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Dry needling

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Dry needling is the use of solid filiform needles for therapy of muscle pain, sometimes also known as intramuscular stimulation.[1] The needles are sold by some companies as "acupuncture needles" but their use is no longer exclusive to acupuncturists. Dry needling contrasts with the use of a hollow hypodermic needle to inject substances such as saline solution, botox or corticosteroids to the same point. Such use of a solid needle has been found to be as effective as injection of substances in such cases as relief of pain in muscles and connective tissue. Analgesia produced by needling a pain spot has been called the needle effect.[2] Acupuncture and dry needling techniques are similar; this was acknowledged by the developers of the technique. "Trigger points and Acupuncture. The distinction between TrPs and acupuncture points for the relief of pain is blurred for a number of good reasons. First... Second, as reported by Melzack, et al., there is a high degree of correspondence (71% based on their analysis) between published locatiions of TrPs and classical acupuncturre points for the relief of pain. Third, a number of studies report similar results when needling TrPs using acupuncture needles as when using hypodermic needles with injected solution.".[3] What distinguishes dry needling from traditional acupuncture is that it does not use the full range of traditional theories of Chinese Medicine. Dry needling would be most directly comparable to the use of so-called 'a-shi' points in acupuncture.[4] The debated distinction between dry needling and acupuncture has become a controversy because it relates to an issue of scope of practice between various professions.

Technique

In the treatment of trigger points for persons with myofascial pain syndrome, dry needling is an invasive procedure in which a filiform needle is inserted into the skin and muscle directly at a myofascial trigger point. A myofascial trigger point consists of multiple contraction knots, which are related to the production and maintenance of the pain cycle. Deep dry needling for treating trigger points was first introduced by Czech physician Karel Lewit in 1979.[5] Lewit had noticed that the success of injections into trigger points in relieving pain was apparently unconnected to the analgesic used.[2]

Proper dry needling of a myofascial trigger point will elicit a local twitch response (LTR), which is an involuntary spinal cord reflex in which the muscle fibers in the taut band of muscle contract. The LTR indicates the proper placement of the needle in a trigger point. Dry needling that elicits LTRs improves treatment outcomes,[6] and may work by activating endogenous opioids.[5]

Inserting the needle can itself cause considerable pain,[5] although when done by well-trained practitioners that is not a common occurrence.[citation needed] No study to date has reported the reliability of trigger point diagnosis and physical diagnosis cannot be recommended as a reliable test for the diagnosis of trigger points.[7][8] Chan Gunn introduced a type of dry needling called intramuscular stimulation in the 1980s that moved away from using trigger points.[1][9] Baldry developed a version called superficial dry needling in 2005, in which the needle is inserted about 5-10mm into the tissue above the trigger point.[1][10]

Efficacy

A systematic review concluded that dry needling for the treatment of myofascial pain syndrome in the lower back appeared to be a useful addition to standard therapies, but that clear recommendations could not be made because the published studies are small and of low quality.[6] A 2007 meta-analysis examining dry needling of myofascial trigger points concluded that the effect of needling was not significantly different to that of placebo controls, though the trend in the results could be compatible with a treatment effect. One study (Lorenzo et al. 2004) did show a short-term reduction in shoulder pain in stroke patients who received needling with standard rehabilitation compared to those who received standard care alone, but the study was open-label and measurement timings differed, limiting the use of the study. Again the small sample size and poor quality of studies was highlighted.[11]

Practice

Dry needling is practiced by physical therapists in many countries, including South Africa, the Netherlands, Spain, Switzerland, Canada, Chile, Ireland, the United Kingdom and New Zealand. In the United States, physical therapists in several states including Virginia, Maryland, Ohio, Colorado,[12] Georgia, New Mexico, and Kentucky perform the technique, and several other states, including Louisiana, Tennessee and North Carolina, have recently updated board positions allowing the practice.

Physical therapists are prohibited from penetrating the skin or specifically from practicing dry needling in California, Hawaii, Nevada, New York, and Florida, though many states have no regulations on dry needling.[13] Additionally, chiropractors are legally allowed to practice dry needling in many states including Alabama, Colorado, Connecticut, Delaware, Florida, Illinois, Maryland, New Hampshire, New Mexico, North Carolina, Rhode Island, South Carolina, Texas, Utah, Virginia, and West Virginia.[citation needed]

Controversy

Many physical therapists and chiropractors have asserted that they are not practising acupuncture when dry needling.[13] They assert that much of the basic physiological and biomechanical knowledge that dry needling utilizes is taught as part of their core physical therapy and chiropractic education and that the specific dry needling skills are supplemental to that knowledge and not exclusive to acupuncture. However, the originators and proponents of dry needling acknowledged the origin and inspiration of this techniqe to be acupuncture. Many acupuncturists have argued that dry needling appears to be an acupuncture technique requiring minimal training that has been re-branded under a new name ("dry needling"). Whether dry needling is considered to be acupuncture depends on the definition of acupuncture, and it is argued that trigger points do not correspond to acupuncture points or meridians.[1] They correspond by definition to the ad hoc category of 'a-shi' acupoints.[14] It is important to note that this category of points is not necessarily distinct from other formal categories of acupoints. Peter T. Dorsher, MD, physiatrist and medical acupuncturist at the Mayo Clinic, concludes that the two point systems are in over 90% agreement.[15] Further to this “The strong (up to 91%) consistency of the distributions of trigger point regions’ referred pain patterns to acupuncture meridians provides a fourth line of evidence that trigger points most likely represent the same physiological phenomenon as acupuncture points in the treatment of pain disorders.”Cite error: The <ref> tag has too many names (see the help page). Other authors have found the same level of correspondence. “Myofascial Pain and Dysfunction: the Trigger Point manual”. Dr Janet Travell 1983. Also described Trigger Pont locations as 922% in correspondence with known acupuncture points. An article in Acupuncture Today May 2011 p 3 “Scope and Standards for Acupuncture: Dry Needling?” further corroborates the 92% correspondence of trigger points to acupuncture points as defined by Deadman et al.

In May 2011 the Oregon Board of Chiropractic Examiners ruled to allow "dry needling" into the chiropractic scope of practice with 24 hours of training. In July 2011 the Court of Appeals of the State of Oregon issued an injunction, preventing chiropractors from practicing dry needling until the case is heard in court. The document issued by the court states that "dry needling" is "substantially the same" as acupuncture and that the "respondent has not explained how 24 hours of training, with no clinical component, provides sufficient training to chiropractors to adequately protect patients."[16]

In September 2011, the Oregon Board of Chiropractic Examiners And Oregon Attorney General appealed said order on the grounds that they feel the commissioner who issued the order was mistaken in his assertion.[17] On November 10, 2011, The Court of Appeals of the State of Oregon issued an Order Denying the Motion for Reconsideration. The document states, "The stay was proper based on a showing by petitioner of irreparable harm and the likelihood of prevailing on merits. The motions are denied."[18] The effect of said ruling is that the entire Appeals Court will now determine if the stay was appropriate. The stay is relevant only in the State of Oregon.

See also

References

  1. ^ a b c d Fernández De las Peñas, César; Arendt-Nielsen, Lars; Gerwin, Robert D. (2009). Tension-Type and Cervicogenic Headache: Pathophysiology, Diagnosis, and Management. Jones & Bartlett Learning. p. 250. ISBN 0-7637-5283-5.
  2. ^ a b K. Lewit (February 1979). "The needle effect in the relief of myofascial pain". Pain. 6 (1): 83–90. doi:10.1016/0304-3959(79)90142-8. PMID 424236.
  3. ^ Travell; Simons. Myofascial Pain and Dysfunction, The Trigger Point Manual, Volume 1. Upper Half of Body, Second Edition. North Atlantic Books.
  4. ^ Aung & Chen, 2007, p. 101.
  5. ^ a b c Baldry, Peter; Yunus, Muhammad B.; Inanici, Fatma (2001). Myofascial pain and fibromyalgia syndromes: a clinical guide to diagnosis and management. Elsevier Health Sciences. p. 36. ISBN 0-443-07003-2.
  6. ^ a b Furlan AD, van Tulder MW, Cherkin DC; et al. (2005). Furlan, Andrea D (ed.). "Acupuncture and dry-needling for low back pain". Cochrane Database of Systematic Reviews (1): CD001351. doi:10.1002/14651858.CD001351.pub2. PMID 15674876. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
  7. ^ Lucas, N. (2009). "Reliability of physical examination for diagnosis of myofascial trigger points: a systematic review of the literature". The Clinical Journal of Pain. 25 (1). Eastern Pain Association: 80–9. doi:10.1097/AJP.0b013e31817e13b6. ISSN 0749-8047. PMID 19158550. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
  8. ^ Tough, Elizabeth A. (2007). "Variability of Criteria Used to Diagnose Myofascial Trigger Point Pain Syndrome-Evidence From a Review of the Literature". The Clinical Journal of Pain. 23 (3). Eastern Pain Association: 278–286. doi:10.1097/AJP.0b013e31802fda7c. PMID 17314589. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
  9. ^ Kermode-Scott, Barbara (August 13, 2002). "Vancouver MD Develops Acupuncture Therapy". The Medical Post, Volume 38, Issue 29.
  10. ^ Baldry, Peter (2005). Acupuncture, Trigger Points, and Musculoskeletal Pain, Third Edition. Elsevier Churchill Livingston. ISBN 0-443-06644-2.
  11. ^ Tough, Elizabeth A. (2009). "Acupuncture and dry needling in the management of myofascial trigger point pain: A systematic review and meta-analysis of randomised controlled trials". European Journal of Pain. 13 (1): 3–10. doi:10.1016/j.ejpain.2008.02.006. PMID 18395479. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
  12. ^ Colorado Physical Therapy Licensure, Policy 30-2, Director's Policy on Intramuscular Stimulation, July 20, 2005
  13. ^ a b Dommerholt, Jan (2008). "The "Dry Needling Issue"". Qi-Unity Report. Retrieved 16 June 2010.
  14. ^ Aung & Chen, 2007, p. 101.
  15. ^ Peter T. Dorsher (May 2006). "Trigger Points and Acupuncture Points: Anatomic and Clinical Correlations". Medical Acupuncture. 17 (3).
  16. ^ James W Nass, Order Staying Administrative Rule Pending Judicial Review, Court of Appeals State of Oregon, No. A148924, July 29, 2011
  17. ^ OBCE & Oregon State Attorney General Motion Requesting Reconsideration of Administrative Stay, September 22, 2011
  18. ^ Order Denying Motion for Reconsideration, Court of Appeals, State of Oregon, No. A148924, November 10, 2011
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