1. Dry Needling for Pain Relief
John Utz, MSPT, CSCS
Owner

2. Objectives:
Understand the anatomy and mechanics of the Myofascia with regard to Trigger Points.
Learn how dry needling actually works to resolve myofascial pain and improve functional mobility.
Discuss some of the research RE: Dry Needling
Appreciate how is Dry Needling different from Acupuncture.
Role DN plays in the practice of Physical Therapy
Demonstration: QA

3. What is Dry Needling?
Dry needling is a technique physical therapists use to alleviate pain and restore normal movement.
A “dry” needle (no medication or injection), is inserted through the skin into the muscle or fascia.
Source: APTA document Description of Dry Needling in Clinical Practice: An Educational Resource Paper. 

4. What is Dry Needling? Goal of Dry Needling:
Desensitize supersensitive structures (Trigger Points),
Restore motion and function
Induce a healing response to the tissue.
Often accompanied by other manual treatments, when
Dry Needling is performed by an experienced clinician, it
is extremely beneficial for quick and tangible results.

5. How Does Dry Needling work?
A thin filiform needle penetrates the skin and stimulates underlying myofascial trigger points (MTP) and muscular and connective tissues.
The needle allows a physical therapist to target tissues that are not manually palpable.
Needling can create micro-trauma that can stimulate body’s natural healing process without “injury”.

6. How does dry needling work?
By Releasing Myofascial Trigger Points (MTP)
“Myo” = muscle tissue, “Fascia” = the connective tissue in and around the muscle. 
Myofascial pain often results from muscle injury, excessive tension (overuse), or compromised neural/electrical stimulus on the tissue. 
When over-stressed or injured, the myofascia will often form trigger points: areas of hyperirritable tissue held in a constant shortened/contracted state creating bands or nodules that can be palpated.
To understand how Dry Needling works, you have to appreciate the anatomy and physiology of muscle.

7. How does it work? Anatomy of a Muscle

8. How does it work? Myofascial Trigger Point (MTP)

9. How does it work? Myofascial Tigger Points (MPT)
Latent and Active Trigger Points –
- Caused by:
Increased spontaneous electrical signal to motor endplate,
Increased nociceptive, inflammatory, and immune system related chemicals
- Contracted Muscle creates ishemic changes (less O2) and lowered PH.
- MPT can alter the normal function of a muscle and lead to compensatory patterns of movement, further exacerbating the problem.
Active MPT can be visualized by magnetic eased resonance imaging and sonography and feature a reduction in circulation.
Referred pain - a trigger point in one muscle can create pain in another area. 
Often, trigger points are present secondary to other sources of pain, such as arthritis or bulging discs. Often it is the trigger point(s) that may actually cause the painful symptoms, not the arthritis or disc.
As such, they are often called "the great mimickers".

10. How does it work? MTP – Referred Pain

11. How Does it work? MTP
Local Twitch Response (LTR):

12. How does it work? MTP – Local Twitch Response (LTR)
LTR - spinal cord reflex, involuntary contraction of the taut band.
mitigation of spontaneous electrical activity or motor endplate noise
a reduction of the concentration of numerous nociceptive, inflammatory, and immune system related chemicals
relaxation of the taut band.
restores the local circulation
reduced local and referred pain,
improved range of motion
decreased palpable pain locally and at areas away from trigger point
Deep DN normalizes the chemical milieu and pH of skeletal muscle
Superficial DN is thought to activate mechanoreceptors coupled to slow conducting unmyelinated C-fiber afferents, and indirectly, stimulate the anterior cingular cortex (where pain is processed in brain).
Description of Dry Needling in Clinical Practice - APTA

13. What does the research say?
JOSPT – Journal of Orthopedic and Sport Physical Therapy
Dry Needling Versus Cortisone Injection in the Treatment of Greater Trochanteric Pain Syndrome: A Noninferiority Randomized Clinical Trial
Authors: Kindyle L. Brennan, PT, PhD1, Bryce C. Allen, MD1, Yolanda Munoz Maldonado, PhD
Conclusion
“Cortisone injections for GTPS did not provide greater pain relief or reduction in functional limitations than DN. Our data suggest that DN is a noninferior treatment alternative to cortisone injections in this patient population.”

14. What does the research say?
Acupuncture in Medicine 2017;35:85-92.
Therapeutic effects of dry needling in patients with upper trapezius myofascial trigger points.
Conclusions
“The results of this study showed that one session of DN targeting active MTrPs appears to reduce hyperactivity of the sympathetic nervous system and irritability of the motor endplate. DN seems effective at improving symptoms and deactivating active MTrPs, although further research is needed.”

15. What does the research say?
JOSPT – Journal of Orthopedic and Sport Physical Therapy
The Effectiveness of Trigger Point Dry Needling for Musculoskeletal Conditions by Physical Therapists: A Systematic Review and Meta-analysis
Authors: Eric Gattie, PT, DPT1, Joshua A. Cleland, PT, PhD2, Suzanne Snodgrass, PT, PhD3
Conclusion: “Very low-quality to moderate-quality evidence suggests that dry needling performed by physical therapists is more effective than no treatment, sham dry needling, and other treatments for reducing pain and improving pressure pain threshold in patients presenting with musculoskeletal pain in the immediate to 12-week follow-up period. Low-quality evidence suggests superior outcomes with dry needling for functional outcomes when compared to no treatment or sham needling.”

16. How is Dry Needling different from Acupuncture?
Eastern Acupuncture – helps disruptions to the flow of energy, or “Qi”. Needles stimulate acupuncture points or acupressure points, releasing this qi. The qi then travels through channels called meridians.
Western Acupuncture - neurohormonal pathways stimulate the nerve. The nerve actually sends signals to the brain, and the brain releases neural hormones such as beta-Endorphins.

17. Are there risks to DN? Contraindications: Precautions:
Fear / phobia of needles
Unwilling or unable to give consent
Into an area of lymphedema or certain locations (vascular)
DVT
1st Trimester of Pregnancy
Into joint capsule after a replacement
Precautions:
On blood thinners
Compromised immune system
Avoid local skin lesions

18. Side effects to DN? The more common side-effects included
bruising (7.6%),
bleeding (4.7%),
pain during treatment (3%), and pain after treatment (2.2%).
The uncommon side-effects were aggravation of symptoms, drowsiness, headache and nausea, each occurring at less than 1% frequency.

19. DN in Arizona To practice Dry Needling in AZ:
28+ hours of continuing education
Both clinical and anatomic with cadavers
Pass practical and written examinations
Must submit all evidence to AZ State Board Physical Therapy.

20. Why only licensed Clinicians?

21. DN and Physical Therapy Treatment
When used in combination with appropriate tissue work, stretching and exercise, DN is quite effective at alleviating pain and restoring normal movement patterns.

22. Q &A. Demonstration?