DRY NEEDLING

DR VARDHMAN JAIN (PT)

Founder NMDN
Hydrotherapist (Hallawick Method)
INPP (USA) , Therasuit (USA) , Ergonomist
 Is
Dry Needling
within
the
Scope
of
Physiotherapist
Practice?
 Is it within the scope of
physiotherapy?
• Dry needling is practiced by physical therapists in many countries,
including
– SA
– Bangladesh
– Netherland
– Spain
– United States of America
– Switzerland
– Canada
– Chile
– Ireland
– United Kingdom
– Australia and New Zealand
– and Many More
Dry Needling-Definition
Dry Needling
A skilled intervention performed
by a physical therapist 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.
(American Physical Therapy Association Dry
Needling Task Force, May, 2012)
 Dry Needling-Definition
• Dry needling encompasses the insertion of needles without injectate
into, alongside, or around nerves, muscles, or connective tissues 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.

• Considering the mechanical, chemical, endocrinological,

microvascular, neural, and central effects of both superficial and
deep dry needling at TrP and non-TrP locations,

• “The position statements by the APTA”

 Is
Dry Needling
Acupuncture?
 Dry Needling versus Acupuncture

Similarities Differences

The Tool Evaluation

Application

Overall Goal
+ Traditional Chinese
Acupuncture
Needle insertion points
are founded in knowledge
of meridians

www.kinetacore.com
+

Dry Needling in
Physical Therapy

Needle insertion points based

on assessment and
knowledge of neuroanatomy
 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.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).
Dry Needling: A Trigger point
Concept?
 Dry Needling Targets Neural,
Muscular, and Connective Tissues,
Not Just TrPs
• American Physical Therapy Association (APTA)
and State Boards of Physical Therapy should
therefore clearly articulate that dry needling
encompasses stimulation of
neural, muscular, and connective tissues, and
not just ‘TrPs’.
 Dry Needling for Tendinopathy, Not
Just TrPs
• Several recent studies 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 vasodilation
and collagen proliferation.
 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’; that is, the practice of
examining and treating muscle, joint or neural
impairments that are not local, but are distal or
proximal to the patient′s symptoms, has gained
widespread acceptance in the orthopedic manual
physical therapy community.
+
Dry Needling Terminology

Functional
Dry
Needling
(FDN)

Intramuscular
Trigger Point
Dry Needling
Dry Manual
Therapy
(TDN)
Needling (IMT)

Intramuscular
Stimulation
(IMS)
 Dry Needling various Transition?

• ‘Dry needling’ in their methodology, other studies use

alternative terminology such as
– deep dry needling
– superficial dry needling
– TrP acupuncture
– paraspinal needling
– intramuscular and nerve root needling
– needle electrical intramuscular stimulation
– needle release
– acupuncture needling
– needling therapy
– and electroacupuncture
 Dry Needling various Transition?
• Physiotherapists and/or medical physicians within both government
administered national health services and mainstream university
health systems in the UK, Canada, USA and Germany use the
term ‘acupuncture’ to describe dry needling
methodologies.

• The same is true of articles published in mainstream, highly

respected journals, including theBritish Medical Journal,
European Journal of Pain, Archives of Physical Medicine
& Rehabilitation, Pain, Annals of Internal
Medicine Headache, Rheumatology, Spine, andCochrane
Database of Systematic Reviews.

• Even the Physical Therapy Journal sponsored by the APTA has used
acupuncture and dry needling interchangeably in a recent
publication.
Emergence of New Concept
 NMDN Concept Core Idea:

• NO MANIPULATION

• MINIMUM NUMBER OF NEEDLE

• FASTER REHABILITATION WITH ADJOURNING

MODALITIES & EXERCISE PROGRAM
 Dry Needling Alters Trigger Points in the Upper
Trapezius Muscle and Reduces Pain in Subjects with
Chronic Myofascial Pain
Lynn H. Gerb

• Results
• Primary outcomes: 41 subjects had a change
in trigger point status from active to latent or
resolved; and 11 had no change (p < .001).
Reduction in all pain scores was significant
(p<.001).
Trapezius
 Anatomy
Origin
Medial third of superior nuchal line of occipital bone. External occipital protuberance.
Ligamentum nuchae. Spinous processes and supraspinous ligaments of seventh cervical
vertebra (C7) and all thoracic vertebrae (T1–12).
Insertion
Posterior border of lateral third of clavicle. Medial border of acromion. Upper border of
crest of spine of scapula, and tubercle on this crest.
Action
Upper fibers: pull shoulder girdle up (elevation). Help prevent depression of shoulder girdle
when a weight is carried on the shoulder or in the hand.

Middle fibers: retract (adduct) scapula.

Lower fibers: depress scapula, particularly against resistance, as when using hands to get up
from a chair.

Upper and lower fibers together: rotate scapula, as in elevating the arm above the head.
 Common Symptoms
• Upper Trapezius
– TrP1 & TrP2 feels like headaches on the temples / "tension" headaches
– facial, temple, or jaw pain
– pain behind the eye
– dizziness or vertigo (in conjunction with the sternocleidomastoid muscle)
– severe neck pain
– a stiff neck
– limited range-of-motion
– intolerance to weight on your shoulders
• Middle Trapezius
– mid-back pain
– headaches at the base of your skull
– TrP5 refers superficial burning pain close to the spine
– TrP6 refers aching pain to the top of the shoulder near the joint
• Lower trapezius
– mid-back, neck, and/or upper shoulder region pain
– possibly referral on the back of your shoulder blade, down
the inside of the arm, and into the ring and little fingers
(TrP7), very similar to a serratus posterior superior referral
pattern
– headaches at the base of the skull
– TrP3 can refer a deep ache and diffuse tenderness over
the top of your shoulder
– TrP4 is probably an attachment trigger point and is located
next to the inner border of the scapula. It refers pain
primarily to the area bordering the scapula on the same
side.
 Special Aspect
• This muscle often compensates in rotator cuff injuries.
• Tension in the trapezius adds to tension in the
multifidi, and that can lead to pinched spinal nerves.
• Tightness in the upper and lower trapezius and
serratus anterior is related to shoulder-joint stiffness
• Middle trapezius TrPs can cause burning pain that
seems to be skin deep but can penetrate deeper. TrPs
in this region can cause dizziness and loss of balance,
and may be misdiagnosed as disc pain, neuralgia,
bursitis, or arthritis. Middle trapezius TrPs above the
interior top (superior) corner of the shoulder blade can
cause goosebumps in a characteristic pattern
• Continuous trapezius muscle activity of anything
over eight minutes can be associated with a risk
of neck pain (Ostensvik, Veiersted, and Nilsen
2009).
• A patient with these Muscles of the Shoulder,
Arm, and Hand TrPs may be misdiagnosed with
cervical radiculopathy or atypical facial
neuralgia.
• Spine manipulation affecting the C3–C4 segment
can relieve pressure/pain sensitivity of TrPs in
the upper trapezius (Ruiz-Saez et al. 2007).
• Sensitivity (C2–T2), motor function (M.
deltoideus, C5), strength.
• In patients with ‘bull neck’ (short neck, very
hypertensive muscles) give intensive
physiotherapy initially.
 Perpetuation of Trigger Points
• large breasts
• tensing your shoulders
• cradling a phone between your ear and shoulder
• a chair without armrests, or the armrests are too high
• typing with a keyboard too high
• sewing on your lap with your arms unsupported
• jogging
• sleeping on your front or back with your head rotated
to the side for a long period
• playing a violin
• sports activities with sudden one-sided movements
• sitting without a firm back support (sitting slumped)
• any profession or activity that requires you to bend over for extended
periods (i.e.. dentists/hygienists, architects/draftsmen, and
secretaries/computer users)
• bra straps that are too tight (either the shoulder straps or the torso strap)
• a purse or daypack that is too heavy
• a mis-fitting, heavy coat
• carrying a day pack or purse over one shoulder -- even if you think you are
not hiking up one shoulder, you are, no matter how light the item
• whiplash (a car accident, falling on your head, or any sudden jerk of the
head)
• head-forward posture
• walking with a cane that is too long
• turning your head to one side for long periods to have a conversation
• tight pectoralis major muscles
 Indications
• Chronic tension and neck ache
• •stress headache
• cervical spine pain
• whiplash
• tension/cluster headache
• facial/jaw pain
• neck pain and stiffness
• upper shoulder pain
• mid-back pain
• dizziness
• eye pain
• emotional stress
• depression.
 Differential diagnosis
• Capsular-ligamentous apparatus.

• Articular dysfunction (facet)

• Glenohumeral separation

• Sprain/Strain injury

• Adhesive capsulitis (Frozen shoulder)

• Bursitis

• Osteoarthritis
 Helpful Hints
• Modify or replace your mis-fitting furniture.

• Get a headset or speaker for your phone, or hold the phone with one hand. Shoulder
rests are not adequate.

• Wear bras that fit properly.

• Restoration of proper posture, especially head positioning, is critical to treating trigger

points since head-forward posture can both cause and perpetuate trigger points

• Putting your hands in your pockets when standing takes the weight off the trapezius
muscle.

• Putting shoulder pads in a heavy coat can help take the weight off the upper trapezius
Force couple of UT with middle/lower
trapezius and serratus Anterior.
• the majority of the UT fibres attach onto the distal third of the
clavicle, and due to their horizontal arrangement, they also rotate
the clavicle medially – this rotation compresses and stabilises the
sternoclavicular (SC) joint. This SC joint compression allows load to
be transferred away from the cervical spine and instead is directed
towards the sternum and axial skeleton.
• the UT works synergistically with the other trapezius muscles
(middle and lower) to produce a force couple on the scapula;
therefore the UT has both a functional role in movement and
stabilisation of the scapula. To highlight the individual and
synergistic role of the trapezius muscle, the individual heads work
in the following ways
 +
• UT draws the clavicle backwards, medially and
upwards at the sternoclavicular joint. It helps to
control the neutral position of the scapula. It has
some potential to produce movement to the
cervical spine and contributes to the stability of
the cervical spine.
• Middle trapezius produces scapula retraction
and upward rotation, as well as drawing the
clavicle and scapula backwards and medially
together with UT allowing scapula upward
rotation. It controls or resists scapula protraction,
and downward rotation.
• Lower trapezius produces scapula upward
rotation, external rotation, posterior tilt and
depression. It controls or resists scapula
elevation, abduction and downward rotation, as
well as controlling the neutral position of the
scapula.
 Dry Needling Procedure
• Patient positioning
• Patient is either supine or prone.

• Needle type
• Use 0.25 to 0.30mm × 30mm needle.

• Needling directions
• Needle in a lateral to medial direction, staying well above the apex
of the lung and posterior to the brachial plexus.

• Precautions
• Avoid the lung by holding the upper trapezius between the fingers
and thumb, as shown in the image.
 Trapezius Pain
• True trapezius pain can be seen clinically only
when it weak.
• Most of the cases we see clinically are
trapzeius compensating for other muscles like:
 Upper Trap Dominates Latissimus
Dorsi
• forward flexion society is the new norm. Hunching over
phones and desks for endless hours sets up repetitive
motion chaos for the body. Adaptation to the stress
response of the modern external environment breeds
compensation layers. Think tight muscles, aches, pains, etc.
• How often do you see people open up into a power
extension posture? Shoulders down and back, walking tall,
feeling lean and mean? Probably have to squint. You just
might see them and a Unicorn too.
• The human cashew posture annihilates thoracic spine
extension and the ability to efficiently rotate the torso.
Rotation (transverse plane) is highly energy efficient and
less costly for the body to generate, absorb, disperse and
release force.
The upper trap could be having a tug-
of-war with the pec minor
• The pec minor is a downward rotator of the
scapular. As the arm is being lifted and the
scapular is upwardly rotating, the pec minor
needs to relax. If the pec minor is overly tight
and hypertonic, it will try and pull the scapular
back down again.
• So the upper trap along with the serratus
anterior will have their work hard to try and fight
this downward drag. Again this is a
compensation.
 The upper trapezius can compensate
for weak upward rotators such as
serratus anterior.
• The upper trap should only really come in to
shoulder elevation movements in the last phase
of movement when the arm is approaching a
vertical position.
• It does this to elevate the scapular and clear the
acromion process away from the head of the
humerus. If it comes in too early and is active too
early, then perhaps it is compensating for
weakness in other upward rotators such as the
serratus anterior.
+
upper Trapezius and Diaphragm

• weak diaphragm make difficult to take deep breaths, for deeper breath
then taking in laboured manner with accessory muscles, mainly trapezius
and scalene.
 upper trapezius can compensate for
Gluteus Muscle
• due to weak firing of gluteus muscles and
balance the erect posture trapezius can
overfire to compensate for Gluteus muscles
+
Upper Trapezius and Rectus Abdominis
+ Upper Trapezius Compensating for
Lower and middle trapezius
• A new journal article in Physical Therapy in Sport
(the journal I recently reviewed) discusses imbalance
between upper and lower trapezius muscle activity
and the association of subacromial shoulder
impingement.
• What this means is that the upper trapezius is a little
more than 3 times more active than the lower
trapezius during scapular plane elevation in patients
with subacromial impingement.
• LET's Assess?

• Who wants to TRY?