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For the right touch, See a physical therapist.© Iowa Physical Therapy Association & Foundation Celebrating 65 Years as a State Chapter of the 521 E Locust St, Suite 202 • Des Moines, IA 50309-1939 Phone 515-222-9838 • Fax 888-414-3183 [email protected] • www.iowaapta.org Iowa Physical Therapy Association Discussion on Dry Needling Thursday, August 27, 2015 Nevada, Iowa 1. Welcome and Introduction 2. APTA power point updating current status and recent activity 3. FSBPT Document review/reference 4. 2015 Iowa Legislative activity review 5. Current Acupuncturist Activities 6. Chiropractic Position 7. General Overview of Strategy for 2016 Legislative year & rest of 2015 From: "Shuman, Angela" <[email protected]> Date: August 19, 2015 at 11:00:31 AM CDT To: "Shuman, Angela" <[email protected]> Subject: FSBPT Dry Needling Competencies Report Now Available Dear APTA State Advocate, As you know, the issue of dry needling by physical therapists is one of the bigger PT scope of practice challenges currently playing out in the states. Yesterday, the Federation of State Boards of Physical Therapy (FSBPT) released its analysis of competencies for dry needling by physical therapists. The FSBPT report – which can be found HERE – is the result of many months of work by FSBPT and a task force comprised of physical therapists who perform and/or teach DN. The FSBPT contracted with the Human Resources Research Organization (HumRRO) to conduct the study in accordance with current best-practices in practice analysis procedures. As noted in the report, more than four-fifths of what PTs need to know to be competent in dry needling is acquired during the course of their entry-level education, including knowledge related to evaluation, assessment, diagnosis and plan of care development, documentation, safety, and professional responsibilities. Advanced or specialized training almost solely related to the needling technique and the psychomotor skills, is required to make up the deficit. The specific knowledge for competency in dry needling is noted in Table 2 on page 12 of the report, which may be helpful if your state is currently looking at possible PT Board regulations or legislation on this issue. Overall the report should assist in combating arguments made by opponents related to education, training, and competency for dry needling. Specific questions about the dry needling report can be directed to the FSBPT at [email protected]. Please let me know if you have any questions. Best, Angela L. Shuman Sr. State Affairs Specialist American Physical Therapy Association 1111 N. Fairfax Street Alexandria, VA 22314 703-706-3199 From: Federation of State Boards of Physical Therapy [mailto:[email protected]] Sent: Tuesday, August 18, 2015 5:44 PM Subject: Dry Needling Competencies Report Now Available To view this email as a web page, go here Dry Needling Competencies Report Now Available! August 18, 2015 For several years, U.S. jurisdictions have sought information from the Federation of State Boards of Physical Therapy (FSBPT) regarding the ability of physical therapists to perform dry needling. However, no publically available studies have explicitly examined what PTs must know and be able to do to perform dry needling safely and effectively. FSBPT contracted with the Human Resources Research Organization (HumRRO) to conduct the study in accordance with current best-practices in practice analysis procedures. HumRRO is a non-profit, social and behavioral science research and consulting firm dedicated to the measurement and improvement of human and organizational performance. As an independent contractor, HumRRO was instrumental in carrying out an objective, unbiased analysis. More than four-fifths of what PTs need to know to be competent in dry needling is acquired during the course of their entry-level education, including knowledge related to evaluation, assessment, diagnosis and plan of care development, documentation, safety, and professional responsibilities. Advanced or specialized training, almost solely related to the needling technique and the psychomotor skills, is required to make up the deficit. Read the report here: http://www.fsbpt.org/FreeResources/RegulatoryResources.aspx For more information, contact [email protected]. American Physical Therapy Association - 1111 N. Fairfax Street, Alexandria, VA, 22314. 800-999-APTA (2782). To manage the types of email messages you receive from APTA, please visit www.apta.org/email Dry Needling in Other States – APTA synopsis Dry needling is now specifically recognized in the following PT practice acts: Georgia, Utah, Arizona, Tennessee, and Delaware. All but Delaware pursued legislation because of a negative attorney general opinion. Not allowed (5): California, Hawaii, Idaho, South Dakota, New York Questionable, under active challenge; use caution (7): Illinois, Florida, Michigan, Nebraska, Oregon, Pennsylvania, Washington No opinion from the state, use caution (11): Alaska, Arkansas, Indiana, Minnesota, Missouri, North Dakota, Oklahoma, Connecticut, Rhode Island, New Jersey, Maine Allowed - included in practice act, board rules, board opinion, board statement, attorney general opinion (27 and DC): Arizona, Nevada, Montana, Wyoming, Utah, Colorado, New Mexico, Texas, Kansas, Iowa, Louisiana, Mississippi, Alabama, Georgia, Tennessee, South Carolina, North Carolina, Kentucky, Wisconsin, Ohio, West Virginia, Virginia, Maryland, Delaware, Massachusetts, New Hampshire, Vermont. There have been several positive attorney general opinions in other states, and most if not all of them have involved an interpretation of practice acts that includes dry needling as the use of “mechanical devices”. Iowa’s practice act includes mechanical devices, so that could be helpful in making the argument that dry needling is included in the Iowa practice act, but of course it’s not the only factor. Dry Needling in Orthopaedic Physical Therapy Practice Jan Dommerholt, PT, MPS NOTE: Consistent with ethical guidelines,the author wishes to disclose that he is co-founder and co-program director of the Janet G.Travell, MD Seminar SeriesSM, the only US-based continuing education program that offers courses for physical therapists in the technique of dry needling. Readers, check with your own state practice acts on the use of this technique. offer academic programs that include dry needling courses. The University of Castilla - La Mancha offers a postgraduate degree in conservative and invasive physical therapy. At the University of Valencia, dry needling is included in the curriculum of the master’s degree program in manipulative physical therapy. In Switzerland, dry needling courses are offered via the accredited continuing education program of the ‘Interessengemeinschaft für Manuelle Triggerpunkt Therapie’ (Society for Manual Trigger Point Therapy). Physical therapists in the UK are increasingly being trained in joint injection techniques.2 In the United States,dry needling is not included in physical therapy educational curricula and relatively few physical therapists employ the technique. Dry needling is erroneously assumed to fall under the scopes of medical practice or oriental medicine and acupuncture. However, physical therapy state boards of Maryland, New Hampshire,New Mexico,and Virginia have already ruled that dry needling does fall within the scope of physical therapy in those states. The Tennessee Board of Occupational and Physical Therapy recently rejected dry needling by physical therapists. The general counsel of the Illinois Department of Regulation advised that dry needling would not fall within the scope of practice of physical therapy but should be covered by the board of acupuncture. In the mean time, physical therapists who are adequately trained in the technique of dry needling are successfully employing the technique with a wide variety of patients. INTRODUCTION Orthopaedic physical therapists employ a wide range of intervention strategies to reduce patients’pain and improve function. From time to time, new treatment approaches are being introduced to the field of physical therapy. The arrival of manual therapy in the United States is a good example. Although for several decades, manual physical therapy was already an essential part of the scope of orthopaedic physical therapy practice in Europe, New Zealand, and Australia, manual therapy did not make its debut in the United States until the 1960s.1 Initially many US state boards of physical therapy opposed the use of manual therapy. In spite of the early resistance,manual physical therapy has become a mainstream treatment approach. Manual therapy techniques are now taught in academic programs and continuing education courses. During the past few years,physical therapists,the APTA,and the AAOMPT even have had to defend the right to practice manual therapy especially when challenged by the chiropractic community! A similar development is in progress with the relatively new technique of dry needling. While some physical therapy state boards have already decided that dry needling falls within the scope of physical therapy practice, others are still more hesitant. The goal of this paper is to introduce the American orthopaedic physical therapy community to the technique of dry needling. DRY NEEDLING TECHNIQUES Several dry needling approaches have been developed based on different individual theories, insights, and hypotheses. The 3 main schools of dry needling are presented: the myofascial trigger point model, the radiculopathy model, and the spinal segmental sensitization model. DRY NEEDLING Dry needling is commonly used by physical therapists around the world. For example, in Canada, many provinces allow physical therapists to use dry needling techniques. In Spain, several universities Myofascial Trigger Point Model Dry needling is used primarily in the treatment of myofascial trigger points (MTrPs), defined as “hyperirritable spots in skeletal muscle associated with hypersensitive palpable nodules in a taut band.”3 The Orthopaedic Practice Vol. 16;3:04 11 MTrPs are the hallmark characteristic of myofascial pain syndrome (MPS). A recent survey of physician members of the American Pain Society showed general agreement that MPS is a distinct syndrome.4 Throughout the history of manual physical therapy,MPS and MTrPs have received little or no attention, although several studies have demonstrated that MTrPs are commonly seen in acute and chronic pain conditions,and in nearly all orthopaedic condiVecchiet and colleagues demontions.5 strated that acute pain following exercise or sports participation is often due to acutely painful MTrPs. Myofascial trigger points are often responsible for complaints of pain in persons with hip osteoarthritis,6 pain with cervical disc lesions,7 pain with TMD,8 pelvic pain,9 headaches,10 epicondylitis,11 etc. Hendler and Kozikowski concluded that MPS is the most commonly missed diagnoses in chronic pain patients.12 A brief review of the current knowledge of MTrPs and MPS is indicated to better understand the place of dry needling within orthopaedic physical therapy. Already during the early 1940s, Dr. Janet Travell (1901-1997) realized the importance of MPS and MTrPs. Recent insights in the nature, etiology, and neurophysiology of MTrPs and their associated symptoms have propelled the interest in the diagnosis and treatment of persons with MPS worldwide. The mechanism that underlies the development of MTrPs is not known, but altered activity of the motor end plate, or neuromuscular junction, is most likely. Changes in acetylcholine receptor (AChR) activity, in the number of receptors, and changes in acetylcholinesterase (AChE) activity are consistent with known mechanisms of end plate function, and could explain the changes in end plate activity that occur in the MTrP. There is a marked increase in the frequency of miniature end plate potential activity at the point of maximum tenderness in the taut band in the human, and in the neuromuscular junction end plate zone of the taut band in the rabbit model and in humans. Normally, ACh is broken down by AChE. Preliminary results of studies by Shah and associates at the National Institutes of Health indicate that a number of biochemical alterations are commonly found at the active MTrP site using microdialysis sampling techniques.13 Among the changes found are elevated bradykinin, substance P, and calcitonin gene-related peptide (CGRP) levels, and lowered pH when compared to inactive (asymptomatic) MTrPs and to normal controls.13The combination of increased levels of CGRP and lowered pH suggest that the milieu of a MTrP is too acidic for AChE to function efficiently. The possible implications for the development of MTrPs is outside the scope of this article and will be addressed in a future article.14 The administration of botulinum toxin can block the release of ACh, and is therefore now widely used in the management of chronic and persistent MPS. Abnormal end plate noise (EPN) associated with MTrPs can be visualized with electromyography using a monopolar teflon-coated needle electrode and a slow insertion technique.15,16 Active MTrPs are spontaneously painful, refer pain to more distant locations, and cause muscle weakness, mechanical range of motion restrictions, and several autonomic phenomena. One of the unique features of MTrPs is the phenomenon of the local twitch response (LTR), which is an involuntary spinal cord reflex contraction of the contracted muscle fibers in a taut band following palpation or needling of the band or trigger point.17 The LTR can be visualized with needle electromyography and ultrasonography.18,19 To make a diagnosis of MPS, the minimum essential features that need to be present are the taut band, an exquisitely tender spot in the taut band, and the patient’s recognition of the pain complaint by pressure on the tender nodule.20 Simons,Travell, and Simons add a painful limit to stretch range of motion as the fourth essential criterion.3 Referred pain, the LTR, and the electromyographic demonstration of end plate noise are confirmatory observations and not essential for the clinical diagnosis. From a biomechanical perspective, National Institutes of Health researchers Wang and Yu hypothesized that MTrPs are severely contracted sarcomeres whereby myosin filaments literally get stuck in titin gel at the Z-band of the sarcomere (Figures 1 and 2).21 Titin is the largest known protein that connects the Z-band with myosin filaments within a sarcomere. Approximately 90% of titin consists of 244 repeating copies of fibronectin I - Band A - Band I - Band M Band Actin Titin H Zone Myosin Z -line Figure 1. Schematic representation of a normal sarcomere. Figure 2. Schematic representation of a MTrP with myosin filaments literally stuck in titin gel at the Z-line (after Wang K, Yu L. Emerging Concepts of Muscle Contraction and Clinical Implications for Myofascial Pain Syndrome. Presented at Focus on Pain 2000, Mesa, AZ: Janet G. Travell, MD Seminar Seriessm.) type III and immunoglobin domains, which may contribute to the sticky nature of titin once muscle fibers are contracted. Histological studies have confirmed the presence of extreme sacromere contractions, resulting in localized tissue hypoxia.22 Brückle and colleagues established that the local oxygen saturation at a MTrP site is less than 5% of normal.23 Hypoxia leads to the release of local release of several nociceptive chemicals, including bradykinin, CGRP, and substance P,among others,which have been detected in abnormal high concentrations at MTrPs.13 Bradykinin is a nociceptive agent that stimulates the release of tumor necrosing factor and interleukins, some of which in turn can stimulate the further release of bradykinin. Calcitonin gene-related peptide modulates synaptic transmission at the neuromuscular junction by inhibiting the expression of AChE,which is another likely mechanism that contributes to the excessively high concentration of ACh. Split fibers, ragged red fibers, type II fiber atrophy, and fibers with a motheaten appearance have been detected in MTrPs.22 Ragged red fibers and moth12 eaten fibers are also associated with muscle ischemia and represent an accumulation of mitochondria or a change in the distribution of mitochondria or the sarcotubular system respectively. Combining these various lines of research, it can be concluded that MTrPs function as peripheral nociceptors that can initiate, accentuate, and maintain the process of central sensitizaton.24 As a source of peripheral nociceptive input, MTrPs are capable of unmasking sleeping receptors in the dorsal horn, resulting in spatial summation and the appearance of new receptive fields, which clinically are identified as areas of referred pain. The MTrPs are commonly associated with other pain states and diagnoses, including complex regional pain syndrome, and should be considered in the clinical management.25 Treatment of MTrPs is only one of the components of the therapeutic program, and does not replace other therapeutic measures, such as joint mobilizations, posture training, strengthening, etc. As MTrPs are easily accessible to trained hands, inactivating MTrPs is one of the most effective and fastest means to reduce pain. Dry needling is the most precise method currently available to physical therapists. Myofascial trigger points can be identified by palpation only. There are no other diagnostic tests that can accurately identify an MTrP, although new methodologies using piezoelectric shockwave emitters are being explored.26 Excellent inter-rater reliability has been established.20,27 Simons, Travell, and Simons describe 2 palpation techniques for the proper identification of MTrPs. A flat palpation technique is used for example with palpation of the infraspinatus, the masseter, temporalis, and lower trapezius. A pincher palpation technique is used for example with palpation of the sternocleidomastoid, the upper trapezius, and the gastrocnemius. Trigger point dry needling Janet Travell pioneered the use of MTrP injections that eventually led to the development of dry needling. Her first paper describing MTrP injection techniques was published in 1942, followed by many others. Together with Dr. David Simons she wrote the 2-volume Trigger Point Manual.3,28 Many studies have confirmed the benefits of trigger point injections even though a recent review article could not demonstrate clinical efficacy Orthopaedic Practice Vol. 16;3:04 beyond placebo.5,29 In 1979 Lewit confirmed that the effects of needling were primarily due to mechanical stimulation of a MTrP with the needle.30 Dry needling of a MTrP using an acupuncture needle caused immediate analgesia in nearly 87% of needle sites. In over 31% of cases, the analgesia was permanent. Twenty percent had several months of pain relief,22% several weeks, and 11% several days. Fourteen percent had no relief at all.30 Dry needling an MTrP is most effective, when local twitch responses (LTR) are elicited.31 A LTR has been shown to inhibit abnormal end plate noise. Current (unpublished) research strongly suggests that a LTR is essential in altering the chemical milieu of an MTrP (Shah, 2004, personal communication). Patients commonly describe an immediate reduction or elimination of the pain complaint after eliciting LTRs. Once the pain is reduced, patients can start active stretching, strengthening, and stabilization programs. Eliciting a LTR with dry needling is usually a rather painful procedure. Post- needling soreness may last for 1 to 2 days, but can easily be distinguished from the original pain complaint. Patients with chronic pain frequently report to have received previous trigger point injections; however, many state that they never experienced LTRs. Accurate needling requires clinical familiarity with MTrPs and excellent palpation skills. Dr. Peter Baldry has adopted the Travell and Simons trigger point model, but prefers a gentler and less mechanistic approach to needling MTrPs when possible. According to Baldry, using a superficial needling technique is nearly always effective. With superficial dry needling,the needle is placed in the skin and cutaneous tissues overlying an MTrP. Baldry agrees that both superficial and deep dry needling have their place in the management of MTrPs.32 A recent study confirmed that both superficial and deep dry needling are effective with dry needling having a stronger and more immediate effect.33 Radiculopathy Model In Canada,Dr.Chan Gunn developed his ‘radiculopathy model’ and coined the term ‘intramuscular stimulation’ instead of dry needling.34 Gunn has expressed the belief that myofascial pain is always secondary to peripheral neuropathy or radiculopathy and therefore, myofascial pain would always be a reflection of neuropathic pain Orthopaedic Practice Vol. 16;3:04 in the musculoskeletal system. Because of muscle shortening, which in this model is always due to neuropathy, ‘supersensitive nociceptors’may be compressed,leading to pain. The radiculopathy model is based on Cannon and Rosenblueth’s “Law of Denervation.” According to this law, the function and integrity of innervated structures is dependent upon the free flow of nerve impulses to provide a regulatory or trophic effect. When the flow of nerve impulses is restricted, the innervated structures become atrophic, highly irritable, and supersensitive. Striated muscles are thought to be the most sensitive innervated structures and according to Gunn, become the “key to myofascial pain of neuropathic origin.” Because of the neuropathic supersensitivity, Gunn states that muscle fibers “can overreact to a wide variety of chemical and physical inputs including stretch and pressure.” The mechanical effects of muscle shortening may result in commonly seen conditions, such as tendonitis, arthralgia, and osteoarthritis. Shortening of the paraspinal muscles is thought to perpetuate radiculopathy by disc compression, narrowing of the intervertebral foramina,or by direct pressure on the nerve root. Gunn found that the most effective treatment points are always located close to the muscle motor points or musculotendinous junctions. They are distributed in a segmental or myotomal fashion in muscles supplied by the primary anterior and posterior rami. In Gunn’s model, MTrPs do not play an important role. Because the primary posterior rami are segmentally involved in the muscles of the paraspinal region, including the multifidi, and the primary anterior rami with the remainder of the myotome, the treatment must always include the paraspinal muscles as well as the more peripheral muscles. Gunn found that the tender points usually coincide with painful palpable muscle bands in shortened and contracted muscles. He suggests that nerve root dysfunction is particularly due to spondylotic changes. He maintains that relatively minor injuries would not result in severe pain that continues beyond a ‘reasonable’ period, unless the nerve root would already be in a sensitized state prior to the injury. Gunn’s assessment technique is based on the evaluation of specific motor, sensory,and trophic changes. The main objective of the initial examination is to determine which levels of neuropathic dys13 function are present in a given individual. The examination is rather limited and does not include standard medical and physical therapy evaluation techniques, including common orthopaedic or neurological tests, laboratory tests, electromyographic or nerve conduction tests or radiologic tests, such as MRI, CT scan, or even X-rays. Motor changes are assessed through a few functional motor tests and through systematic palpation of the skin and muscle bands along the spine and in the peripheral muscles of the involved myotomes. Gunn emphasizes to assess trophic changes in the paraspinal regions segmentally corresponding to the area of dysfunction. Trophic changes may include orange peel skin (peau d’orange), dermatomal hair loss,differences in skin folds, and moisture levels (dry vs. moist skin).34 Unfortunately, Gunn’s radiculopathy model as a hypothesis to explain chronic musculoskeletal pain has not really been developed beyond its initial inception in 1973. Although Gunn has published numerous interesting case reports and review articles restating his opinions, most components of the model have not been subjected to scientific investigations and verification. In fact,many of Gunn’s underlying assumptions are contradicted by more recent research findings. For example, Gunn’s notion that persistent nociceptive input is uncommon contradicts many recent neurophysiological studies confirming that persistent and even relative brief nociceptive input can result in pain producing plastic dorsal horn changes. The major contributions of Gunn to the field of MPS and dry needling are the emphasis on segmental dysfunction and the suggestion that neuropathy may be a possible cause of myofascial dysfunction. Certainly with regard to motor dysfunction associated with MPS, the combined impact of the primary anterior and posterior rami is an important consideration. For example, from a segmental perspective, it would be likely to see dysfunction of the C5-C6 paraspinal muscles when MTrPs are present in the more peripheral infraspinatus muscle. The Spinal Segmental Sensitization Model The Spinal Segmental Sensitization Model is developed by Dr.Andrew Fischer and combines aspects of Travell and Simons’ trigger point model and Gunn’s radiculopathy model.35 Fischer proposes that the “pen- tad of the vicious cycle of discopathy, paraspinal muscle spasm and radiculopathy”consists of paraspinal muscle spasm frequently responsible for compression of the nerve root, narrowing of the foraminal space,and a sprain of the supraspinous ligament with radicular involvement. Fischer advocates a comprehensive medical evaluation. According to Fischer, the most effective methods for relief of musculoskeletal pain include preinjection blocks, needle and infiltration of tender spots and trigger points, somatic blocks, spray and stretch methods, and relaxation exercises. Based on empirical observations,Fischer routinely infiltrates the supraspinous ligament,which “inactivates tender spots/trigger points in the corresponding myotome, relaxing the taut bands,and increasing the pressure pain thresholds as documented by algometry.” The MTrP injections with Fischer’s needling and infiltration technique are thought to “mechanically break up abnormal tissue” and “a layer of edema.” The main differences between Fischer’s and Gunn’s approach are the extent of the physical examination, the use of injection needles by Fischer, and acupuncture needles by Gunn, Fischer’s recognition of the importance of MTrPs, and the infiltration of the supraspinous ligament. Furthermore, Fischer’s model seems more dynamic. He has integrated many new research findings into his approach;for example,Fischer acknowledges that central sensitization is often due to ongoing peripheral nociceptive input. Fischer’s proposed interventions use multiple injection techniques and are therefore not that useful for physical therapists. As far is known, the Maryland Board of Physical Therapy Examiners is the only physical therapy board that has ruled that physical therapists may perform MTrP injections. MECHANISMS OF DRY NEEDLING Although muscle needling techniques have been used for thousands of years in the practice of acupuncture, there is still much uncertainty about their underlying mechanisms. The acupuncture literature may provide some answers, however, due to its metaphysical and philosophical nature, it is difficult to apply traditional acupuncture principles to the practice of using acupuncture needles in the treatment of MPS. Mechanical Effects Dry needling of an MTrP may mechanically disrupt the integrity of the dysfunc- tional motor end plates. From a mechanical point of view, needling of MTrPs may be related to the extremely shortened sarcomeres. It is plausible that an accurately placed needle provides a localized stretch to the contracted cytoskeletal structures, which may disentangle the myosin filaments from the titin gel at the Z-band. This would allow the sarcomere to resume its resting length by reducing the degree of overlap between actin and myosin filaments. If indeed a needle can mechanically stretch the local muscle fiber, it would be beneficial to rotate the needle during insertion. Rotating the needle results in winding of connective tissue around the needle,which clinically is experienced as a ‘needle grasp.’ Comparisons between the orientation of collagen following needle insertions with and without needle rotation demonstrated that the collagen bundles were straighter and more nearly parallel to each other after needle rotation.36 Langevin and colleagues report that brief mechanical stimulation can induce actin cytoskeleton reorganization and increases in proto-oncogenes expression, including cFos and tumor necrosing factor and interleukins.36 Moving the needle up and down as is done with needling of a MTrP may be sufficient to cause a needle grasp and a resultant LTR. As a result of mechanical stimulation, group II fibers will register a change in total fiber length, which may activate the gate control system by blocking nociceptive input from the MTrP and hence cause alleviation of pain.32 The mechanical pressure exerted via the needle also may electrically polarize the connective tissue and muscle. A physical characteristic of collagen fibers is their intrinsic piezoelectricity, a property that allows tissues to transform mechanical stress into electrical activity necessary for tissue remodeling, possibly contributing to the LTR.37 Neurophysiologic Effects In his arguments in favor of neurophysiological explanations of the effects of dry needling, Baldry concludes that with the superficial dry needling technique, A-delta nerve fibers (group III) will be stimulated for as long as 72 hours after needle insertion. Prolonged stimulation of the sensory afferent A-delta nerve fibers may activate the enkephalinergic inhibitory dorsal horn interneurons, which would imply that superficial dry 14 needling causes opioid mediated pain suppression.32 Another possible mechanism of superficial dry needling is the activation of the serotonergic and noradrenergic descending inhibitory systems, which would block any incoming noxious stimulus into the dorsal horn.The activation of the enkephalinergic, serotonergic, and noradrenergic descending inhibitory systems occurs with dry needle stimulation of A-delta nerve fibers anywhere in the body.32 Skin and muscle needle stimulation of A-delta and C(group IV) afferent fibers in anesthetized rats was capable of producing an increase in cortical cerebral blood flow, which was thought to be due to a reflex response of the afferent pathway, including group II and IV afferent nerves and the efferent intrinsic nerve pathway, including cholinergic vasodilators.38 Superficial needling of certain acupuncture points in patients with chronic pain showed similar changes in cerebral blood flow.39 Gunn’s and Fischer’s techniques of needling both the paraspinal muscles and peripheral muscles belonging to the same myotome, appear to be supported by several animal studies. For example,Takeshige and Sato determined that both direct needling into the gastrocnemius muscle and into the ipsilateral L5 paraspinal muscles of a guinea pig resulted in significant recovery of the circulation, after ischemia was introduced to the muscle using tetanic muscle stimulation.40 They also confirmed that needling of acupuncture points and non-acupuncture points involved the descending pain inhibitory system, although the actual afferent pathways Acupuncture were distinctly different. analgesia involved the medial hypothalamic arcuate nucleus of the descending pain inhibitory system, while non-acupuncture analgesia involved the anterior part of the In both hypothalamic arcuate nucleus. kinds of needle stimulation, the posterior hypothalamic arcuate nucleus was involved. There is no research to date that clarifies the role of the descending pain inhibitory system with needling of MTrPs. Chemical Effects The studies by Shah and colleagues demonstrated that the increased levels of various chemicals, such as bradykinin, CGRP, substance P, and others, at MTrPs are immediately corrected by eliciting a LTR with an acupuncture needle. Although it is not known what happens Orthopaedic Practice Vol. 16;3:04 to these chemicals when a needle is inserted into the MTrP, there is now strong albeit unpublished data that suggest that eliciting a LTR is essential.13 STATUTORY CONSIDERATIONS Whether from a legal or statutory perspective, physical therapists can perform dry needling techniques, has not been considered in most states. However, the physical therapy state boards of Maryland, New Mexico, New Hampshire, and Virginia have officially determined that dry needling falls within the scope of physical therapy practice in those states. Dry needling by physical therapists must be regulated by state boards of physical therapy and not by state boards of acupuncture or oriental medicine. Dry needling is not equivalent to acupuncture and should not be considered a form of acupuncture. For example,the New Mexico Acupuncture and Oriental Medicine Practice Acta defines acupuncture as “the use of needles inserted into and removed from the human body and the use of other devices,modalities and procedures at specific locations on the body for the prevention,cure or correction of any disease, illness, injury, pain, or other condition by controlling and regulating the flow and balance of energy and functioning of the person to restore and maintain health.” Obviously, dry needling involves the use of needles inserted into and removed from the human body; however, that is the only similarity between dry needling and acupuncture. Similarly, if a hammer is associated with carpenters, do plumbers become carpenters every time they use a hammer? The objective of dry needling is not to control and regulate the flow and balance of energy and is not based on Eastern esoteric and metaphysical concepts. The fact that needles are being used in the practice of dry needling does not imply that an acupuncture board would automatically have jurisdiction over such practice. If so, physicians and nurses would also need to conform to the statutes of acupuncture, as they also “insert and remove needles.” Many boards of physical therapy in the United States have adopted a variation of the “Model Practice Act for Physical Therapy” developed by the Federation of State Boards of Physical Therapy (http://www.fsbpt.org). Neither the Model Practice Act or any of the actual state practice acts address whether dry needling falls within the scope of physical Orthopaedic Practice Vol. 16;3:04 therapy practice. However, based on the definitions of physical therapy practice, dry needling may well fall within the scope of practice in nearly all states. The respective statutes commonly include statements like “the practice of physical therapy means administering treatment by mechanical devices,” “mechanical modalities,” or “mechanical stimulation.” Exclusions to the practice of physical therapy are frequently defined as “the use of roentgen rays and radioactive materials for diagnosis and therapeutic purposes, the use of electricity for surgical purposes, and the diagnosis of disease.” Most state physical therapy acts do not specifically prohibit the use of needles. Whether physical therapists are legally allowed to penetrate the skin has been addressed in few statutes and usually only in the context of performing electromyography and nerve conduction tests. The Model Practice Act does include “electrodiagnostic and electrophysiologic tests and measures.” For example, the Missouri Revised Statutesb indicate that “physical therapy [...] does not include the use of invasive tests,” yet, the statutes state specifically “physical therapists may perform electromyography and nerve conduction test” even though they “may not interpret the results.” The California Physical Therapy Actc does address the issue of “tissue penetration:” “A physical therapist may, upon specified authorization of a physician and surgeon, perform tissue penetration for the purpose of evaluating neuromuscular performance as part of the practice of physical therapy [...] provided the physical therapist is certified by the board to perform tissue pena b c d New Mexico Statutes Annotated 1978, Chapter 61, Professional and Occupational Licenses, Article 14A, Acupuncture and Oriental Medicine Practice, 3, Definitions Missouri Revised Statutes, Chapter 334, Physicians and Surgeons – Therapists – Athletic Trainers, Section 334.500, Definitions California Business and Professions Code, Division 2, Healing Arts, Chapter 5.7, Physical Therapy, Section 2620.5 The 2003 Florida Statutes, Title XXXII, of Professions and Regulation Occupations, Chapter 486, Physical TherapyAct,Section 486.021,Definitions, 11,Practice of Physical Therapy 15 etration and provided the physical therapist does not develop or make diagnostic or prognostic interpretations of the data obtained.” It is not clear whether the California practice act would allow dry needling at this time. In any case, it appears that physical therapists would need to be certified by the board to perform tissue perforation. The definition of physical therapy practice in the 2004 Florida Statutesd includes “the performance of acupuncture only upon compliance with the criteria set forth by the Board of Medicine, when no penetration of the skin occurs.”The Florida board does not indicate how acupuncture or for that matter, dry needling, would be performed without penetrating the skin and this remains a mystery. Interestingly, the physical therapy practice act in Florida does include “the performance of electromyography as an aid to the diagnosis of any human condition.” In order to practice dry needling, physical therapists would have to be able to demonstrate competency or adequate training in the examination and treatment of persons with MPS and in the technique of dry needling. Many statutes address the issue of competency by including language like “a physical therapist shall not perform any procedure or function for which he is by virtue of education or training not competent to perform.” Obviously, physical therapists employing dry needling must have excellent knowledge of anatomy and be very familiar with the indications, contraindications, and precautions. In summary, most physical therapy practice acts may allow dry needling, according to the various definitions of “practice of physical therapy.” Whether individual state boards would interpret their statutes in a similar fashion as the Maryland, New Mexico, New Hampshire, and Virginia physical therapy state boards have, remains to be seen. REFERENCES 1. Paris SV. A history of manipulative therapy through the ages and up to the current controversy in the United States. J Manual Manip Ther. 2000;8 (2):66-77. 2. Baker R, et al. A Clinical Guideline for the Use of Injection Therapy by Physiotherapists.London:The Chartered Society of Physiotherapy;2001. 3. Simons DG, Travell JG, Simons LS. Travell and Simons’ Myofascial Pain and Dysfunction; the Trigger Point Manual. 2nd ed. Baltimore, Md: Williams & Wilkins; 1999. 4. Harden RN, Bruehl SP, Gass S, Niemiec C,Barbick B.Signs and symptoms of the myofascial pain syndrome: a national survey of pain management providers. Clin J Pain. 2000;16(1):64-72. 5. Dommerholt J. Muscle pain syndromes. In:Myofascial Manipulation. Cantu RI, Grodin AJ, ed. Gaithersburg, Md:Aspen; 2001:93-140. 6. Bajaj P, et al. Trigger points in patients with lower limb osteoarthritis. J Musculoskeletal Pain. 2001;9(3):17-33. 7. Hsueh, TC, Yu S, Kuan TS, Hong CZ. Association of active myofascial trigger points and cervical disc lesions. J Formos Med Assoc.1998;97(3):174-180. 8. Kleier DJ. Referred pain from a myofascial trigger point mimicking pain of endodontic origin. J Endod. 1985;11(9):408-411. 9. Ling FW, Slocumb JC. Use of trigger point injections in chronic pelvic pain. Obstet Gynecol Clin North Am. 1993;20(4):809-815. 10.Mennell J. Myofascial trigger points as a cause of headaches. J Manipulative Physiol Ther. 1989;12(4):308-313. 11.Simunovic Z. Low level laser therapy with trigger points technique: a clinical study on 243 patients. J Clin Laser Med Surg. 1996;14(4):163-167. 12.Hendler NH,Kozikowski JG.Overlooked physical diagnoses in chronic pain patients involved in litigation. Psychosomatics.1993;34(6):494-501. 13.Shah J, et al. A novel microanalytical technique for assaying soft tissue demonstrates significant quantitative biomechanical differences in 3 clinically distinct groups: normal, latent and active. Arch Phys Med Rehabil. 2003;84:A4. 14.Gerwin, RD, Dommerholt J, Shah J. An expansion of Simons’integrated hypothesis of trigger point formation. Curr Pain Headache Rep.In press 2004. 15.Simons, DG, Hong C-Z, Simons LS. Endplate potentials are common to midfiber myofascial trigger points. Am J Phys Med Rehabil.2002;81(3):212-222. 16.Couppé C, et al. Spontaneous needle electromyographic activity in myofascial trigger points in the infraspinatus muscle: A blinded assessment. J Musculoskeletal Pain.2001;(3):7-17. 17.Hong C-Z,Yu J. Spontaneous electrical activity of rabbit trigger spot after transection of spinal cord and peripheral nerve. J Musculoskeletal Pain. 1998;6(4):45-58. 18.Gerwin RD, Duranleau D. Ultrasound identification of the myofascial trigger point. Muscle Nerve. 1997;20(6):767768. C-Z, Torigoe Y. Electro19.Hong physiological characteristics of localized twitch responses in responsive taut bands of rabbit skeletal muscle. J Musculoskeletal Pain.1994;2:17-43. 20.Gerwin RD, Shannon S, Hong CZ, Hubbard D, Gervitz R. Interrater reliability in myofascial trigger point examination. Pain. 1997;69(1-2):65-73. 21.Wang K,Yu L. Emerging Concepts of Muscle Contraction and Clinical Implications for Myofascial Pain syndrome (abstract). In: Focus on Pain. Mesa, Ariz: Janet G.Travell, MD Seminar Seriessm; 2000. 22.Windisch A,Reitinger A,Traxler H,et al. Morphology and histochemistry of myogelosis. Clin Anat.1999;12(4):266271. 23.Brückle W, Suckfull M, Fleckenstein W, Weiss C,Muller W.Gewebe-pO2-Messung in der verspannten Rückenmuskulatur (m. erector spinae). Z Rheumatol. 1990;49:208-216. 24.Mense S,Hoheisel U.New developments in the understanding of the pathophysiology of muscle pain. J Musculoskeletal Pain.1999;7(1/2):13-24. 25.Dommerholt J. Complex regional pain syndrome; part 1: history, diagnostic criteria and etiology. J Bodywork Movement Ther. 2004;8(3):167-177. 26.Bauermeister W. The diagnosis and treatment of myofascial trigger points using shockwaves. In: Myopain. Munich: Haworth; 2004. 27.Sciotti VM, Mittak VL, DiMarco L, et al. Clinical precision of myofascial trigger point location in the trapezius muscle. Pain. 2001;93(3):259-266. 28.Travell,JG, Simons DG. Myofascial Pain and Dysfunction: The Trigger Point Manual. Vol. 2. Baltimore, Md: Williams & Wilkins; 1992. 29.Cummings TM, White AR. Needling therapies in the management of myofascial trigger point pain: a systematic review. Arch Phys Med Rehabil. 2001;82(7):986-992. 30.Lewit K.The needle effect in the relief of myofascial pain. Pain.1979;6:83-90. 31.Hong CZ. Lidocaine injection versus 16 dry needling to myofascial trigger point. The importance of the local twitch response. Am J Phys Med Rehabil. 1994;73(4):256-263. 32.Baldry PE. Myofascial Pain and Fibromyalgia Syndromes.Edinburgh: Churchill Livingstone; 2001. 33.Ceccherelli F, Rigoni MT, Gagliardi G, Ruzzante L. Comparison between superficial and deep acupuncture in the treatment of lumbar myofascial pain: a double-blind randomized controlled study. Clin J Pain.2002;18:149-153. 34.Gunn CC. The Gunn Approach to the Treatment of Chronic Pain.2nd ed.New York,NY:Churchill Livingstone;1997. 35.Fischer AA. Treatment of myofascial pain. J Musculoskeletal Pain. 1999;7 (1/2):131-142. 36.Langevin HM, Churchill DL, Cipolla MJ. Mechanical signaling through connective tissue: a mechanism for the therapeutic effect of acupuncture. Faseb J. 2001;15(12):2275-2282. 37.Liboff AR.Bioelectromagnetic fields and acupuncture. J Altern Complement Med.1997;3(Suppl 1):S77-S87. 38.Uchida S, Kagitani F, Suzuki A, et al. Effect of acupuncture-like stimulation on cortical cerebral blood flow in anesthetized rats. Jpn J Physiol. 2000;50(5):495-507. 39.Alavi A, et al. Neuroimaging of acupuncture in patients with chronic pain. J Altern Complement Med. 1997;3(Suppl 1): S47-S53. 40.Takeshige C, Sato M. Comparisons of pain relief mechanisms between needling to the muscle, static magnetic field, external qigong and needling to the acupuncture point. Acupunct Electrother Res. 1996;21 (2):119-131. Jan Dommerholt, Pain & Rehabilitation Medicine, Bethesda, MD. Jan can be reached via email at dommerholt@ painpoints.com. Orthopaedic Practice Vol. 16;3:04 Should Dry Needling for Myofascial Pain be Within the Scope of Practice for Physical Therapists? Sinéad A. FitzGibbon, PT, MS Doctoral Student, graduate program in Orthopedic and Sports Physical Therapy, Rocky Mountain University of Health Professions, Provo, UT & Co-owner Manual and Sports Physical Therapy, Sag Harbor, NY INTRODUCTION Health care expenditure in the United States reached $2.2 trillion in 2007, increasing 6.2% from the previous year, and amounted to 16.2 % of the gross domestic product.1 Professional services, including physical therapy, accounted for $62 billion of this cost.1 Myofascial pain is one of the leading complaints of patients presenting in general medical practice, with reported prevalence of 20% to 93% in general practice2,3 thus imposing significant financial burdens on state and national health care budgets.3 With high prevalence and associated costs, there is unrelenting pressure on insurers, clinicians, and researchers to reduce costs while optimizing outcomes. The physical therapy profession is at the forefront of cost containment by promoting comparisons of the effectiveness of different interventions in management of musculoskeletal pain.4 Physical therapists use nonsurgical, nonpharmaceutical modalities in the prevention and treatment of disability.5 Moreover, the 2020 vision statement of the American Physical Therapy Association (APTA) reflects the emerging priorities of the profession by emphasizing the provision of expert care using evidence-based practice.6 With 44 states allowing direct access to physical therapists (PTs) at a lower cost than physical therapy via physician referral,7 PTs are a part of the vanguard of cost containment in health care. Physiotherapists began musculoskeletal care in 1894 as a group of nurses practicing remedial massage in the United Kingdom (UK), and evolved into established professional organizations on both sides of the Atlantic. Today there are 170,000 practicing PTs in the United States and 36,000 chartered physiotherapists in the United Kingdom, with therapists recognized as expert clinicians in management of musculoskeletal and myofascial pain.8,9 Physiotherapists practicing internationally in the United Kingdom, Australia, New Zealand, and throughout Europe use dry needling alongside traditional modalities in management of myofascial pain.10-12 The multimodal, direct access practice model is beneficial to both the consumer and the clinical practitioner, as well as cost effective for all involved parties.7 There are growing numbers of national and international courses in dry needling for physical therapists,13-15 with 5,500 physiotherapists in the UK16 and over a thousand such therapists in Australia17 now licensed to use needling in physical therapy practice. Direct access to physical therapy gives patients suffering from myofascial pain a gateway into a broad spectrum of pain management techniques. Physical therapy professionals are expert first-line clinicians in delivery of pain management modalities. With inclusion of dry needling in the battery of techniques available to skilled clinicians, cost-effective nonsurgical pain management options could improve patient outcomes and contribute to containing health care costs. In order to understand how dry needling by physical therapists can enhance pain management, knowledge of its history and current use is warranted. This paper will outline the background of the trigger point theory and describe dry needling as used in management of myofascial pain. It will then compare and contrast the educational processes of acupuncturists and physical therapists with regard to use of needling. Finally, the case will be made for broadening the physical therapist’s scope of practice to include dry needling, with special reference to use of evidence-based practice in the current fiscally challenging medical environment. DRY NEEDLING: BACKGROUND Dry needling, generally understood as the insertion of filiform (fine filament) needles without use of saline or other liquid substances, has its roots in ancient practice of acupuncture. Nearly 3,000 years of Chinese acupuncture has resulted in regional Asian variations in technique and ideology.18,19 Development of modern Chinese medical and therapeutic practices has com212 bined with western empirical medical practices to result in the practice of dry needling. This is the use of filiform needles to treat myofascial trigger points without reference to oriental medicine philosophy and principles of practice. Dr. Janet Travell developed and popularized the treatment of myofascial trigger points (MTrP) using dry needling techniques.20,21 This method of myofascial pain management has become popular among physical therapists and medical doctors worldwide, especially over the past 3 decades. Histopathology, electrical activity, neurophysiology and clinical features of MTrPs have been studied since the 1940s, and though this body of knowledge continues to grow, the mode of efficacy of needling MTrPs remains poorly understood. Myofascial Trigger Points, Definitions, and Mode of Efficacy A MTrP is defined as a highly localized and hyper-irritable spot in a palpable taut band of skeletal muscle tissue.22 The main criteria used for diagnosis of MTrPs are the following: a tender spot in a taut band of contractile skeletal muscle, patient pain report upon palpation of this point, a predictable pattern of referred pain from palpation of this point, and a local twitch response elicited upon palpation.3 Despite widespread use of these criteria, there have been few studies that have examined interexaminer reliability and diagnostic sensitivity and specificity,3,23-24 nor has there been standardization of the manner in which the examination is conducted.21 TRIGGER POINT THEORY AND NEEDLING RESPONSE Trigger points are known to occur and to be maintained at the level of a spinal segmental reflex.2 It is thought that excessive local release of acetylcholine2 or calcium22 at the neuro-motor endplate results in spontaneous electrical activity (SEA), with sustained depolarization and shortening of sarcomeres.21 The resultant prolonged local muscle spasm is thought to impair blood Orthopaedic Practice Vol. 23;4:11 flow, cause tissue damage, and perpetuate an inflammatory cycle.2,21,22 To date, therapy has been aimed at inhibiting muscle spasm and reducing the pain of MTrPs using many modalities, including spraying with ethyl chloride followed by specific stretching, deep massage, injection of various substances, and dry needling.2,21,25 Elicitation of local twitch response has been demonstrated to occur with needle insertion into active MTrPs.2,21,26 Pain relief is associated with reduced electrical activity following needle insertion into an MTrP in which a twitch response is observed.21,22,26,27 Activation of spinal endogenous opioids is a likely factor in the effectiveness of many therapeutic interventions in pain management. Direct stimulation of peripheral nociceptors by needling may act to desensitize the central nervous system via SEA endplate inhibition and enhance stimulation of opioid activity within spinal wide-range dynamic neurons.22,28 While acupuncture and dry needling are theorized to have similar mechanisms of action, the education, philosophy of practice, and techniques are quite dissimilar. COMPARING ACUPUNCTURE AND DRY NEEDLING Acupuncture is one of the oldest forms of therapy, and is based on Chinese philosophy, namely that disease is an outward manifestation of internal imbalance of Yin and Yang energetic forces.18 Although filiform needles are used in both dry needling and acupuncture, the similarities are limited. Whereas acupuncture is used to diagnose and manage systemic conditions, dry needling of myofascial trigger points purportedly targets specific tissue responses without reference to energetic systems.22, 27 Acupuncture education entails 3 years of study with mentored residency and competency examinations. Dry needling certification is adjunctive to a medical degree, or a physical therapy masters or doctoral qualification, which takes 5 to 7 years of study. Certification for dry needling in the United States occurs after 50 hours of post-graduate coursework and 200 to 400 documented interventions. Competency examination is required in the United Kingdom, Europe, and Australia with some programs demanding rigorous dissertations at the culmination of a full academic year of acupuncture related physiotherapy.29 Such competency exams are similar in depth to APTA board certification areas such as orthopaedic sports, and women’s health physical therapy certifications. Medical doctors and Orthopaedic Practice Vol. 23;4:11 physical therapists practice dry needling when it is determined to be within the scope of practice by their relevant states. Available evidence for efficacy of acupuncture and dry needling in myofascial pain is limited, and conclusive results are few.18,19,25,30 Most studies have been limited by small sample size, nonstandardization of techniques and poor research design, with few high quality studies or systematic reviews. The majority of published manuscripts investigating the effects of acupuncture and needling underscore the need for high quality clinical research in this area.18,30-32 Dry Needling Within the Scope of Physical Therapy Practice Canada, the United Kingdom, Ireland, the Netherlands, Norway, Switzerland, Belgium, Spain, Chile, South Africa, Australia, and New Zealand, among other nations, and some 18 states in the United States have determined that dry needling techniques fall within the scope of physical therapy practice.33,34 Other states such as California, New York, North Carolina, Hawaii, and Tennessee have proscribed the practice outright.35 In order to understand the potential benefits and risks of amending state practice acts, the arguments of the stakeholders on both sides need to be addressed. ACUPUNCTURISTS Acupuncturists have been licensed to practice in the US since 197336 and many programs obtained national certification in 1982,37 culminating in 16,000 acupuncturists currently in practice38 nationwide. Forty-three states require certification for licensure.39 Acupuncture practitioners have been opposed to the inclusion of dry needling in physical therapy practice acts in Virginia and Colorado40,41 and other states.35 Their objections are based on the duration of the needling certification programs, concerns for the safety of patients and encroachment on professional territory by physical therapists.35,40,41 with resultant specific criteria changes to the practice acts in these states. Acupuncture professional associations claim that physical therapists can become certified in dry needling techniques with a course of only 54 hours, while the majority of acupuncture certification programs have requirements of 1,90542 to 3,000 hours of education from some 57 accredited programs.35,43 This claim disguises the fact that dry needling certification is a postgraduate course following graduation 213 from one of 200 masters or doctoral physical therapy programs that receive accreditation from the Commission on Accreditation in Physical Therapy Education (CAPTE).44 Entry-level DPT programs typically comprise 2,676 hours of education33,45 and a more extensive anatomy component than acupuncture programs.33 Concern for patient safety is not without merit, since skin penetration carries risk of infection, disease transmission, and potential injury to soft tissue, nerve, and blood vessels. However, there is no documented evidence of increased litigation involving therapists practicing dry needling or other skin penetration techniques in states where this is allowed.46,47 Regarding the territorial concerns, acupuncture practitioners are concerned that the use of dry needling by physical therapists encroaches on their professional practice grounds. Dry needling has been identified as a component of acupuncture practice, with acupuncturists invited to participate and teach on dry needling courses.14,46 However, dry needling practitioners limit their practice to management of MTrPs, with no claim to diagnosis or management of systemic disease processes. Diagnosis and treatment of conditions using oriental medicine techniques remains the domain of the acupuncture and oriental medicine professions, and this is affirmed by physical therapy practitioners teaching courses in the United States and internationally.46 PHYSICIANS Physicians in particular, have been concerned about skin penetration by physical therapists, objecting to the use of electromyography (EMG) by physical therapists despite the inclusion of such procedures in many state physical therapy practice acts for decades.33,46,48 Several states license physical therapists to use skin penetration in EMG testing,33 and to date there has been no documentation of any injuries or health hazards for such therapists.33,46 Insurance companies providing liability coverage for physical therapists practicing dry needling impose no additional requirements, other than that they practice in a state that permits the technique.47 CHIROPRACTORS The Maryland chiropractic profession took an interesting position towards dry needling, initially opposing dry needling, determining that it fell within the regulatory practices of the state board of Acupuncture. However, the Maryland Chiropractic Board reversed its position in 2007 and allowed chiropractors to use dry needling under their physical therapy privileges, since the physical therapists in the state had been licensed to do so since 1987. As in other states and international communities, acupuncture is determined to be “the use of oriental medical therapies for the purpose of normalizing energetic physiological functions including pain control, and for the promotion, maintenance, and restoration of health.36,41,49 The Maryland Chiropractic Board ruling was based on the fact that acupuncture uses needle insertion into fixed points and is based on pre-scientific philosophies, whereas dry needling into myofascial trigger points is solely a local soft-tissue technique. Thus dry needling is not based on Chinese philosophy of energetic systems, does not constitute acupuncture, and is therefore not subject to the regulation of the acupuncture licensing boards.49 PHYSICAL THERAPISTS The APTA is the national professional organization of 72,000 physical therapists in the United States.8 The APTA does not yet have an official position on dry needling by physical therapists, but recognizes that it is a technique being used by some of its members.50 The APTA acknowledges that state licensing boards, which have jurisdiction over administration of each state’s PT act, have been consulted regarding whether dry needling falls within the scope of practice. The answer across the states is mixed, with 5 states explicitly proscribing dry needling (NV, NY, NC, ID, TN), stating that it is not in the scope of practice. Fifteen boards have interpretive opinions that it is within the scope of practice in states allowing it, and there have been no definitive statements by the remaining 32. Arizona and Pennsylvania are legally prohibited from issuing an interpretive statement. Statements by physical therapy boards in the 18 states that have amended the scope of PT practice to include dry needling include language stipulating that neither the state medical board nor the acupuncture board could rule on the eligibility of appropriately trained physical therapists to practice dry needling.51,52 Some states issue contradictory statements. For example, Florida proscribes “skin penetration” in dry needling by physical therapists, but allows them to perform and analyze EMGs, which by definition involves skin penetration. Tennessee takes the position that since no academic institutions in that state teach dry needling to physical therapy students, it should remain outside of the scope of PT practice.33 This introduces the dilemma of what to do once dry needling is part of entry-level DPT programs, as it is currently at Georgia State University,53 for example. It may be time to encourage a national review of the scope of practice for physical therapists. A recent report by the Federation of State Boards of Physical Therapy (FSBPT) outlines that there is a historic basis, education and training, and a scientific basis for use of dry needling by physical therapists, provided competency is determined to ensure safe practice.54 The FSBPT conducts an analysis every 5 years to determine actual practices within the profession. Also, the highly respected American Academy of Orthopedic Manual Therapists supports dry needling in the PT scope of practice and indicates that research supports its use.55 As with any policy or practice change, the process is likely to be slow and piecemeal in nature, but gradual implementation of such changes can facilitate reflection and necessary critical analysis. In order to reflect on the possibility of changing the scope of practice of physical therapists, it is important to understand the process by which practice guidelines are determined. Determining the Scope of Practice for the Physical Therapists In the United States, state physical therapy boards determine the legal scope of physical therapy practice in each state. The Federation of State Boards of Physical Therapy (FSBPT) Model Practice Act provides language to states for reference and consideration in the development of their individual practice acts. In evaluating the current climate of health care practice and education, the FSBPT recognizes the overlap of many skills and procedures among professions, stating that it is “no longer reasonable to expect each profession to have a completely unique scope of practice.”54 Devised with the collaboration of the medical, nursing, social work, pharmacist, occupational and physical therapy professional communities, the FSBPT document provides a protocol for state boards to use in decision making about whether an intervention should be included in the scope of practice. This protocol assists in decision-making when considering practice act changes, with the primary focus on whether the proposed changes “will better 214 protect and enhance consumers’ access to competent health care services.”54 Proposed changes to the scope of practice should evaluate 4 critical areas: established history of specific practices, adequate training, adequate evidence of benefit to public health, and appropriate regulation. The FSBPT maintains that adequate evidence in each of these areas suggests that scope of practice changes would be in the public’s best interest.54 This position echoes that of the Federation of State Medical Boards (FSMB), an allied, parallel organization for physicians and osteopaths. This group outlines the multifactorial nature of scope of practice decisions, including workforce needs and availability, financial motivations, economic circumstances, and consumer demand, with the ultimate goal of protecting public health and safety.56 In order for there to be a rational, useful approach to broadening the scope of practice of a health care practitioner, there must be judicious use of the guidelines that have been developed for this purpose. Guidelines for Changes to the Scope of Practice According to the FSBPT and the FSMB, scope of practice should be reviewed when the following factors have been considered: where there exists a need for the proposed scope of practice; when the existing scopes of practice, if altered, will result in a positive change in public health and safety; where there exists formal education, training, and accreditation processes for the change in scope of practice; where appropriate evaluation and disciplinary procedures are established; where accountability and liability issues have been clarified and where the effects on other practitioners have been reviewed.54,56 Using these criteria, the broadening of the scope of practice for physical therapists to include dry needling, would be approved. First, more than a third of the US physical therapy boards have issued interpretations that dry needling is within the PT scope of practice. Such changes in physical therapy state practice acts parallel the practices of Canada and many countries in Europe, Asia, and South America. Second, there has been no increased incidence of injury to the health of patients when managed by physical therapists who use techniques that puncture the skin. Third, there are 3 main US programs for accredited needling education programs, and reciprocity already exists among the international programs for dry needling certification. Fourth, Orthopaedic Practice Vol. 23;4:11 physical therapists practicing dry needling are accountable under standard rules of practice, and have the same requirements to carry malpractice and liability insurance as those who do not practice needling. Finally, there is no documented adverse financial effect on other practitioners when physical therapists are licensed to practice dry needling. In fact, there may be an opportunity for both acupuncturists and physical therapists to improve their position in the market if both groups could market their nonsurgical, nonpharmaceutical approach to pain management. Planning or Policy Strategies that Might Mitigate Differences In negotiations, success results from collaborative efforts to resolve any impasse.57 The APTA and the American Association of Acupuncture and Oriental Medicine (AAAOM) could collaborate on combined statements, with a unified marketing campaign for consumer education to differentiate between acupuncture and dry needling. University programs for dry needling could be developed in collaboration with all interested parties.33,58 Combined physical therapist and acupuncturist lobbying for third party payor reimbursement could be more successful than the current situation where each professional community struggles for reimbursement independently.59,60 Benefits could include improved teamwork of medical doctors, physical therapists, and acupuncturists to optimize patient care. Reduced costs for the consumer could result as all providers compete in the open market for myofascial pain management services. As continued research would determine best practices, collaborating professionals would be quick in adjusting their practice to reflect new knowledge. The concept of an extended scope of practice for physical therapists is not an expansion of physical therapists interest in needling therapy, but is a component of a global shift in health care service utilization. Extended Scope of Practice in Health Care Professions An international summit on advanced scope of practice and direct access to physical therapy was held in Washington in October 2009 to examine current international demands and practices, and to determine the implications of increased practice scope on interprofessional relationships, professional boundaries, and role definitions.61 National and international developments Orthopaedic Practice Vol. 23;4:11 to alter the scope of practice of physical therapists and other medical professionals are underway, in order to mitigate the current stresses on the health care system.54,56,61 These scope of practice changes follow the development of the nurse practitioner and physician assistant professions, whose origins as legitimate medical professionals grew, in the past 50 years, out of the financial and workforce constraints on the general physician and medical community.62,63 Physical therapists are currently being trained in joint injections,64 musculoskeletal triage in emergency rooms,65 and first-line health care management.66 The changing tide of clinical practice is not likely to reverse, as increasing demands on finite financial resources continue.1 SUMMARY Current US and International Practice, Recommendations for the Future Dry needling is already within the scope of physical therapy practice in many areas (18 US states34); skin penetration by physical therapists for EMG is allowed in many US states, and Canada, South America, Europe, Asia, Australia, and New Zealand. With minimal risk and increased benefits to the majority of stakeholders, dry needling practiced within an increased scope of PT professionals will be of benefit to the public, bringing American clinicians in-line with their international colleagues. The APTA’s “2020 vision” for physical therapy includes a commitment to lifelong learning with use of evidence-based practice.6 Articles published in respected, peer-reviewed journals underscore the continued need for expert clinicians to critically appraise and conduct research. The current emphasis in physical therapy education is on research to support and challenge clinical practices. With increasing use of dry needling by physical therapists, the research emphasis should include dry needling within efficacy and comparative effectiveness studies. Doctoral level physical therapists who acquire these skills as part of their core curricula67 are well suited for such 215 analysis and research, and their dissertations could explore the comparative effectiveness of dry needling and other manual therapy techniques. Many techniques are not unique to a specific profession. There are ongoing battles for territory between chiropractors and physical therapists over manipulation and joint mobilization,68,69 between athletic trainers and physical therapists over manual therapy techniques,70 with physicians and physical therapists performing EMG tests,71,72 and physicians referral to in-house physical therapy practices.73,74 The global trends in health care management are to look broadly across the professional spectrum to determine where patients can benefit from skilled care provided by appropriately trained clinicians, at the lowest cost. The future objective will be to use best practices for best outcomes and for the best financial value. The territorial battles are likely to continue, but will diminish in intensity as adversaries compete to demonstrate optimization of outcomes and not compete over ownership of specific techniques. CONCLUSIONS Physical therapists are positioned as expert clinicians in the health care community with a broad spectrum of techniques for nonsurgical management of musculoskeletal pain and dysfunction. Inclusion of dry needling within the scope of PT practice will ensure further high-quality research and clinical practice with better outcomes in this field. Use of dry needling by qualified, licensed physical therapists will bring American physical therapy professionals in line with current international standards of practice, and provide patients with more options for management of musculoskeletal pain. In the costly arena of arthritis, movement dysfunction, and pain management, extending the physical therapy scope of practice to include dry needling will improve in consumer choice, increase evidence-based practice, and facilitate cost-containment. REFERENCES 1. US Department of Health and Human Services: National health expenditure highlights 2007. http://www.cms.hhs. gov/NationalHealthExpendData/downloads/highlights.pdf. Accessed October 1, 2009. 2. Wheeler AH. Myofascial pain disorders: theory to therapy. Drugs. 2004;64(1):45-62. 3. Tough EAM, White ARMD, Richards SP, Campbell JMD. Variability of Criteria Used to Diagnose Myofascial Trigger Point Pain Syndrome-Evidence From a Review of the Literature. Clinical Journal of Pain March/April. 2007;23(3):278-286. 4. American Physical Therapy Association. 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American Physical Therapy Association: About APTA. http://www.apta. org/AM/Template.cfm?Section=About_ A P T A & Te m p l a t e = / Ta g g e d P a g e / Ta g g e d P a g e D i s p l a y. cfm&TPLID=41&ContentID=23725. Accessed October 1, 2009. 9.Careers Research: Physiotherapist. http://www.ca.courses-careers.com/ articles/physiotherapist.htm. Accessed October 1, 2009. 10.Australian Physiotherapy Association: Acupuncture and Dry Needling Group. http://www.physiotherapy.asn.au/index. php/groups/acupuncture-and-dry-needling. Accessed October 1, 2009. 11.New Zealand Society of Physiothera- pists: Physiotherapy Acupuncture Association of New Zealand. http://www. physiotherapy.org.nz/. Accessed October 12 2009. 12. Acupuncture Association of Chartered Physiotherapists: Comment of new “N.I.C.E.” guidelines for acupuncture. http://www.aacp.uk.com/RelatedFiles// Reports/PressRelease.pdf. Accessed October 20, 2009. 13. Global Education of Manual Therapists GEMt: Advancing the art and science of physical therapy: courses. http://www. gemtinfo.com/. Accessed October 20, 2009. 14.Myopain Seminars: setting the standards for myofascial trigger point education worldwide. http://www.myopainseminars.com/sponsoredcourses. html. Accessed October 12, 2009. 15. Institute for the Study and Treatment of Pain: iSTOP: courses. http://www.istop. org/training.html. Accessed October 12, 2009. 16.Acupuncture Association of Chartered Physiotherapists: Clinical Interest Group of the Chartered Society of Physiotherapists. http://www.aacp.org.uk/. Accessed October 12, 2009. 17.Australian Physiotherapy Association: Acupuncture and Dry Needling Group (ADNG). http://www.physiotherapy. asn.au/index.php/groups/acupunctureand-dry-needling Accessed September 29, 2009. 18. Furlan ADMD, van Tulder MP, Cherkin DP, et al. Acupuncture and Dry-Needling for Low Back Pain: An Updated Systematic Review Within the Framework of the Cochrane Collaboration. Spine. 2005;30(8):944-963. 19. World Health Organization: Acupuncture; Review and analysis of reports on controlled clinical trials. http://apps. who.int/medicinedocs/en/d/Js4926e/. Accessed October 11, 2009. 20.Pain Education: Dr. Janet G.Travell: the mother of myofascial trigger point knowledge. http://www.pain-education. com/100143.php. Accessed October 20, 2009. 21. Travell J, Simons DG. Myofascial pain and dysfunction: the trigger point manual. 2nd ed. Baltimore: Williams and Wilkins; 1987. 22.Hong C-Z, Simons DG. Pathophysiologic and electrophysiologic mechanisms of myofascial trigger points. Arch Phys Med Rehabil. 1998;79(7):863-872. 216 23.Hsieh C-YJ, Hong C-Z, Adams AH, et al. Interexaminer reliability of the palpation of trigger points in the trunk and lower limb muscles. Arch Phys Med Rehabil. 2000;81(3):258-264. 24.Gerwin RD, Shannon S, Hong C-Z, Hubbard D, Gevirtz R. Interrater reliability in myofascial trigger point examination. Pain. 1997;69(1-2):65-73. 25. Tough EA, White AR, Cummings TM, Richards SH, Campbell JL. Acupuncture and dry needling in the management of myofascial trigger point pain: A systematic review and meta-analysis of randomised controlled trials. Eur J Pain. 2009;13(1):3-10. 26.Chen J-TMD, Chung K-CP, Hou C-RBSN, Kuan T-SMD, Chen S-MMD, Hong C-ZMD. Inhibitory Effect of Dry Needling on the Spontaneous Electrical Activity Recorded from Myofascial Trigger Spots of Rabbit Skeletal Muscle. Am J Phys Med Rehabil. 2001;80(10):729-735. 27. Gerwin RD. Neurobiology of the myofascial trigger point. Baillière’s Clin Rheumatol. 1994;8(4):747-762. 28.Fine PG, Milano R, Hare BD. The effects of myofascial trigger point injections are naloxone reversible. Pain. 1988;32(1):15-20. 29. Physiotherapy Acupuncture association of New Zealand Inc. 2011; http://www. paanz.org.nz/mainmenu85/page104/ Certificate+in+Acupuncture+Qualificat ion.html. Accessed February 18, 2011. 30. Irnich D, Behrens N, Gleditsch JM, et al. Immediate effects of dry needling and acupuncture at distant points in chronic neck pain: results of a randomized, double-blind, sham-controlled crossover trial. Pain. 2002;99(1-2):83-89. 31. Gunn C, Milbrandt W, Little A, Mason K. Dry Needling of muscle motor points for chronic low back pain: a randomized clinical trial with long term follow up. Spine. 1980;5(3):13. 32. Gerwin R. Interexaminer-reliability and myofascial trigger points. Arch Phys Med Rehabil. 2000;81:2. 33.American Association of Acupuncture and Oriental Medicine: Qi Unity Report: Dommerholt: Dry needling response letter. http://www.bethesdaphysiocare.com/professionals/pdf/qiunity_dryneedlingissue08.pdf. Accessed October 7, 2009. 34.Is dry needling within your scope of practice? . 2011; http://www.kinetacore. Orthopaedic Practice Vol. 23;4:11 com/physical-therapy/Is-Dry-NeedlingIn-Your-Scope-of-Practice/page63. html. Accessed June 10, 2011. 35. American Association of Acupuncture and Oriental Medicine: AAAOM Dry Needling Letter http://www.aaom.info/ qiunity/07/10/dry_needling_letter.pdf. Accessed October 1 2009. 36.Academy of Chinese Medicine USA: history of acupuncture in the USA. http://www.acmusa.org/acuhisty.htm. Accessed October 19, 2009. 37. National Certification Commision for Acupuncture and Oriental Medicine. http://www.nccaom.org/about/about. html. Accessed October 1, 2009. 38. American College of Acupuncture and Oriental Medicine: FAQ’s. http://www. acaom.edu/en/cms/?842. Accessed October 10, 2009. 39. National Certicication Commission for Acupuncture and Oriental Medicine: state licensure requirements. http:// www.nccaom.org/applicants/state_data/ State_sheet.htm. Accessed October 22, 2009. 40. American Association of Acupuncture and Oriental Medicine: News alert: Dry needling response letter. http:// www.aaaomonline.org/pressroom. asp?pagenumber=48266. Accessed October 12, 2009. 41. Dry Needling and Acupuncture, Emerging Professional Issues. http://www. aaaomonline.info/qiunity/07/10/2a. html. Accessed October 1 2009. 42. Council of Colleges of Acupuncture and Oriental Medicine: FAQ: duration of program. http://www.ccaom.org/faqs. asp#7. Accessed October 23, 2009. 43. Accreditation Commision for Acupuncture and Oriental Medicine: accredited programs. http://www.acaom.org/ accprgs.asp. Accessed October 21, 2009. 44.American Physical Therapy Association: CAPTE Accredited Physical Therapist Education Programs http://www.apta.org/AM/Template. cfm?Section=CAPTE3&Template=/ aptaapps/accreditedschools/acc_schools_map. cfm&process=3&type=PT. Accessed October 20, 2009. 45.American Physical Therapy Association: Capte Accredited Physical Therapy Education Programs. http://www.apta. org/AM/Template.cfm?section=PT_ Pr o g r a m s & t e m p l a t e = / a p t a a p p s / accreditedschools/acc_schools_map. Orthopaedic Practice Vol. 23;4:11 cfm&process=3&type=PT. Accessed October 23, 2009. 46. Dommerholt J. Dry Needling in Orthopaedic Physical Therapy Practice. Orthop Phys Ther Practice. 2004;16(3):6. 47. Herder T. Healthcare Providers Service Organization: dry needling inquiry (personal communication) ed2009:1. 48. Guide to Physical Therapy Practice. 2nd ed. Alexandria, VA: American Physical Therapy Association; 2003. 49.Maryland Chiropractic Association: Maryland Board of Chiropractic Examiners Now Approves Dry-Needling As Being Within the Scope of Practice for Chiropractors But… http://www.marylandchiro.com/index.php?file=index. html. Accessed October 23, 2009. 50. Bradley B. American Physical Therapy Association: Official Position on Dry Needling for Physical Therapists. (personal communication) ed2009. 51.Oregon Physical Therapist Licensing Board: Board Determines That Dry Needling Is Within PT Scope Of Practice. http://www.oregon.gov/PTBrd/docs/ Publications/Newsletter.Summer.2009. pdf Accessed October 23, 2009. 52.Oregon Physical Therapist Licensing Board: Board Discussion Regarding Use of Dry Needling. http://www. oregon.gov/PTBrd/docs/Executive. Minutes/07.17.2009.Board.Meeting. Minutes.pdf. Accessed October 2, 2009. 53.Georgia State University: School of Health Professions: graduate course descriptions. http://chhs.gsu.edu/pt/ docs/CourseDescriptions.pdf. Accessed October 1, 2009. 54. Federation of State Boards of Physical Therapy: Changes in Healthcare Professions’ Scope of Practice:Legislative Considerations. 2010; https://www.fsbpt. org/download/ScopeOfPractice200908. pdf Accessed February 17, 2011. 55.AAOMPT. Dry Needling: American Academy of Orthopedic Manual Physical Therapists position statement. 2009; http://www.aaompt.org/about/statements.cfm. Accessed Feb 19 2011. 56.Federation of State Medical Boards: Assessing Scope of Practice in Health Care Delivery:Critical Questions in Assuring Public Access and Safety. http://www.fsmb.org/pdf/2005_grpol_ scope_of_practice.pdf. Accessed October 21, 2009. 57. Fisher R, Ury W, Patton B. Getting to “Yes”, negotiating agreement without 217 giving in. 2nd ed: Houghton Mifflin Harcourt; 1992. 58. Georgia State University, Department of Physical Therapy: Course Descriptions. http://chhs.gsu.edu/pt/docs/CourseDescriptions.pdf. Accessed October 10, 2009. 59.American Association of Acupuncture and Oriental Medicine: Federal Acupuncture Coverage Act of 2009. http://www.aaaomonline.info/hinchey_ hr_646_fact_sheet.pdf. Accessed October 26, 2009. 60. American Physical Therapy Association: Health Care Reform: Government Affairs Update. http:// www.apta.org/AM/Template.cfm? S e c t i o n = A d v o c a c y & Te m p l a t e = / C M / C o n t e n t Di s p l a y. cfm&ContentID=64984. Accessed October 26, 2009. 61. International Summit on Direct Access and Advanced Scope of Practice in Physical Therapy. http://www.directaccesssummit.com/brochure.pdf Accessed October 25, 2009. 62. American Association of Nurse Practitioners: Frequently Asked Questions: Why Choose A Nurse Practitioner as your Healthcare Provider? http://www. aanp.org/NR/rdonlyres/67BE3A606E44-42DF-9008-DF7C1F0955F7/ 0/09FAQsWhatIsAnNP.pdf Accessed October 28, 2009. 63.Yale School of Medicine: Physician Assistant program: History of the Physician Assistant program. http:// medicine.yale.edu/pa/profession/history_profession.aspx Accessed October 28, 2009. 64.Chartered Society of Physiotherapy: clinical guidelines for the use of injection therapy by physiotherapists. http:// www.csp.org.uk/uploads/documents/ csp_guideline_injection.pdf Accessed October 20, 2009. 65. Anaf S, Sheppard LA. Physiotherapy as a clinical service in emergency departments: a narrative review. Physiotherapy. 2007;93(4):243-252. 66. Canadian Physiotherapy Association: Manitoba Branch:Physiotherapy and Primary Health Care: Evolving Opportunities. http://www.manitobaphysio.com/pdf/FinalMBPHCReportJune_05_000.pdf. Accessed October 1, 2009. 67. American Physical Therapy Association: 2020 Vision Statement. N om ina tio ns 68. American Physical Therapy Association: Position on Thrust Joint Manipulation Provided by Physical Therapists. http://www.apta.org/AM/ Template.cfm?Section=State_Gov_t_ Affairs&Template=/CM/ContentDisplay.cfm&ContentID=56434. Accessed October 23, 2009. 69. Virginia Board Of Medicine: Department Of Health Professions: Study of Spinal Manipulation Pursuant to Request from the Chair of the Senate Committee on Education and Health. http://www.apta.org/AM/ Template.cfm?Section=State_Gov_t_ Affairs&Template=/CM/ContentDisplay.cfm&ContentID=54887. Accessed October 23, 2009. 70. National Athletic Trainers Association: Endorsed Model Legislative Definitions/Terms. http://www.apta. org/AM/Template.cfm?Section=Top_ Issues2&Template=/MembersOnly. cfm&ContentID=26425. Accessed October 23, 2009. 71. American Physical Therapy Association: Electrophysiologic Examination And Evaluation HOD P06-96-20-04. http://www.apta.org/ AM/Template.cfm?Section=Top_ Issues2&Template=/CM/ContentDisplay.cfm&ContentID=35129. Accessed October 23, 2009. 72. American Physical Therapy Association: letter to the American Medical Aassociation on EMG. http://www.apta. org/AM/Template.cfm?Section=Top_ Issues2&Template=/MembersOnly. cfm&ContentID=33478. Accessed October 23, 2009. 73. American Physical Therapy Association: Position on PhysicianOwned Physical Therapy Services (POPTS). http://www.apta.org/ AM/Template.cfm?Section=Top_ Issues2&Template=/MembersOnly. cfm&ContentID=26141. Accessed October 23, 2009. 74. American Physical Therapy Association: Statement to the Federal Trade Commission/Department of Justice Joint Hearings on Health Care Competition Law and Policy. http://www.apta. org/AM/Template.cfm?Section=Top_ Issues2&Template=/MembersOnly. cfm&ContentID=26146. Accessed October 23, 2009. Orthopaedic Section Awards Now is the time to be thinking about and submitting nominations for the Orthopaedic Section Awards! There are many therapists in our profession who have contributed so much, and who deserve to be recognized. Please take some time to think about these individuals and nominate them for the Orthopaedic Section’s highest Awards. Let’s celebrate the success of these hard-working people! • James A. Gould Excellence in Teaching Orthopaedic Physical Therapy • Outstanding Physical Therapy & Physical Therapist Assistant Student Award • Paris Distinguished Service Award • Rose Excellence in Research Award • Richard W. Bowling - Richard E. Erhard Orthopaedic Clinical Excellence Award Visit our Web site for more information about the awards offered by the Orthopaedic Section and the criteria for nominating an individual: http://www.orthopt.org/awards.php. 218 Orthopaedic Practice Vol. 23;4:11 Narrative Review Dry needling: a literature review with implications for clinical practice guidelines1 James Dunning1,2, Raymond Butts3,4, Firas Mourad5, Ian Young6, Sean Flannagan7, Thomas Perreault8 1 Alabama Physical Therapy & Acupuncture, Montgomery, AL, USA, 2American Academy of Manipulative Therapy, Montgomery, AL, USA, 3University of South Carolina, Columbia, SC, USA, 4Palmetto Health Research Physical Therapy Specialists, Columbia, SC, USA, 5Sportlife Physiotherapy, Montichiari, Italy, 6Spine & Sport, Savannah, GA, USA, 7OneAccord Physical Therapy, Casa Grande, AZ, USA, 8Portsmouth-Newington Physical Therapy, Portsmouth, NH Background: Wet needling uses hollow-bore needles to deliver corticosteroids, anesthetics, sclerosants, botulinum toxins, or other agents. In contrast, dry needling requires the insertion of thin monofilament needles, as used in the practice of acupuncture, without the use of injectate into muscles, ligaments, tendons, subcutaneous fascia, and scar tissue. Dry needles may also be inserted in the vicinity of peripheral nerves and/or neurovascular bundles in order to manage a variety of neuromusculoskeletal pain syndromes. Nevertheless, some position statements by several US State Boards of Physical Therapy have narrowly defined dry needling as an ‘intramuscular’ procedure involving the isolated treatment of ‘myofascial trigger points’ (MTrPs). Objectives: To operationalize an appropriate definition for dry needling based on the existing literature and to further investigate the optimal frequency, duration, and intensity of dry needling for both spinal and extremity neuromusculoskeletal conditions. Major findings: According to recent findings in the literature, the needle tip touches, taps, or pricks tiny nerve endings or neural tissue (i.e. ‘sensitive loci’ or ‘nociceptors’) when it is inserted into a MTrP. To date, there is a paucity of high-quality evidence to underpin the use of direct dry needling into MTrPs for the purpose of short and long-term pain and disability reduction in patients with musculoskeletal pain syndromes. Furthermore, there is a lack of robust evidence validating the clinical diagnostic criteria for trigger point identification or diagnosis. High-quality studies have also demonstrated that manual examination for the identification and localization of a trigger point is neither valid nor reliable between-examiners. Conclusions: Several studies have demonstrated immediate or short-term improvements in pain and/or disability by targeting trigger points (TrPs) using in-and-out techniques such as ‘pistoning’ or ‘sparrow pecking’; however, to date, no high-quality, long-term trials supporting in-and-out needling techniques at exclusively muscular TrPs exist, and the practice should therefore be questioned. The insertion of dry needles into asymptomatic body areas proximal and/or distal to the primary source of pain is supported by the myofascial pain syndrome literature. Physical therapists should not ignore the findings of the Western or biomedical ‘acupuncture’ literature that have used the very same ‘dry needles’ to treat patients with a variety of neuromusculoskeletal conditions in numerous, large scale randomized controlled trials. Although the optimal frequency, duration, and intensity of dry needling has yet to be determined for many neuromusculoskeletal conditions, the vast majority of dry needling randomized controlled trials have manually stimulated the needles and left them in situ for between 10 and 30 minute durations. Position statements and clinical practice guidelines for dry needling should be based on the best available literature, not a single paradigm or school of thought; therefore, physical therapy associations and state boards of physical therapy should consider broadening the definition of dry needling to encompass the stimulation of neural, muscular, and connective tissues, not just ‘TrPs’. Keywords: Dry needling, Literature review, Trigger point, Practice guidelines, Physical therapy Introduction 1 This paper should be attributed to: Alabama Physical Therapy & Acupuncture, Montgomery, AL, USA. Correspondence to: James Dunning, 1036 Old Breckenridge Lane, Montgomery, AL 36117, USA. Email: [email protected] 252 ß W. S. Maney & Son Ltd 2014 DOI 10.1179/108331913X13844245102034 MORE OpenChoice articles are open access and distributed under the terms of the Creative Commons Attribution Non-Commercial License 3.0 Local injection therapies, often referred to as ‘wet needling’, use hollow-bore needles to deliver corticosteroids, anesthetics, sclerosants, botulinum toxins, or other agents.1,2 In contrast, ‘dry needling’ refers to the Physical Therapy Reviews 2014 VOL . 19 NO . 4 Dunning et al. insertion of thin monofilament needles, as used in the practice of acupuncture, without the use of injectate.3–6 Dry needling is typically used to treat muscles, ligaments, tendons, subcutaneous fascia, scar tissue, peripheral nerves, and neurovascular bundles for the management of a variety of neuromusculoskeletal pain syndromes.3,6,7 Given the broad base of international literature presently available on the technique, it is particularly concerning that the primary US-based, National Physical Therapy Association8 and several State Boards of Physical Therapy9–13 have recently narrowed their definition of dry needling to an ‘intramuscular’ procedure, i.e. the insertion of needles into nodules within taut bands of muscle, more commonly referred to as ‘trigger points’ (TrPs) or ‘myofascial trigger points’ (MTrPs). More specifically, these professional organizations have equated the procedure of dry needling with the term ‘intramuscular manual therapy’ (IMT) or ‘trigger point dry needling’ (TDN). Certainly, IMT, or the insertion of needles into TrPs within muscle bellies, is one aspect of dry needling; however, IMT or TDN should not be used synonymously with the term dry needling. In addition to TrPs within muscular tissue, an extensive body of literature, including both peerreviewed articles and randomized controlled trials, supports the insertion of dry needles throughout the body at non-TrP sites for the purpose of reducing pain and disability in patients with neuromusculoskeletal conditions. Just as the Maitland,14 Kaltenborn,15 and McKenzie16 approaches are each unique brands of manual therapy, ‘TDN’ and ‘IMT’ are individual aspects of dry needling. Each describes a single framework, paradigm, or approach that falls under the much larger field of dry needling.5,6,9,10,17–25 Dry Needling Targets Neural, Muscular, and Connective Tissues, Not Just TrPs The first, peer-reviewed journal article on dry needling published by a Western, medical physician6 did not limit needle insertion to muscular ‘TrPs’; rather, the 241-patient study reported that only 2 of the 14 target structures were muscular TrPs.6 The other structures needled included ligaments, scar tissue, tendons, bones, and teno-osseus insertion sites, all of which are types of connective tissue.6 In addition, ‘a high density of neurovascular structures’ has been found at dry needling target sites.26 As early as 1977, Melzack et al.27 stated that ‘Trigger points are firmly anchored in the anatomy of the neural and muscular systems… and the stimulation of particular nerves or tissues by needles could bring about an increased input to the central biasing mechanism, which would close the gates to [pain] inputs from selected body areas’.27 In a more recent commentary titled ‘Treatment of Myofascial Pain Dry needling Syndrome’, Hong stated that the purpose of ‘the fastin and fast-out needle technique’26,28–30 in a fan or cone shape is to ‘ensure that all or most sensitive loci (i.e. tiny nerve endings) are encountered’.28 Widely considered one of the world authorities on both dry needling practice and experimental research, Hong further reported that ‘high-pressure stimulation by needling’26,28,31–33 or ‘mechanical irritation of the needle’26,34 to ‘multiple sensitive loci or nociceptors within the same MTrP’26,28,31–34 likely ‘elicits a local twitch response that subsequently provides a very strong neural impulse to the MTrP circuit to break the vicious cycle so that MTrP pain is relieved’.26,28,33,34 Interestingly, ‘bilateral or mirror image evoked potentials’ or ‘local twitch responses’34 (LTRs) have been recorded in the contralateral trapezius during unilateral dry needling stimulation of active TrPs on the ipsilateral, symptomatic trapezius.34 Audette et al.34 concluded, ‘the LTR is generated by inducing a spinal reflex that involves sensory input to the spinal cord by mechanical irritation of the needle at sensitive loci in the TrP which then results in a motor, efferent response of the alpha motor neuron pool’.34 The presence of bilateral LTRs during unilateral dry needling ‘argues strongly for a central abnormality rather than a purely peripheral [muscular] abnormality in patients with active MTrPs’.34 Thus, within the context of myofascial pain syndromes, dry needles likely come in contact with both muscle and connective tissue.6 It is held by several research teams that needles inserted into MTrPs likely touch, tap, or prick tiny nerve endings or neural tissue for the purpose of pain reduction. Based on the most recent literature,6,21,26,28–37 the definition of dry needling by the American Physical Therapy Association (APTA) and State Boards of Physical Therapy should therefore clearly articulate that dry needling encompasses stimulation of neural,26,28–31,33,36,38–54 muscular,5,17,18,21,26,29,30,33,48,55–69 and connective tissues,6,48–54,70–72 and not just ‘TrPs’.73,74 2013 APTA Definition: Dry Needling Targets Both Muscular and Connective Tissues Page two of the January 2012 Resource Paper8 titled, Physical Therapists & the Performance of Dry Needling defined dry needling as ‘an invasive technique used by physical therapists (where allowed by state law) to treat myofascial pain that uses a dry needle, without medication or injection, which is inserted into areas of the muscle known as trigger points…’8 Notably, an updated February 2013 APTA version of this document titled, Description of Dry Needling in Clinical Practice: an Educational Resource Paper, defines dry needling as including both muscular and connective tissues, but not neural stimulation.75 The paper reads, ‘dry needling is a Physical Therapy Reviews 2014 VOL . 19 NO . 4 253 Dunning et al. Dry needling skilled intervention that uses a thin filiform needle to penetrate the skin and stimulate underlying myofascial trigger points, muscular, and connective tissues for the management of neuromusculoskeletal pain and movement impairments’.75 Interestingly, the 2013 definition implies that only muscle and connective tissue may be targeted by dry needles in the treatment of neuromusculoskeletal pain.26,28,31–34 Yet, nerve endings, referred to as ‘sensitive loci’ or ‘neurovascular bundles’ are clearly supported as needle stimulation targets in the existing literature.26 How can physical therapists treat the ‘neuro’ in neuromusculoskeletal with dry needles without placing needles near, beside, or onto neural tissue (i.e. peri-neural needling)? By adding neural targets to the position statement, the APTA would provide a stronger and more evidence-based framework for state boards to follow. Narrowly Focused Position Statements by State Boards of Physical Therapy To date, a number of State Physical Therapy Boards9–13 continue to have limited definitions of dry needling. As a result, many physical therapists believe that they are only able to treat patients by targeting intramuscular TrPs with dry needles, as their respective State Boards do not authorize them to insert needles into connective tissues (e.g. ligaments, tendons, teno-osseus junctions, musculotendinous junctions, scar tissue) or to perform peri-neural or peri-neurovascular needling. Several State Boards of Physical Therapy have issued narrowly focused position statements on dry needling: N 254 Mississippi (Effective: 10 September 2012): The Mississippi State Board of Physical Therapy updated its regulations to read, ‘Intramuscular manual therapy is a physical intervention that uses a filiform needle no larger than a 25-gauge needle to stimulate trigger points, diagnose and treat neuromuscular pain and functional movement deficits; is based upon Western medical concepts; requires an examination and diagnosis, and treats specific anatomic entities selected according to physical signs’.10 N North Carolina (Effective: 14 June 2012): The North Carolina Board of Physical Therapy Examiners revised its definition of dry needling to read, ‘Intramuscular Manual Therapy (IMT), which is generally referred to as dry needling, is defined as a technique to treat myofascial pain using a dry needle (without medication) that is inserted into a trigger point with the goal of releasing/inactivating the trigger points and relieving pain’.9 N Louisiana (Effective: 20 October 2011): Rule 311 of the Louisiana Physical Therapy State Board uses the terms ‘dry needling’ and ‘intramuscular dry needling’ interchangeably, and as a result, requires a physical therapist to ‘successfully complete…no fewer than 50 hours of face-to-face instruction in intramuscular dry needling treatment and safety’.11 Physical Therapy Reviews 2014 VOL . 19 NO . 4 N Nebraska (Effective: 20 June 2011): The Nebraska State Board of Physical Therapy opined, ‘Dry needling is a mechanical modality technique used to treat myofascial pain that uses a dry needle, without medication, that is inserted into a trigger point with the goal of releasing/inactivating the trigger points’.12 N Colorado (Effective: 30 June 2012): The Colorado State Physical Therapy Board opined, ‘Dry needling (also known as Trigger Point Dry Needling) is a physical intervention that uses a filiform needle to stimulate trigger points, diagnose and treat neuromuscular pain and functional movement deficits; is based upon Western medical concepts; requires an examination and diagnosis, and treats specific anatomic entities selected according to physical signs. Dry needling does not include the stimulation of auricular or distal points’.13 Whether these State Boards of Physical Therapy9–13 will update their position statements and/or practice acts to include both neural and connective tissue as possible target structures for dry needling remains to be seen. However, Arizona has recently provided a reason to be optimistic. In January 2013, the Arizona Physical Therapy Association set the standard by becoming the first US-based, physical therapy association to explicitly recognize neural, muscular, and connective tissue as target sites for dry needling.76 The definition of dry needling that appears in the Arizona position statement reads, It is the position of the Arizona Physical Therapy Association that dry needling for the management of neuromusculoskeletal conditions is consistent with the scope of practice of licensed physical therapists in Arizona. Dry Needling is a skilled intervention performed by a physical therapist that uses a thin filiform needle to penetrate the skin and stimulate underlying neural, muscular and connective tissues for the evaluation and management of neuromusculoskeletal pain and movement impairments.76 Page two of the January 2012 APTA Resource Paper8 titled, ‘Physical Therapists & the Performance of Dry Needling’, also states, ‘Preliminary research supports that dry needling improves pain control, reduces muscle tension, normalizes biochemical and electrical dysfunction of motor endplates, and facilitates an accelerated return to active rehabilitation’. However, although the reference list of the 141-page resource paper8 cited four systematic reviews,17,19,24,56 one clinical review,21 and one unpublished evidence summary,77 the 23 randomized controlled trials that were reportedly reviewed and rated by a single expert on a 0–5 scale for quality and level of support for dry needling, were not individually identified or specifically referenced in any way.8 Moreover, while the ‘median quality of the research was 4’ and the ‘median support for dry needling was 3’, the specific studies included in the analysis remains a mystery.8 This resource paper8 also failed to describe available Dunning et al. literature on neuromusculoskeletal conditions that supports the use of ‘TrP’ dry needling. It is concerning that the APTA8,75 and several State Boards of Physical Therapy9–13 continue to omit neural and/or connective tissue as possible target structures when defining dry needling in official position statements. Perhaps position statements that compartmentalize dry needling to ‘IMT’ – i.e. confine it to muscle bellies, tight knots, or ‘myofascial TrPs’,8–11 – fit better with the traditional physical therapy framework. Given that other professions continue to question whether dry needling is within the scope of practice of a physical therapist, declaratory statements by State Boards of Physical Therapy that operationalize dry needling with an ‘intramuscular’9–13 framework may be a more defensible position. Certainly, ‘nerve points’42,43 sound a little ‘Eastern’ to some, and may, at face value, be confused with traditional Chinese acupuncture; however, dry needling neither attempts to move qi along meridians, nor does it rely on diagnoses from traditional Chinese acupuncture or Oriental medicine.78,79 TrP Needling is Only One Kind of Dry Needling In 2009, the APTA recommended ‘IMT’ as the term to be used by physical therapists to describe the intervention of dry needling.8 The following excerpt is from page two of the January 2012 Resource Paper titled, ‘Physical Therapists & the Performance of Dry Needling’: Dry needling is an invasive technique used by physical therapists (where allowed by state law) to treat myofascial pain that uses a dry needle, without medication or injection, which is inserted into areas of the muscle known as TrPs. A TrP describes a taught band of skeletal muscle located within a larger muscle group. Trigger points can be tender to the touch and can refer pain to distant parts of the body. Physical therapists utilize dry needling with the goal of releasing/inactivating the TrPs and relieving pain.8 This definition seems to suggest that physical therapists should only insert needles into muscle bellies in an attempt to inactivate TrPs. This recommendation makes sense considering Itoh et al.80 found that ‘TrP acupuncture’ of the splenius capitis, upper trapezius, levator scapulae, sternocleidomastoid, suboccipitals, scaleni and paravertebrals was more effective in the short-term (i.e. at week 13) at reducing pain and disability than classical or sham acupuncture in patients with chronic, non-radiculopathic neck pain. In contrast, Tough et al. concluded in a 2009 systematic review and meta-analysis that ‘there is limited evidence deriving that deep needling directly into myofascial trigger points has an overall treatment effect when compared to standardized care’.24 Moreover, ‘the result of the meta-analysis of direct Dry needling dry needling [for myofascial trigger point pain] compared to placebo control treatment did not attain statistical significance’.24 There is a paucity of highquality evidence to underpin the use of direct dry needling into myofascial TrPs for the purpose of short/ long-term pain and disability reduction in patients with musculoskeletal pain syndromes.18,20,23,24,80 Rather, the vast majority of the dry needling literature has demonstrated that targeting TrPs (i.e. muscle tissue) and non-TrP structures (i.e. neural and connective tissues) in combination, or non-TrP structures alone, is effective for the reduction of pain and disability in knee osteoarthritis,50–51,81–83,85–90,166–168 hip osteoarthritis,53,91–94 piriformis syndrome,60 carpal tunnel syndrome,36,37,40,41,44,45,47 migraine,95–101 tension type headache,97,98,102 temporomandibular disorder,59,67,103–107 shoulder pain,108–110 neck pain,23,24,29,35,61,63–65,80,111–114 low back pain,4,5,19,20,66,69,115–125 and plantar fasciitis.48,49,54,56,126,127 While many of these studies directly use the term ‘dry needling’,5,18,21,26,33,56,64,67,104,110 in their methodology, other studies use alternative terminology such as ‘deep dry needling’,67 ‘superficial dry needling’,55,128 ‘TrP acupuncture’,20,80 ‘paraspinal needling’,64 ‘intramuscular and nerve root needling’,65 ‘needle electrical intramuscular stimulation’,129 ‘needle release’,113 ‘acupuncture needling’,63,113 ‘needling therapy’,17 ‘acupuncture’36–38,40,41,47,49–55,61,69,72,81–88,90,92,94–100,105–108, 112,115–117,119–123,130–135 and ‘electroacupuncture’.37,46, 93,126,127,136–139 Some studies have even chosen to use both ‘acupuncture and dry needling’19,23,24,62,77 in their titles. Importantly, none of the studies used medicine and/or injectate in conjunction with their needling procedure; therefore, all studies fit within the strict definition of dry needling, regardless of terminology. To our knowledge, no published randomized controlled trials, to date, have used the words ‘IMT’ to describe a dry needling intervention for any condition. Interestingly, the most common term used to describe dry needling is ‘acupuncture’. Physiotherapists and/or medical physicians114–116,119,171–174 within both government administered national health services and mainstream university health systems53,90, 97–99,114,123,133,134, in the UK,49,51,52,84,100,101,131,132 Canada,114 USA and Germany53,90,97–99,123,133,134 use the term ‘acupuncture’ to describe dry needling methodologies. The same is true of articles published in mainstream, highly respected journals, including the British Medical Journal,84,89,100,101,112,124 European Journal of Pain,24,131 Archives of Physical Medicine & Rehabilitation,17,22,60,109,140,141 Pain,6,44,87,111,123,125, 133,136,142 Annals of Internal Medicine,4,81,86,88,117,132 Headache,95,96 Rheumatology,35,51,82,85 Spine,5,19,66,114, 118,119,121,135 and Cochrane Database of Systematic Reviews.62,108 Even the Physical Therapy Journal sponsored by the APTA has used acupuncture and Physical Therapy Reviews 2014 VOL . 19 NO . 4 255 Dunning et al. Dry needling dry needling interchangeably in a recent publication.52 It would therefore be a mistake to ignore the findings of high-quality, randomized controlled trials,37,40,53,54,63,81,84,89,90,92,99,100,107,114,115,119,125,132,143 systematic reviews,17,19,23,56,83,97,121,144 meta-analyses,24,85 Cochrane reviews,62,108,145 the British practice guidelines,124 the European practice guidelines,146,147 and the joint clinical practice guidelines from the American College of Physicians and the American Pain Society117 simply because they used the term ‘acupuncture’ instead of dry needling in their title and/ or methods section. Moreover, ignoring RCTs published by PhD and licensed acupuncturists (LAc) in well-respected, peer-reviewed journals would be shortsighted. By disregarding these studies, physical therapists may limit their ability to support the use of dry needling in clinical practice for treating knee osteoarthritis, shoulder pain, carpal tunnel syndrome, migraine headache, tension type headache, hip pain, low back pain, and neck pain. Physical Therapists Should Not Ignore the Findings of Western Acupuncture Trials ‘Acupuncture’ literally translates to ‘needle penetration’ (i.e. ‘acu’5needle; ‘puncture’5penetration), and the vast majority of the ‘acupuncture’ trials are not claiming to move qi along meridians or channels. Furthermore, the vast majority of the so-called ‘acupuncture’ RCTs have used Western medical diagnoses (not traditional Chinese or Oriental medicine78,79 diagnoses such as bi syndrome, qi, blood stagnation, and kidney yang deficiency143,148) such as chronic neck pain,23,24,29,35,61,63–65,80,111–114 plantar fasciitis,48,49,54,56,126,127 knee osteoarthritis,50–52,81–90, and carpal tunnel syndrome.36,37,40,41,44,45,47 These same ‘acupuncture’ trials have investigated the efficacy of inserting thin filiform needles (without medicine) into ‘Ah-Shi points’ (Chinese for ‘auwh that’s where it hurts’ or ‘that’s it’; synonymous with trigger points57,58,154) and/or non-trigger point locations. Thus, while the terminology, theoretical constructs, and philosophies are different, the actual procedure of inserting thin monofilament needles, as used in the practice of acupuncture, without the use of injectate is very similar across professions.3 The use of McKenzie16 exercises by a chiropractor does not make him or her a physical therapist; likewise, the use of dry needles by a physical therapist does not make him or her an acupuncturist. Rather, these techniques are shared procedures among a variety of healthcare professions. As an additional comparison, physical therapist researchers do not ignore or exclude studies published by MDs, DOs, and DCs when citing references to support the use of spinal manipulation treatments for a variety of neuromusculoskeletal conditions simply because the authors consider the techniques as ‘chiropractic’ or 256 Physical Therapy Reviews 2014 VOL . 19 NO . 4 ‘osteopathic manipulations’. Physical therapists should therefore not ignore the findings of large scale randomized controlled trials available in the Western or biomedical ‘acupuncture’ literature that use the same ‘dry needles’ to treat patients with neuromuscular conditions.49,51–53,84,90,97–101,114,123,131–134 Poor Inter-Examiner Reliability for TrP Location Barbero et al.150 reported ‘moderate to high’ intrarater reliability of an experienced physiotherapist for determining the location of MTrPs within the upper trapezius muscle. However, in a recent systematic review on the reliability of physical examination for the diagnosis of myofascial TrPs, Lucas et al.144 concluded, ‘There is no accepted reference standard for the diagnosis of trigger points, and data on the reliability of physical examination for trigger points is conflicting’. In addition, a predictable pattern of pain referral and the local twitch response are each no longer considered to be sufficient or necessary for the diagnosis of a TrP.22,25,144 After reviewing nine studies on reliability, Lucas et al.144 further concluded: None of the nine studies in this systematic literature review specifically reported inter-rater reliability estimates for the identification of the location of active trigger points in symptomatic participants…. At present, there is no data on the reliability of pinpointing the exact location of active trigger points…. The existing data on reliability pertain only to agreeing if a muscle has the signs of a trigger point and not the exact location of the taut band or the nodule within the taut band.144 Lew et al.151 reported that the inter-examiner agreement was only 21%, and Sciotti et al.142 reported error rates of 3.3–6.6 cm among examiners attempting to identify the specific location of TrPs in the upper trapezius muscle. In another recent literature review, Myburgh et al.22 found poor interexaminer reliability of manual palpation of TrPs in various muscle groups. Only ‘tenderness’ of the upper trapezius, not the actual location of the TrP, was found to be moderately reliable. In 2011, Myburgh et al.152 similarly reported ‘good agreement between experienced practitioners’ for the ‘presence or absence’ of a clinically relevant TrP in the upper trapezius muscle. However, this study, like the many others,153–157 failed to investigate the inter-rater reliability for determining the specific location of the TrP within the target muscle. If clinicians are not able to reliably identify TrPs, they may not be able to consistently activate/deactivate them by penetrating the nodule within the taught band, as is commonly taught by Travell and Simons.73,74 In fact, in a recent systematic review, Tough et al.25 concluded, ‘There is a lack of robust Dunning et al. empirical evidence validating the clinical diagnostic criteria [for TrP identification or diagnosis] proposed by both Travell and Simons (1999) and Fischer (1997)’. High-quality evidence suggests that manual examination for the identification of the specific location of the ‘TrP’ is not a valid22,25,152 or reliable22,142,144,151 process between-examiners. Poor reliability of TrP identification also makes it rather challenging, if not impossible, for Physical Therapists to be in compliance with the APTA8 and several State Physical Therapy Boards.9,10,11,12,13 As Lucas et al.144 summarizes, ‘It is not yet evident that examiners can agree on the precise location of an active TrP; hence, they cannot be relied upon to accurately insert the needle into the nodule of the taut band’. Perhaps ‘TrP dry needling’, or ‘IMT’,8–13 as performed by physical therapists, does not meet the criteria of evidencebased practice (i.e. a valid and reliable diagnostic and therapeutic intervention). Ah-Shi Acupuncture Points and TrPs: Different Theories, Similar Locations Although ‘IMT’ or ‘TrP needling’ involves insertion of needles into muscle bellies, Melzack et al.27 reported: a high degree (71%) of correspondence between MTrPs and acupuncture points, and it is very likely that all MTrPs are Ah-Shi acupuncture points… [however], trigger points are firmly anchored in the anatomy of the neural and muscular systems, while acupuncture points are associated with an ancient conceptual but anatomically non-existent system of meridians, which carry Yin (spirits) and Yang (blood).27 Melzack et al.27 further concluded, ‘trigger points and acupuncture points for pain, though discovered independently, and labeled differently, represent the same phenomenon and can be explained in terms of the same underlying neural mechanisms’. More recently, Dorsher and Fleckenstein,57 both medical physicians, found that 238 (93.3%) of 255 common MTrPs anatomically corresponded with classical acupoints. Furthermore, ‘the marked correspondences of the pain indications (up to 97%) and somatovisceral indications (up to 93%) of anatomically corresponding common MTrP-classical acupoint pairs provide a second, clinical line of evidence that trigger points and acupuncture points likely describe the same physiologic phenomena’.58 Dorsher further demonstrated a strong correspondence between the distributions of the myofascial referred-pain patterns73,74 and acupuncture meridians78,79 of anatomically corresponding common MTrP-classical acupoint pairs. Dry needling Biomechanical, Chemical, Endocrinological, and Vascular Effects of Dry Needling The biomechanical,70–72,158 chemical,141,159 and vascular129,138,140,160–162 effects of needling either superficial55 subcutaneous tissue (non-muscular) or deep23,24,73,74 intramuscular tissue without injectate have been well documented. Improved microcirculation around the knee joint has been demonstrated following ‘dry’ needling into non-TrP locations,138 and improved muscle blood flow has been found following ‘manual acupuncture’ in the lower extremities.163,164 Following needle electrical intramuscular stimulation targeting MTrPs in patients with shoulder and cervical myofascial pain syndrome, microcirculation above the area of the MTrPs was found to have increased from 127.3 to 310.2 BPUs per Laser Doppler Flowmetry, a greater than two-fold increase. Furthermore, low blood flow seemed to correlate with pain intensity,129 suggesting that reduced microcirculation plays a role in the pathophysiology of myofascial pain syndrome.162,165 Electrical dry needling in patients with knee osteoarthritis has also resulted in endocrinological changes, including increases in beta-endorphins and decreases in cortisol.136 Non-Trigger Point Dry Needling in Knee Osteoarthritis and Carpal Tunnel Syndrome: Highly Effective Multiple studies have used dry needling of the knee joint without targeting specific trigger points to treat pain and disability in patients with knee osteoarthritis.50–52,81–85,89,90,131 Recent systematic reviews and meta-analyses provide strong and overwhelming evidence for the effectiveness of acupuncture in the treatment of knee osteoarthritis.166–168 According to the Cochrane Database systematic review on acupuncture for peripheral joint osteoarthritis, Manheimer et al.167 found acupuncture to be associated with a statistically significant and clinically meaningful short term improvement in OA pain when compared to a wait list control. Additionally, this systematic review,167 which included 12 RCTs of patients with knee OA and 4 trials of patients with either knee or hip OA, reported statistically significant reductions in pain following acupuncture in patients with knee OA at 6 months when compared with sham acupuncture. Moreover, in an individual patient data meta-analysis of 9 RCTs comparing real, sham and no acupuncture for chronic pain conditions, Vickers et al.168 reported superior outcomes using real acupuncture in the treatment of knee OA. Additionally, a very recent meta-analysis166 of 11 high-quality RCTs concluded that real acupuncture provides a significant reduction in pain immediately following treatment compared to other physical treatment methods, including sham acupuncture. In contrast to the findings of the Cochrane Database Physical Therapy Reviews 2014 VOL . 19 NO . 4 257 Dunning et al. Dry needling systematic review167 and two recent meta-analyses,166,168 it is noteworthy that an earlier trial84 found the addition of real acupuncture to a course of advice and exercise for the treatment of knee OA provided no additional improvement in the WOMAC pain subscale at 6 months when compared to sham acupuncture. The data from Foster et al.84 also failed to demonstrate a significant relationship between patient treatment preferences and clinical outcomes or patient expectations and pain at 6 and 12 months. However, the results of Foster et al.84 should be viewed cautiously due to the limited number of treatment sessions in the acupuncture protocol compared to other studies,53,81,88,90 which may have rendered the true acupuncture intervention suboptimal, a concession that the authors independently made. More importantly, unlike other trials,81,82,87–90 the subjects in the Foster et al.84 trial did not have radiographically confirmed knee osteoarthritis. Nevertheless, despite the methodologic differences of the Foster et al.84 trial, a cost-utility analysis of the Foster et al.84 data by Whitehurst et al.52 concluded that advice and exercise plus real acupuncture delivered by physical therapists still provided a cost effective use of health care resources. Likewise, there is robust evidence that peri-neural needling of non-trigger point structures helps reduce pain and disability while improving sensory and motor nerve conduction velocities.36,37,40,41,47 Perineural needling has also been shown to stimulate microcirculation in patients with mild to moderate carpal tunnel syndrome.36,37,40,41,47 Such findings suggest that organizations that teach physical therapists a TrP ‘search and destroy’ method of dry needling may not be evidence based. Rather, therapists may be much more effective treating conditions such as osteoarthritis and carpal tunnel syndrome by focusing on non-TrP locations such as neural, connective, and muscle tissue. Dry Needling for Tendinopathy, Not Just TrPs Several recent studies7,158,161,164,169–171 support the use of dry needling in the management of tendinopathy; more specifically, dry needling has been shown to positively influence tendon healing by increasing blood flow via local vasodilation161,163,164,169 and collagen proliferation.158,170 It is theorized that the lack of blood flow and subsequent hypoxic environment contributes to ‘tendon dysrepair’172 and leads to the pain and disability associated with chronic tendinopathy.7 In comparison to a superficial heating modality, and following dry needling using ‘vertical pecking’ between the tendon and its sheath, Kubo et al.161 found statistically significant increases in blood flow and oxygen saturation levels around the Achilles tendon. Following dry needling to burninjured mice, and when compared with conventional dressing, Lee et al.170 found significantly greater basic fibroblastic growth factor and accelerated tissue healing rates. Likewise, Langevin et al.158 reported significantly greater fibroblastic activity following rotational needle manipulation in a mouse model. Clearly, dry needling both superficial and deep non-TrP locations results in significant mechanical,70–72,158 chemical,141,159 endocrinological,136 microvascular,138,161,163,164,170 neural,36,41,47 and central effects 38,39,44,46,130,137,160 (i.e. activation of the descending pain inhibitory systems, cortex, hypothalamus, and inactivation of the limbic system per recent fMRI, and PET studies). As such, the physical therapy profession must re-evaluate whether it is truly ‘best practice’ to limit dry needling to muscle TrPs. There is Limited Evidence Supporting the Effectiveness of Deep TDN Compared to sham or placebo treatments, a recent systematic review and meta-analysis173 recommended ‘dry needling [directly into MTrPs] for decreasing pain in patients with upper quarter myofascial pain syndrome’; however, the data in this meta-analysis was based on three ‘immediately after’ and two ‘at 4weeks’ post-treatment studies. More specifically, although the findings of Kietrys et al.173 support the immediate and short-term effectiveness of dry needling, it does not provide any evidence for the long-term effects of direct TDN on pain or disability in patients with upper quarter myofascial pain syndrome. There are three trials20,80,113 that seem to be frequently cited by clinicians in support of deep TDN; however, all three studies have significant methodologic limitations. First, Ma et al.113 used a ‘mini-scalpel needle release’ surgical procedure instead of monofilament dry needling in an effort Table 1 Duration needles left in situ for neuromusculoskeletal condition. Neuromusculoskeletal condition Duration needles left in situ 10 minutes,20 15 minutes,68 20 minutes116,119,125,177 or 30 minutes.69,123,139 30 minutes,37,40,41 40 minutes47 or 60 minutes.36 5 minutes,56,178,179 15 minutes49 or 20 minutes.126,127 20 minutes51,81,82,87,88,136 or 30 minutes.88–90,138 5 minutes18 or 10 minutes.110 10 minutes,80 20 minutes61,132,174,180 or 30 minutes.111,112,133,181 20 minutes95 or 30 minutes.96,98–101 Low back pain Carpal tunnel syndrome Plantar fasciitis Knee osteoarthritis Shoulder pain Neck pain Headaches 258 Physical Therapy Reviews 2014 VOL . 19 NO . 4 Dunning et al. to remove or disrupt a TrP within the upper trapezius. As such, the study113 should not be cited in support of ‘sparrow pecking’, ‘pistoning’, ‘fast-in fast-out’ intramuscular and deep TDN in patients with myofascial pain syndrome. Second, although Itoh et al.20 found that deep (20 mm) TrP acupuncture of myofascial TrPs is more effective than either superficial (3 mm) TrP acupuncture or standard acupuncture, the conclusions should be cautiously considered given the following methodological shortcomings: (1) the sample contained just 35 patients that were further split into three smaller groups, (2) the longest outcome measures for pain and disability were taken just 4 weeks after the final needling session, (3) the improvements in pain seen in the deep TrP acupuncture group was ‘reversed’ by the end of the 3-week no treatment interval, (4) the between-group differences for pain and disability were not statistically significantly different by week 13. Third, after comparing TrP, standard, and sham acupuncture, Itoh et al.80 concluded that TrP acupuncture is more effective than standard (traditional/classical) acupuncture and nonpenetrating sham acupuncture for reducing pain and disability in patients with chronic, non-radiculopathic neck pain. However, the 40-patient sample size was divided among three smaller groups, and outcome measures for pain and disability were taken only 3 weeks post-treatment. Multiple Needles Should Be Left In Situ for 10– 30 minutes Although the optimum dosage50,51,83,85,124 (frequency of treatment sessions per week or month), duration (length of time the needles should remain in situ), and intensity (the number of needles used and degree of manual manipulation or electrical stimulation) has yet to be determined23,24,50,51,83,85,114,135,174 for many neuromusculoskeletal conditions, the vast majority of ‘dry’ needling randomized controlled trials attempt to elicit a deqi response.175,176 Deqi has been defined as a dull ache, heaviness, distension, numbness, tingling, cramping, pressure, fullness, spreading, warmth, or coolness.175,176 In addition, most trials have left multiple needles in situ for between 5 and 40-minute durations; moreover, a recent systematic review and meta-analysis19 within the framework of the Cochrane collaboration concluded, ‘for low back pain of any duration, needle retention for about 10 minutes is better than removal immediately after insertion’.19 Table 1 provides the durations and specific studies that multiple needles were left in situ for a variety of neuromusculoskeletal conditions. Even when ‘pistoning’, ‘sparrow pecking’, or ‘fastin-and-out’ maneuvers were used with the intent of eliciting an LTR in muscular TrPs, multiple needles were often left in place for ten minutes or Dry needling longer.20,80 While several studies29,35,59,63,64,67,102,104,182,183 have demonstrated immediate and/or short-term improvements in pain and/or disability following ‘inan-out’ techniques, to date, there are no high-quality long-term trials23,24 to support the practice of immediately removing the needles after pricking TrPs or eliciting LTRs; therefore, this practice should be questioned. Local, Proximal, and Distal Needling ‘Regional interdependence’ has been defined as ‘the concept that seemingly unrelated impairments in a remote anatomical region may contribute to, or be associated with, the patient’s primary complaint’;184 that is, the practice of examining and treating muscle, joint or neural impairments that are not local, but are distal or proximal to the patient9s symptoms, has gained widespread acceptance in the orthopedic manual physical therapy community.184-190 For example, there are several trials that support the use of thrust manipulation to the cervical, cervicothoracic, thoracic, and upper rib articulations in the treatment of patients with the primary complaint of shoulder pain185-190 or shoulder impingement191,192– i.e. treating proximal structures to affect distal symptoms. Likewise, patients with lateral epicondylalgia often seek conservative treatment by a physical therapist. In addition to providing manual therapy to the humero-radial joint and needling the forearm extensor muscles,183 physical therapists often manipulate the neck and wrist based on supporting evidence in the literature.193,194 That is, physical therapists commonly deliver manual therapy both proximal193 and distal194 to the site of pain. The fact that the Mississippi and Colorado State Boards of Physical Therapy believe that IMT and dry needling, respectively, do not include the stimulation of distal points seems misleading and clinically illogical.10,13 Based on this line of reasoning, physical therapists in Mississippi10 and Colorado13 are not allowed to target TrPs in the adductor magnus muscle in patients with ‘generalized internal pelvic pain…or pain shooting up inside the pelvis’74 because the pain is located ‘distal’ to the patient’s pain complaint. It is worth noting that this clinical reasoning is directly contrary to that recommended by Travell and Simons. According to Travell and Simons, ‘deep pain in the ipsilateral sacroiliac joint’74 may be caused by a TrP in a very ‘distal’ location, namely the soleus muscle. Interestingly, the most recent literature on myofascial pain syndrome provides clear evidence for needling distal sites, a finding analogous to the acupuncture tradition of treating distal acupoints to influence anatomically remote pain.149 More recently,33 ipsilateral or contralateral dry needling to MTrSs (myofascial trigger spots) in the Physical Therapy Reviews 2014 VOL . 19 NO . 4 259 Dunning et al. Dry needling distal gastrocnemius muscle (lower leg) was shown to suppress spontaneous electrical activity (i.e. end plate noise) in MTrSs within the more proximal biceps femoris muscle. Furthermore, after either tibial nerve transection or L5-6 spinal cord transection in rabbits, Hsieh et al.33 found that the remote effects in the bicep femoris disappeared. According to Hsieh et al.,33 the physiologic basis for the remote and/or distal effects of dry needling may be related to activation of the diffuse noxious inhibitory control (DNIC) system, as induced by noxious stimulation provided by the needles. Simply put, ‘the pathway for the remote effect appears to be a spinal reflex’.33 Such a finding implies that inserting a needle into the left hand would potentially lead to pain relief in the right hand. The recent findings of Hsieh et al.33 add support to the practice of needling contralateral to the side of pain and/or needling distal to the site of pain in order to reduce end plate noise and suppress activity of more proximal painful TrPs. In another recent experimental study,26 dry needling of primary MTrPs in patients with shoulder pain was found to inhibit the activity of satellite or secondary MTrPs situated in the shoulder, elbow, or forearm. That is, the target MTrP was found either proximal or distal to the patient’s site of discomfort.26 It follows then that the APTA8 and Physical Therapy State Boards10,13 should consider that the best practice for dry needling may require the placement of needles both ‘local and/or distal’ to the patient’s primary source of pain. Physical therapists often deliver manual therapy and/ or orthotic interventions to the tarso-metatarsal, subtalar, or talocrural joints in order to manage patients with low back pain;195–199 likewise, the insertion of needles without injectate into bodily areas that are asymptomatic but distal or proximal to the site of pain is supported by the myofascial pain syndrome literature.149 As Melzack et al.27 points out: The stimulation of particular nerves or tissues by needles…would close the gates to [pain] inputs from selected body areas. The cells of the midbrain reticular formation are known to have large receptive fields…. It is possible, then, that particular [distant] body areas may project especially strongly to some reticular areas, and these, in turn, could bring about a complete block of inputs from particular parts of the body.27 terms ‘TDN’ or ‘IMT’ should not be used interchangeably or synonymously with the term ‘Dry Needling’. Dry needling encompasses the insertion of needles without injectate3 into, alongside, or around nerves,17,28,36,40,42,43,47,55,65,159 muscles,5,6,20,23,24,65,109 or connective tissues6,7,48,49,70–72,126,170,172 for the management of pain and dysfunction in neuromusculoskeletal conditions. Dry needling neither attempts to move qi along meridians nor does it rely on diagnoses from traditional Chinese or Oriental Medicine.78,79 Considering the mechanical,70–72,158 chemical,141,159 endocrinological,136 microvascular,138,161,163,164,170 36,41,47 neural, and central effects38,39,44,46,130,137,160 of both superficial and deep dry needling at TrP and non-TrP locations, the position statements by the APTA8,75 and many State Boards of Physical Therapy9–13 do not seem to be consistent with the existing literature. Funding None. Conflicts of Interest Dr. James Dunning is the President of the American Academy of Manipulative Therapy (AAMT). Through Spinal Manipulation Institute (SMI) and Dry Needling Institute (DNI), AAMT provides postgraduate training programs in dry needling and spinal manipulation to licensed physical therapists, osteopaths and medical doctors. Drs. James Dunning, Raymond Butts, Thomas Perreault, and Firas Mourad are senior instructors for SMI and DNI. Academic Affiliation The senior author, James Dunning, is currently a PhD student at Nova Southeastern University, Fort Lauderdale, FL, USA. Ethics Approval N/A. Contributors JD participated in the conception, design, initial drafting and revision of the manuscript. FM participated in the design and revision of the manuscript. RB participated in the conception, design, and revision of the manuscript. IY participated in the drafting of the manuscript and revision of the manuscript. SF and TP participated in the revision of the manuscript. All authors read and approved the final manuscript. References Conclusion Just as the Maitland,14 Kaltenborn,15 and McKenzie16 approaches are unique brands of manual therapy, so is ‘TDN’ and ‘IMT’ to dry needling. They provide a single framework or paradigm within the much broader field of dry needling.5,17–25 Therefore, the 260 Physical Therapy Reviews 2014 VOL . 19 NO . 4 1 Speed CA. Injection therapies for soft-tissue disorders. Best Pract Res Clin Rheumatol. 2003;17(1):167–81. 2 Speed CA. Injection therapies for soft-tissue lesions. Best Pract Res Clin Rheumatol. 2007;21(2):333–47. 3 Casanueva B, Rivas P, Rodero B, Quintial C, Llorca J, Gonzalez-Gay MA. Short-term improvement following dry needle stimulation of tender points in fibromyalgia. Rheumatol Int. Apr 23, 2013. [epub ahead of print] Dunning et al. 4 Manheimer E, White A, Berman B, Forys K, Ernst E. Metaanalysis: acupuncture for low back pain. Ann Intern Med. 2005;142(8):651–63. 5 Gunn CC, Milbrandt WE, Little AS, Mason KE. Dry needling of muscle motor points for chronic low-back pain: a randomized clinical trial with long-term follow-up. Spine (Phila Pa 1976). 1980;5(3):279–91. 6 Lewit K. The needle effect in the relief of myofascial pain. Pain. 1979;6(1):83–90. 7 Neal BS, Longbottom J. Is there a role for acupuncture in the treatment of tendinopathy? Acupunct Med. 2012;30(4):346–9. 8 APTA. 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