Dr. James Escaloni, PT, OCS, Cert. MDT, Cert. DN, Cert. SMT, Dip. Osteopractic

Dr. Ron Pavkovich, PT, CIDN, Cert. DN, Cert. SMT, Dip. Osteopractic

Review the mechanisms of action behind dry needling (DN) based upon most recent evidence.

Review the current evidence to substantiate the use of DN.

Graduated from University of Kentucky in 2007 with Master’s in Physical Therapy

Regis University with tDPT Board certified, residency & fellowship trained in orthopedics Certified in Mechanical Diagnosis & Therapy, Vestibular Rehabilitation,

Spinal Manipulation, Dry Needling, The Selective Functional Movement Assessment (I & II) & Functional Movement Screen (I & II), Functional Capacity Evaluations; Diploma in Osteopractic

Former board member for the Kentucky Strength & Conditioning Association

Faculty for KORT/Select Medical’s Orthopaedic Residency Program & the American Academy of Manipulative Therapy

DPT Bellarmine University in Louisville, KY Initial cohort of AAMT Fellowship candidates and

Osteopractors Integrative Dry Needling certified Mulligan & Fellowship trained in manual therapy and

orthopedics Workwell PWS, FJA, FCE certified Former KY State Trooper Father of twins and triplets 14 months apart Faculty for the American Academy of Manipulative Therapy

Acupuncture really means:

Acu – sharp

Puncture – To pierce with a pointed instrument

The real difference we should consider is that dry needling is different from traditional Chinese medicine (TCM)

According to TCM, the general theory is based on the premise that bodily functions are regulated by an energy called qi (氣) which flows through the body; disruptions of this flow are believed to be responsible for disease.

Evaluation can consist of examination of tongue and pulse for irregularities in qi flow

Needle placement helps to balance qi flow

Dry needling is a technique used to treat dysfunctions in skeletal muscle, fascia, and connective tissue, and, diminish persistent peripheral nociceptive input, and reduce or restore impairments of body structure and function leading to improved activity and participation.

Decrease spontaneous electrical activity (SEA) at the site of the Trigger Point & help resolve trigger points (energy crisis hypothesis)

Can remove a source of irritation to peripheral tissues by needling shortened paraspinal muscles

Decreases pain at the site of needle insertion peripherally, spinally, and supraspinally

Help with long term potentiation associated with increased sensitization of pain modulated within the central nervous system

Excessive release of acetylcholine which produces sustained depolarization of muscle fibers

Sustained contractions of muscle sarcomeres compresses local blood supply restricting the energy needs of the local region

This crisis in energy produces sensitizing substances that interact with nociceptive (pain) nerves in the area, which can produce localized pain within the muscle at the neuromuscular junction

Butts 2014

Nerve Endplate

Muscle

Ach

Nerve Endplate

Muscle

Trigger Point/Motor Band

Neuromuscular Junction-Nerve Dysfunction

Spontaneous Electrical Activity SEA

Sustained contracture of the sarcomeres leads to decreased capillary flow into the muscle which results in:

Lowering of local pH

Release of sensitizing substances

Activation of muscle nociceptors and pain

Butts 2014

Per Shah et al. 2008

Acidic pH stimulates the production of bradykinin during local ischemia and inflammation

Bradykinin has been directly linked to hyperalgesia and chronic pain

Acidic pH modulates the motor end plate by inhibiting acetylcholinesterase & calcitonin gene regulated peptide (CGRP)

This increases concentration of acetylcholine at the synaptic cleft

Per Wang and Yu 2000

Sarcomeres become severely contracted due to myosin getting stuck in titin gel at the Z-disc

Gunn’s theory of

spondolysis/spondylitis

Mechanical disruption of end-plates that provide stretch to disentangle myosin filaments from titin at Z-disc

Dommerholt 2004

Enhances migration of opioid-containing immune cells to the site of inflammation by enhancing expression of ICAM-1 & endogenous anandamide (in electro-needling; EN)

Kim et al 2008, Chen 2009

The upregulation process of I-CAM 1 causes the molecule to line blood vessels in the vicinity of the problem

I-CAM 1 catches immune cells with opioids to get more at the site of the problem

Per Zhang 2005, EN causes release of endongenous opioids from the immune system into inflamed skin

Many immune cells have been observed to produce B-Endorphin per Su 2011

Sustained needling with winding (not pistoning) affects adenosine significantly in rat models to cause significant pain reduction Goldman 2010

After needle rotation, fibroblasts became aligned with collagen fibers and change shape from a rounded appearance to a more spindle-like shape

The importance of this effect is that pulling of collagen fibers during needle manipulation may transmit a mechanical signal

The subsequent signal transduction may contribute to the therapeutic effect of needling Langevin 2001

Needle puncture of skin can cause immediate analgesia in areas other than muscle tissue equal to or greater than medication

Lewit 1979

Needle penetration alone can have a better local response to pain than lidocaine and equal to Botox

de Abreu Venancio 2009

de Abreu Venancio R, Guedes Pereira Alencar Jr F, & Zamperini C. Botulinum toxin, lidocaine, and dry-needling injections in patients with myofascial pain and headaches. CRANIO. 2009; 27(1), 46-53.

Physiology of Peripheral Mechanisms

Boal & Gillette 2004

Hyperanalgesia has been demonstrated in animal models (rats) to be

established by C-fiber activation of dorsal horn neurons

•Normal processing

of acute pain

• Sub-acute or chronic c-fiber pain leading to referred pain

• Inhibitory interneuron can’t slow down nociceptor signaling

Rainey 2008

EN in the periphery has different effects on acute pain vs. chronic pain at the spinal level

Acute pain

Low and high frequency stimulation (2 & 100 Hz) inhibits thermal pain at the spinal cord through µ, δ, and K opioid receptors during acute pain

Chronic pain

Low and high frequency stimulation (2 & 100 Hz) inhibits thermal pain at the spinal cord through µ and δ opioid receptors during chronic pain

µ and δ opioid receptors are located on the presynaptic primary afferent and postsynaptic dorsal horn neurons

Besse 1990

Nociception/orphanin FQ (N/OFQ) is an opioid related peptide that is recognized by opioid like channels (ORL1), and plays an important role in pain modulation

Peterson et al. 2002 found that N/OFQ and ORL1 were distributed in the dorsal horn and the dorsal root ganglia

Fu et al. in 2006 tested selective antagonists to N/OFQ during EN and found it blocked the pain relieving effects

Fu et al. in 2007 found that EN at 2 and 60 Hz increased N/OFQ and ORL1 receptivity in an inflammatory rat model

At the spinal level

Zhang et al 2004

EN plus morphine suppressed pain more than morphine or needling alone.

Could be useful to decrease total medication needed for patient to return to function

Carpenter et al. 2000

Found that N/OFQ inhibits C-fiber evoked responses and wind up

The wind-up phenomenon is very important in the formation of a chronic pain response

Nociceptive signals in a wind-up response become more efficient at delivering pain and do not require as much of a stimulus to evoke a potential

4 and 60 Hz EN inhibited thermal pain and IL-1 receptor mRNA in the periaqueductal gray Ji et al. 2003

EN inhibits melanocortin-4 receptors to attenuate interleukin receptor activity in the periaqueductal gray; This blockage eased mechanical and thermal hyperalgesia Chu et al. 2012

Increased connectivity between the periaqueductal gray (PAG) and left posterior cingulate cortex (PCC) with electro-needling of the 1st dorsal interossei Zyloney 2010

Zyloney 2010 (cont.)

No direct connection between PAG and PCC

The PCC is part of the default mode network (DMN) which is active when the individual is not focused on the outside world and the brain is at wakeful rest

Activity in the DMN decreases in response to repeated painful stimuli, and chronic pain patients seem to exhibit permanently altered DMN activity

Patients with LBP have lower activation in the DMN

Electro-needling may improve firing patterns and connectivity with the DMN to improve chronic pain

Zyloney 2010 (cont.)

Authors speculate that EN stimulation may reduce brain responses to calibrated pain stimuli by interfering with the functional connectivity between the PAG and insula.

Anterior insula is responsible for sensitivity and preprogrammed perception of pain

Recalibration of the biopsychosocial aspects of pain?

Hsieh 2011 (cont.)

Gastroc needling with endplate noise recordings (EPN):

Divided into ipsilateral DN

Contralateral DN

Sham ipsilateral DN

Sham contralateral DN

Divided into:

Intact nervous system

Tibial nerve transection

L5-6 spinal cord (rat model)

Transection of the T1-2 spinal cord

Hsieh 2011 (cont.)

EPN = Complex noise-like potentials generated by a large increase (up to 1,000 times) in spontaneously released acetylcholine packets resulting in subsynapticminiature end-plate potentials

If tibial nerve was transected, the TrP on the ipsilateral side had no outstanding effects

However the contralateral side was unaffected

If the lumbar cord was transected, neither side had outstanding EPN findings

If the thoracic cord was transected, both sides showed effects similar to the control (normal EPM)

Statement in question:

“If one has myofascial pain, the trigger points are the cause”

Circular reasoning?

TrPs cause myofascial pain because painful muscles contain them

Quinter 2015 (cont.)

Reliability studies on the TrP diagnosis are present, however:

These studies suggest that when shown where a problem may exist, examiners may agree

However, when blinded as to diagnosis, those who claimed expertise in the field were unable to detect putative TrPs in the majority of subjects with a myofascial pain syndrome (MPS) diagnosis

“physical examination cannot be relied upon to diagnose a condition that is supposed to be defined by that physical examination. That is, the pathognomonic criterion for making the diagnosis of MPS is unreliable”

Quinter 2015 (cont.)

A rubbing palpation which can produce a transient contraction can be responsible for a sensation of hardness during palpation in the absence of pathology

This is produced by the myotatic (stretch) reflex

This correlates with the localized twitch response (also evocable on palpation of normal human muscle)

15 RCT’s included in this SR for DN for neck pain.

“STRONG” evidence for DN to have a (+) effect on pn. intensity.

“MODERATE” evidence for use to improve lateral flexion ROM (similar to Lidocaine injection).

“WEAK” evidence regarding effects on functionality & QOL.

Conclusion: “DN recommended for neck pain w/ TrPs in the upper traps.

1 session of deep DN to 1 latent MTrP & 1 active MTrP (in the infraspinatus mm. may the PPT of the ECRB mm. area immediately following & 1 week after the intervention in older adults with NSSP.

DN recommended for pain reduction in the neck and shoulder in the short & medium term.

Wet needling (including Lidocaine) is better than DN in the medium term.

s/p ORIF proximal humerus or RTC repair.

Single session of TrP-DN in week 1 of a multi-modal PT approach MAY cause faster pain improvement post-operatively.

Again, only 1 session???

Limited evidence on DN for shoulder conditions.

Optimal freq., duration, and intensity has not been yet established for DN, though lit. denotes leaving needles in-situ 10-30 min.

Clinically, it is extremely BENEFICIAL!

4 RCTs of DN vs. Lidocaine.

1 RCT of DN vs. placebo

Results: Meta-analysis showed NO difference b/w DN & Lido immediately, @ 1 months, and @ 3-6 months.

Discussion: Not shown in the analsis, patterns favored Lido immediately & DN @ 3-6 months.

12 RCT’s included after review of 246 articles

4 meta-analyses performed:

DN vs. sham/ control immediate, @ 4 weeks, DN vs “other”tx’s immediate, & @ 4 weeks.

Results: “Based on BEST (grade A) evidence, DN is recommended vs. placebo/ sham for dec. pn. Immediately & @ 4 weeks for upper quarter MFPS.

Limitations: small # of high-quality of RCT’s

PRP vs. DN

PRP is superior, BUT DN was effective at improving pain and function.

Only 2 visits in 4 weeks??

NO SR’s on DN for LBP, ONLY ACU (I tried to keep ACU lit. out of this presentation)

23 trials included (6 high quality)

“MOD” evidence ACU better than no tx

“STRONG” evidence for NO DIFF. b/w ACU vs. sham in short term

“STRONG” evidence for ACU as a “useful supplement” to “other” interventions”

Conclusion: ACU vs.no tx & as an adjunct SHOULD be advocated in Eur. Guidelines for treating chronic LBP.

33 randomized, placebo-controlled trials included.

Like LBP, NO DN SR’s on knee pain, so again, ACU noted here.

Results: Among “other” interventions reviewed (TENS, LLLT), electro-ACU administered in an intensive 2-4 week tx regimen, seems to offer “clinically relevant” short-term pain relief for knee OA.

Eccentric exercises MAY be more effective than an Air-Heel brace…

BUT LESS effective than acupuncture for Achilles tendinopathy of more than 2 months duration.

ACU intervention could improve pain and activity in patients with chronic Achilles tendinopathy compared with eccentric exercises.

3 RCT’s reviewed

Looked at DN, ACU, Local Injections (Botox/ local anesthetics/ steroids, & saline)

Conclusions: “Limited evidence for the effectiveness of DN &/ or injections of MTrPs assoc. w/ plantar heel pain.

HOWEVER: Poor quality & heterogeneous nature of the included studies precludes definitive conclusions.

N= 84

TrP DN

Showed improved pain and 1st step pain, BUT…

Did not meet MCID for primary outcome measure (1st step pain)

This study basically says DN NOT effective for plantar heel pain, BUT… (next slide)

MCID not met in the previous study possibly due to a few possible reasons…

The author’s DID NOT needle the medial calcaneal tubercle (the MAIN pain originator!)

They claim to needle TrP’s in the quadratus plantae…but can we ACTUALLY palpate these???? (hint….NO!!)

DN for management of CAI.

Inclusion of TrP-DN within the lateral peroneus muscle into a proprioceptive/strengthening exercise program resulted in better outcomes in pain and function 1 month after the therapy in ankle instability.

Update to a SR w/ MA in 2007…

Limited evidence that direct TrP DN hads an overall tx effet vs standard care.

The MA indicates DN is better than placebo, but heterogeneity of the included studies requires a “cautious” interpretation of this finding.

Included only 6 studies

Pt treated 2 times over 26 days for UT/ neck pain after moving boxes.

Elimination of pain after 1st visit.

ITB/ Gr. Troch Bursitis

2x/ week for 8 weeks

Tx with DN only

Clinically meaningful improvement in pain and reported disability.

N=4

4-8 sessions of exrcise/ stretching and DN

Also 12 ¼ month long-term follow up.

Clinically meaningful improvement in disability and pain in short term and long term follow-up.