You Mean Zac Didn’t go to a PRI Course?
Yes. From time to time I occasionally take a gander at what else is out there in PT land. It was probably about time I check out this whole dry needling thing and see what the fuss is about.
I took the Spinal Manipulation Institute’s version based on some recommendations from a few colleagues I trust. Ray Butts was MC’ing for the weekend.
I know needling is quite the controversial topic, but I was amazed at the sheer quantity of evidence supporting this modality. Like, an insane amount. I am not sure what the “haterz” found their criticisms on, so please comment if you have some ammo (I am a noob to this after all).
And Ray’s lecture on dry needling mechanisms? Oooohhh lawwwwd. Easily one of the best foundational science lectures I have ever heard. Period. The passion this group has not only for science but the physical therapy profession is inspiring. They made me excited to be a PT. Perhaps even inspired me to contemplate the PhD route.
All that said, I am unsure as to where needling will fit into my practice. The assessment that would point you toward needling someone was sorely lacking. I’ve noticed this problem to be quite common in manual therapy courses. It’s pretty much you hurt here/have this diagnosis, then use this protocol.
My second big gripe it how long it takes. Ray advocated we leave the needles in situ for 8-30 minutes. That is a long-ass time, especially when I have much faster treatments at my disposal.
Moreover, a lot of the research shows several visits needed before meaningful change occurs.
The difference maker for me would have to be that the treatment effects are so good that spending that much time is worth it. If that’s the case, I may find a place for it in my PRI-brain.
Do I think you should attend their course? Let’s just say I plan on taking DN-2 at some point. I really enjoy the way they presented the material; and if you need a manual technique it’s not a bad place to go. Needling may have some power that perhaps other techniques may lack.
Want to know what that power is? Then you better keep reading.
Dry Needling vs. Acupuncture
I know what you are thinking. You are channeling your inner Frank Costello right this second:
The big differences are assessment and intent. SMI supports a medical assessment and treatment making anatomical sense. These two qualities are not always seen in the acupuncture realm.
In fact, it is this difference that actually makes medical acupuncturists safer than traditional acupuncturists. The literature shows double the adverse events comparing the two in some cases. Knowledge of anatomy is critical.
That said, SMI draws heavily from the acupuncture literature. And if rationale and style are the two big differences, I am totally cool with that.
Ray likened it to PT manipulation versus chiropractic adjustment. The psychomotor qualities are quite similar, but the purported mechanisms are often quite different. Either way, the literature is valuable.
What Exactly are we Needling?
Who knows? Likely, we are not going after trigger points in the traditional sense. The research has been pretty clear at debunking both our ability to “find” them (the error rate is 3.3-6.6 cm) and the classic Travell and Simons referral patterns.
What does exist is an inflammatory mess within the purported area. The longer inflammatory mediators are present, the more likely C-fibers will fire. Increased C-fiber firing increases area nociceptor and central receptor quantity, and eventual interneuronal death via substance P production.
And guess what? If you stick a needle in the area and achieve a localized twitch response (LTR), the inflammatory mediator concentration immediately changes.
You can call this area a trigger point, sore spot, or an AIGS. We are simply arguing semantics. It’s all the same (I’ll call them MTrPs from here on).
Let’s just agree on how to diagnose them. Here are the evidence-based assessment pieces for MTrPs as of this writing:
- There is a sore spot.
- The pain produced is familiar to the patient.
The Inner Workings
So how are needles going to help with all this jazz? Many ways.
Endogenous opioids play a huge role here. When this system kicks in, there is decreased immune molecule activity, reduced intracellular sodium, and increased potassium. This change increases resting membrane potential from -70 mV to -150 mV. That change makes it pretty tough for nociceptors to produce action potentials.
Everyone loves the nervous system, but some aneural cells also stimulate opioid production. Both keratinocytes and fibroblasts have been shown to produce opioids, which may be why many skin-level therapies are effective for pain.
Another purported mechanism occurs through adenosine production. When a needle is inserted, ATP production increases. When ATP is initially produced and binds with P2X receptors, pain is produced. This binding creates the desirable de qi response; that deep ache one feels when needled.
From there, ATP breaks down to ADP (which binds with P2Y receptors to produce pain) and finally adenosine. Once adenosine is produced, it can block nociception at the spinal cord level.
That’s not the only central mechanism with needling. Much of the literature has demonstrated that folks with active MTrPs on one side show many more latent MTrPs on the contralateral side. Does this not look an awful lot like mirror pain? A central phenomenon?
Moreover, if you look at decreasing limbic and paralimbic area activity, needling has been shown to dominate tactile stimulation. A needle might be a great way to shut down an amygdala hijack.
The Dunning Difference
The way SMI teaches needling is quite a bit different from your Kinetacores and Myopains from my understanding. The latter two are all about LTRs.
It is thought that the LTR helps remove accumulated acetylcholine in the neuromuscular junction. This molecule eventually cascades to increased calcium within the muscle, which can contribute to hyperactivity at the extrafusal motor endplate. Remove acetylcholine = remove hypertonicity = remove inflammatory markers.
However, this maneuver is not the show. Over the long term needling, with or without a LTR, has similar effects.
SMI likes to wind the needle. This technique has been shown to reorganize collagen fibers, stimulate keratinocytic and fibroblastic opioids via mechanotransduction, and increase ATP production.
This Ain’t Your Average Headache Lecture
I don’t want to spoil all the fun, but Ray changed my perception on headaches quite a bit; at least how big of an impact we can have.
Migraines were the big eye opener here. The symptoms of migraines both with and without aura have many parallels to cervicogenic headaches.
It may be the case that many diagnosed migraines are actually cervicogenic headaches, or at the very least have a cervicogenic trigger.
Which means guess what? We can help these people. The big tests to rule out a cervicogenic component:
- Lateral glides
- C1-C2 rotation – usually decreased in this population
If you do end up treating these folks (which per SMI involves needling and upper cervical manipulations), usually you will see improvements occur in the following order:
Frequency → duration → intensity
- “We’re going to have to start thinking outside of the box or we’ll be in the rehab museum.”
- “Let ‘em ride the lightning.”
- “Are you tracking on that?”
- “We don’t believe in vertebral subluxation but we can learn from those articles.”
- “You want to hang out and party with the median nerve, not tap it.”
- “As with many decisions of the APTA, it’s a decision of indecision.”
- “We don’t needle nipples. That’s not my bag.”
- “They probably need more needling than your average cat.”
- “We won’t do any fetal needling ya know what I mean?”
- “If you really want to piss off OTs, this will do it.”
- “That Butts guy is full of poop.”
Zac- I’ve taken both of SMI’s DN classes and both from Ray. I agree, Ray, having a PhD in neuroscience, knows his stuff and his were some of the better lectures I’ve heard. In additino, he puts a ton of energy into his class. How did you feel about some of the needling techniques in the C/S, hitting tapping into the capitus muscles, and the ones in the thorax and peri-scapular regions? I’ve had really good resutls from using their protcol for people presenting with heel pain, which they teach in DN-2.
I haven’t used the techniques on anyone yet, so I cannot comment. I want to make sure I have the techniques down a bit better before I go needling patients. I also haven’t felt the need to go that route yet. That said, those techniques were part of the reason I attended the course.
Look forward to DN-2
Hi Zac, great write up, and thanks for giving us an insight into you first dry needling experience.
I think for the right patient (no yellow/red flags or other psychosocial issues) dry needling can be extremely effective. I prefer the more aggressive method of finding tight areas (that restrict ROM and painful/tender to touch), needle them directly and activating a twitch response and then moving onto the next spot. I don’t think there is much point leaving the needles in for 8-30 minutes. The twitch is what gets the results, from my experience. So you can still do your other manual therapy, exercise intervention, education e.t.c. and needling may only take 5-10 minutes.
As your learnt in the course, there seems to be lots of different mechanisms about how/why dry needling works. I have been a patient many times myself receiving dry needling. As the researchers are showing, there are chemical changes, physical changes and stimulation of endorphins e.t.c.
In addition, I believe there must be something about the deep stimulation of the muscle fibers acitvating the homunculus/somatosensory cortex that provides pain relief, and deep relaxation of that part. These mechanisms obviously haven’t been fully explored yet, but I would love to be involved in some research down the track.
Of course, dry needling must be explained properly and used in the right context. All of your Pain science stuff must be incorporated so that you are not setting off alarms and creating nocebos. This is a real skill and a work in progress. You must ensure the autonomic nervous system is balanced (ie. not in sympathetic mode) prior to needling.
Having said that – I think you have an amazing tool there that is very powerful and will help create good quality movement i.e. less pain and improved ROM.
Good luck with practicing!
All the best,
Appreciate the comments Dan.
They did show a couple studies that activated somatosensory homunculus. The big differentiator for me was reduced limbic activity. To me that’s the difference.
I look forward to using it at some point 🙂
Good review. I guess Ray updated the course a bit since I took the DN-1 class. It’s definitely quality stuff I use in one form or another almost daily. The Differential Diagnosis class should be helpful for knowing when to needle what as part of the evaluation. I’d recommend taking that, but I’m very biased. Glad you liked it!
Appreciate the words of wisdom James. Will definitely consider. As of right now needling is to fit into a PRI framework
I would really be interested in you posting any experiences regarding use of DN to help someone achieve neutrality (esp those pesky PECs). I could see in situ placement for extended periods for paraspinal release being performed before some short seated work for a little extra inhibition. Especially if you are having a tough time getting them neutral.
Then once you start getting them into alternating activities or maybe they are having a hard time progressing from say a 2 to a 3 for HAdLT, you try some DN to the R GMax vs changing the exercise?
I have been through Kinetacore’s training but I have also been through Dunnings Spine Manip 1-3 courses (Dunning for 1 and Ray for 2/3) and am considering taking DN 1-2, I quickly learned that I didn’t need twitches to see changes in people and that most of what I was affecting was the neurological system more than the specific muscle I just addressed.
PS You have to take a course with Dunning, even if just once. Its an experience to remember and yes that entire group is incredibly passionate about PT and our future.
Always appreciate your perspective.
I will be curious as well. In my mind it’s a possible way to get one neutral or provide compensatory pain relief for someone who cannot undergo integration for whatever reason.
Thank you for the review. I will definitely add this to my list of courses to attend.
I have taken 2 courses from Kinetacore and 2 from Dr. Ma’s philosophy (Integrative Dry Needling and Systemic Dry Needling). They all have slightly different methods, but have stated that the LTR is not the holy grail. It is the primary focus in Kinetacore’s intro course but is de-emphasized in their Functional Therapeutics course.
Best of luck adding DN to your treatments!
Thank you for the comments John. Didn’t realize they were all so different. Too much to learn!
I’m curious how this group addresses the consistent findings in the needling literature that shows needling’s effects are not meaningfully better than a sham intervention? For more on this, I’d encourage you to read about a innovative needling trial by the bright minds at BodyInMotion.org, (http://www.bodyinmind.org/acupuncture-sensory-discrimination-low-back-pain/) who found that attention to the area getting needled versus distraction from it had a significant influence on reducing pain. They suggest that needling can promote improved awareness of the painful area, and cite a bunch of research in the area of sensorimotor training in support of that thesis. If this is the case: that you can just perform some sensory-discriminative training on a patient’s sore back and improve their pain, then that begs the question of why insert the needle through the skin? It become an issue of doing the least potentially harmful/most conservative intervention. No?
Incidentally, I’m perplexed by you decision to resort to “MTrP” as your label for tender spots on the one hand while acknowledging that PTs use a different explanatory model for performing manipulation on the other: “Ray likened it to PT manipulation versus chiropractic adjustment. The psychomotor qualities are quite similar, but the purported mechanisms are often quite different.” Doesn’t the term “MTrP” imply a mechanism? Isn’t this more than semantics? Why not just call it a “tender spot” and leave it at that?
Thank you for this thoughtful review.
Appreciate your comments and for reading my blog. Nice to see you around here.
SMI did mention the sham treatment studies you speak of. The question is if the sham provided is a true sham. A lot of the acupuncture literature calls a sham intervention placing the needles in non-acupoint locations. There is still a needle being inserted though, and still affecting the surrounding structures in some way. Can we call this a sham? I would argue no.
I am familiar with that study by Moseley and I enjoy what they did regarding the sensory discrimination. Redirecting attention the way they did no doubt aids in homuncular refreshments and makes it an active intervention; two things I like. Big fan of sensory discrim.
One might argue that performing sensory discrim without needle insertion may be effective, and as a user I agree. There are some studies out there, however, that compare needling to tactile stimulation alone. If you look at what occurs in the brain, needling reduces limbic and paralimbic signalling compared to tactile stim; no doubt important in our individuals who we treat. Although I agree with you in trying more conservative measures first…I still have yet to needle anyone 🙂
My decision was one of convenience; MTrP is fewer letters than tender spot and I can control-V the piss out of it 🙂 Moreover though, based on the current literature (i.e. sore spot pain reduction) I feel as though the trigger point model has been updated. However, I do not use that word with patients due to current conceptions of the term. When we talk among ourselves though, I would still say it is a semantic issue based on what I wrote.
Thank you again for the excellent comment,
If that’s the type of sham literature that SMI cited in their course, then they were cherry-picking. There’s lots of sham needling research where needles were NOT inserted through the skin. There’s a famous one- I believe an NIH/NCCAM funded study- where toothpicks were used on patients with LBP who had very similar results to those who received the real needling. Any differences in the short term can be attributed to diffuse noxious inhibitory control (DNIC), which accounts for activation of descending opioid pathways and also explain any subsequent changes in the local biochemical mileu around the tender spot (how ’bout just “TP”?).
There’s been much “irrational exuberance” around this latest, greatest treatment fad in PT, in my opinion. It’s pretty sexy cuz the therapist gets to show off his anatomy skills while finally legitimately performing an invasive procedure. With needling, it seems that the “D” in “DPT” has finally come to fruition.
Too bad it doesn’t work. https://www.sciencebasedmedicine.org/acupuncture-doesnt-work/
I agree wholeheartedly with you regarding the excitement around needling. It most certainly is not the end-all-be-all, and the fact that it has no learning component drops it down on my list. I have a hard time reflecting upon which previous patients I have had that I would even consider using this modality on…I can think of one patient who I would’ve performed DN, and the reason for that is he was one of those gents who liked “uncomfortable techniques.”
That’s what drove me to taking the course. Curiosity and patient preference. Some patients like that stuff…is it wrong to provide a tx that the patient prefers? I feel there is enough evidence in certain cases that DN has been shown effective (headaches are the prime example). SMI also showed “conditions” in which it’s not so effective (e.g. TMD).
To say DN doesn’t work may be throwing the baby out of the bathwater. In those trials in which DN is not “effective” there are some people who still get “better” from it. Instead of calling placebo, ought we consider looking at multiple characteristics in those individuals (and multiple outputs i.e. HRV, ROM, etc etc) to see if there is another explanation for treatment efficacy?
Appreciate the discussion, John.
Always love reading your blog. I must say however, I believe you may have been bamboozled by “citation overload” wherein a plethora of literature is presented with the preferred slant given to the unwitting customer.
When in fact, much or most of the citations are typically of poor quality, or the authors draw conclusions which far over reach what the data provided. If you just simply grab at random say…10 of the articles that were provided and perform your own in depth analysis (or bring them to someone who does research for a living….like I did)…and I think you will find yourself suddenly less inspired and more underwhelmed.
Anyhow…here is another side to read:
I greatly appreciate your comments and readership.
There definitely was citation overload present; understandable considering they’re selling a product. To SMI’s credit, they did show certain instances in where DN had mixed evidence (e.g. TMD) and provided mostly high-quality studies (lot’s of SRs and RCTs). Though I probably am not as well-versed on either side to comment…nor am I passionate enough about DN to move my current study to the area. I think that group (and even BOM, Moseley is not a big manual therapy guy) have great biases towards their methodology…as with most things, the answer is likely in the middle.
Hi Zac, thank you for writing this blog, I find it interesting.
I wonder, when a patient is being dry needled, what is the premise?
In other words, what tissue/physiological response is the needle affecting that is relevant in rehabilitating the patient in pain?
Thank you for reading my blog; appreciate your comment.
There are a lot of potential mechanisms; local changes in the biochemical milleu, spinal cord inhibitory mechanisms via alpha motor neuron reflexes, endogenous opioid activity, reduction in limbic/paralimbic activity. These factors may play a role in reducing someone’s pain. It seems that there are a lot of central factors that occur with needle insertion.
I think PTs should get out of the “alleviating pain” business, which would include using techniques like DN, among many others. There’s a big and important difference between providing pain alleviation- literally any witch doctor can do that- and providing the kind of care that brings about long-term resolution of a persistent pain problem.
The DN literature shows that this intervention provides short-term alleviation of pain, which I realize is very seductive in our perverse reimbursement structure and intense turf war environment. If we value ourselves as professionals and our patients as more than just sources of income and pleasant emotions, we need to take a broader view and rise above base enticements.
Incidentally, the claim made in the SR by Kietrys et al of “grade A” evidence in favor of DN is bogus. Any impartial statistician who has a journeyman familiarity with meta-analysis will tell you exactly why: it essentially boils down to too much heterogeniety, too much reliance on a single outlier, and a profound misunderstanding of what constitutes “grade A” evidence.
I agree that long-term resolution is the ideal, which has to belong in the patient’s hands. One could argue that any manual therapy alone could fit the criteria you discuss.
When a manual intervention is used to create an environment in which the patient can learn a nonthreatening movement strategy however, that changes the context in which these interventions are used. For the right person under the right context, DN is one of many possible interventions that could be implemented to create this environment.
Also, I do not believe Kietry’s et al was not used in the SMI manual. Familiar with that study’s shortcomings.
Thanks for your review. I have a bit more guarded view of the applicability of dry needling and recently outlined my concerns. I’ve presented 9 considerations to poner:
Thoughts and discussion encouraged.
I appreciate your comment and blog share.
Let me preface that I am not well-versed in the DN/acupuncture literature aside from what I’ve learned in the courses and what your blog (as well as the few others that popped up since your wrote yours). I really don’t use it enough to warrant a deep study yet, and I’m currently interested in other things right now.
After reading these pieces, I think I can safely say that the evidence regarding DN is mixed from an intervention standpoint. There is some biological plausibility presented in the literature that is quite enticing in my eyes. It’s just hard to say yes or no without a patient in front of us. I explained my rationale for applying manual interventions in this article here which I think you’d appreciate, and why in certain instances DN could be a justifiable intervention: https://zaccupples.com/2015/07/20/manual-therapy-musings/
Again appreciate the comment,
Did you feel there was adequate instructors to introduce the techniques to each group and proper instruction on safety. Safety as in the basics of needle insertion depth angle and bony landmarks do as not to needle unintended areas or puncture vital areas ? I would like to take a needling course and curious as to your thoughts with regards to the smi courses. Thanks
I did. The instructor went through every group to make sure the technique was done appropriately and they provided substantial evidence on safety. They are my go-to both from a teaching and price standpoint.
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