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Cervical Spine Manipulation Low Estimate 0.005 Paralysis, Stroke, Death

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Questions?

1

Joe Donnelly, PT, DHS, OCS Clinical Associate Professor

Department of Physical therapy Mercer University

A Curriculum for Dry Needling in an Entry Level Professional DPT Program

Curriculum   OSHA blood borne pathogens and sharps handling   Gross Anatomy   Applied anatomy   Foundational musculoskeletal sciences   Neuroscience   Management of the patient/client with musculoskeletal

conditions I and II   Neuromusculoskeletal Interventions I, and III   Psychosocial considerations

Gross and Applied Anatomy   Muscles of the appendicular and axial skeleton and, peripheral

nervous system structures are learned   Palpation as a test and measure is taught and valued   Competency assessment

2

Pedagogy   Collaborative Clinical Reasoning

 Reasoning Strategies   Diagnostic   Narrative   Forward   Ethical problem solving   Management strategies

 Clinical pattern development   Foundational musculoskeletal sciences   Management of Musculoskeletal Conditions I and II   Neuromusculoskeletal Interventions I and III

Clinical Reasoning Hypothesis Categories

 Activity limitations and participation restrictions  Patient’s perspectives on their experiences  Pathobiological mechanisms  Physical Impairments and associated structure or

tissue sources (sources of symptoms)  Contributing factors  Precautions / contraindications  Management and interventions  Prognosis

Myofascial Pain Clinical Patterns

  Migraines   Tension type

headaches   TMJ dysfunction   Epicondylalgia   LBP   Post laminectomy

syndrome

  Neck pain   CTS   Radiculopathy   WAD   FMS   CRPS

3

Foundational Musculoskeletal Sciences   Muscle response to injury

  Pathophysiology of Active and Latent MTrP’s

  Physical stress theory   Bracing, taping and splinting

  Clinical reasoning  Development of clinical patterns

  Application of anti-inflammatory modalities (thermal, ionto, US)

  Neurogenic vs non-neurogenic inflammation

Neuroscience   Somatosensory system   Current theories of the anatomical, physiological, and

psychological basis of pain and pain relief.   Muscle and its role in nociception   Peripheral sensitization   Central sensitization   Continuum of pain   Neurogenic inflammation

Gifford, LS: Pain, the tissues and the nervous system. Physiotherapy 84:27-33, 1998

Tissue Injury

Environment of

Injury

Processing experiences, attitudes, beliefs, body image, culture, motor patterns

Output motor, endocrine, autonomic systems

Action / Responses

input

4

Continuum of pain

Physiologic Pain

Pathophysiologic pain (neuropathic pain)

CRPS I, II

Pathobiologic Mechanisms

Neuroscience Musculoskeletal sciences

Clinical Reasoning

Continuum of Pain Presentation

Inflammation

Non-Neurogenic

Neurogenic

C fiber mediated

SNS - mediated

Injury

Microtrauma

Macrotrauma Input

Nociceptive

Processing

Centrally evoked

Affective

Output

Sympathetic / Motor

Physiologic Pain

Pathophysiologic pain (neuropathic pain)

CRPS I, II

Pathobiologic Mechanisms

Management of patients/clients with Musculoskeletal Conditions I, II

 Clinical reasoning and pain sciences  Clinical Pattern development

 Glut max, med, min, piriformis, multifidus, QL, longissimus, iliocostalis, Quads, RF, Adductors, Gastroc, soleus, tib post, foot intrinsics.

 Orthopaedic examination scheme  Grand rounds presentations

5

Psychosocial considerations   Distinction among acute, recurrent, and chronic pain   Psychological and behavioral components of pain experience

and relationship to acute or chronic nature of pain   Anxiety, fear, crisis reactions, stress   Impact on spirituality and meaningfulness, hope and

hopelessness   Psychological effect of unrelieved pain on perceptions of

control and self-efficacy   Depression, wish to die, suicidal risks   Impact of persistent pain on habits, roles, occupational

performance, and future quality of life

Neuromusculoskeletal Interventions I and III

  Manual therapy techniques   STM, MTrP release, spray and stretch  Thrust/ non-thrust manipulations

•  Functional retraining •  PNF •  Bracing, taping , kinesiotaping •  Dry Needling

A Curriculum for Dry Needling in a Residency in Orthopaedic Physical

Therapy Program Mercer University

Department of Physical Therapy Post-professional Programs

Residency in Orthopaedic Physical Therapy Residency in Neurologic Physical Therapy Fellowship in Physical Therapist Education

6

Curriculum

  Foundations of Orthopaedic Physical Therapy •  Basic Spine •  Basic extremity •  Advanced spine •  Advanced extremity •  CI credentialing •  Teaching entry level DPT •  Practice management and healthcare policy

Curriculum   Foundations of Orthopaedic Physical Therapy

 Collaborative clinical reasoning  Orthopaedic examination  Pain Sciences  Biomechanics of tissue and response to stress  Pathophysiology MTrP’s  OSHA blood borne pathogens and sharps handling

•  Basic Spine • Grand rounds presentations •  Clinical reasoning forms

•  Basic extremity • Grand rounds presentations •  Clinical reasoning forms

Curriculum   Advanced Spine

 Clinical reasoning reflection  Thrust manipulation  Diagnostic imaging

  Advanced extremity  Clinical reasoning reflection  Thrust manipulation   Pain sciences role of muscle nociception  Dry needling of extremity muscles

1  

Dry  Needling:  An  Emerging  Technique  in  Physical  Therapist  Prac:ce  

•  Jan  Dommerholt,  PT,  DPT                                          Joseph  M.  Donnelly,  PT,  DHS,  OCS;  Timothy  W.  Flynn,  PT,  PhD,  OCS,  FAAOMPT  

ObjecDves  1.  IdenDfy  key  components  of  

myofascial  pain  and  dysfuncDon  2.  Discuss  the  differences  and  

similariDes  between  acDve  and  latent  myofascial  trigger  points  

3.  Discuss  dry  needling  in  the  context  of  pain  sciences  

4.  Compare  and  contrast  various  dry  needling  approaches  

 

Is Dry Needling within the Scope of Physical Therapy

Practice?

 

2  

Scop

e  of  PT  PracDce  

Australia Belgium Canada Chile

Denmark Ireland

The Netherlands

New Zealand Norway

South Africa Spain

Sweden Switzerland

US (most states) among others

1997 – first formal dry needling course in the United States

Janet G. Travell, MD Seminar Series

Maryland  was  the  first  state  to  approve  dry  needling  in  1984  

12/21/12  

3  

Washington  

Oregon  

California  

Nevada  

Idaho  

Montana  

Wyoming  

Colorado  Utah  

New  Mexico  Arizona  

Texas  

Oklahoma  

Kansas  

Nebraska  

South  Dakota  

North  Dakota  Minnesota  

Wisconsin  

Illinois  

Iowa  

Missouri  

Arkansas  

Louisiana  

Alabama  

Tennessee  

Michigan  

Pennsylvania  

New  York  

Vermont  

Georgia  

Florida  

Mississippi  

Kentucky  

South  Carolina  

North  Carolina  

Maryland  Ohio   Delaware  Indiana   West    

Virginia  

New  Jersey  

ConnecDcut  

Massachuse\s  

Maine  

Rhode  Island  

Virginia  

New  Hampshire  Michigan  (upper  peninsula)  

Alaska  

USA  –  States:  Dry  Needling  2013  

Hawaii  

States that have approved dry needling by PTs

1989 – 2012

1 | P a g e

Physical�Therapists�&��the�Performance�of��Dry�Needling�An�Educational�Resource�Paper�

��������

����Produced�by�the�APTA�Department�of�Practice�and�APTA�State�Government�Affairs��January�2012�

On October 17, 2009, the Amer i can Academy o f O r t h o p a e d i c M a n u a l P h y s i c a l T h e r a p i s t s approved dry needling as a procedure within the scope of physical therapy practice.

4  

Does everyone

agree?

5  

somasimple.com  

•  Dry  needling  is  not  appropriate  since  it  is  unknown  what  we  are  jamming  a  needle  into.  There  is  no  solid  evidence  that  the  mythical  trigger  point  exists.  Therefore,  how  can  you  jab  a  needle  into  something  that  your  not  sure  is  even  present?  Also,  there  is  no  way  to  know  that  the  tender  point  we  are  feeling  has  anything  to  do  with  the  paDent's  pain  experience.  In  essence  what  we  are  doing  is  poking  a  foreign  object  into  a  paDent  to  effect  an  area  of  muscle  that  we're  not  sure  has  anything  to  do  with  someone’s  pain.  What  happened  to  'do  no  harm'?  

People  who  are  willing  to  use  dry  needling  don't  want  to  learn  to  use  their  hands...  maybe  they  don't  really  like  "feeling"  other  people's  nervous  systems  change  -­‐  they  want  to  always  keep  some  kind  of  physical  object  between  them  and  it  -­‐  maybe  they  see  the  "object"  as  "objecDve”    

What are we talking about?

Dry  Needling  Approaches  

•  Not  all  techniques  are  created  equal  

6  

 The  applicaDon  of  OMT  is  based  on  a  comprehensive  assessment  of  the  paDent’s  NMS  system  and  of  the  paDent’s  funcDonal  abiliDes.  This  examinaDon  serves  to  define  the  presenDng  dysfuncDon(s)  in  the  arDcular,  muscular,  nervous  and  other  relevant  systems;  

  www.ifompt.com

Clinical  reasoning    

a  process  in  which  the  therapist,  interacDng  with  the  paDents  and  significant  others,  structures  meaning,  goals  and  health  management  strategies  based  on  clinical  data,  client  choices  and  professional  judgment  and  knowledge          Jones  MA,  Rive\  DA.  (2004)  Clinical  reasoning  for  manual  therapists.  Edinburgh:  Bu\erworth  Heinemann    

Paradigm Shift external clinical evidence can inform, but not replace individual clinical expertise

Evidence – based physical therapy

Evidence – informed

Physical therapy

Pencheon D: What's next for evidence-based medicine? Evidenced-Based Healthcare Public Health, 2005. 9:319-321

7  

Muscle pain always follows •  Joint injury or dysfunction •  Nerve injury or dysfunction

Muscle pain is irrelevant as pain is produced by the brain

EndodonDst  •  Nearly  perfect  ergonomics,  shoulders  low,  forearms  supported,  wrists  in  slight  extension  

•  But…..severe  neck  and  shoulder  pain  

Franssen,  J.,  C.  Bron,  J.  Dommerholt:  Myofascial  Trigger  Points  in  the  Workplace.    In  Fernández-­‐de-­‐las-­‐Peñas,  C.,  J.A.  Cleland,  P.  Huijbregts:  Neck  and  Arm  Pain  Syndromes:  Evidence-­‐Informed  Screening,  Diagnosis,  and  Management.                                                                  Elsevier,  2011:  Chapter  6:78-­‐93    

Perfect  Posture  

No  guarantee  

•  Proper  spinal  alignment  •  Normal  curvature  •  No  forward  head  

posture  

8  

9  

 Cytological  Analyst:    Pain  neck/shoulders/arms  with  mulDple  TrPs  

Franssen,  J.,  C.  Bron,  J.  Dommerholt:  Myofascial  Trigger  Points  in  the  Workplace.    In  Fernández-­‐de-­‐las-­‐Peñas,  C.,  J.A.  Cleland,  P.  Huijbregts:  Neck  and  Arm  Pain  Syndromes:  Evidence-­‐Informed  Screening,  Diagnosis,  and  Management.                                                                  Elsevier,  2011:  Chapter  6:78-­‐93    

Unique Characteristics of Muscle Pain

•  Aching, cramping pain, difficult to localize and referred to deep somatic tissues

•  Muscle pain activates unique cortical structures

•  Inhibited more strongly by descending pain-modulating pathways

•  Activation of muscle nociceptors is much more effective at inducing neuroplastic changes in dorsal horn neurons

Strong activation of the anterior cingulate cortex and periaquaductal gray (PAG)

Svensson P, Minoshima S, Beydoun A, Morrow TJ, and Casey KL, Cerebral processing of acute skin and muscle pain in humans. J Neurophysiol. 78(1): 450-60, 1997

Niddam DM, Chan RC, Lee SH, Yeh TC, and Hsieh JC, Central modulation of pain evoked from myofascial trigger point. Clin J Pain. 23(5): 440-8, 2007

Myofascial Pain: activates anterior cingulate cortex/ periaquaductal gray (PAG) → associated w/ affective-emotional pain component and w/ hightened attention to painful stimuli

Cutaneous Pain:

No involvement of ant. cing. cortex.

10  

Myofascial Trigger Point

§  Data  on  the  reliability  of  physical  examinaDon  for  trigger  points  are  conflicDng  

§  Examiners  are  not  representaDve  of  those  who  would  normally  use  the  test  in  pracDce  

§  Evidence  for  the  diagnosDc  reliability  of  TPs  is  available  from  only  a  limited  number  of  studies  

Clin  J  Pain.  25(1),  2009  

0

20

40

60

80

100

STCM TRAP INFRASP LATS EDC

%

Taut Band

Interrater  Reliability  

0

20

40

60

80

100

STCM TRAP INFRASP LATS EDC

Trigger Point

0

20

40

60

80

100

STCM TRAP INFRASP LATS EDC

Tenderness

0

20

40

60

80

100

STCM TRAP INFRASP LATS EDC

%

Pain Rec.

0

20

40

60

80

100

STCM

TRAP

INFRASP

LATS

EDC

Referred Pain

Gerwin, R.D., et al., Interrater reliability in myofascial trigger point examination. Pain, 1997. 69(1-2): p. 65-73.

0

20

40

60

80

100

STCM

TRAP

INFRASP

LATS ED

C

%

Local twitch

11  

Barbero  et  al  J  Manual  Manipula:ve  Ther.  Vol  20  (4):171-­‐177,  2012    

An  experienced  physiotherapist  can  reliably  idenDfy  MTrP  locaDons  in  the  upper  trapezius  muscle  using  a  palpaDon  protocol  

§  IdenDficaDon  of  clinically  relevant  TP(s)  in  the  region  of  the  upper  trapezius  musculature  is  a  reproducible  procedure.    

§  When  performed  by  two  experienced  clinicians,  agreement  is  substanDal.  

§  a  pairing  of  one  experienced  and  one  inexperienced  observer,  both  of  who  have  undergone  a  standardizaDon  protocol,  can  yield  moderate  agreement.  

12  

MSc  Veterinary  Physiotherapy              

Mapping  the  Loca:on  PaNern  of  Myofascial  Trigger  Points  in  the  Superficial  Musculature  of  Racing  Greyhounds  

             Roddy  McConnell    

 23 racing greyhounds (19 dogs; 4 bitches; aged 1.8-5.5 years; mean age 3.4 years) from 4 race kennels in the Republic of Ireland

±  High MTrP density was found in key propulsive muscles in the greyhound in particular the biceps femoris, triceps brachii and gastrocnemius, which is in line with other research in the field

±  There was no significant link established between canine

lameness and MTrP incidence (p>0.05)

•  Multiple MTrPs were identified in the infraspinatus muscle on the painful side

•  Multiple latent MTrPs were identified bilaterally

European Journal of Pain 12 (2008) 859–865

� Chen  Q,  Bensamoun  SF,  Basford  JR,  Thompson  JM,  An  KN.  IdenDficaDon  and  QuanDficaDon  of  Myofascial  Taut  Bands  with  MagneDc  Resonance  Elastography.  Arch  Phys  Med  Rehab  2007,  88:1658-­‐61.    

� Chen  Q,  Basford  JR,  An  KN.  IdenDficaDon  of  Myofascial  Taut  Band  Using  MagneDc  Resonance  Elastography.  Clin  Biomech  2008,  23  :623-­‐9.    

 

13  

Sikdar S, et al. Novel Applications of Ultrasound Technology to Visualize and Characterize Myofascial Trigger Points and Surrounding Soft Tissue Arch Phys Med Rehabil. 2009;90:1829-38

Hariharan Shankar and Sapna Reddy Pain Medicine 2012

This is a successful demonstration of utility of ultrasound imaging of taut

bands in the management of myofascial pain syndrome

J  Ultrasound  Med  2012;  31:1209–1219    

J  Ultrasound  Med  2011;  30:1331–1340  

14  

AcDve  TrPs  are  larger  (0.35  –  0.40  cm2)  than  latent  TrPs  (0.27  cm2)    

Sikdar  S,  OrDz  R,  Gebreab  T,  Gerber  LH,  Shah  JP,  Understanding  the  vascular  environment  of  myofascial  trigger  points  using  ultrasonic  imaging  and  computaDonal  modeling.  Conf  Proc  IEEE  Eng  Med  Biol  Soc    1:  5302-­‐5,  2010.  

O2- tissue saturation in TrPs  

Brückle, W., et al., Gewebe-pO2-Messung in der verspannten Rückenmuskulatur (m. erector spinae). Z. Rheumatol., 1990. 49: p. 208-216.

12/21/12  

15  

Low  O2  

Low  pH  

pH

0

1

2

3

4

5

6

7

8

0:00 2:24 4:48 7:12 9:36 12:00 14:24 16:48

Time

pH

un

its Gr.1

Gr.2Gr.3

Shah, J.P., et al., An in-vivo microanalytical technique for measuring the local biochemical milieu of human skeletal muscle. J Appl Physiol, 2005. 99: p. 1980-1987 Shah JP, Danoff JV, Desai MJ, Parikh S, Nakamura LY, Phillips TM, and Gerber LH, Biochemicals associated with pain and inflammation are elevated in sites near to and remote from active myofascial trigger points. Arch Phys Med Rehabil. 89(1): 16-23, 2008"

Pain 129 (2007) 102–112

•  Acidic pH has a profound effect on the initiation and perpetuation of muscle pain

•  A more acidic milieu may activate ASIC1 or ASIC3 muscle nociceptors, which in turn could produce mechanical hyperalgesia

16  

• ASIC1a  • ASIC3  Low  pH  

• Central  sensiDzaDon  

• InflammaDon  Hyperalgesia  

Low    pH  

Release  of  nocicepDve  substances  

CGRP  

BK  

ATP  

5-­‐HT  

PG  

Downregulates  AChE   Excessive  ACh  

Microdialysis  System  

Shah, J.P., et al., An in-vivo microanalytical technique for measuring the local biochemical milieu of human skeletal muscle. J Appl Physiol, 2005. 99: p. 1980-1987

17  

CGRP

0

50

100

150

200

250

300

350

400

0:00 2:24 4:48 7:12 9:36 12:00 14:24 16:48

Time

pg/ml

Shah, J.P., et al., An in-vivo microanalytical technique for measuring the local biochemical milieu of human skeletal muscle. J Appl Physiol, 2005. 99: p. 1980-1987 Shah JP, Danoff JV, Desai MJ, Parikh S, Nakamura LY, Phillips TM, and Gerber LH, Biochemicals associated with pain and inflammation are elevated in sites near to and remote from active myofascial trigger points. Arch Phys Med Rehabil. 89(1): 16-23, 2008"

Substance P

0

50

100

150

200

250

300

350

400

0:00 2:24 4:48 7:12 9:36 12:00 14:24 16:48

Time

pg/m

l Gr.1Gr.2Gr.3

Shah, J.P., et al., An in-vivo microanalytical technique for measuring the local biochemical milieu of human skeletal muscle. J Appl Physiol, 2005. 99: p. 1980-1987 Shah JP, Danoff JV, Desai MJ, Parikh S, Nakamura LY, Phillips TM, and Gerber LH, Biochemicals associated with pain and inflammation are elevated in sites near to and remote from active myofascial trigger points. Arch Phys Med Rehabil. 89(1): 16-23, 2008"

•  Norepinephrine  •  TNG  –  α  •  Interleukin  1,  6,  8,  12  •  Substance  P  •  Serotonin  •  Calcitonin  Gene  Related  PepDde  

Shah, J.P., et al., An in-vivo microanalytical technique for measuring the local biochemical milieu of human skeletal muscle. J Appl Physiol, 2005. 99: p. 1980-1987 Shah JP, Danoff JV, Desai MJ, Parikh S, Nakamura LY, Phillips TM, and Gerber LH, Biochemicals associated with pain and inflammation are elevated in sites near to and remote from active myofascial trigger points. Arch Phys Med Rehabil. 89(1): 16-23, 2008"

18  

TrPs  are  persistent  sources  of  nocicepDve  input,  which  excite  muscle  nociceptors  and  contribute  to  peripheral  and  central  sensiDzaDon    

A  nociceptor  is  a  receptor  specialized  in  detecDng  sDmuli  that  objecDvely  can  damage  Dssue  and  

subjecDvely  are  perceived  as  painful    

12/21/12  

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Mense: The Pathogensis of Muscle Pain Current Pain and Headache Reports 2003, 7:419-425

Molecular Level

Muscle Nociceptors

Myofascial  TrPs  (referred  pain  

pa\ern)  

LiberaDon  of  algogenic  mediators  

Aδ  and  C  fibers  Aβ  fibers  

Peripheral  SensiDzaDon  

12/21/12  

20  

TrP  

Allodynia  

Hyperalgesia  

Central  SensiDzaDon  

SensiDzaDon  of  2nd  order  neurons  in  the  dorsal  horn    and  trigeminal  nucleus  caudalis  

Increased  pain  transmission  

Sensory  cortex  and  thalamus  

Central  SensiDzaDon  

Central  SensiDzaDon  

 DisinhibiDon  is  a  major  mechanism  for  triggering  and  maintaining  central  sensiDzaDon  

 

21  

Fernández de las Peñas C, Galán del Rio F, Fernández Carnero J, Pesquera J, Arendt-Nielsen L, Svensson P, Bilateral widespread mechanical pain sensitivity in women with myofascial temporomandibular disorder: evidence of impairment in central nociceptive processing. J Pain 10(11): p. 1170-1178, 2009

J Pain 2007:8(11): p. 869-78"

Migraine  sites  coincide  with  referred  pain  from  TrPs    Pain  is  oxen  contributed  to  by  TrPs  that  enhance  the  level  of  central  neuronal  excitability  

 trigger  points  redeveloped  axer  1  hour  of  conDnuous  typing  in  all  condiDons  

22  

General  otolaryngology  prac:ce    Over  a  period  of  5  months,  106  of  257,  41%,  of  consecu:ve  new  pa:ents  presented  with  a  chief  complaint  caused  by  a  myofascial  disorder  

Current  Pain  and  Headache  Reports  2004,  8:457–462  

 Trigger  points  in  episodic  tension-­‐type  headache:    upper  trapezius  (75%)    

temporalis  (74%)  SCM  (60%)  

Trigger  Points      •  93.9%  of  migraineurs  

•  29%  of  controls  

Calandre EP, Hidalgo J, Garcia-Leiva JM, Rico-Villademoros F. Eur J Neurology 2006; 13:244-249

23  

MulDple  acDve  MTrPs  (7.4  ±  2.2)  were  idenDfied  bilaterally  in  FMS  paDents,  but  no  acDve  MTrPs  were  found  in  controls.  

PAIN  147  (2009)  233–240  

Arthritis  Research  &  Therapy  2011,  13:R48  

European  Journal  of  Pain  15  (2011)  61–69  

In  fibromyalgia  patients,  local  treatment  of  trigger  points  not  only  relieves  local  symptoms  but  also  significantly  improves  the  widespread  FS  symptoms  in  terms  of  reduction  of  both  spontaneous  diffuse  pain  and  tenderness  at  all  tender  point  sites.  

24  

Moseley  summarized,    “any  strategy  that  has  an  inhibitory  effect  on  nocicepDve  input  is  probably  appropriate  in  the  short  term  unless  it  simultaneously  acDvates  non-­‐nocicepDve  threatening  inputs”    

What are TrPs?

ContracDle  AcDvity  1.  Electrogenic  sDffness:  

muscle  tension  coming  from  electrogenic  muscle  contracDon,  based  on  observable  EMG  acDvity  in  normals  who  are  not  completely  relaxed      

The  term  electrogenic  refers  to  the  fact  that  the  a-­‐motor  neuron  and  the  neuromuscular  endplate  are  acDve  under  these  condiDons.  

25  

ContracDle  AcDvity  

2.  Electrogenic  spasm  that  specifically  idenDfies  pathological  involuntary  electrogenic  contracDon    May  or  may  not  be  painful  

ContracDle  AcDvity  3.  Contracture  arising  endogenously  within  the  

muscle  fibers  independent  of  EMG  acDvity  

Simons  DG,  Mense  S,  Understanding  and  measurement  of  muscle  tone  as  related  to  clinical  muscle  pain.  Pain    75(1):  p.  1-­‐17,  1998  

12/21/12  

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Trigger  Point  Endplate  Noise  

Macgregor  J,  Graf  von  Schweinitz  D,  Needle  electromyographic  acDvity  of  myofascial  trigger  points  and  control  sites  in  equine  cleidobrachialis  muscle-­‐-­‐an  observaDonal  study.                                

Acupunct  Med    24(2):  p.  61-­‐70,  2006.  

Hong  C-­‐Z,  Yu  J,  Spontaneous  electrical  acDvity  of  rabbit  trigger  spot  axer  transecDon  of  spinal  cord  and  peripheral  nerve.  J  Musculoskeletal  Pain    6(4):  p.  45-­‐58,  1998.  

Simons  DG,  Hong  C-­‐Z,  Simons  LS,  Endplate  potenDals  are  common  to  midfiber  myofascial  trigger  points.  Am  J  Phys  Med  Rehabil    81(3):  p.  212-­‐222,  2002  

Couppé  C,  Mid\un  A,  Hilden  J,  Jørgensen  U,  Oxholm  P,  Fuglsang-­‐Frederiksen  A,  Spontaneous  needle  electromyographic  acDvity  in  myofascial  trigger  points  in  the  infraspinatus  muscle:  A  blinded  assessment.  J    Musculoskeletal  Pain    9(3):  p.  7-­‐17,  2001.  

• The  degree  of  endplate  noise  is  directly  related  to  the  irraDbility  (sensiDvity)  of  TrPs  

• AcDve  TrPs  are  spontaneously  sensiDve  

• Latent  TrPs  require  digital  sDmulaDon  

27  

•  14 subjects •  Injections with

glutamate or isotonic saline in latent TrP or non-TrP tissue (gastrocnemius)

•  Needle EMG vs surface EMG

Exp Brain Res 187(4):623-629, 2008

Exp Brain Res 187(4):623-629, 2008

•  Activation of nociceptive muscle afferents may electrically induce muscle cramps by increasing the response of group II spindle afferents and the afferent input to motor neurons

•  Does not explain the induction of muscle cramps with peripheral denervation

•  Noxious stimulation of latent MTrPs may decrease inhibitory input to motor neurons and as a result induce muscle cramps

•  Confirms the existence of nociceptive hypersensitivity at latent MTrPs and provides the first evidence that there exists non-nociceptive hypersensitivity (allodynia) at latent MTrPs

•  Finally, the occurrence of referred muscle pain is associated with higher pain sensitivity at latent MTrPs

Clin J Pain 25(2):132-137, 2009

28  

Ge  HY,  Serrao  M,  Andersen  OK,  Graven-­‐Nielsen  T,  Arendt-­‐Nielsen  L.  Increased  H-­‐reflex  response  induced  by  intramuscular  electrical  sDmulaDon  of  latent  myofascial  trigger  points.  Acupunct  Med.  2009  Dec;27(4):150-­‐4.      Ge  HY,  Zhang  Y,  Boudreau  S,  Yue  SW,  Arendt-­‐Nielsen  L.  InducDon  of  muscle  cramps  by  nocicepDve  sDmulaDon  of  latent  myofascial  trigger  points.  Exp  Brain  Res.  2008  Jun;187(4):623-­‐9.      Li  LT,  Ge  HY,  Yue  SW,  Arendt-­‐Nielsen  L.  NocicepDve  and  non-­‐nocicepDve  hypersensiDvity  at  latent  myofascial  trigger  points.  Clin  J  Pain.  2009;25(2):132-­‐7.      Wang  YH,  Ding  XL,  Zhang  Y,  Chen  J,  Ge  HY,  Arendt-­‐Nielsen  L,  et  al.  Ischemic  compression  block  a\enuates  mechanical  hyperalgesia  evoked  from  latent  myofascial  trigger  points.  Exp  Brain  Res.  2010  Apr;202(2):265-­‐70.      Xu  YM,  Ge  HY,  Arendt-­‐Nielsen  L.  Sustained  nocicepDve  mechanical  sDmulaDon  of  latent  myofascial  trigger  point  induces  central  sensiDzaDon  in  healthy  subjects.  J  Pain.  2010;11(12):1348-­‐55.      Zhang  Y,  Ge  HY,  Yue  SW,  Kimura  Y,  Arendt-­‐Nielsen  L.  A\enuated  skin  blood  flow  response  to  nocicepDve  sDmulaDon  of  latent  myofascial  trigger  points.  Arch  Phys  Med  Rehabil.  2009  Feb;90(2):325-­‐32.    

IMT  Infraspinatus  

Increased  Shoulder  ROM  

Increased  PPT  

Anterior  Deltoid  

Extensor  Carpi  Radialis  Longus  

Infraspinatus  

•  TrP dry needling of the infraspinatus (randomly selected side)

•  TrP on the contralateral side was not •  Shoulder pain intensity, ROM, shoulder internal

rotation, and pressure pain threshold of the MTrPs in the infraspinatus, anterior deltoid, and extensor carpi radialis longus muscles were measured in both sides before and immediately after dry needling

Am J Phys Med Rehabil 2007; 86(5):397 - 403

29  

•  Active and passive ROM of shoulder internal rotation, and the pressure pain threshold of MTrPs on the treated side, were significantly increased (P<0.01)

•  Pain intensity of the treated shoulder was significantly reduced (P<0.001) after dry needling

Am J Phys Med Rehabil 2007; 86(5):397 - 403

•  AcDve  vs  latent  •  Disturbed  motor  funcDon  

•  Muscle  weakness  and  sDffness  

•  Restricted  range  of  moDon    

•  VasoconstricDon  •  VasodilaDon  •  Goose  bumps  •  LacrimaDon  •  Local  tenderness/pain  •  Referred  pain  

Myofascial Trigger Point

Central De-Sensitization: Undoing the Damage

Goal of treatment: remove noxious stimuli to produce desensitization

30  

Dry Needling!•  Meta Review •  Respectable data-

base

Dry needling appears to be a useful adjunct to other therapies for chronic low back pain Furlan AD, van Tulder MW, Cherkin DC, Tsukayama H, Lao L, Koes BW, Berman BM: Acupuncture and dry-needling for low back pain. The Cochrane Database of Systematic Reviews 2005, Issue 1

Dry Needling!

Lucas, K.R., Polus, B.I., and Rich, P.S., Latent myofascial trigger points: their effect on muscle activation and movement efficiency. J Bodywork

Movement Ther. 2004; 8: 160-166

Dry needling of latent MTrPs restores normal muscle activation patterns

Dry Needling!

DiLorenzo et al: Hemiparetic Shoulder Pain Syndrome Treated with Deep Dry Needling Dying Early Rehabilitation: A Prospective, Open-Label, Randomized Investigation. J Musculoskeletal Pain 12(2) 2004

•  Less severe and less frequent pain •  Less analgesic medication •  Restoration of normal sleep patterns •  Increased compliance with the rehabilitation program

31  

Dry Needling!

J Altern Compl Med 13(6), 2007: 617–623

Pain Pressure Threshold FACES VAS

EliciDng  a  LTR  ±  The  best  results  are  accomplished  when  needling  elicits  a  LTR  ±  The  electrical  discharge  is  most  significant  at  the  MTrP  ±  In  the  taut  band,  away  from  the  MTrP,  the  LTR  is  much  weaker:  

Hong C-Z and Torigoe Y: Electrophysiological characteristics of localized twitch responses in responsive taut bands of rabbit skeletal muscle. J Musculoskeletal Pain, 1994:2:17-43.

DiagnosDc  criteria  

•  taut band

•  spot tenderness within the taut band

•  local twitch response

32  

Contralateral  LTR  ± Unilateral  neck  pain  ≥  6  months  ± AcDve  MTrP  in  trapezius  or  levator  scapulae  ± LTR  elicited  by  needle  sDmulaDon  caused  contralateral  

LTR  in  61.5%    ± AcDve  MTrPs  may  represent  a  central  nervous  system  

abnormality,  involving  segmental  changes    ± Different  degrees  of  chronicity,  degree  of  plasDcity,  glia  

cell  acDvaDon?  

 Bilateral  acDvaDon  of  motor  unit  potenDals  with  unilateral  needle  sDmulaDon  of  acDve  myofascial  trigger  points.    J.F.  Aude\e,  F.  Wang,  H.  Smith.    Am  J  Phys  Med  Rehabil  83(5):368-­‐374,  2004  

Inte

grat

ed T

rigge

r Poi

nt H

ypot

hesi

s

Dommerholt, J. and McEvoy, J., Myofascial Trigger Point Release Approach, in Orthopaedic Manual Therapy; from Art to Evidence, C. Wise, Editor., F.A. Davis: Philadelphia, in press.

How does dry needling

work?

33  

Exact Mechanism is unknown

Mechanical Results in disruption of muscle fiber adhesions and increases circulation to the region

Neurophysiological Local twitch response is a spinal cord reflex that results in immediate release of muscle hypertonicity

CGRP

0

50

100

150

200

250

300

350

400

0:00 2:24 4:48 7:12 9:36 12:00 14:24 16:48

Time

pg/ml

Biochemical Local twitch response results in favorable biochemical effects (based on Shah’s research at NIH) which reduce pain

Possible Adverse Side Effects Soreness    

(typically  1  h  -­‐2  days)    Slight  bleeding  /  bruising  

FaDgue  Fain:ng  /  Lightheadedness  

Pneumothorax  

34  

somasimple.com  •  So,  could  you  tell  me  […]  why  we  shouldn't  apply  dry  

needling?  

•  Because  it  hurts.  

What  I  don't  get  is  how  needles  can  be  considered  by  them  as  non-­‐threatening!  I  think  needles  are  less  threatening  to  them!  Not  to  the  paDents  or  to  the  paDents'  nervous  systems!  It's  they  who  do  not  want  to  have  to  learn  to  actually  touch  people  the  right  way.  Needles  give  them  some  sort  of  distance  psychologically,  so  they  can  keep  themselves  sort  of  removed  from  the  dyad.      Needles  are  supposed  to  be  threatening.  And  they  are.    

•  pain  intensity  can  be  dissociated  from  the  magnitude  of  responses  in  the  "pain  matrix",    

•  the  responses  in  the  "pain  matrix"  are  strongly  influenced  by  the  context  within  which  the  nocicepDve  sDmuli  appear,  and  

•  non-­‐nocicepDve  sDmuli  can  elicit  corDcal  responses  with  a  spaDal  configuraDon  similar  to  that  of  the  "pain  matrix".  

Legrain  V,  Ianne�  GD,  Plaghki  L,  Mouraux  A:  The  pain  matrix  reloaded:  a  salience  detecDon  system  for  the  body.  Prog.  Neurobiol.  93(1):  111-­‐24,  2011  

The  condi:oned  pain  modula:on  (CPM  

•  The  inhibiDon  of  one  source  of  pain  by  a  second  noxious  sDmulus,  termed  the  condiDoning  sDmulus.    

•  This  procedure  can  acDvate  an  endogenous  pain  inhibitory  mechanism  that  inhibits  early  nocicepDve  processing."    

•  In  other  words,  if  we  can  "convince"  the  paDent  that  the  condiDoning  sDmulaDon  (i.e.,  dry  needling)  will  lead  to  a  reducDon  in  pain,  it  will  lead  to  a  larger  inhibitory  CPM.  

Bjorkedal  E,  Flaten  MA:  ExpectaDons  of  increased  and  decreased  pain  explain  the  effect  of  condiDoned  pain  modulaDon  in  females.  Journal  of  pain  research  5:  289-­‐300,  2012.  

35  

Adverse events following dry needling: A prospective survey of

Chartered Physiotherapists

•  Brady  S,  McEvoy    J,  Dommerholt  J,  Doody  C:  Adverse  events  following  trigger  point  dry  needling:  a  prospecDve  survey  of  chartered  physiotherapists.  submi\ed,  2012.

Common Adverse Events: (1-10/100)

Adverse Event Number No per 100 treatments

Bleeding 516 7.75 Bruising 325 4.88 Pain during treatment

219 3.29

Pain after treatment

159 2.39

Uncommon Adverse Events (1-10/1000)

Adverse Event Number No per 1000 treatments

Aggravation of symptoms

62 9.31

Drowsiness 17 2.55

Feeling faint 13 1.95

Nausea 10 1.5

Headache 8 1.2

36  

Rare (1-10/10,000)

Adverse Event Number No per 10,000

Treatments (estimated) Fatigue 3 4.51

Emotional 3 4.51

Itching 1 1.5

Numbness 1 1.5

Shaky 1 1.5

Risk  of  a  significant  adverse  event  by  physiotherapists:    

0.04%  

 If  pain  is  a  puzzle,  we  should  not  throw  away  pieces  of  the  jigsaw  just  because  we  are  obsessed  with  a  preconceived  single  soluDon  

                                                                                           

Patrick  Wall