INTRODUCTIONTRIGGER POINT DRY NEEDLING

Nichole Bluemle PT, DPT, MS, CSCS, OCS

Objectives

Define Dry Needling Define Trigger Point Causes of Trigger Points Goals of Dry Needling Mechanism of Dry Needling Contraindications Risks/Complications/Adverse Reactions Technique Post Treatment Reasons for failure APTA Stance NM PT State board Summary Recommended Resources

Video overviewhttp://www.youtube.com/watch?v=1bst-eDCjwg

Trigger Point Dry Needling TDN, Functional Dry Needling (FDN),

Intramuscular Stimulation (IMS), Intramuscular Manual Therapy (IMT)

Invasive procedure where a monofilament needle is inserted into a trigger point

Called dry needling because it does not involve injection of a “wet” substance like trigger point injections

Myofascial Trigger Point “Hyperirritable spots in

skeletal muscle associated with hypersensitive palpable nodules in a taught band.” (Travell and Simons 1992)

Characteristics of Myofascial Trigger Points Localized tenderness upon palpation of a

taut band of muscle LTR to cross-fiber stimulation of a taut band Pain to deep palpation that is recognized

pain Referred pain to a characteristic region

based on myofascial referral maps Autonomic phenomena (sweating,

piloerction, vasomotor)

Referral Maps

Causes of Trigger Points Repetitive movements/low level muscle

contractions Compressive forces Trauma (contusion/strain) Unaccustomed eccentric contractions/

eccentric contractions in untrained muscles (DOMS)

Emotional stress Postural stress Dehydration

Goal of Dry Needling Illicit a local twitch response (LTR) in

involved muscle

Desensitize hypersensitive musculoskeletal structures while restoring motion and function

Mechanisms of Dry Needling Releasing shortened muscles Removing irritation of spinal nerve roots by

relieving short paraspinal muscles Promote healing through local inflammation

response (increased blood flow to include platelet derived growth factor)

Decrease spontaneous electrical activity and biochemicals in myofascial trigger points

Decrease pain associated with myofascial trigger points

Mechanical Effects(Dommerholt J. 2004)

Disrupts the integrity of dysfunctional motor end plates

Cause a LTR

Alter muscle fiber length

Neurophysiological Effects(Baldry PE. 2001)

Suggests that dry needling stimulates A-delta nerve fibers (type III) for 72 hours post-needlingProlonged stimulation of A-delta fibers may

activate enkephalinergic inhibitory dorsal interneurons

Activate descending inhibitory systems which would block noxious stimulus into the dorsal horn

Chemical Effects(Shah J. et al. 2005)

Decrease in chemicals at the active trigger point location immediately after a local twitch responseBradykininCGRP (calcitonin gene related peptide)Substance P

Contraindications Denial of consent High level patient fear/apprehension Bleeding disorders or on anti-coagulants Pregnancy Directly over joint replacement/breast

implant/pacemaker Infection/illness Unstable bone injury Malignant tumor

Risks/Adverse Reactions Pneumothorax Vasovagal reaction Muscle soreness Fatigue Bruising Pain during insertion Infection

Always a possibility but reduced likelihood by adhering to sterile guidelines

Minimize Infection Risk Always wash hands between patients Treatment area well lit and clear of clutter Sterile, one time use individually

packaged needles Clean treatment field (alcohol pad) Sharps container closed between

patients Single use firm fitting gloves

Needle Technique Identify anatomical landmarks, taut band, and the

trigger point Clean the area with alcohol pad Place the needle over the trigger point and tap into

skin at a 90deg angle (angle may need to be altered based on anatomy)

Advance the needle into the trigger point Piston (redirect the needle, pull the needle up to

the subcutaneous layer, redirect, again advance into muscle)

Remove needle and apply direct pressure

Post-treatmentRe-evaluate Stretch/PROM/AROM Instruct patient in self mobilization

techniques Heat Movement facilitation tape Hydration

Reasons for Failure Diagnostic error Incomplete management of perpetuating

factors Trigger point missed or inadequately

treated Referred zone treated Inadequate post care

Scope of Practice Determined by individual state board if in scope

of practice and if/what training requirements must be met

Many states determine dry needling to be in the scope of practice for Physical Therapists, Acupuncturists, Chiropractors

Summary Dry needling performed by a trained

clinician (PT, DO, DC, L.Ac) can relieve myofascial pain caused by trigger points commonly involved in orthopedic conditionsRelease shortened musclesReduce spontaneous electrical activity at the

neuromuscular junctionReturn biochemicals that cause

hypersensitization to normal levelsPromote self healing

Recommended Resources

Questions?Contact Info:

Nichole Bluemle PT, DPT, MS, CSCS, OCSwww.durangophysicaltherapy.comdurangoPT@gmail.com