.

Post Graduate Faculty of University of Western States

Practicing Dry Needling for over 20 years and teaching for over 11 years

Trained over 800 practitioners to date

Copyright © 2020 by David B. Fishkin DC MPH. & Dry Needling Institute, LLC All rights reserved.

Myofascial Trigger Point Dry Needling

A Diagnostic and Treatment Modality for The Manual Medicine Practice

By

David B. Fishkin, DC, MPHDry Needling Institute, LLC

www.dryneedlinginstitute.com301‐444‐4890


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Course Objectives for the six hour education program

Upon completion of this education program the learner will:

1. Understand the various theories and models that underlie dry needling technique.

2. Know all safety and indication/contraindication parameters for needling services.

3. Understand OSHA/NIOSH and WHO safety practices for Needle handling4. Understand Public Health safety practices in the clinical setting 5. Observe several applications of dry needling to understand practice integration.

Upon achieving these objectives the learner will be prepared for the hands on prtionof the training program. Upon completion you will be certified to deliver dry needling services safely and effectively to the public.


COURSE OUTLINE1. Introduction to the DN approach (50 minutes)

2. Theories and mechanisms of Dry Needling (50 minutes)1. Historical overview 2. Major theories of Dry Needling

3. Tensegrity (25)1. Mechanisms, Neurovascular and bio‐mechanical considerations2. Soft tissue dysfunction3. Central and peripheral mechanism of dry needling

4. Tunnels and Tunneling (25)1. Definitions2. Peripheral Anatomy

5. Protocol for Dry Needling as a diagnostic tool (50 minutes) 1. Trigger point/tender point characteristics2. Parameters of size, number and distribution3. Active, passive and latent trigger/tender points4. Differential Diagnoses utilizing DN technique

6. Patient Selection/Indications/Contraindications (50 minutes)1. Age, severity of condition, co‐morbidities2. Safety (WHO/OSHA)3. Patient prep/positioning4. Disposal 5. Avoiding and minimizing potential adverse reactions

7. Jurisprudence (25minutes)1. Informed consent2. State Law

8. Integrating DN treatment into daily practice demonstration (25 minutes)Copyright © 2020 by David B. Fishkin DC MPH. & Dry Needling Institute, LLC All rights reserved.

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Body Composition

Who Is

ControllingWho?


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Which Tissues Are The Issues

Muscle,Fascia,Lig, Tend

Bone,SynovialJoint

Nerve,Blood,Lymph


Mechanisms of Trauma

1. Awareness, Intentional, Reaction Time2. Unaware, Unintentional, No Reaction Time

Abnormal concentric and eccentric contraction demand on a muscle, macrotrauma, and recurrent microtrauma (low amplitude repetitive motion disorder – LARMD) leads to increased calcium release from the sarcolemma and prolonged shortening of the sarcomeres.

Prolonged shortening compromises the circulation, with the subsequently reduced oxygen supply leaving the cells unable to produce enough ATP to begin the active process of relaxation.


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Manual


Soft Tissue vs Synovial

Instrument Assisted Manipulation (IAM)• Activator, Pettibon

Manipulation of Hard Tissue

Treatment of Soft Tissue

Compression Techniques• Massage• Nimmo• Graston

Decompression Techniques• Cupping• Rock Tape / Kinesio Tape• A.R.T.

Light Therapy• Laser• Far Infrared

Sound/Energy• Ultrasound• Vibration• Magnetic

Electrical• Low Volt/High Volt• Microcurrent• Interferential• Russian

Thermal• Cryo• Heat• Hydro

Why does soft tissue not receive the respect it deserves?


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Historically hard tissue has always had the upper hand primarily and simply because it is easier to identify visually, is more dramatic and more impressive to the general public and used by doctors to drive clinical decisions. Is this justified?

The first real diagnostic discovery and modality, x‐ray, happens to show the harder tissues of bone better than the softer tissue to the untrained eye. It also misleads the trained eye.


One of the main problems with MRI as it relates to musculoskeletal ‐soft tissue injury is one of correlation. It is very often the case that the MRI fails to reveal visual evidence of injury in the area that the patient complains. Alternatively the MRI may show evidence of other pathology that may be unrelated to the patient complaint.


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• Does this mean that the patient is lying?

• Are the other findings really the culprits in the patient complaint?

• To what extent does what we see or don’t see explain the clinical picture?


This raises several questions; • what is the resolution of the MRI or its ability to “see” tissue changes,

• or how much does tissue need to change in order to “see” a change and

• what does that change mean?


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What is the relationship if any between the imaging and the patient complaint?

Can we even measure and what do we measure to establish the true nature of the clinical picture in an

objective way without direct patient involvement?


What are our diagnostic options to better appreciate soft tissue

injury?


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The emerging technological advances in Musculoskeletal Ultra Sound Diagnostic Imaging now allow us to image soft tissue in much greater detail. With MSK‐USD we can image soft tissue down by layer of tissue down to the cortical surface of the bone.

This more micro level has opened up a new knowledge base and will help to better correlate patient complaint to tissue damage.


Additionally, at lower cost, greater ease to the patient (claustrophobia) and portability this will greatly expand it use in the clinical setting.

An additional advantage of MSK‐USD not capable by other currently available technologies is that of motion in real time.


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This aspect of MSK‐USD is not widely used yet but will continue to grow over time. This will offer a dramatic addition to the soft tissue realm that will complement, and in some cases, replace X‐ray and MRI. This will become a powerful tool particularly in the medico‐legal environment.


MSK‐USD Machine


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THE THREE PILLARS OF DRY NEEDLING

THEORY

TENSEGRITY

TUNNELS


A Historical Overview Of Dry Needling

1938 Sir Thomas Lewis makes the casual observation of pain referral.

Kellgren begins the process by injecting hypertonic saline into tissues and documents the results in his 1938 paper “A Preliminary Account of Referral Pains Arising from Muscle.”

In the 1930’s Dr. Janet Travell became aware of her own trigger points in the shoulder and also became interested in this area of treatment.

Edeiken coined the term “trigger zones” and Travell later coined the term “trigger points”.

In 1940 Travell began injecting trigger points with 1% procaine and in 1941 she began to use vapocoolant spray.

She co‐authored a paper 1952 with Rinzler illustrating these referral patterns.


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A Historical Overview Of Dry NeedlingCont’d

Dr. David Simons, who passed away in 2010, has made important contributions to the understanding of the mechanisms of myofascial trigger points.

An important milestone paper was by Karel Lewit who observed that inserting a hollow bore needle produced the same positive clinical response as did injecting the patient with a pharmaceutic agent.

Dr. C. Chan Gunn of Vancouver British Columbia (developer of Deep Dry Needling) published articles on the use of dry needling utilizing solid filament needles traditionally used by acupuncturists for the treatment of myofascial trigger points in, what he termed, the peripheral nerve model.

Peter Baldry M.D. (proponent of superficial dry needling), Andrew Fischer M.D. (developer of Algometry), have made important contributions to our understanding of the dry needling concept as well.


The Various Modelsof

Myofascial Trigger PointDry Needling


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The Radiculopathy ModelIn Gunn's view, shortening of the para‐spinal muscles, particularly the multifidi muscles,leads to…

disk compression

narrowing of the inter‐vertebral foramina

direct pressure on the nerve

**A trigger point is a result of nerve dysfunction and not the source itself. **


The Radiculopathy ModelCont’d

Muscle shortening is a fundamental feature of musculoskeletal pain syndromes.

A distinguishing factor between muscle spasm and muscle contracture is that muscle spasm will be reflected in EMG activity whereas a short muscle will not reveal any motor unit activity.

Gunn emphasized evaluating the paraspinal regions for trophic changes, which may include orange peel skin, dermatome hair loss, and differences in skin folds and moisture levels.


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The Trigger Point Model

Myofascial Trigger Points (MTrPs) are defined as "hyper‐irritable spots in skeletal muscle that are associated with a hypersensitive palpable nodule in a taut band"(Simons and Travell).

Myofascial Trigger Points are thought to be due to excessive release of acetylcholine from select motor end plates.

Acetylcholine is normally broken down by acetylcholine esterase.

In Myofascial Trigger Points breakdown is NOT occurring and leads to altered tissue function which then

Leads to end plate noise as documented on EMG studies.


The Trigger Point ModelCont’d

Trigger Points can be divided into:

• Active

• Passive

• Latent


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Active Myofascial Trigger Points

Spontaneously trigger local pain in the vicinity of the myofascial trigger point

and/or

Refer pain

and/or

Paresthesia to more distant locations and several autonomic phenomena



Passive myofascial trigger points

Do not trigger local or referred pain without being stimulated

May alter muscle activation patterns that contribute to limited range of motion and weakness.

Latent myofascial trigger points

The third type, Latent points refers to the concept of delayed onset in contralateral or anterior/posterior tissue to the site of active or passive trigger points (document negative findings adjacent/anterior/posterior).

Latent points are not manifest but can easily convert and may also be found on the non‐symptomatic contralateral side.

A unique feature of myofascial trigger points‐ local twitch response (LTR).

How important is this??


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Spinal Segmental Sensitization and Pentad Model

Dr. Andrew Fischerproposes:

Local compression of the neural foramina, as a result of disc space narrowing and paraspinal spasming, leads to sensitization of the nerves. The change in the articular relationships within the segment causes a persistent sprain of the spinous ligaments.

The interspinous and supraspinous ligaments are innervated by the medial branch of the posterior dorsal ramus as are the deepest back muscles and zygapophyseal joints.

Inactivating the irritative focus in the supra and inter spinous ligaments will:

• lead to down line inactivation of trigger/tender points,

• relaxation of taut bands and increasing pressure pain thresholds (PPT) to less than 2kg/cm difference as compared to the normo‐sensitive side as measured by algometry.


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Spinal Segmental Sensitization and Pentad ModelCont’d

Fischer delineates a set of five signs (pentad) that cycle together

• Supraspinous ligament sprain

• Radicular involvement which includes opposite side referral, sensory dysfunction traction signs and symptoms

• Segmental paraspinal spasm of deep muscle

• Narrowed space between the spinouses

• Narrowed disc space with associated neural foraminal narrowing both leading to sprain of the spinous ligaments


Central Model

Input stimuli (dose) to the system whether osseous manipulation, mobilization, massage and needling all cause a response in supraspinal regions.

Needling will send signals to the cord and up motor pathways to the brain

A strong response from the hypothalamus

Influences the pituitary and subsequent endocrine function.


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Central ModelCont’d

Local microscopic damage from needling (lesion inoculation)

Causes a central humoral anti‐inflammatory response from the hypothalamus‐pituitary‐adrenal axis.

The hypothalamus has three primary activities:

• Provides inputs to the brainstem

• Modifying autonomic regulation

• Controls endocrine function and integrates with brainstem activity

• Plus a fourth

• Has centers that influence posture and locomotion



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Differential Diagnosis Using DN

Diagnostically, trigger point deep dry needling can assist in differentiating between pain that originates from

• Joint

• Trapped nerve

• Muscle

Local stimulation or de‐formation of a sensitized myofascial trigger point can reproduce the patient's pain complaint due to MTrPs when the DDN technique is used.


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Differential Diagnosis Chart for Muscle vs Joint


Introducing

BioTensegrityCopyright © 2020 by David B. Fishkin DC MPH. & Dry Needling Institute, LLC All rights reserved.

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BioTensegrity

Tensegrity is an art/architectural principle that describes natural geometry in terms of compression and tension vectors. This principle has been adopted by science and applied to the human body.

A tensegrity requires several conditions to fit either Kenneth Snelson's or Buckminster Fuller's definition, who are the originators of this principle.


Tensegrity 1) A continuous connective tensioned

network that supports discontinuous compression struts.

2) Struts must be free floating in a web of tension and not touching.

3) If anatomical structures operate as tensegrities, in most orientations, the bones do not pass a direct load across the joint– rather the tension members.

4) ligaments, tendons, and fascia transfer loads and the bones float in this tension matrix.


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TensegrityTensegrities are self–contained non–redundant whole systems. All components are dynamically linked such that forces are translated instantly everywhere; a change in one part is reflected throughout.

Every part in a tensegrity is reliant on the entire structure for its continued existence. In terms of living forms, a discontinuity in a structure marks the boundary or interface between separate tensegrities.


The light at the end of

the Tunnel Syndromes


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Tunnel SyndromesNerves passing through bony, fibrous, osteofibrous and fibromuscular tunnels are typical places where trigger points develop.

Near the surface layers of tissue are very common locations to find MFTrP’s.

Kennard and Haugen (1955) ‐Trigger Points occur in places where blood vessels and nerves lie close to the surface. Virtually all peripheral nerves carry afferent, efferent motor sensory and autonomic nerve fibers.

Trigger Points will tend to manifest more acutely if the nerve trunk

• Larger

• More superficial

• Around bony foramen,

• Near neuromuscular attachments

• Neurovascular bundles.


Regional Locations For Biomechanical,Fibromuscular And Osteofibrous Stress Points

Head /Face/Cervical

• Superior Nuchal Line

•Greater Occipital

•Great Auricular

• Supraorbital

• Infraorbital

• Spinal Accessory

•C7‐T1 supra and interspinous ligament


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Cont’d

Shoulder/Upper extremities

•Dorsal Scapular

• Suprascapular

• Lateral pectoral

• Lateral antebracial cutaneous

•Deep radial

• Superficial radial



Cont’d

Thoracic

•T6‐T7‐T8supra and interspinous ligament

•Posterior cutaneous T6

•T12‐L1‐L2‐ supraspinous and interspinous ligament

•Posterior cutaneous L2, L5


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Cont’dLumbar/Pelvic/Lower Extremities

• L5‐S1 supraspinous and interspinous ligaments

• Superior Cluneal

• Inferior gluteal

• Iliotibial

• Proximal quadriceps insertion (mechanical)

• Lateral popliteal

• Sural

• Saphenous

• Common fibular

• Tibial

• Deep fibular(peroneal)

• Pudendal


Trigger Point Characteristics

• Active trigger points are apparent to the patient and will refer pain with or without palpation.

• Passive trigger points are not apparent and are activated by palpation with a local pain response.

• Latent points are not manifest but can easily convert and may also be found on the non‐symptomatic contralateral side.

• A nodular taut band that will contract on pinging of the tissue is typical of active TrP’s.

• Satellite trigger points develop as a sequela to the primary ones often in compensating agonist or antagonist muscles or from a visceral referral.


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Trigger Point CharacteristicsCont’d

• Trigger points are hypoxic. Radioisotope studies by Popelianskii in 1976 revealed slowing of capillary perfusion at TrP sites while a study by Lund et al in 1983 revealed low tissue oxygenation in the trigger points of fibromyalgic patients. Hypoxia leads to an acidic environment.

• Acidic environment leads to a decrease in AchE and increase in noxious biochemicals leading to increase in pain and motor endplate activity.

• The contracted muscle is in energy crisis because the ATP supply has been exhausted and cannot replenish due to the hypoxia.

• Increased swelling either felt by the patient and or seen by doctor. Brenstrup in 1957 showed by histologic staining techniques evidence of acid muccopolysaccharides and interstitial edema. Increased concentration of hyaluronic acid has increased water binding capacity. This edema might distort peripheral nerve endings.

• Often associated with eccentric contraction that is atypical or forceful for the individual leading to muscle fiber damage and hyper‐contraction.


Trigger Point CharacteristicsCont’d

• Number, size and distribution of primary and secondary trigger points reflect health status. Documenting these points has prognostic utility for treatment planning and assessing whether a patient mayhave a quicker or slower clinical response to treatment.

• Chronic patients will experience reactivation of trigger points and will require follow up care.

• As you move distally from primary points, the greater the number and distance the more entrenched the problem.

• Persistent trigger point activation will cause central sensitization.


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Mechanisms Of Action on MFTrPby Dry Needling

1. Can normalize chemical environment of active MTrPs. (Shah)

2. Mechanical disruption of contraction knots. (Simons and Travell)

3. Micro trauma to the tissue causing muscle regeneration without scar formation muscle regeneration recruits satellites cells, which repair or replace damaged muscle fibers. (Schultz)

4. Mechanical stimulation to collagen fibers excites their piezoeelectricpotentials which generate remodeling. (Liboff)

5. Superficial dry needling may help to reduce pain because of the central release of oxytocin. (Lundeberg)

6. Superficial dry needle stimulation may affect A Delta nerve fibers leading to activation of central nervous system opioid mediated pain suppression. (Baldry)



Mechanisms Of Action on MFTrPby Dry Needling

cont’d

7. Animal model studies reveal that skin and muscle needle stimulation results in increased cortical cerebral blood flow due to a reflex response of the afferent pathway. (Alavi)

8. Insertion of needle to fascia causes a grasping of the needle winding of connective tissue tight mechanical coupling between needle and tissue measurable changes in connective tissue architecture.

9. Collagen bundles assume a straighter more parallel orientation after the rotation. These studies support the idea of superficial dry needling using a rotational component. (Langevin)

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PuttingItALL

Together



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Comparison Of Dry Needling To Other Well Known Procedures

• Cold Laser: high up front capital investment, not well established in all body areas, depth of penetration dissipates significantly with increasing tissue depth.

• Iontophoresis: Capital cost/use of pharmaceutic agents, their toxicity and contraindications such as allergic response limits their use.

• Manipulation Under Anesthesia: High cost and limited application (Death)

• EMG: Capital cost/tissue trauma/accuracy is operator dependent/ results often do not correlate with patient symptoms especially with chronic conditions.

• Injection therapy: limited as to number of sites and frequency of injections due to drug toxicity considerations.


The Perfect Marriage

• Manipulation stimulates muscle spindles and Golgi tendon organs but may be short-lived, needle stimulation activates muscle spindles and Golgi tendon organs as well but leaves persistent stimulation to the same structures.

• Dry needling and manipulation potentiate their individual effects on the body. Likewise improvement to autonomic dysfunction occurs as well due to relaxation of muscle releasing deep spasm improving skin temperature and lymphatic constriction.

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Steroid Injection Side Effects:1. Infection

2. Impaired healing

3. Weakened tissue elements

4. Local atrophy of fatty tissue

5. Dimpling of skin

6. Skin pigmentation

7. Inflammation due to crystal deposits

8. Suppression of the hypothalamic-pituitary axis

9. Localized bleeding

10. Accidental pneumothorax

11. Joint destruction by avascular necrosis

12. Can trigger a psychotic event in patients prone to depression or mental illness

13. Central Serous Retinopathy

Alternative Therapeutic Injections

• Viscosupplementation

• Hyaluronic Acid (intra‐articular)

• Platelet Rich Plasma/Autologous Blood Injections

• Intramuscular & Intratendon

• Ultrasound guided injection therapy for MFTrP neutralization and debridement of compressive and tethered tissue.


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Tensegrity and Inflammation Keep in mind the role and existence of inflammation due to causes other than tensegrity alone.

Consider:

• Environmental• Behavioral• Chemical• Genetic and Congenital sources

• Metabolic• Autoimmune• Iatrogenic causes

• Certain anti‐biotics such Flouroquinolones [Cipro, Avelox]


Why Is Dry Needling Not Acupuncture?

This is a common question posed by patients.

1. MFTrPDN requires a physical examination, diagnosis, location of anatomic points based on western understanding of anatomy, neurology and physiology.

2. It does not use theories of meridians, energy, pulse points or tongue characteristics to make a determination of why or where to place a needle.

3. Acupuncture is a separate system of healing with its own ancient laws and philosophy.

The tool is the ONLY common element


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Benefits of Dry Needling1. Is both diagnostic and therapeutic

2. Brings about resolution of symptoms more rapidly and potentiates the effect of the synovial joint manipulation/mobilization

3. Per treatment cost is minimal and cost to benefit ratio is very high

4. Wide application throughout the body

5. Does not interfere with most patient’s drug regimen or interfere with implanted devices such as pacemakers

6. There is no contraindication to the number of sites or frequency of treatment

7. Can be safely used with patients who are very osteoporotic, have compression fractures or cancer


Important Characteristics Of Successful Dry Needling Application

1. To accurately palpate myofascial trigger points and tender points (target acquisition).

2. The skills to accurately needle the identified points.

3. To visualize the three‐dimensional image of the located point.

4. A thorough working knowledge of anatomy and the typical routes of peripheral nerves exiting close to the surface.

5. A thorough history and physical examination to correlate muscle weakness, range of motion restrictions, pain response by patient and autonomic phenomena with myofascial trigger points in the vicinity of exam.


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What May Patients Expect To Experience?

During needling patients could feel:

• Numbness

• Heaviness

• Achiness

• Red papule and itchiness reaction due to histamine release

• Raised, hardened tissue

• Reduction in sensation of pressure

• Tiredness

• Relaxed

• Reproduction of referred pain

All are within normal parameters of response.


Contraindications

Absolute Contraindications

1. Needle phobic patients.

2. Patients with genetic bleeding disorders.

3. Local infection sites.

4. Open wounds.

5. Known tumor sites or apparent benign growths such as a lipoma or raised skin lesions.

6. Any needling technique in a complicated high‐risk pregnancy.

7. Over a pacemaker.


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Contraindicationscont’d

Relative Contraindications

1. Deep needling technique in the lumbar region of an uncomplicated pregnancy prior to full term.

2. Patients on anticoagulant therapy.

3. Burn and skin graft sites, chemotherapy burn sites, contrast material burn sites or acne scarred.


Contraindicationscont’d

Proceed with Caution

1. Patients of questionable mental status should be considered carefully.

2. Patients who have a history of seizures require careful monitoring.

3. Children.

4. Transmissible blood disorders.

5. Post‐Surgical Lymphedema. (No longer true as per the APTA)


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Potential adverse responses

• Vasovagal syncope made more possible by dehydration, low blood pressure and very athletic people, tall & large people.

• Pneumothorax ‐ be especially careful with smokers, active lung infection or respiratory involvement, especially in the elderly and significant scoliosis.

• Pain at needle site and latent post treatment reaction 24‐48 hrs.

• Bruising.

• Nausea.

• Sweating.

• Venous bleeding.


Needle Anatomy

Needle in sealed pack

Needle with backing paper removed (unsealed pack)


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Needle Anatomy

Needle out of pack (still in guide tube)

Needle contents (exploded view)



NEEDLE LENGTH

0.5” 1.2” 1.5” 2.0” 3.0” 4.0”

15mm 30mm 40mm 50mm 75mm 100mm

NEEDLE GAUGE

Red Pink Blue Yellow

Color of tabs are sometimes different

30 32 34 36 38 40

0.30 0.25 0.22 0.20 0.18 0.16

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Precautions

1. Wash hands, wear non‐latex, non‐sterile, nitrile gloves.

2. Do not insert needle to the very end at the junction between it and the handle.

3. Correlate needle length to the tissue being penetrated to avoid organ penetration.

4. The vaso‐vagal reaction may be strong in the new patient or very tense patient therefore needle all patients in the prone, supine or lateral recumbent positions until the tolerance to needling has been established.

5. If the patient has not been seen in six months then treat them as new with respect to positioning.

6. Use fewer needles initially, especially with new patients, acute patients, thinner body types, the elderly and younger patients.


EXPOSURE TO BLOOD BORNE PATHOGENS


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Prevention Of Infection(adopted from World Health Organization)

• A clean working environment ‐ use protective covering of working surfaces where appropriate.

• Clean hands of the practitioner ‐ Practitioners should always wash their hands before treating a patient.

• Preparation of the needling sites • The needling sites should be clean, free from cuts, wounds or infections.

• The point to be needled should be swabbed with 70% ethyl or isopropyl alcohol, from the center to the surrounding area using a rotary scrubbing motion, and the alcohol allowed to dry.

• Sterile needles and equipment, and their proper storage• Disposable sterile acupuncture needles and guide tubes are to be used in all

instances.

• All disposable needles should be discarded immediately after use and placed in a special container.

• Each sterile filiform needle should be used for puncturing once, and once only.

• Aseptic technique ‐The needle shaft must be maintained in a sterile state prior to insertion.Needles should be manipulated by the handle if possible and with a gloved finger to handle the shaft.

• Careful management and disposal of used needles and swabs.


Exposure Control Plan

1. Report all exposures to bodily fluids and needle sticks.

2. Inform all staff members of potential hazards and discuss with them hepatitis B vaccine prophylactically.

3. High‐risk exposure: HIV, hepatitis B, hepatitis C, hepatitis D.

4. If exposed get tested to consider HBV vaccine series. If you work with a high‐risk population consider HBV vaccine prophylactically.

5. Keep a hospital grade cleaner on hand for table surfaces in the event of contact.

6. Keep an eye wash on hand in case of exposure.


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NIOSH Publication No. 2000‐108:

NIOSH Alert: Preventing Needlestick Injuries in Health Care

Settings


NIOSH ALERT• Employers of health care workers should implement the use of improved engineering controls to reduce needle stick injuries:

• Eliminate the use of needle devices where safe and effective alternatives are available.

• Implement the use of needle devices with safety features and evaluate their use to determine which are most effective and acceptable.

• Needle stick injury reduction can best be accomplished when the use of improved engineering controls is incorporated into a comprehensive program involving workers:

• Analyze needle stick and other sharps‐related injuries in your workplace to identify hazards and injury trends.

• Set priorities and prevention strategies by examining local and national information about risk factors for needle stick injuries and successful intervention efforts.

• Ensure that health care workers are properly trained in the safe use and disposal of needles.

• Modify work practices that pose a needle stick injury hazard to make them safer.

• Promote safety awareness in the work environment.

• Establish procedures for and encourage the reporting and timely follow‐up of patient

• Evaluate the effectiveness of prevention efforts and provide feedback on performance.


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NIOSH ALERT

Recommendations for Workers

To protect themselves and their coworkers, health care workers should be aware of the hazards posed by needle stick injuries and should use safety devices and improved work practices as follows:

1. Avoid the use of needles where safe and effective alternatives are available.

2. Help your employer select and evaluate devices with safety features.

3. Use devices with safety features provided by your employer.

4. Avoid recapping needles.

5. Plan safe handling and disposal before beginning any procedure using needles.

6. Dispose of used needle devices promptly in appropriate sharps disposal containers.

7. Report all needle stick and other sharps‐related injuries promptly to ensure that you receive appropriate follow‐up care.

8. Tell your employer about hazards from needles that you observe in your work environment.

9. Participate in bloodborne pathogen training and follow recommended infection prevention practices, including hepatitis B vaccination.



Region Patient Age Weight

Max Interspinoustissue depth

Max Spino-laminar

junction tissue depth

Max Transverse process tissue

depth

Cspine -C5/C6 Male 62 210 60 mm 69 mm 80 mm

Cspine -C5/C6 Male 53 165 39 mm 49 mm 58 mm

Cspine -C5/C6 Female 61 140 37 mm 53 mm 57 mm

Cspine -C5/C6 Female 28 115 36 mm 48 mm 55 mm

Tspine -T7/T8 Female 44 210 39 mm 48 mm 43 mm

Tspine -T7/T8 Female 61 130 19 mm 28 mm 29 mm

Lumbar -L5/S1 Male 45 250 86 mm 95 mm 110 mm

Lumbar -L5/S1 Male 66 220 30 mm 45 mm 73 mm

Lumbar -L5/S1 Female 58 160 53 mm 69 mm 76 mm

Lumbar -L5/S1 Female 49 123 29 mm 41 mm 55 mm

Actual Tissue Depth (as measured by MRI) by Region, Gender, Age and Weight

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North Carolina Scope and Informed Consent

North Carolina State Law – Chapter 90:Article 8

§ 90‐143. Definitions of chiropractic; examinations; educational requirements.

(a) "Chiropractic" is herein defined to be the science of adjusting the cause of disease by realigning the spine, releasing pressure on nerves radiating from the spine to all parts of the body, and allowing the nerves to carry their full quota of health current (nerve energy) from the brain to all parts of the body.

Scope of Practice (added May 2009)

Chiropractic is an alternative, conservative form of health care which does not duplicate allopathic medicine and is successful at treating a wide variety of ailments. Chiropractic principles were first discovered in 1895, and chiropractic has been recognized as a learned profession in North Carolina since 1917. North Carolina’s licensure laws require that a chiropractic physician possess a four‐year baccalaureate degree and a four‐year Doctor of Chiropractic degree awarded by a college approved by the Council on Chiropractic Education (CCE), an accrediting agency recognized by the U.S. Department of Education.

Doctors of Chiropractic are trained in physical examination, diagnosis, treatment, management, reassessment and referral. The State of North Carolina, through its Board of Chiropractic Examiners, examines licensure applicants for clinical competency and the ability to identify a broad spectrum of illness and injury. Comprehensive training and rigorous licensure standards allow chiropractors to serve as primary care portals of entry into the health care system “Primary care” does not mean full‐service care, nor does it necessarily entail performing surgery or prescribing drugs. It means that the physician possesses the training to identify a patient’s health problems and either treat or refer as warranted by the diagnosis and any scope of practice considerations.

It is within the chiropractic scope of practice to use diagnostic methods including but not limited to blood and urine evaluation, diagnostic imaging, electro‐diagnostic studies, orthopedic and neurological examination, meridian procedures and nutritional deficit assessment.

It is within the chiropractic scope of practice to use therapeutic procedures including but not limited to spinal manipulation and rehabilitative activity, durable medical equipment, physiological therapeutics, body work, massage, acupuncture and nutritional management. Nutritional supplements and other natural substances are those described in 21 NCAC 10 .0209 and may be administered via the most efficacious and safe method taught by recognized chiropractic colleges and universities, as limited by law.

III. Informed Consent (added July 2008)

A chiropractic physician is legally and ethically obligated to obtain informed consent from his patient prior to the start of treatment. Consent cannot be considered informed unless, at a minimum, the physician orally explains the risks associated with the proposed course of treatment, answers any questions the patient may have, and obtains the patient’s permission to treat.

The physician shall note in the patient’s clinical record the date of the informed consent consultation, the matters discussed, and the authorization to treat given by the patient. A standardized form may be used only as a written acknowledgment by the patient that the consultation occurred and that consent was given. A form cannot replace the face‐to‐face discussion between physician and patient contemplated by this guideline.

If the patient is a minor or an incompetent adult, the informed consent consultation shall include the patient’s parent or legal guardian.


Implementation1. Patients should be scheduled as you would for other passive modalities.

2. Needling can be performed before rehab if there is decreased ROM, after rehab exercises in general and prior to any manual therapies. (ART, Graston, Nimmo, SprayNStretch etc.)

3. PNF technique should be done after needling if acute. If chronic, PNF can be done before and after needling.

4. Needles can be kept in place during certain procedures such as flexion‐distraction (when needles are in the glutes for example) or when using the Fishkin Extremity Positioner and certain other passive movements such as extremity mobilization but not active ones.

5. Can be co‐administered with electrical modalities or cold laser, needles are placed first.

6. Massage, wet heat, ultrasound, infrared and other heat producing modalities should be administered after needling to enhance blood flow. Use ice prior to needling or w/o needling.

7. Patient can be treated serially over the course of an hour (Fishkin method). Treat and re‐exam multiple times consecutively until the condition has improved. A very effective approach for the acute patient.


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Paperwork

• Pre‐Treatment Consent verbal and written

• Post Treatment Discharge Instructions

• Specific Documentation Language


Is Dry Needling Right For Your Practice?


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What Is Dry Needling• Supportive Procedure modality to all Chiropractic techniques

• This modality focuses on hypomobility/fixation in the soft tissue

• Why another soft tissue modality?

• Closest approximation to the Chiropractic Manipulation but for the soft tissue.

• A thin needle can reach tissue depth with effectiveness not achievable with any other soft tissue technique.

• Disrupting the soft tissue lock improves the effectiveness of Chiropractic outcomes


What Will You Accomplish By Adding Dry Needling?• Quicker stabilization of the patient’s acute pain and management of chronic

• A comfortable and tolerable way to address acute and chronic conditions

• Compared with Manual Therapy Techniques this modality can deliver similar results with decreased time and effort resulting increased patient volume

• Decreased stress on your body and increased patient comfort

• Another management option for complex cases especially opioid issues

• Many professional sports teams and the military are utilizing this treatment to maintain peak performance and readiness

• Improved income at current patient levels


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Does Anyone Pay?

Insurers• Depending on the region, company and policy

• Many Workers Compensation commissions and PI do cover Dry Needling

• Dedicated CPT codes have been developed as of January 2020

Patients• People will spend their own money to get effective treatment

• Athletes and military personnel are demanding and getting this modality

• Patients are looking for alternatives to pharmacology


Why Train with Dr. Fishkin and the Dry Needling Institute, LLC?• Dry Needling is not the same everywhere it is taught and practiced

• Some forms practiced are very uncomfortable for the patient and often will deter follow up care

• Fishkin Dry Needling Technique (FDN)is very comfortable and covers more areas of the body than other courses with attention to:

• Safety

• Quality of teaching and pragmatic practice integration

• FDN is comprehensive and efficient

• When you complete the weekend training you are competent to treat Monday morning


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What Do You Get?Good food and refreshments throughout the weekend

You will receive:• Certificate of attendance for 18 CEU hours through University of Western States Chiropractic College.• Toolkit (starter kit of needles that lasts up to 2 weeks depending on usage)• Training Manual• Flash Drive of additional materials including doc ready forms, policies and research

The course includes the following items for your use at the class:• Massage Table• Fitted sheets• Head rest paper• Procedure tray• Standard Pillow w/ cover• Body Pillow w/ cover• Cotton Balls (non‐sterile)• Sharps Containers• Alcohol Dispensers• Isopropyl Alcohol• Nitrile Gloves• Hand Sanitizer• Pillow Cases• Skin Markers

You won't need to supply anything to take the course, except your shorts!


Now What?Be Trained and Certified to protect the public and

yourself

Register Now by calling…(301)‐444‐4890

Date: September 25‐27, 2020Friday 2‐7, Sat 8‐6, Sun 8–2

Location: Hyatt House Raleigh/RDU/Brier Creek

10030 Sellona St Raleigh, NC 27617

919‐405‐7001

https://raleighbriercreek.house.hyatt.com


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Documents

Dr. David Fishkin DC, MPH...1. Trigger point/tender point characteristics 2. Parameters of size, number and distribution 3. Active, passive and latent trigger/tender points 4. DifferentialDiagnoses