Introduction trigger point dry needling

1. Nichole Bluemle PT, DPT, MS, CSCS, OCS Introductiontrigger point dry needling

2. 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

3. Video overview http://www.youtube.com/watch?v=1bst-eDCjwg

4. 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

5. Myofascial Trigger Point • “Hyperirritable spots in skeletal muscle associated with hypersensitive palpable nodules in a taught band.” (Travell and Simons 1992)

6. 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)

7. Referral Maps

8. 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

9. Goal of Dry Needling • Illicit a local twitch response (LTR) in involved muscle • Desensitize hypersensitive musculoskeletal structures while restoring motion and function

10. 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

11. Mechanical Effects(Dommerholt J. 2004) • Disrupts the integrity of dysfunctional motor end plates • Cause a LTR • Alter muscle fiber length

12. Neurophysiological Effects(Baldry PE. 2001) • Suggests that dry needling stimulates A-delta nerve fibers (type III) for 72 hours post-needling • Prolonged stimulation of A-delta fibers may activate enkephalinergic inhibitory dorsal interneurons • Activate descending inhibitory systems which would block noxious stimulus into the dorsal horn

13. Chemical Effects(Shah J. et al. 2005) • Decrease in chemicals at the active trigger point location immediately after a local twitch response • Bradykinin • CGRP (calcitonin gene related peptide) • Substance P

14. 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

15. 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

16. 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

17. 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

18. Post-treatment Re-evaluate • Stretch/PROM/AROM • Instruct patient in self mobilization techniques • Heat • Movement facilitation tape • Hydration

19. Reasons for Failure • Diagnostic error • Incomplete management of perpetuating factors • Trigger point missed or inadequately treated • Referred zone treated • Inadequate post care

20. 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

22. 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 conditions • Release shortened muscles • Reduce spontaneous electrical activity at the neuromuscular junction • Return biochemicals that cause hypersensitization to normal levels • Promote self healing

23. Recommended Resources

24. Questions? Contact Info: Nichole Bluemle PT, DPT, MS, CSCS, OCS www.durangophysicaltherapy.com durangoPT@gmail.com