Dry Needling Therapy

What is Dry Needling?

Dry needle is a term that defines a type of needle therapy. It was coined by Janet Travell, MD (December 17, 1901 – August 1, 1997), who as cardiologist found that many of her patients who had  symptoms similar to those of a heart attack, such as pain in the chest that radiated down the arm, were in fact suffering from trigger points (TrPs) in the muscles of the chest. Her observations led to further study on the effect of trigger points on patients at the Cardiac Consultation Service at Sea View, the city hospital for tuberculosis on Staten Island 1https://www.ncbi.nlm.nih.gov/pmc/articles/PMC152828/. These patients’ main complains were not generally around their pulmonary disease. Instead, they complained of pain around the shoulders and arms, and through palpation she determined that the pain was referred pain from trigger points.

To treat these TrPs, Dr. Travell developed manual techniques that included the use of  vapocoolants, a type of spray containing ethyl chloride or Fluori-Methane. The technique is called “spray and stretch”. The explanation of the physiological effect of the technique is beyond the scope of this article. But in her work she found the sudden change of temperature from the spray in conjunction with manual stretching of muscle tissue,  had an effect on the local area where the TrPs were found leading to their release.

In her efforts to further her understanding in the treatment of TrPs,  Dr. Travell took interest in the work of Dr John Kellgren, a British Rheumatologist from University College Hospital, London who had published and article on the British Medical Journal titled, “A Preliminary Account of Referred Pains Arising from Muscle.2Kellgren JH. A preliminary account of referred pains arising from muscle. Br Med J 1938;1:325–7 Dr. Kellgren had been experimenting as far back to the early 1930’s with saline injections into muscle tissues. He discovered that injecting a muscle often generated pain in an area distal from the site of the injection. He also noticed that when applying digital pressure to tender tissue, that pain was reproduced in the same pattern as the saline injection. An important discovery by Dr. Kellgren was that the referred pain patterns from either the saline injection, or manual pressure on tender points, was the same pattern on almost all of the patients on which he experimented. From subject to subject, the pain pattern was very similar.

At some point during experimentation, it was found that there was no difference in the outcome of trigger points when treated with a substance infiltrated through the hypodermic needle, or when the trigger point was stimulated by the needle without a chemical solution. In a study conducted by Czech Republic physician Karl Lewitt, evidence indicated that the effect of the needle without a chemical substance yielded equal or better response to the common practice of chemical infiltration.3 Lewit K. The needle effect in the relief of myofascial pain. Pain 1979; 6: 83–90 Thus, the term Dry Needle was coined in contrast to the use of saline or other pain reducing medicines.4Cummings TM, White AR. Needling therapies in the management of myofascial trigger point pain: a systematic review. Arch Phys Med Rehabil 2001; 82: 986–92 5Ga H, Choi JH, Park CH, Yoon HJ. Acupuncture needling versus lidocaine injection of trigger points in myofascial pain syndrome in elderly patients–a randomised trial. Acupunct Med 2007; 25: 130–6. 6Hong CZ. Lidocaine injection versus dry needling to myofascial trigger point. The importance of the local twitch response. Am J Phys Med Rehabil 1994; 73: 256–63.

Dry Needling, then, is the release of trigger points by way of stimulation through the use of a needle in the absence of a liquid chemical substance. The release of such TrPs, is accomplished when the needle stimulation leads to a reflex reaction known as a twitch response or fasciculation7https://en.wikipedia.org/wiki/Fasciculation

Is Dry Needling The Same As Acupuncture?

Currently in the United States there is a battle brewing between the acupuncture profession and the physical therapy profession. Acupuncturist assert that physical therapists are illegally practicing acupuncture and circumventing state laws by claiming that Dry Needling is a totally different therapeutic modality from acupuncture. Physical therapists on the other hand, argue that Dry Needling is not acupuncture because the main objective of Dry Needling is to restore function and not to cure or heal disease.

Furthermore, physical therapists take the stand that acupuncture is practiced by inserting needles at specific points found along meridians with the aim to restore the flow of Qi (energy) and thus restoring health. Dry Needling aims at releasing taught bands of muscle tissue found in multiple places around the body’s musculature independent or separate from the meridians found in Chinese medicine.

Acupuncturists claim that it is the blockage of Qi (pronounced “chee”) that leads to pain. The insertion of a needle on specific points corresponding to the meridian linked to an organ, can promote the flow of Qi, leading to pain relief. The physical therapist, based on current research, asserts that taught bands of sarcomeres, a lower PH value, poor blood flow and low oxygen levels in the immediate tissue, coupled with peripheral and central sensitization is the cause of pain and that only when the focal area of the sarcomere’s contracture or muscle shortening, aka the trigger point, is released through needle stimulation, can the function of the musculature be restored and pain relieved.

So is Dry Needling the same as acupuncture? A simple answer is yes.. The word acupuncture dating back to the 17th century is a compound term. Acu, from the Latin meaning needle, and puncture meaning to penetrate the skin. Physical therapists practicing Dry Needling are penetrating the skin with the same filiform needles that an acupuncturist uses. However, one could make the argument that the use of a hypodermic needle puncturing the skin for a subcutaneous injection is the practice of acupuncture. Yet, no one seems to worry about nurses and other medical professionals practicing needle-puncture. We know that at some point in her practice, Janet Travell preferred to use a hypodermic needle without a solution, to activate trigger points.. She felt that the thickness of the hypodermic needle facilitated the twitch response better than the thinner filiform needles used in acupucnture. 8Travell, Simons, & Simons, 1999, pp. 154–155

“A 22-gauge, 3.8-cm (1.5-in) needle is usually suitable for most superficial muscles. In hyperalgesic patients a 25-gauge, 3.8-cm (1.5-in) needle may cause less discomfort, but will not provide the clear “feel” of the structures being penetrated by needle and is more likely to be deflected by the dense contraction knots that are the target… A 27-gauge needle, 3.8-cm (1.5-in) needle is even more flexible; the tip is more likely to be deflected by the contraction knots and it provides less tactile feedback for precision injection” 9Travell, Simons, & Simons, 1999, p. 156).

A more in depth answer, in my opinion, is no. Dry Needling and acupuncture are not the same. The Chinese term for acupuncture is made up of two characters: Zhēn 针 which literally translates as “needle” and Jiǔ 灸 which points to the use of a burning herb.. Some have translated the compounded term ZhenJiu as Fire needle, or burning needle. Historically we know that originally the practice of acupuncture was primarily related to using heat therapy, or moxibustion, and that the meridian system did not exist as we now know it. We also know that in the early development that bones and stones where used instead of needles.. Needles are a later innovation.

The fact that physical therapists use a filiform needle does not indicate the practice of acupuncture. The needle is simply a tool.. Just like holding a hammer does not make one a carpenter, or a knife in the hand does not make one a butcher or a surgeon, and a sax does not make one a jazz musician. The use of a needle in acupuncture aims at restoring the flow of Qi. The choice of acupuncture points is dictated by the traditional framework of the practitioner which may include the doctrines of Traditional Chinese Medicine, or by the protocols of Master Tung, or the methods of Dr. Tan. Auricular acupuncture, where the earlobe is a map of the human body may be another model for point location. And yes, tender points could be the criteria for point selection.

But none of those paradigms are aligned with the physical therapist methods for choosing where to needle. The choices are made based on palpation, pain referral patterns, function of muscle groups and orthopaedic tests. Needle technique in the hands of Dry Needle practitioner aims to always obtain fasciculation or twitch response. Thicker needles are preferred in Dry Needling in contrast to the super thin, hairlike needles used by many acupuncturist. In my practice of acupuncture here in Saint Augustine, I’m happy to include Dry Needling into my treatment protocols. I have completed the foundational courses offered by Myopain Seminars and will be completing advanced studies in June of 2017. I will update this article when I complete the program.

UPDATE

First, I have completed the Myopain Seminars training and passed the practical and theoretical exams. I am now a Certified Myopain Trigger Point Therapist.

Second, I would like to add that there are many physical therapists who are practicing acupuncture under the Dry Needle umbrella. Some are retaining needles and using distal acupuncture in their treatment. There are physical therapists that are using electroacupuncture.. I think this is unfortunate and a violation of scope of practice and beyond Dry Needle as I was taught at Myopain Seminars.. I find this detestable and unethical.

References   [ + ]

1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC152828/
2. Kellgren JH. A preliminary account of referred pains arising from muscle. Br Med J 1938;1:325–7
3. Lewit K. The needle effect in the relief of myofascial pain. Pain 1979; 6: 83–90
4. Cummings TM, White AR. Needling therapies in the management of myofascial trigger point pain: a systematic review. Arch Phys Med Rehabil 2001; 82: 986–92
5. Ga H, Choi JH, Park CH, Yoon HJ. Acupuncture needling versus lidocaine injection of trigger points in myofascial pain syndrome in elderly patients–a randomised trial. Acupunct Med 2007; 25: 130–6.
6. Hong CZ. Lidocaine injection versus dry needling to myofascial trigger point. The importance of the local twitch response. Am J Phys Med Rehabil 1994; 73: 256–63.
7. https://en.wikipedia.org/wiki/Fasciculation
8. Travell, Simons, & Simons, 1999, pp. 154–155
9. Travell, Simons, & Simons, 1999, p. 156).