Pre-Course Reading and Review

Transcription

1 Pre-Course Reading and Review Note: This course has both a written and practical examination on the last day. To receive course credit the participant must achieve an 80% or better on both the written and practical examinations. Each participant is required to complete this pre-reading manual prior to the first day of the course. Course description: The clinical lab-based course: Neurologic Dry Needling for Pain Management and Sports Rehabilitation is based on the anatomy and physiology of the musculoskeletal and peripheral nervous systems. The course content is based on over 40 years of research and experience applying the physiological mechanisms of dry needling within a systematic approach. The Integrative Dry Needling training program will develop the knowledge and clinical skills required to effectively identify and treat painful neuromuscular conditions in any region of the body. IDN Conceptual Model of the 3 S s and the 3 I s: **I wrote this section as a simple way to describe how we view pain and dysfunction as a systemic issue and how Neurologic Dry Needling can be utilized to address it. The 3 I s describe the problem with musculoskeletal pain and dysfunction, Inflammation, Irritation, and Inhibition. The 3 I s do not occur in isolation, they are coupled with one another in an injurious situation. Each of the I s occur locally (Symptomatic), Segmentally and Systemically. If pain and dysfunction are treated solely at the site of the symptoms you may get to the point but will miss the system, as we like to say. The human body works as an integrated organism and must be viewed and treated in this way. The human body shares neurology and circulation and to believe that an injury remains local to the site, absent an effect on the rest of the body, is limiting your treatment effect. This reminds me of the guru based treatment models of the 1980 s and 90 s. Clinicians would utilize a specific manual therapy paradigm and would become cult-like in their treatment approach and if it failed the patient was labeled not-fixable. Since that time, the PT profession has become more eclectic in 1

2 viewing the body as greater than the sum of its parts. This eclectic view is in perfect alignment with the IDN system of dry needling. The days of focusing on a point as the source of pain and dysfunction are numbered and it is time that we begin to move toward a more reliable and global assessment and comprehensive treatment. The global thinking of the 3 I s and the 3 S s is the model that sums up both the injury of the system and a comprehensive treatment. The dilemma lies in the fact that we do not fully understand the experience of pain, dysfunction or the physiological mechanisms of dry needling. This is today s reality and if we can embrace it, we can continue to move our thinking forward. The more you read about inflammation the more it becomes apparent it is centered at the root of pain and dysfunction in the human body. This creates Irritation of peripheral nerves that can create the sensory experience of pain and the motor effects that drive neuromuscular Inhibition. If inflammation could be managed more effectively, we may be better able to mitigate its effect on both pain and motor dysfunction. This is not a revelation but a basic fact of treating most musculoskeletal conditions. Following injury, the inflammation will reside in local tissues however, it will quickly become widespread (systemic) and involve multiple tissues but specifically the nervous system, such as is seen in chronic conditions. Neurogenic inflammation results from bioactive chemicals activating sensory neurons, which in turn activates the release of sensitizing chemicals from peripheral nerve terminals (Irritation). This bidirectional process from local peripheral tissue to the CNS causes a more widespread inflammatory process. The Inflammation that produces pain and dysfunction can be local, segmental and or systemic, which is what creates the challenge. This may explain why the modern continuing education seminars now focus on assessing and treating the body as a whole and less focused on identifying the specific tissue that is at fault. The tissue specific diagnoses that to aim identify the involved structure is faulty reasoning and should be reconsidered. Sizer et al. s paper on sound clinical reasoning outlines the need for a multifactorial construct in encouraging innovative practice. Acknowledging the lack of diagnostic accuracy in clinical testing, palpation and even patient report makes treatment design challenging to say the least. That may have led some to attempt to create a cookbook style of treatment where it is assumed that a common grouping of signs and symptoms will all respond to a specific treatment regimen. We all know how that worked out and essentially lead back to the not fixable conclusions for patients that did not fit or respond favorably to the treatment mold they were put into. IDN s 3 S s concept of treatment provides no preconceived notions of the source of the 3 I s instead provides a foundation upon which to build a treatment plan. Symptomatic (local)- This is certainly the most obvious type of pain and dysfunction to treat as the patient tells you it hurts here. This is usually an acute to sub-acute injury and the area may be swollen with a loss of motion. Segmental- Manual therapy clinicians understand that when treating musculoskeletal pain and dysfunction the spinal component cannot be ignored. They have been trained to first clear the spine to reduce the likelihood of 2

3 missing a segmental problem based on a peripheral complaint. The segmental effects of needling help to reduce the symptoms of the Local (symptomatic) points. Systemic- This is where the most confusion and even misunderstanding of mechanism is experienced. In the human body there is shared neurology, circulation and physiology that we cannot separate into pieces or parts. We base our systemic treatment on homeostatic points that are key neurological areas in the body that have stronger therapeutic signaling to the CNS and are present in reproducible locations and patterns. The innervation zones of homeostatic points are extensions of major peripheral nerves that are present in consistent locations around the body based on the predictable anatomy of the peripheral nervous system. This is in stark contrast to locating the highly variable myofascial trigger points. In some patient presentations (acute symptoms) treating just symptomatic points (local) may be all that is needed to get the desired effect. As you move from the acute patient to the sub-acute and into the chronic, the need to expand the treatment methods becomes empirically evident by the reduced clinical results. Assessment tools, such as quantitative sensory testing, may be used to identify the possible central mechanism driving the symptoms. We believe it is relevant to address the 3 S s together, because clinically this approach has a better chance to address the 3 I s of pain and dysfunction. 1. What is dry needling (DN) therapy and how effective is it? Overall, dry needling can offer clinical results that other conventional medical techniques may not offer or offer with limited efficacy. (1) Local effects of needling Dry needling lesions in the soft tissue is a therapeutic modality for soft tissue dysfunction. Soft tissue dysfunction involves soft tissue injuries including tissue inflammation, sensitized nerve tissue, scar tissue formation, tissue adhesion, and deficiency of blood and lymphatic circulation. The process of inserting a needle starts with puncturing the skin, and then involves physical stretching the tissues (down and up, and /or rotation movement of needle shaft), which creates lesions in the soft tissue. When the needle is removed, the lesions can remain for a few days. Needling process thus provides both physical (tissue stretching) and biochemical (lesions) stimuli. This lesion-induced process activates physiological mechanisms of remodeling of injured and inflamed soft tissues in and around the needling site. The tissue remodeling process includes (1) local physical stress reduction (tissue tension) and (2) normalizing local inflammation, and (3) replacement of injured tissues with fresh tissues of the same type. 3

4 (2) Systemic effects of needling Each needling process is invasive and creates both local and systemic effects the restoration of both local tissue homeostasis* (tissue remodeling of injured tissues) and systemic homeostasis. Restoration of systemic homeostasis involves reducing both physical and physiological stress. Physical stress means muscular, which creates biomechanical imbalance such as joint and posture imbalance. Physiological stress may include local physiological dysfunction (inflammation, tissue ischemia, etc.) and all body systems like immune, cardiovascular, endocrine, and all others. So, simple insertion of an invasive needle creates both local and systemic therapeutic effects. * Homeostasis: The property of a system that regulates its internal environment and tends to maintain a stable, relatively constant condition of properties. In simple terms, it is a process in which the body's internal environment is kept stable, despite changes in external conditions. (3) Electrical nerve stimulation (ENS) reinforces the efficacy of manual needling Electrical nerve stimulation further increases the efficacy of manual needling by rhythmic vibration of the tissues. This rhythmic vibration also creates both local and systemic effects. A powerful local effect includes reducing tissue tension, including tension of scar tissue, and loosing tissue adhesion. All these manual and electrical procedures restore vasoregulation of blood and lymphatic circulation, and reduce inflammation. Specifics of the procedure will be discussed in class. (4) Non-specific pathophysiologic feature of needling It is important to understand that needling itself does not treat any diseases, but restores tissue homeostasis, during which the process of biological self-healing and selfrepair physiology-mechanisms are activated. After needling many pathological conditions can be improved, including joint biomechanics. Thus, needling is a non-specific therapy. (5) Precise selection of specific points (traditional Acupoint or trigger points) is clinically unnecessary. Traditional view of selecting precise needling points is not supported by clinical evidence. The ancient view requires precise location of a so-called Acupoint. More modern view requires precise location of trigger points. These empirical procedures are clinically effective but not supported by empirical or evidence-based data. In general, needling the sensitized and inflamed area will achieve the same clinical efficacy as selecting precise trigger or acupoint locations. This is because the most critical pathology of soft tissue dysfunction involves tissue inflammation and related conditions such as vasoregulation-dependent dysfunction, especially tissue blood and lymphatic 4

5 circulation. Trigger point nodules are not the cause of the inflammation in many cases. Inflammation is one of the reasons causing the formation of nodules. Trigger points become active due to inflammation. As inflammation is reduced, trigger points become latent. Thus, the concepts of trigger points causing pain needs to be reexamined. (6) Molecular mechanism of dry needling Dry needling normalizes inflammation. This needling-induced anti-inflammatory process triggers regulatory mechanisms of blood and fluid circulation in inflamed tissues. The anti-inflammatory process of dry needling involves balancing sympathetic nervous system, thus balancing between vasodilators such as adenosine and nitric oxide (NO) and vasoconstrictors such as superoxide and many others. We are just at the beginning to understand the needling mechanisms at this level. Example of balancing sympathetic nervous system by dry needling: Needling reduces secretion of norepinephrine from sympathetic nerves, which stimulate the adrenaline hormones, and increases secretion of acetylcholine of parasympathetic nerves, which normalize immune physiology. Reference (Note: all these research papers show needling improves local circulation a. Adenosine A1 receptors mediate local anti-nociceptive effects of acupuncture. Nanna Goldman et al. Nature Neuroscience Vol. 13/No.7, July 2010, pp b. Acupuncture blocks cold stress-induced increases in the hypothalamus-pituitaryadrenal axis in the rat. Ladan Eshkevari, et al., Journal of Endocrinology, 217.1, pp c. Acupuncture prevents chronic stress-induced increases in neuropeptide Y. Ladan Eshkevari et al., Experimental Biology and Medicine. 237: *Comment: These papers explored the molecular mechanisms of needling on lab animals. But the researchers did appear to realize that all these molecular procedures affected the vasodilation of the injured tissues. (7) The unique features of the systemic approach of the Integrative Dry Needling System Treatment of soft tissue dysfunction: All modern dry needling models were developed by medical clinicians to treat clinical symptoms, especially soft tissue pain. For this reason, all other dry needling techniques focus on local symptoms or regional symptoms in general. Both doctors and patients will apply these techniques when pain is felt. Unfortunately, in many cases the most effective treatment is during pre-pain or pre-symptom stage, not the symptom-stage. 5

6 Systemic approach: In fact, all local symptoms have systemic effects over all of the human systems. This includes the physiologic systems and biomechanical balance of neuromusculoskeletal system because soft tissue pain always affects the biomechanical balance of part or all of the musculoskeletal system. The Integrative Dry Needling system (IDN) connects the local symptoms with the body as a whole, especially the systemic balance of biomechanics of human movement, which is very important in sports medicine. Prevention of pathologic conditions: Using IDN it is possible in many cases we can prevent soft tissue dysfunction if applied in pre-symptom stage or symptom-free persons. This is especially important for athletes, musicians, physical therapists and chiropractic doctors as their professional injuries shorten their careers. Unfortunately, both medical professionals and patients ignore the preventative approach. Health promotion: IDN is beneficial for prevention of soft tissue dysfunctions, which are a major pathologic condition involved in almost all diseases. IDN for sports medicine: We developed the IDN system for athletes because the techniques will (a) optimize physical performance by reducing biomechanical and physical stress during the pre-symptom stage, (b) prevent chronic soft tissue injuries and some acute injuries, (c) provide treatments for conditions such as overtraining stress, soft tissue injuries related to the respective professions and rehabilitation after surgeries. 2. The clinical limitation of needling therapy DN therapy is a process of physiological adjustment to normalize homeostasis to promote self-healing. However, as the severity of pathological condition (stressor) increases, the self-healing potential decreases. If the patient s self-healing potential is severely hindered, their response to DN therapy may be limited. Dry needling efficacy varies from person to person. The same soft tissue pain symptom can be completely cured in some persons (28%), partially relieved in most persons (64%) and have low or no efficacy in a few patients (8%). DN therapeutic results for soft tissue pain management are reliably predictable and depend on (1) the self- healing potential and (2) the healing potential of the symptom(s) of each patient. The predictability arises from the fact that most soft tissue pains manifest through localized symptoms. For nonsoft tissue pain symptoms, DN efficacy is less predictable. 6

7 Contemporary Dry Needling Dry needling (DN) is a specific clinical technique for musculoskeletal pain and human movement dysfunction. Historically, modern medical doctors developed DN in the 1970 s. The founders of DN are Dr. Janet Travell (White house physician of President JFK) and Dr. C. C. Gunn (Canadian physician). Contemporary DN includes several modalities, which are improved techniques of its founders techniques, as modern medical techniques are continuously improving when medical science advances. In the US, DN is based on modern medical science including training in human anatomy, physiology, pathology, histology, neurology, kinesiology, human biomechanics and musculoskeletal dysfunction. Healthcare practitioners that have completed training as a medical physician, chiropractic physician, physical therapist and athletic trainers are qualified to study & practice DN. For these practitioners, current DN technique training requires 50+ hours of face-to-face hands-on training. DN is a modern clinical technique practiced worldwide by health care professionals who deal with musculoskeletal dysfunction. It is only in the US that acupuncturists attempt to politically prevent other medical professionals from practicing DN treatment. Traditional Chinese Medicine (TCM) Acupuncture TCM Acupuncture is a part of ancient Chinese medicine, which is based on Chinese ancient philosophy and clinical experience to treat human diseases. Historically TCM acupuncture was developed 2,500 years ago in Chinese civilization. The clinical theories and techniques were based on ancient experience and described in TCM classics <Yellow Emperor s Cannon of Internal Medicine> published 2,000 years ago, which is still the major textbook in all TCM acupuncture schools. Even the modern versions of all TCM acupuncture textbooks are based on this ancient Yellow Emperor s Cannon of Internal medicine. To study and practice TCM acupuncture requires the practitioners to finish 3 years of acupuncture schooling which is based on Chinese classics including philosophy of Chinese medicine such as theories of Yin-yang, Five element interaction, meridian theories, and pulse-tongue diagnosis, and disease classification according to Chinese medicine. To practice TCM acupuncture requires practitioners to pass license examinations, which do not include any knowledge or skills of dry needling. The knowledge and clinical skills of DN are not included in education and license exams of TCM acupuncture. Licensed acupuncturists do not have the background knowledge and training needed to study and practice DN. They need to study modern medical courses before taking DN training. 7

8 Empirical Model type Traditional model Trigger point model 1 st generation of dry needling Physiologic feature of the model The model reveals systemic and nonspecific effects of needling physiology. A system of accumulation of ancient and modern clinical data. 1. Local muscle pathohistology and pathophysiology of trigger points are emphasized. 2. Local gross anatomy is emphasized Weakness of the model 1. Model development is disadvantaged by its philosophy 2. Modern medical understanding is irrelevant (some improvement in modern versions) Complicated out-ofdate theories and unnecessary clinical procedures. 1. Systemic physiology of needling effect is ignored 2. Pain physiology of sensory nerve is underestimated 3. Anti-Inflammatory physiology of needling is neglected Historical notes Empirical development in Chinese agricultural civilization at least 2,500 years ago. Empirical development 1930 s: J. Kellgren 1940 s: J. Travell s -2010: J. Travell & D. G. Simon Gunn approach 2 nd generation of dry needling Peripheral nerve model 3 rd generation of dry needling Spinal segmental physiology of needling stimulation is emphasized Concept of soft tissue dysfunction is considered Integration of all known models. Both systemic & local effects of needling are emphasized. 1. Pain physiology of nervous system and soft tissue dysfunction Non-segmental physiology of needling effect is ignored Continued 2. Biomechanics of pain is revealed. 3. Clinical procedure is comprehensive but simple 4. Preventive effect of needling is emphasized Empirical development by Dr. C. C. Gunn since 1970 s Empirical development: 1970 s: H.C. Dung; 1990 s H.C. Dung & Y. T. Ma 2000 s YT Ma 3rd generation of dry needling 8

9 3. Law of dry needling (Ma, YT.) a. All needling models clinically work. All models are partially truthful models. b. All theories are tentative and subjective to change as science advances. Differentiation of facts from theories is needed in understanding the therapy. c. If any scientific research support one model, in fact, support all models. d. If any scientific research denies or falsifies the theory of particular model, they only deny that theory, not the clinical techniques of the model. e. Each model has its unique benefits and unique limitations. f. Physiologically all models do not conflict with each other. Thus, it is possible to integrate all models into a new model with new theories. All roads go to Rome. But some roads are speedier, easier, safer, more efficient, and even more effective for beginners. 4. Evidence-based research: Survey of Trigger Point Approach Clin J Pain, Vol. 25, Number 1, January 2009 Reliability of Physical Examination for Diagnosis of Myofascial Trigger Points: A Systemic Review of the Literature. Nicholas Lucas, Petra Macaskill, Les Irwig, Robert Moran, and Nikolai Bogduk. Conclusion: No study to date has reported the reliability of trigger point diagnosis according to the currently proposed criteria. Physical examination cannot currently be recommended as reliable test for the diagnosis of trigger points. International Journal of Osteopathic Medicine 12 (2009) (pp. 2-13) Therapeutic Needling in Osteopathic Practice: An Evidence-informed Perspective Luke D. Rickards (pg. 3). Conclusion: It should be noted that the validity of myofascial trigger points remains controversial. There is currently no accepted diagnostic reference standard, and consensus on the physical diagnostic criteria for myofascial trigger points is limited. These issues pose a serious challenge to claims that direct needling of a clinically relevant pathological entity is responsible for improved outcomes in patients who received these treatments. In fact, needling of tender, symptomatic sites and hypertonic muscles are common recommendation for pain conditions, which may indicate that clinical efforts to accurately identify and then penetrate the foci of myofascial trigger points are unnecessary. 9

10 Others to view: Myburgh C. A systemic, critical review of manual palpation for identifying myofascial trigger points: evidence and clinical significance. Archives of physical medicine and rehabilitation. 2008; 89(6): Myburgh C. Standardized manual palpation of myofascial trigger points in relation to neck/shoulder pain: the influence of clinical experience on inter-examiner reproducibility. Manual Therapy ; 2: Evidence-based research: Highest quality of evidence: Randomized trials or systemic reviews of randomized trials. Produce the lowest likelihood of bias. Other evidence: Rigorous observational studies; anecdotal reports from experts. Limitations of evidence-based medicine: Evidence, whether strong or weak, is never sufficient to make clinical decisions. Individual values and preferences must balance this evidence to achieve optimal shared decision-making and highlight that the practice of evidence-based medicine is not one-size fits all approach. It has been recognized that providing evidence from clinical research is a necessary but not a sufficient condition to provide optimal care. 5. Integrated Neuromuscular Point System Three clinical types of neuro-trigger points: 1). Homeostatic (HNTrP) 2). Symptomatic (SNTrP) 3). Paravertebral (PNTrP) Homeostatic Neuro-trigger point markers for patient evaluation and prognostic prediction use Deep Radial nerve and Saphenous nerve points. 6. Anatomy and Physiology of neuro-trigger point: A. Pathophysiology of neuro-triggers: a. Three phases: latent, passive and active b. Three physical properties: sensitivity, specificity, and sequence B. Formation of pathological neuro-trigger points (tender or painful neuro-triggers): a. Systemic pattern-predictable and sequential (HNTrP & PNTrP) b. Symptom-dependent pattern: (SNTrP) D. Differentiation of three types of neuro-triggers points a. Homeostatic neuro-trigger points (HNTrP): Systemic, baseline of health. b. Symptomatic neuro-trigger points (SNTrP): Local severity of the stress c. Paravertebral neuro-trigger points (PNTrP): Link between postural control and viscera. 7. Clinical Protocol: Application of one standard but individualized protocol for all symptoms is possible 10

11 because DN therapy normalizes physiological homeostasis to maximize self-healing of all healable symptoms. However, this standard protocol has to be individualized, as no 2 patients are identical. 9. Healing Patterns of DN Therapy Healing patterns of patients are not predictable. (Especially in C and D groups.) 1. Immediate: acute condition in healthy patients 2. Cumulative: patients feel better after each DN treatment within 1-2 days. 3. Wavering but gradually improving: patients may feel alternatively better and worse, but gradually healing becomes faster and more stable. 4. No-change-then-better: no improvement at first 2-3 weeks. Stop treatment for one week and patients suddenly or gradually feel better. 5. Worse-then-better: mostly in stubborn and severe conditions. Some patients may interpret the needling sensation as more pain after treatment. 6. Non-responders: most are in the D group. 10. Clinically Important Mechanisms of DN Therapy Note: All the mechanisms listed here help identify the most effective neuro-trigger points/areas for needling. A. Local Mechanisms: See soft tissue dysfunction (below) B. Systemic Normalization of Pathophysiological Imbalance Pathological stimulations reach all levels of CNS (spinal cord, brain stem, pons, thalamus, limbic system and cortices). They disturb, interrupt or suppress normal interaction and cause dysregulation of a variety of physiological functions. Dry needling signals also reach these levels and interact with pathological signals. Needling stimulates the release of neural transmitters and bioactive factors from CNS and causes immune and endocrine systems to release immune factors and hormones to regulate physiological and biochemical environments of pathological tissues, thus affecting cells and microenvironment and leading to self-healing. There are somatic and emotional imbalances. Any imbalance can be a stress to the body. Systemic somatic stresses may include pain, low/high temperature, fever, infection, injuries, surgeries, hypoxia, overwork and repetitive overuse. Emotional stress may include fear, anxiety, depression, worry, hopelessness, helplessness and grief, etc. 11

12 11. Adverse effects: DN is a medical modality with certain risks. It is very critical for both experienced and beginning practitioners to understand what adverse effects may occur during treatment, how to prevent them and how to manage them. We will go over very specific discussions and labs to assure that you will completely understand the precautions and know how to safely perform dry needling. 12. Visceral reflex: If the patient s condition involves internal organ(s), the diseased organ(s) will project the pathological signals to the certain part(s) of the body, which are represented as tender points, soft tissue nodules, skin discoloration, or painful area. Most internal pathological insults affect only part or parts of the body in the beginning and tender Symptomatic Neuro-triggers (SNTrPs) are formed in the specific area (s). If the affected area harbors HNTrPs, these HNTrPs are also SNTrPs. For example, in patients with a kidney problem, HNTrP #15 and #14 (Homeostatic Neuro-Trigger Point chart below) are more tender than other HNTrPs. If the pathology of the kidneys continues to develop, the whole lumbar area can become tender. 13. Somatic reflex: A part of the body can refer or radiate its pain to another part of the body. For example, inflamed low back muscles and nerves can project their pain to the thigh, leg and foot. Usually HNTrP#15 and #22 are the centers of the pain and the pain may project to HNTrP #14 and #16 of the gluteal area, to HNTrP #18 and its vicinity of the thigh, and #11, #24 and #10 of the leg. 14. Systemic Pathological Sensitization: Systemic pathology makes tender points appear systemically. For example, fibromyalgia sensitizes all the primary Homeostatic neuro-trigger points in particular locations according to personal pathology. 15. Soft tissue dysfunction DN therapy non-specifically promotes physiological normalization of dysfunctional or injured soft tissues. Self-healing begins after acute or chronic injuries of soft tissues. However, during this self-healing process, inflammation, contracture of soft tissues, adhesion formed between different soft tissues, scar formation within the same and between different soft tissues becomes the pathology of chronic soft tissue dysfunction. These compensatory changes cause the blockage of fluid and blood circulation in the affected soft tissues. Thus, inflammation, contracture, adhesion, scarring and blockage 12

13 are the major pathologies of chronic soft tissue dysfunction. All human diseases create, more or less, soft tissue dysfunction. Many clinical symptoms are related or produced by the compensatory changes of soft tissues. The efficacy of medical intervention in treating many external injuries and internal dysfunction depends how much we can solve the pathologies of the soft tissue, the inflammation, contracture, adhesion, scarring and blockage of local microcirculation. Chronic soft tissue syndrome is the pathological conditions caused by the compensatory inflammation, contracture, adhesion, scarring and blockage of circulation in the soft tissues after acute or chronic injuries. 16. Pathology of chronic soft tissue syndrome Chronic soft tissue syndrome is new soft tissue dysfunctions developed during the process of recovery after initial acute or chronic injuries (see below). The soft tissues involved include muscles, ligaments, tendons, fascia, capsules, bursae, nerves, blood and lymph vessels, and viscera with their related soft tissues. After injuries like external physical tear or internal tissue ulcer or inflammation, contracture, adhesion, scarring and blockage of local circulation will occur. These compensatory changes result in various chronic symptoms. 17. The types of soft tissue injuries: Injuries, as consequences of tissue destruction from physical deformation, tear, breakage, necrosis, and blockage of circulation, result in dysfunction and injuries of soft tissues. These injuries can be classified into the following types. (1) Violent physical injuries: crushing, beating, falling, compressing, pushing and pulling. (2) Cumulative injuries: injuries caused by frequent or repetitive activities, which involve particular tissues. (3) Emotional stress: emotional stress causes dilation or constriction of blood vessels, strong contraction or cramp of muscles resulting in injuries of blood vessels. Emotional depression induces slow humoral and blood circulation resulting in retention of fluid. This may lead to swelling or enlargement of tissues and organs which may compress other tissue or organs to cause injuries. (4) Unconscious injuries: slight physical injuries in daily life. (5) Overloading fatigue: overworking (limbs and muscles), overeating (digestive organs), over-exercising (physical training). (6) Injuries from chemical toxins: alcoholics, drug-abuse, smoking, overmedication, pollutants, etc. (7) Over-weight injuries: (8) Post-surgical injuries: (9) Disease-related injuries: Example-rheumatoid arthritis causes inflammation, edema, and necrosis of soft tissues, etc. 13

14 (10) Environmentally-related injuries: extreme temperatures, burning and toxins. (11) Injuries caused by abnormal physiology: imbalance between sympathetic and parasympathetic nervous system. 18. Pathological process of soft tissue dysfunction/injuries: The major consequences of soft tissue dysfunction/injuries are from inflammation, contracture, adhesion, trophic deficiency, scarring and blockage of circulation. (1) Contracture/cramp: To protect from further injuries, some soft tissues (muscles, tendons, ligaments, fascia) become contracted or shortened after initial acute injuries. Some contractures of soft tissue is demonstrated as cramps happening during exercise. (2) Adhesion: Adhesion is a pathological consequence after soft tissue injuries. Adhesions in the limbs and spine demonstrate more symptoms due to more physical motion; adhesions found in the face and abdomen demonstrate less symptoms. There are two types of soft tissue adhesions: (a). Adhesion caused by external physical impact: Violent force, cumulative stress, subconscious damage in daily life, overloading injuries, overweight conditions, and emotional abnormalities (stress or depression) cause injuries of soft tissues such as broken capillaries and fibers. During the process of recovery from those injuries, different soft tissues like muscles, ligaments, blood vessels, and nerves may adhere to each other. (b). Adhesion caused by internal pathological insults This adhesion can be caused from internal pathology, invasive infections, environmental conditions and post-surgical injuries. (3) Scarring External and internal scars are formed during the process of soft tissue healing if the injuries are severe enough or involve large areas. Internal scars are often the pathological factors for chronic soft tissue dysfunctions. (4) Blockage of circulation: The injuries cause damage in soft tissues such as breakage of blood and lymph vessels, tear of fibers, bleeding, and fluid retention. During the healing process, scarring and fibrillation can block the normal circulation channels, resulting in retention of fluid in one part of the tissues and low or slow circulation in another part. This condition can become the pathology of the chronic soft tissue dysfunctions. 14

15 (5) Trophic deficiency: Injured tissues become weak and finally deformed because of lack of nutrition and exercise. This affects the range of motion and the mechanical balance of the joint. It takes time to restore the normal size and function of the muscles, which is one of the differences between acute and chronic injuries. 19. Three stages of self-healing of soft tissue after injuries: (1). Inflammation and immune reaction. The coagulation process and immune reaction release active biological factors like platelet factors (PDGF), TGF, PDECGF and activated immune cells such as white blood cells to digest the injured tissues. (2). Cellular regeneration and differentiation: primordial cell regeneration and differentiation into the same type of cells of the injured tissues. (3). Reconstruction of the injured tissues. Endothelial cells move to the injured parts to form the tissues and capillaries. Safety Considerations: Dry needling in well-trained hands is a very safe modality. There are adverse events that can occur and are usually very mild and of short duration. There are, however regions of the body that can pose serious complications if they are not approached in a very specific manner with a well thought out protocol. In class, safety is our main focus! 1. Lung considerations- Care must be taken in the following areas: Supraclavicular- anterior chest between shoulder blades- lateral chest walls. 2. Kidney Considerations: Right kidney is 2 lower than the left Difference between anatomical point and clinical point at the L2 level will be discussed and practiced. 3. Needling Depth: The graphic represents the safest up to needle depths that will be used in the foundation course. We will further outline the danger areas and safety techniques, but this is a quick reference. 4. Syncope considerations: Patients that are at the greatest risk to experience a fainting or dizziness reaction are: 15

16 Patients with low blood pressure <110/70 Very strong, young 20 +/- year-old male athletes Be careful with thin females Patients that are dehydrated To reduce the risk of a syncopal episode initially treat the patient in a recumbent position and use fewer needles until their tolerance to needle treatment can be determined. Needle Dosage: The current literature is lacking on a definitive and scientific answer to the question of how is dry needling dosage clinically determined? Currently, the answer relies mostly on empirical and historical knowledge. In general, our definition of needling dosage is based on the number and extent of the therapeutic lesion(s) produced from the needle insertions. Therapeutic lesion is defined as the neurophysiological response of the body to the needle penetrations; the more therapeutic lesion(s) produced, the higher the needle dosage delivered. The extent of a therapeutic lesion(s) is not solely dependent on the number of needles used, but also on the gauge of the needle and how it is manipulated while in situ. Based on that description it is understandable that we do not have a standardized nomenclature to quantify the amount of therapeutic lesion required for optimal clinical effect. This is in contrast to exercise or medication prescription that can have a very specific and easy to follow prescription. For example, the always popular, but highly questionable 3 sets of 10 for exercise or take 2 pills 3 times per day. The lack of a standardized system to measure needle dosage leaves us with vague statements such as continue needling until it stops twitching, until the energy flows, until the muscle relaxes, or the intuitive until the pain goes away? This highlights one of the major limitations in dry needling research, lack of identification of the needle dosage used to obtain the clinical effect. When deciding on the treatment dosage for dry needling there are several patient factors to consider. For the purpose of this paper, I would suggest the following short list of considerations related to needle dosage: Age and health status of the patient State of the condition being treated (acute/chronic) Patient experience with dry needling especially within the last 6 months Healing potential based on the IDN Quantitative Analysis When the subjective and physical examinations have been completed, the decision to utilize dry needling has been made, and patient consent obtained, the next step is determining location and dosage of needling. On the first day of treatment it is recommended to talk more and needle less. By this we refer to educating the patient 16

17 about dry needling while also reducing the potential for significant post-needle soreness. Determination of the patient s tolerance and response to needling is a process so being conservative initially is prudent. With that said, the first treatment should have a therapeutic effect but not at the expense of dogma that states the mission is to eliminate knots or points at all costs. There are several techniques of dry needling that can be integrated into each treatment session, each can be used separately or can be used in combination. The following describes the most common clinical applications utilized: 1. Superficial needling: The needle is inserted into the dermal and epidermal layers and not into the muscle tissue. This type of needling is the most conservative and very unlikely to cause pain or post-treatment soreness. A minor therapeutic lesion is still produced allowing the patient to receive the neurological and physiological benefits. 2. Deep Needling: The needle is inserted directly into the muscle tissue. There are various levels of needle penetration from inoculating just the outer layer of muscle or needling through the entire thickness of the muscle. Depending on how deep the needle is placed will determine the neurophysiological responses that result because penetrating deeper provides greater stimulation to the additional soft tissue and neurological levels. When the needle is set without needle manipulation it would be considered a basic deep needling technique of low dosage but is a progression of dosage over superficial needling. 3. Needle manipulation: The amount of dosage (therapeutic lesion) obtained is also based on the variables of speed, amplitude and intensity of the needle manipulation or movement. This is a progression from basic deep needling and has several manipulation techniques that can be utilized depending on the specific goals you are trying to accomplish. In a subsequent paper, I will describe in detail these different techniques and their specific uses: Needle rotation- The in-situ needle is rotated until a definitive endpoint is reached signifying the soft tissue has completely wound around the needle shaft inducing additional therapeutic lesion. Needle tenting- When the soft tissue is wound tightly around the needle it is pulled up causing a traction or stretch of the tissue inducing additional therapeutic lesion. Needle pistoning A high velocity up and down conical movement of the needle. There are various levels of intensity of pistoning that are dependent on the speed, and amplitude of the needling. The higher the speed and amplitude the larger the therapeutic lesion produced. Pistoning is considered the most aggressive needling technique and produces the greatest post-needling soreness. 17

18 4. Electrical Needle Stimulation (ENS): ENS delivers a mild electrical stimulation to soft tissue via attaching alligator type clips onto the solid monofilament needles. ENS is a progression of dosage of manual needling by inducing rhythmic vibrations (of non-contractile tissue) and repeated muscle contractions. Because the needle is in situ the repeated muscles contractions will induce additional lesion. 5. Time in situ. Empirically, the length of time a needle is left in situ (without manipulation) does not influence the dosage, if we define dosage as amount of therapeutic lesion produced. Dosage determination: Research does not currently exist that provides a definitive guideline of needling dosage for specific diagnoses or conditions. Dry needling is a nonspecific treatment that relies on the body s ability to self-heal the needle induced therapeutic lesions via multiple physiological processes. Because each patient s situation, injury and condition are unique, trying to determine the correct dosage is complicated to say the least. Each clinician has their opinion on proper dosage, based primarily on their clinical experience and empirical evidence. This is important information, but it is not easily quantifiable to other patients or for use by other clinicians. We propose a clinical model that quantifies needling dosage into more general categories of low, moderate or high. Each category has an increasing number of needles and progressively more aggressive needling techniques that generate larger therapeutic lesions. Low Dosage: Applies to the initial treatment session for all patients. Also, patients with compromised physical conditions, low healing potential or are at an advanced age require a cautious start. The following is recommended for this category: Superficial needling techniques Basic deep needling technique (no needle manipulation) Number of needles: 5-10 needles Moderate Dosage: Applies to patients that have had prior needling treatment (low dosage) with a positive reaction within the last 6 months. They are in relatively good physical condition and have been assessed to have good healing potential. Deep needling can now include needle manipulation techniques of moderate intensity, which may include pistoning, rotation and or tenting techniques. ENS can be introduced and provided for up to 5 minutes of active muscle contraction. Number of needles: Up to 20 needles High Dosage: Applies to patients that have had significant experience with dry needling treatment and are likely healthy, active individuals with excellent healing potential. 18

19 Deep needling with high intensity needle manipulations, which may include pistoning, rotation and or tenting techniques. ENS treatment time can be extended up to 10+ minutes and multiple areas can be treated in one session. Number of needles: 21+ needles Summary: In this short paper we provided general categories for the prescription of dry needling dosage focusing only on the induced therapeutic lesion. What needs to be addressed in a subsequent paper is the patient s perception and response, which are linked to dosage and ultimately the therapeutic outcome. The current guidelines are intended to help all clinicians, but specifically clinicians new to dry needling treatment, with the clinical decision-making related to the original question of How many needles should be used? These guidelines were never intended to be the definitive answer as it is not currently possible to specifically quantify the non-specific and systemic modality of dry needling. As research progresses and physiological healing processes are better elucidated, we may be better able to quantify the amount of therapeutic lesion required to get the desired treatment effect. Textbook for the course: Ma YT. (2016) Dr. Ma's Neurologic Dry Needling. 1st. ed. Naples, Florida: Laterna Medica Press. Needling supplies: Of course, all the supplies for the course are provided however, if you wish to purchase supplies prior to the course so that you can begin needling on Monday morning you can go to We have set up starter kits for you with recommended needles, electric stimulation units, etc. 19

20 Dry Needling Research 1. Overall Effectiveness of Dry Needling (DN) on Pain and Disability Deep DN of Myofascial Trigger Points (MTrP) 2. Local Twitch Response (LTR) 3. DN of Symptomatic versus Non-symptomatic Points 4. Superficial DN 5. Superficial versus Deep DN 6. Tendon Needling 7. Paravertebral DN 8. Non-segmental Distant DN Relevant Information for Practical Application of DN Overall Effects of DN on Pain and Disability Systematic Reviews with Meta-analysis Level 1a Evidence Gattie, 2017 Trigger Point DN for Musculoskeletal Conditions by Physical Therapists Liu, 2015 DN for MTrP associated with neck and shoulder pain Hu, 2018 DN for Low Back Pain Kietrys, 2013 DN for upper quarter MPS Consistent results across systematic reviews for various conditions that DN is more effective than sham, control, or placebo. Mixed results when DN was compared to other interventions. Local Twitch Response Clinical relevance of the LTR Conflicting literature for need to elicit or exhaust a LTR More pain relief Hong,1994; Tekin,2013; Rha,2011 Similar pain relief as no LTR Perreault,2017; Koppenhaver,2017 Rha, 2011 Limited visibility Not easily detectable in lumbar musculature as the upper trapezius More Post treatment soreness Hong,1994; Matin-Pintado-Zugasti, 2018

21 Local Twitch Response Shah et al. (2008) Active MTrP have a greater amount of sensitizing chemicals compared to latent TrP or normal tissue. These sensitizing chemicals were shown to be elevated systemically Lowered concentrations of sensitizing and inflammatory chemicals occurred in the active groups who experienced the LT Explains the temporary pain reduction and PPT clinically This suggests that elevations of biochemicals associated with pain and inflammation may not be limited to localized areas of active MTPs but occur systemically. Edwards and Knowles (2003) Superficial Needling 2 studies have evaluated the effectiveness of superficial needling versus control or placebo Compared superficial needling with active stretching to active stretching alone and a control group for 6 weeks. Needling group had significantly less pain than the control group and increased PPT compared to the active exercise only group MacDonald et al. (1983) Compared superficial needling to placebo for chronic lumbar MTrPs Needling group had significantly better results on pain reduction Superficial vs. Deep Needling Superficial versus deep dry needling or acupuncture for reducing pain and disability in spine-related painful conditions: A systematic review with meta-analysis. Griswold (2019) 10 studies included in the MA involving 2603 comparisons of deep and superficial needle insertion for pain relief. Deep Needling (>10 mm into muscle) Superficial Needling (<10 mm or Subcutaneous) Both superficial and deep needling effective for pain reduction Deeper insertion shown to be more effective than superficial Secondary analysis Needling local or a combination of local and remote the site site of pain results in greater pain reduction than remote only.

22 DN of Symptomatic vs. Non-Symptomatic Wong et al. (2015) - Systematic Review with Meta-analysis Investigated the comparative effectiveness between local needling of tender points and distant needling of non-tender points for chronic musculoskeletal pain. Moderate evidence that both local and distant points elicit pain reduction compared to controls. Local needling of an inflamed area (tender) elicited better pain reduction than a selected local acupuncture points. Tendon Needling Conclusions: Within group changes observed up to 6 months demonstrating statistical and clinically meaningful changes for impairment and functional data. The evidence suggests that tendon needling improves patient-reported outcome measures in patients with tendinopathy. Segmental and Distal Effects Tsai (2010) Needling of the extensor carpi radials both deep and superficially improved pain and PPT in the UT, and increased cervical ROM. Hsieh (2007) Needling the infraspinatus eliciting as many LTR as possible for 1-2 minutes reduced pain locally and satellite TrP (Anterior deltoid, Extensor carpi radialis longus) Travell and Simons 1998

23 Segmental and Distal DN for LBP Basic insertion without needle manipulation produced similar outcomes on pain and disability as NTM for NSLBP. Targeted segmental and distal peripheral nerve distributions (Not MTrP) Paravertebral Needling Couto (2013) A randomized sham-controlled trial: Deep needling at the spinal root level where symptoms were in the area of that root s myotomes, dermatomes, and sclerotomes + local needling Comparison groups included local DN and sham e-stim Significantly greater reductions in pain, and increase in PPT for paravertebral + local needling Ga (2007) RCT of 40 subjects with MPS of the upper trapezius 2 groups Local TrP needling Local TrP needling and Paravertebral needling Inclusion of paravertebral points resulted in greater ROM and more pain reduction Summary Superficial dry needling is more effective than placebo, sham, or no treatment; not as effective as deep needling Needling of non-local trigger points reduces pain and increases PPT in primary trigger point sites Inclusion of paravertebral points results in clinically significant results compared to local needling in isolation Further investigation is needed to determine if LTR are necessary; several studies demonstrate immediate or short term improvement in pain/disability but to date no high quality, long term trials to support it. Elevations of biochemicals associated with pain and inflammation may not be limited to localized areas of active MTPs but occur systemically.

24 Homeostatic Neuro-Trigger Points

25 Homeostatic Neuro-Trigger Points

26 C7 Dermatomes C5 C5 C6 C8 T2 C6 C2 L2 C3 L1 T10 T11 T12 S3 V1 V2 C4 T2 T3 T4 V3 T5 T6 T7 T8 T9 S4 Nerves Ophthalmic nerve Maxillary nerve Mandibular nerve Greater auricular nerve C2, 3 Transverse cervical nerve C2, 3 Supraclavicular nerve C3, 4 T2 nerve Upper lateral cutaneous nerve of arm C5, 6 T3 nerve T4 nerve T5 nerve T6 nerve T7 nerve T8 nerve Lower lateral cutaneous nerve of arm C5, 6 Medial cutaneous nerve of arm C8, T1 T9 nerve T10 nerve T11 nerve Subcostal nerve T12 Posterior cutaneous nerve of forearm C5, 6, 7, 8 Lateral cutaneous nerve of forearm C5, 6 Iliohypogastric nerve L1 Ilioinguinal nerve L1 Superficial branch of radial nerve C6, 7, 8 Femoral branches of genitofemoral nerve L1 Median nerve C6, 7, 8 Lateral femoral cutaneous nerve L2, 3 L3 Medial and intermediate femoral cutaneous nerves L2, 3, 4 Obturator nerve L2, 3, 4 L5 L4 Saphenous nerve L2, 3, 4 Lateral cutaneous nerve of calf L4, 5, S1 S1 Superfical peroneal nerve L4, 5, S1 Deep peroneal nerve L5!

27 !! Nerves Greater occipital nerve C2 Greater auricular nerve C2, 3 Lesser occipital nerve C2 Supraclavicular nerve C3, 4 Dorsal rami C3, 4, 5 T2 nerve T3 nerve T4 nerve Upper lateral cutaneous nerve of arm C5, 6 T5 nerve T6 nerve T7 nerve T8 nerve T9 nerve Medial cutaneous nerve of arm C8, T1 Posterior cutaneous nerve of forearm C5, 6, 7, 8 T10 nerve T11 nerve T12 nerve Subcostal nerve T12 Medial cutaneous nerve of forearm C8, T1 Iliohypogastric nerve L1 Dorsal rami L1, 2, 3 Lateral cutaneous nerve of forearm C5, 6 UInar nerve C8, T1 Median nerve C6, 7, 8 C2 C3 C4 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 L1 L2 S2 L2 S3 L3 Dermatomes C5 T2 C6 T1 C8 S2 C7 Dorsal rami S1, 2, 3 Lateral cutaneous nerve of thigh L2, 3 Posterior cutaneous nerve of thigh, S1, 2, 3 L3 Lateral cutaneous nerve of calf L4, 5, S1 L4 L5 Sural nerve S1 Saphenous nerve L3, 4 Medial calcaneal branches of tibial nerve S1 Superfical peroneal nerve L4, 5, S1 S1!!!