1. Erik De Meulemeester, PT, DScPT,OMPT

2.  Definition
 History
 Dry Needling vs. Acupuncture
 Application
 Scope of Practice
 Billing
 Questions?

3.  APTA (2012):
“Dry needling is a skilled intervention provided by
physical therapists that uses a thin filiform needle to
penetrate the skin and stimulate underlying
myofascial trigger points, muscular tissues, and
connective tissues for the management of
neuromuscular pain and movement impairments.

4.  Acupuncture" refers to a form of health care, based
on a theory of energetic physiology that describes
and explains the interrelationship of the body
organs or functions with an associated acupuncture
point or combination of points located on
"channels" or "meridians".

5.  Dry Needling
“Restore function”
 Acupuncture
“Restore normal flow of
the life force”

6.  Western Philosophy
 Dry Needling
 History
 Behavior of symptoms
 Pain patterns
 Objective evaluation
 Functional testing
 Traditional Chinese
Medicine
 Acupuncture
 Meridians of the body
 Tongue:
▪ color
▪ hydration
 Pulse diagnosis
▪ Rate
▪ Quality
▪ Tooth indentations

7.  Intramuscular Stimulation (GunnIMS)
 Intramuscular ManualTherapy (IMT)
 Functional Dry Needling (FDN)®
 Trigger Point Dry Needling (TDN)

8.  1816 - Balfour: thickenings which were painful to the
touch
 1930 - Kellgren: referred pain patterns
 1940 - Karl Lewit:The Needle Effect
 1952 -Travell: myofascial trigger points
 1966 -Travell & Mennell: founded the North
American Academy of Manipulative Medicine

9.  1983 – Simons and
Travell:Trigger Point
Manual
 1996: Chan Gunn –
Intramuscular
stimulation for pain of
radicular origin
 2000’s: PT’s perform
Dry Needling

10.  Intra-muscular stimulation, Invasive
 No injections (“wet needling”)
 Trigger Point

11.  Hyperirritable spot in a taut band of skeletal muscle
fibers.
 Active: pain in response to movement, stretch or
compression,
 Latent: pain or discomfort in response to
compression only

12. Radiculopathies, joint dysfunction, disk pathology,
tendonitis, cranio-mandibular dysfunction,
migraines, tension-type headaches, carpal tunnel
syndrome, whiplash associated disorders, spinal
dysfunction, pelvic pain and other urologic
syndromes, complex regional pain syndrome, …

13.  Excessive acetylcholine (ACh) release in the
neuromuscular junction at the motor endplates
 Abnormal endplate potential
 The development of a taut band
 EMG: Amplitude changes of SEA; Endplate noise

14.  Sustained sarcomere contractures
 Local ischemia and hypoxia.
 Vasoactive and algogenic substances are released
 Sensitize peripheral nociceptors

16.  Sensitize dorsal horn neurons and supraspinal
structures
 Hyperalgesia: increased sensitivity to pain
 Allodynia: pain due to a stimulus which does not
normally provoke pain
 Referred pain

17.  Local twitch response (LTR).
 Involuntary spinal reflex
 localized contraction of affected muscle fibers
that are being dry needled.
 DN is most effective when these LTRs are elicited.

18.  1st:
 insertion of a needle at the endplate region
 reduce available ACh stores
 leading to a lesser SEA.
 2nd:
 LTR causes alterations in the length and tension of
the muscle fibers
 stimulates mechanoreceptors

19.  Axon reflex caused by LTR
 Release of vasoactive substance, such as CGRP and
SP
 Leads to
 vasodilatation in small vessels
 Increased blood flow
 No agreement on remote effects

20.  No lasting effects after 1 session, more lasting
effects after 5 sessions
 Release of endogenous opioids
 Pain Gate control
 Activate the serotonergic and noradrenergic
descending inhibitory system
 Placebo?

21.  Local lymphedema
 Severe hyperalgesia or allodynia
 First trimester of pregnancy
 Allergic to certain metals in the needle

22.  Needle phobia
 Cognitive impairment
 Local Skin lesions
 Local infections
 Vascular disease

23.  Practice consistent with the OSHA Blood Borne
Pathogens standard: wear gloves!
 Explanation of the procedure to the patient
 Sharp needle container, alcohol swabs

24.  Decreased pain and muscle tension
 Improved range of motion
 Improved muscle strength
 Improved function

27.  Palpate the target muscle for a taut band
 Identify a hyperirritable spot within the taut band
confirmingTrPs to be treated.
 Clean the area with alcohol swab

28.  Solid filament needle
 Rounded tip of needle
 In a guide tube with rounded edges
 Diameter x Length: p.e. (0.30) x 60mm

30.  The fili-form needle in its tube is fixed with the non-
needling hand against the suspected area by using a
pincer grip or flat palpation
 With the needling hand, the needle is gently
loosened from the tube.
 The top of the needle is tapped or flicked allowing
the needle to penetrate the skin.

32.  With deep DN, the needle is guided toward the
TrP until resistance is felt and a LTR is elicited.
 The needle is then focused in this area or other
neighboring areas by drawing the needle back
toward the subcutaneous tissue without taking
it out of the skin, and then redirecting the needle
toward the remainingTrPs.

33.  Withdraw the needle completely from the skin
 Apply pressure directly to the skin over the needle
insertion site to prevent possible swelling or post
needling soreness.
 The muscle is then palpated again to reassess for
taut bands andTrPs. Further needling can be
performed for the same muscle or for other
clinically relevant musculature within the same
treatment session.

34.  A minimum of 2 needles is required per
channel,
 Multiple channels can be used
simultaneously.
 The best results are reached when the
needles are placed within the dermatomes
corresponding to the region of dysfunction.

36.  VAS, FPRS
 ROM, Strength, Balance
 NDI, Owestry
 SFMA

37.  Manual soft tissue mobilization
 Dry Needling
 Therapeutic exercise
 Neuromuscular re-education
 Functional retraining
 HEP
 …

38.  Safety First
 Excellent knowledge of Anatomy
 Excellent manual skills; palpation

39.  Common:
 bruising (7·55%)
 bleeding (4·65%),
 pain during treatment (3·01%),
 pain after treatment (2·19%).
 Uncommon:
 aggravation of symptoms (0·88%),
 drowsiness (0·26%),
 headache (0·14%),
 nausea (0·13%).

40.  Little level of evidence supporting the
efficacy and effectiveness
 Lack of precision
 High level of bias

41.  Controlled Clinical trial, N=30
 Each trigger point will be repeatedly needled
for 1–2 min until the pain is resolved.
 Outcome:VAS, DASH, PPT
’significant difference’
 No long term effect, intervention therapist
and data collector are the same

42.  4 RCT’s compared DN to Lidocaine
 1 RCT compared DN to placebo
 Not significant clinical outcome,
 Patterns favoring lidocaine immediately after
treatment
 Patterns favoring dry needling at three to six
months.

43.  RCT, single blinded, N=84
 1 tx per week for 6 weeks
 VAS, FHSQ
 Both groups showed statistical significant
decrease after 6 weeks

44.  RCT, N=17
 Single session or waiting list
 Data collected 10 min post and 1 weeks post
 Decrease in pain greater than MDC:
 pain,
 pressure pain threshold,
 cervical range of motion

45.  “Physical therapists shall not perform any
procedure or function which they are by
virtue of education and training not
competent to perform”
 Not part of entry-level physical therapy
education

46.  Since 2006 increased support from state
boards for dry needling
 Variance in regulatory affairs from state to
state
 Refer to practice act within the state,APTA,
AAOMPT, FSBPT

47.  AAOMPT:
 Executive Committee
 Dry needling is within
the scope of physical
therapist practice.

48.  APTA:
 no official positions on
intramuscular manual
therapy
 internal staff task force is
looking further in to the
need for a policy.
 APTA recognizes that PTs
are performing dry
needling and that PTs who
do it should have
additional education and
be competent to do so.

49.  FSBPT:
 Although the FSBPT
Model Practice Act does
not specifically mention
intramuscular manual
therapy there is nothing
to specifically exclude
the technique.

50.  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”

51.  Many differences between different
therapists and clinics
 CPT code set by
 American Medical Association
 Current ProceduralTerminology Editorial Panel
 Provides a uniform language for medical
services

52.  CPT 97140: ManualTherapy should not be
included: (soft tissue mobilization, joint
mobilization, manipulation by a physician,
initial area, and each additional area, and
manual traction.)
 Currently no CPT code that describes Dry
Needling
 Recommended:CPT 97799: Unlisted physical
medicine/rehabilitation service or procedure

53.  Kinetacore:
 TherapyConcepts:
 Myopain Seminars:

54.  1) Cagnie, B.,V. Dewitte, et al. "Physiologic effects of dry needling." Current Pain
& Headache Reports 17(8): 348-348
 2)APTA (2012). "PhysicalTherapy andThe Performance of Dry Needling: An
Educational Resource Paper." APTA Department of Practice;APTA Department
of Government Affairs.
 3)APTA (2013). "Description of Dry Needling in Clinical Practice: A Resource
Paper Educational " Public Policy, Practice, and Professional Affairs Unit.
 4) Brady, S., J. McEvoy, et al. (2014). "Adverse events following trigger point dry
needling: a prospective survey of chartered physiotherapists." Journal of Manual
& ManipulativeTherapy (Maney Publishing) 22(3): 134-140

55.  5) Clewley, D.,T.W. Flynn, et al. (2014). "Trigger Point Dry Needling as an Adjunct
Treatment for a PatientWith Adhesive Capsulitis of the Shoulder." Journal of
Orthopaedic & Sports PhysicalTherapy 44(2): 92-101
 6) Cotchett, M. P., S. E. Munteanu, et al. (2013). "Effectiveness ofTrigger Point
Dry Needling for Plantar Heel Pain: A Randomized ControlledTrial." Physical
Therapy 94(8): 1083-1094.
 7) Kinetacore, Functional Dry Needling Level I
 8) Ziaeifar, M., A. M. Arab, et al. (2013). "The effect of dry needling on pain,
pressure pain threshold and disability in patients with a myofascial trigger point
in the upper trapezius muscle." Journal of Bodywork & MovementTherapies
18(2): 298-305

56.  9) Joshua Ong, B. a., Leica S. Claydon, PhD, PG CertTertTeach, BSc (2012). "The
effect of dry needling for myofascial trigger points in the neck and shoulders: A
systematic review and meta-analysis.“ Journal of Bodywork & Movement
Therapies (2014) 18, 390 - 398.
 10) Short-Term Changes in Neck Pain,Widespread Pressure Pain Sensitivity, and
Cervical Range of Motion After the Application ofTrigger Point Dry Needling in
PatientsWith Acute Mechanical Neck Pain: A Randomized ClinicalTrial: María J.
Mejuto-Vázquez, PT, Jaime Salom-Moreno, PT, PhD Ricardo Ortega-Santiago,
PT, PhD SebastiánTruyols-Domínguez, PT, PhD, César Fernández-de-las-Peñas,
PT, PhD
 11) APTA (2014). “Official Statement – Billing of Dry Needling by Physical
Therapists" Public Policy, Practice, and ProfessionalAffairs Unit.