1. LT Michael Krok, DPT, OCS, CSCS
2014 Scientific Symposium
I will try to talk fast so that I finish before post-lunch coma sets in
.Introduce self
My interest in dry needling stems from my own personal experiences with chronic pain……Army experience, narcotics, medical board…. needing better answers
Dry Needling
LT Michael Krok, DPT, OCS, CSCS

2. Dry Needling: OBJECTIVES
Understand what dry needling is and is not
Understand what the current literature says and in relation to dry needling
Understand how dry needling is being used in clinics today

3. DRY NEEDLING History, Definitions, and Terminology
Anybody currently practicing dry needling in their clinic?
Anybody that’s hasn’t heard of dry needling?
How many PT’s?
DRY NEEDLING History, Definitions, and Terminology

4. JH Kellgren
Hypertonic saline injections
Referral patterns
Karl Lewit, MD, DSc
“The Needle Effect”
Sir William Gowers
BMJ 1;
Fibrositis”
Palpable tenderness and hardness of the muscle
C. Chan Gunn
1983
1928
1938
1950
1979
1904
1931
1996
Radiculopathic Model
Fred H. Albee,
MD, ScD
“Myofascitis from an orthopedic standpoint”
Janet Travell, MD and David G. Simons, MD
The history of dry needling begins with recognition and description of myofascial dysfunction that began in the early 1900’s.
Sir William Gowers in the early 1900’s introduced the term “fibrositis” and noted palpable tenderness and hardness of the muscle
Fred H. Albee, MD, ScD in 1928 began using the term “Myofascitis”
Max Lange authored the first trigger point manual in 1931 Die Muskelhärten (Myogelosen): he hypothesized that that the “lumps” were due to colloidal accumulation in the muscle tissue.
Arthur Steindler in 1938 began referring to pain from the muscle as “Myofascial pain” and “trigger points”.
1938 is when referral patterns entered the equation. Kellgren used hypertonic saline injections to irritate various soft tissue structures and demonstrated and documented referral patterns. It was during this time that many others began studying referral patterns as well, notably in Germany and Australia.
In 1940 needles entered the equation: Karl Lewit published “The Needle Effect”. In this paper he revealed recognition that, indeed, a needle could be used as an extension of manual treatment of orthopedic dysfunctions.
It was at this same time that Dr. Janet Travell began her work with an initial paper that documented thirty-two pain referral patterns from muscles injected with an irritant. She adopted the terminology “trigger point” and with Dr. David Simons published many more referral patterns and descriptions and definitions of trigger points that are still the most widely used and recognized today. This is published in their two-volume set of red books titled Myofascial Pain and Dysfunction: The Trigger Point Manual (2nd edition). The recognizable trigger point referral maps use an “X” to depict where the irritant was injected into a particular muscle and red dots at sites where subjects reportedly experienced symptoms.
Interesting to note that Dr. Travell was also notable as the first female physician at the White House for President John F. Kennedy and then continued on as the physician for President Lyndon B. Johnson.
In 1996 Chan Gunn, MD published his work The Gunn approach to the treatment of chronic pain: Intramuscular myofascial pain of radiculopathic origin. This contributed consideration of the spinal segment in treatment of myofascial dysfunction.
Treatment of myofascial dysfunction, or trigger points, with the use of a needle began as “ wet needling” This was performed with a hypodermic needle and an injected substance for pain relief until it was conceived that perhaps the same result could be achieved through simply pistoning the needle without the added injectable. Over time the dry hypodermic needle has been replaced with a solid filament needle to treat the tissue without injections and this is what is recognizable today as dry needling.
Coined “Trigger Point”
Myofascial Pain and Dysfunction, The Trigger Point Manual. Lippincott Williams & Wilkins.
Trigger Point Model
DIFFERENTIAL DIAGNOSIS OF
PAIN LOW IN THE BACK
ALLOCATION OF THE SOURCE OF PAIN
BY THE PROCAINE HYDROCHLORIDE METHOD
JAMA. 1938;110(2):
Max Lange
1st Trigger Point Manual
Die Muskelhärten (Myogelosen):
Ihre Entstehung und Heilung
Arthur Steindler
“Myofascial pain”
“Trigger points”

5. Dry Needling-Definition
A skilled intervention performed by a physical therapist that uses a thin filiform needle to penetrate the skin and stimulate underlying myofascial trigger points, muscular and connective tissues for the management of neuromusculoskeletal pain and movement impairments. 
(American Physical Therapy Association Dry Needling Task Force, May, 2012)
Now that we have some of the medical history that led to dry needling, here is one definition:

6. Dry Needling Terminology
Functional Dry Needling (FDN)
Intramuscular Manual Therapy (IMT)
Intramuscular Stimulation (IMS)
Trigger Point Dry Needling (TDN)

7. Is Dry Needling within the Scope of Physical Therapy Practice?
You may be asking…

8. POSITION STATEMENT It is the position of the AAOMPT that dry needling is within the scope of physical therapist practice. October, 2009
AAOMPT has made a formal position statement on dry needling 5 years ago…here it is.

9. SUPPORT STATEMENT Dry needling is a neurophysiological evidence-based treatment technique that requires effective manual assessment of the neuromuscular system. Physical therapists are well trained to utilize dry needling in conjunction with manual physical therapy interventions. Research supports that dry needling improves pain control, reduces muscle tension, normalizes biochemical and electrical dysfunction of motor endplates, and facilitates an accelerated return to active rehabilitation. October, 2009
They have also made a formal statement in support of Dry Needling. Here it is.
Notice that it says, “requires effective manual assessment”. This suggests an important concept that we will discuss later. It also emphasizes that it is an adjunct to our other treatments and that is it supported by research.

10. Federation of State Boards Resource Paper 2010
Federation of state boards first came out with their resource paper of dry needling which they also referred to as “intramuscular manual therapy” in 2010

11. Federation of State Boards Resource Paper 2010
FOSB collaborated with 5 other healthcare regulatory agencies in 2009 to publish Changes in Healthcare Professions Scope of Practice: Legislative Considerations. These organizations contend that if a profession can provide supportive evidence in the four foundational areas listed, then the proposed changes are likely to be in the public’s best interest.
With that in mind the topic of Dry Needling was investigated and
Historical Basis:EMG and NCV testing is allowed in 46 states
Education and Training: con ed and some universities either already do or are considering it in their curriculum Georgia U, Mercer, St Augustine, Ola Grimsby, Regis, Emory
Evidence: building
Regulatory environment: continues to change.

12. Federation of State Boards Resource Paper 2010
CONCLUSIONS:
Dry Needling by Physical Therapists meets requirements of:
Historical basis
Available education and training
Educational foundation (CAPTE)
Supportive scientific evidence
IMT is not an entry level skill and should require additional training
Will this be true for the future though?
‘It appears that there is a historical basis, available education and training as well as an educational foundation in the CAPTE criteria, and supportive scientific evidence for including intramuscular manual therapy in the scope of practice of physical therapists. The education, training and assessment within the profession of physical therapy include the knowledge base and skill set required to perform the tasks and skills with sound judgment. It is also clear; however, that intramuscular manual therapy is not an entry level skill and should require additional training’
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13. Federation of State Boards Resource Paper 2010
CONCLUSIONS (cont.)
Procedures do not define a profession, scope does
There will be overlap of treatment techniques between different scopes
This is when some of the acupuncturists were in a uproar

14. Federation of State Boards Resource Paper 2010
It is clear that no single profession owns any procedure or intervention. Overlap among professions is expected and necessary for access to high quality care.
Federation of State Boards: Intramuscular Manual Therapy (Dry Needling) Resource Paper, 2010

15. APTA Resource Paper January 2012
Physical Therapist Education
Licensure and Regulation
Current Status of Dry Needling in Physical Therapist’s Legal Scope of Practice in the United States
Distinction Between Profession’s Scopes of Practice
Summary Research Review on Dry Needling
Education: DPT
Education includes anatomy, histology, physiology, biomechanics, kinesiology, neuroscience, pharmacology, pathology, clinical sciences, clinical interventions, clinical applications, and screening. Much of the basic anatomical, physiological, and biomechanical knowledge that dry needling uses is taught as part of the core physical therapist education; DN is supplemental to that.
Licensure and Regulation: Scope of practice is up to each state…if silent it is up to licensing board members. Scope of practice changes as contemporary practice evolves
Current Status of DN—we will go over that in a minute
Distinction Between Professions Scopes of Practice—as we just mentioned…—no one profession owns a modality.
Research Review:
154 identified
Excluded:
educational␣in␣nature␣or␣with␣no␣research␣design␣or␣peer␣review␣process,␣such␣ as␣␣lectures,␣posters,␣debates,␣or␣correspondences,␣or␣a␣Delphi␣study␣of␣practitioners␣(36)
those␣not␣on␣topic␣such␣ as␣electrical␣stimulation,␣needle␣injections␣without␣data␣pertinent␣to␣dry␣needling,␣or␣planned␣studies␣with␣no␣data␣ (57)
not in English (2)
not on humans (2)
have newer version of same study (2)
summaries/systematic reviews/clinical reviews
The␣remaining␣46␣individual␣studies␣were␣reviewed␣by␣a␣member␣expert␣in␣research␣analysis␣using␣a␣standardized␣ review␣form.␣The␣results␣of␣the␣review␣included␣10␣case␣reports␣(n<10),␣1␣case␣series␣(n>,␣10),␣12␣observational␣ studies,␣and␣23␣randomized␣controlled␣trials␣(RCT).␣
Results: (0-5)
Quality of research 3, for RCT’s 4
Support of DN 2, for RCT’s 3

16. Is
Dry Needling
Acupuncture?

17. Dry Needling versus Acupuncture
Similarities
Differences
Evaluation Application Overall Goal
The Tool

18. Tools don’t define a profession
Calculator
Accountant =
Tool should never define the profession that uses it.

19. Traditional Chinese Acupuncture
Different portions of the tongue correspond to different organs in the body. They will look for dryness or wetness of the tongue, teeth marks, color and draw conclusions from that. They will also feel the pulses at different depths for the quality and feel of the pulse (lima beans…) and draw conclusions from that.
There are 28 different variations of descriptors for pulse (thready, wiry, direction, ) Traditionally they will check it at wrist, neck and foot.
Evaluation utilizes examination of tongue and pulse

20. Traditional Chinese Acupuncture
Needle insertion points are founded in knowledge of meridians
Acupuncture points are founded in knowledge of meridians
Meridians are strips on the body with points along them. Points along them are measured in ‘cun’ measures and are named numerically and on which meridian they exist (Bladder 41 is posterior knee…the influential point for low back pain).

21. Traditional Chinese Acupuncture
Traditional Chinese Acupuncture
Uses needle to balance energy, life-force, or qi in the body
In acupuncture the goal is ultimately to balance the energy or life force). You may see this in terms of balancing the elements (fire, earth, air, water, and wood). Each of the elements correlating to a different organ in the body with a very complex interaction between these.

22. Dry Needling in Physical Therapy
Needle insertion points based on assessment and knowledge of neuroanatomy
We use our knowledge of :
Myotomes
Dermatomes
Pain pattern recognition and referral patterns
Clinical reasoning (patient presentation, our experience and best available research)

23. Dry Needling in Physical Therapy
Evaluation includes subjective and objective examination of the neuromuscular system

24. Why Dry Needling? Understanding how and why it works starts with…
For what is it used? How do we use it?
Well, it starts with this………. (next slide)

25. Understanding Neuromuscular Dysfunction
“Trigger point” terminology is often found to describe dysfunction of the neuromuscular system. While it is only one of many ways to describe such dysfunction it is what is pervasive in the literature and so will be used as a framework to understand this dysfunction found in the tissue.
Understanding Neuromuscular Dysfunction

26. Trigger Points (Simons, Travell, and Simons, 1999) Definition
Active Trigger Points
hyperirritable spots
taut band of skeletal muscle/fascia
painful upon compression
produce characteristic pain, referred tenderness, motor dysfunction and/or autonomic phenomena
Probably the most widely accepted definition of trigger points to date comes from Travell and Simon’s who we will talk about again in a little bit. The definition is this…

27. Trigger Points (Simons, Travell, and Simons, 1999) Definition
Latent Trigger Points
Painful upon palpation
Sensations not recognizable
Satellite Trigger Points
Develop in a zone of reference of key trigger points
(synergist, antagonist, neural link or referral zone)
These are further classified into latent trigger points and satellite trigger points

28. Trigger Points Travell and Simons Mapping
Travell and Simons in their pioneering work came up with not only a definition but also mapping of trigger points
Myofascial Pain and Dysfunction: The Trigger Point Manual Volume , 1 2nd Edition
Image Copyright Lippincott Williams & Wilkins

29. Trigger Point Characteristics: Spontaneous Electrical Activity
Dysfunctional motor endplate potential at rest
On the right of your screen is a needle EMG of normal muscle tissue, non TrP at rest, on the left is a trigger point
This exists in a very discrete locus of the muscle.
The EPP is a local depolarization of muscle fiber that spreads a short distance along the fibers, dissipating 50-75% per millimeter.
(From Ge H-Y, et. al., 2009)

30. Trigger Point Characteristics: Biochemical Changes
(J Appl Physiol 2005; )
Anybody work for NIH?
And now on to another characteristic of trigger points. Two studies speak to this. One from the Journal of Applied Physiology back in 2005 and the other published in the Archives of Physical Medicine in 2008, both done by Jay Shah who is a physician at the National Institute of Health. The studies build on each other...
(Arch Phys Med Rehabil 2008; 89:16-23)

31. Physiologic Effects of Dry Needling
So we now recall a little of the physiology of neuroanatomical muscle contraction and how it relartes to the so-called “trigger points”.
So how are we going to affect any of this with a needle?
Let’s talk about the effects that we know dry needling has…

32. Physiologic Effects of Dry Needling
Increase Blood Flow 
Decrease Banding 
Decrease SEA 
Biochemical Changes 
CNS Changes 
SEA = Spontaneous electrical activity
Zystra E.,

33. Physiologic Effects of Dry Needling: Decrease SEA
SEA quiets following LTR
Chen
The control was the opposite side with needle inserted slowly so as not to elicit LTR---Adult rabbits
(Chen, 2000)

34. Physiologic Effects of Dry Needling: Biochemical Changes
 nociceptive sensitizing agents:
Substance P (Shah, 2008)
CGRP (Shah, 2008; Hseih, 2012)
 β-endorphin levels of treated muscle (Hseih, 2012)
With repeated needling (Hseih, 2012):
 capillarity of tissue
DN x 1
DN x 1
Sham
Treatment
Sham
Treatment
DN x 5
DN x 5
Hseih found the changes in B endorphin and Substance P levels locally 1 day after but this did not last at 5 days later.
HIF 1 alpha, VEGF and iNOS have been associated with the ability to create angiogenesis in hypoxic tissue. These showed up after 5 days of treatment along with increases in Substance P and TNF alpha, but 5 days after 5 days of treatment the B endorphins increased again.
TNF continued to show up along the path of the needle.
Sham
Treatment
Sham
Treatment
TNF α (Hseih, 2012)

35. Physiologic Effects of Dry Needling: (continued)
Sensory and proprioceptive stimulus drives gate control (Chou, 2012)
 Substance P in DRG, (Hseih, 2012)
Change in Neurotransmitters, cytokines, and chemokines (Shah, 2008)
Sympathetic Response
What does this mean…. Well, it means that dry needling is affecting change at the cellular level of our neuromusculoskeletal system

36. Why does dysfunction exist?
Theoretical Constructs
Why does dysfunction exist?
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37. Theoretical Constructs
Travell and Simons Trigger Point Model
C. Chan Gunn
Radiculopathic Model
The origin of the two main theories that we are going to get into today are that of Travell and Simons and Chan Gunn. They each have books associated with their theories. The Travell and Simons series are the books that most of us are generally familiar with—two huge volumes—they are significant. The Chan Gunn book is a very quick read and a nice compliment to the Travell and Simons
We have found that effective treatment of neuromuscular dysfunction is most effective with an understanding of each of these views.
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Functional Foundational Model

38. Theoretical Constructs
Trigger Point Model
Energy Crisis Theory
Motor End Plate Hypothesis
Radiculopathic Model
Focus = Tissue
Focus = Spinal Segment
What you will notice is that the Trigger Point Model has at its center a focus on TISSUE:
If you were to use it as your sole model you would use the trigger point referral charts, chase down the pain and look for trigger points in the antagonistic or synergystic muscles.
The Radiculopathic Model has at its center a focus on dysfunction of the SPINAL SEGMENT:
If you were to use the Radiculopathic model as your framework to guide your needling you would then be looking for dysfunction in a segmental distribution (myotomal or dermatomal) and treating the spinal segment and myotomal muscles associated with it.
But we think there is more to it than that…What if we look further up the chain???

39. Theoretical Constructs Functional Model
Muscles
CNS
Articular
System
Fascia
We know that muscle tissue is part of the picture,the NMJ, the receptors, the muscle fibers themselves and all the things that go with them.
And we know that the spinal segment and nerve roots are part of the picture too…this is how we get information to the muscles to fire. The spinal segment is how reflexes are mediated.
But we also have the articular system and the fascia as components of how people move. A manual therapist will invariably have tools in their toolbox to address any and all of these, but what may often be overlooked is that the CNS is what is really running the show. The muscles, joints, fascia, and peripheral nerves are DUMB….the CNS overrides it all
Peripheral
Nerves
Zylstra, E:

40. Functional Model Trigger Point Model Functional Model
Radiculopathic Model

41. Functional Model Recognition of Dysfunction
Question 1
WHAT is
Painful?
Question 2
WHY
is it
Painful?
So important to note that we are not only using the needle to treat the painful sturcture but we are also using it to reset the tissue.
Question 3: How is it affecting Function?

42. Treatment of Dysfunction
Manual Therapy
Mobilization/manip ulation
Soft tissue
Neural mobilization
Dry needling to affect restriction or pain generator
Movement re- education
Segmental stabilization
SFMA correctives
Sahrman, Janda, Lee, Johnson, Pilates, Feldenkreis, etc……
Dry needling to restore efficient muscle contraction
Dry Needling is only one piece of your treatment…it is an adjunct to whatever systems you are already using.
Manual therapy could include mobilization, manipulation, soft tissue techniques, DN, neural mob
Movement re-education is whatever system you use (SFMA, segmental stabilization, etc.)

45. What Was Treated? Rectus Femoris
Attachment to Superior Acetabulum and anterior capsule.
Why is that important?

46. Dry Needling may be used to:
Summary
Dry Needling may be used to:
 ROM
 Pain
Restore Function
So, taking into account all the physiologic effects, CLINICALLY this translates to the ability to increase ROM, decrease pain, and restore function….here’s how…

47. Dry Needling in Clinical Practice
 ROM
 blood flow
 banding locally or in segmental muscles
Improve ability of muscle to move through range

48. Dry Needling in Clinical Practice
 PAIN
Deactivate painful “trigger point”
 nociceptive sensitizing agents
 SEA
 banding/compression of adjacent tissues
Segmental Inhibition (DRG and dorsal horn)
Affect on central mediators (PAG and endogenous opioids)

49. Dry Needling in Clinical Practice
RESTORE FUNCTION
Restore length tension relationship
 nociception
Improve somatosensory mapping

50. Questions?
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