J Trigger Point Dry Needling

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tion 2006 However the physical therapy state boards therapy according to the 2006 Florida Statutes states that. of Colorado Georgia Kentucky Maryland New Hamp among others the practice of physical therapy means the. shire New Mexico South Carolina and Virginia have performance of acupuncture only upon compliance with. determined in recent years that TrP DN does fall within the criteria set forth by the Board of Medicine when no. the scope of physical therapy in those states Several penetration of the skin occurs 9 Whether TrP DN would. other state boards are currently reviewing whether dry be considered as falling under this peculiar definition. needling should fall within the scope of physical therapy has not been contested and the Florida Statutes do not. practice and the Director of Regulations of the State provide any guidelines as to how to perform acupuncture. of Colorado has issued a specific Director s Policy on without penetration of the skin9. Intramuscular Stimulation Table 1 6, Table 1 Colorado Physical Therapy Licensure Policies of the Director Director s Policy on Intramuscular. Stimulation or IMS Williams T Colorado Physical Therapy Licensure Policies of the Director Policy 3. Director s Policy on Intramuscular Stimulation Denver CO State of Colorado Department of Regula. tory Agencies 2005, IMS is a physical intervention that uses dry needles to stimulate trigger points diagnose and. treat neuromuscular pain and functional movement deficits. IMS requires an examination and diagnosis and it treats specific anatomic entities selected. according to physical signs,3 IMS is not considered an entry level skill. Physical therapists receive substantial training and have sufficient knowledge in the areas. 4 of reducing the incidence and severity of physical disability movement dysfunction bodily. malfunction and pain, 5 There is substantial medical literature on IMS that has been subjected to peer review. Seven states Georgia Kentucky Maryland New Mexico New Hampshire South Carolina. 6 and Virginia have found IMS to be within the scope of physical therapy as of this Policy s. adoption date, 7 The Director expects physical therapists to obtain the necessary training prior to using IMS.
The Director determines that IMS falls within the scope of physical therapy as defined in. 8 section 12 41 103 6 C R S and may be independently practiced by Colorado licensed. physical therapists, On the other hand the Tennessee Board of Occu The introduction of TrP DN to American physical. pational and Physical Therapy concluded in 2002 that therapists shares many similarities with the introduction. TrP DN is not an acceptable physical therapy technique of manual therapy When during the 1960s Paris expressed. The decision of the Tennessee Board was based on the his interest in manual therapy he experienced consider. need for education and training or in other words the able resistance not only from academia but also from. realization that TrP DN is not commonly included in the employers the American Physical Therapy Association. physical therapy curricula of US academic programs5 7 APTA and even from Dr Janet Travell10 Paris reported. Some state laws have defined the practice of physical that in 1966 Dr Travell blocked his membership in the. therapy as non invasive which would implicitly put TrP North American Academy of Manipulative Medicine an. DN outside the scope of physical therapy in those states organization she had founded with Dr John Mennell. For example the Hawaii Physical Therapy Practice Act on the grounds that manipulation is a diagnostic and. specifies that physical therapists not be allowed to pen therapeutic tool to be reserved for physicians only 10. etrate the skin8 The definition of the practice of physical Similarly the 2002 rejection of TrP DN by the Tennessee. Trigger Point Dry Needling E71, Board of Occupational and Physical Therapy was in part pain14 15 A medical specialist Dr Jennifer Chu developed. based on the testimony of an academic expert witness7 electrical twitch obtaining intramuscular stimulation. In 2006 the APTA omitted an educational activity about this approach combines aspects of the radiculopathy. physical therapy and dry needling from the tentative model with the trigger point model16 23. agenda of its annual conference while the Royal Dutch The radiculopathy model will be reviewed briefly while. Physical Therapy Association upheld the opinion that the MTrP model will be discussed in detail The spinal. TrP DN should not fall within the scope of physical segmental sensitization model and neural acupuncture. therapy practice In October 2006 the Virginia Board are not included in this article due to their exclusive. of Physical Therapy heard arguments from a physician use of injections which are outside the scope of physical. organization against physical therapists using TrP DN therapy practice in most jurisdictions5 12. To the contrary physical therapists in South Africa are Another classification is based on the depth of the. allowed to perform botulinum toxin injections in the needle insertion and distinguishes superficial dry needling. management of persons with MTrPs Within the context SDN and deep dry needling DDN 24 25 Examples of. of autonomous physical therapy practice TrP DN does SDN include Baldry s SDN approach and Fu s Subcutane. seem to fit the current practice model in spite of the ous Needling which fall within the trigger point TrP. reservations of other disciplines and some physical model 24 26 29 The needling approach advocated by the. therapy professional organizations radiculopathy model is a form of DDN The TrP model. In order to practice TrP DN physical therapists includes both superficial dry needling TrP SDN and. need to be able to demonstrate competence or adequate deep dry needling TrP DDN Table 2. training in the technique and that they practice in a. jurisdiction where TrP DN is considered within the Radiculopathy Model. scope of physical therapy practice Many country and The radiculopathy model is based on empirical obser. state physical therapy statutes address the issue of com vations by Canadian medical physician Dr Chan Gunn. petence by including language such as this physical who was one of the early pioneers of dry needling A. therapists shall not perform any procedure or function review of TrP DN would be incomplete without including. which they are by virtue of education or training not a brief summary of Gunn s needling approach although. competent to perform 5 Obviously physical therapists the radiculopathy model no longer includes TrP DN13. employing TrP DN must have excellent knowledge of Initially Gunn incorporated MTrPs in his thinking. anatomy and be very familiar with its indications con but fairly soon he moved away from MTrPs and further. traindications and precautions This article provides developed and defined his DDN approach referred to as. an overview of TrP DN in the context of contemporary intramuscular stimulation or IMS18 20 Gunn introduced. physical therapy practice the term IMS to distinguish his approach from other. needling and injection approaches but the term is fre. Dry Needling Techniques quently used to describe any dry needling technique30. Because dry needling techniques emerged empiri According to Gunn s web site hundreds of doctors and. cally different schools and conceptual models have been physiotherapists from all around the world have been. developed including the radiculopathy model the MTrP trained in the technique31 The web site also mentions. model and the spinal segmental sensitization model1 5 11 that some practitioners employ altered versions of. In addition there are other less common needling IMS not endorsed by Professor Gunn or the medical. approaches such as neural acupuncture and automated community 31. or electrical twitch obtaining intramuscular stimula The Gunn IMS technique is based on the premise that. tion14 22 In neural acupuncture acupuncture points are myofascial pain syndrome MPS is always the result of. infiltrated with lidocaine for the treatment of myofascial peripheral neuropathy or radiculopathy defined by Gunn. Table 2 Models of Needling,Radiculopathy Spinal Segmental. Model Sensitization Model,Superficial DN Yes No No. Deep DN Yes Yes No,Injection therapy Yes No Yes,TrP trigger point DN dry needling.
E72 The Journal of Manual Manipulative Therapy 2006. as a condition that causes disordered function in the myotomes Gunn emphasized evaluating the paraspinal. peripheral nerve 30 In Gunn s view shortening of the regions for trophic changes which may include orange. paraspinal muscles particularly the multifidi muscles peel skin peau d orange dermatomal hair loss and. leads to disc compression narrowing of the intervertebral differences in skin folds and moisture levels dry versus. foramina or direct pressure on the nerve root which moist skin 13. subsequently would result in peripheral neuropathy and Although Gunn et al completed one of the first dry. compression of supersensitive nociceptors and pain needling outcome studies which demonstrated that IMS. The radiculopathy model is based on Cannon and can be an effective treatment option there are no studies. Rosenblueth s Law of Denervation which maintains that that substantiate the theoretical basis of the radicu. the function and integrity of innervated structures is lopathy model or of the IMS needling interventions5 33. dependent upon the free flow of nerve impulses32 When Although Gunn emphasized the importance of being able. the flow of nerve impulses is restricted all innervated to objectively verify the findings of neuropathic pain34. structures including skeletal muscle smooth muscle there also are no interrater reliability studies and no. spinal neurons sympathetic ganglia adrenal glands studies that support the idea that the described findings. sweat cells and brain cells become atrophic highly ir are indeed indicative of neuropathic pain5 For example. ritable and supersensitive30 Gunn suggested that many there is no scientific evidence that an MTrP is always a. common diagnoses such as Achilles tendonitis lateral manifestation of radiculopathy resulting from trauma to. epicondylitis frozen shoulder chrondromalacia patel a nerve even though it is conceivable that one possible. lae headaches plantar fasciitis temporomandibular cause of the formation of MTrPs is indeed nerve damage. joint dysfunction myofascial pain syndrome MPS and or dysfunction35 Interestingly Gunn did not regard his. others might in fact be the result of neuropathy30 Chu model as a hypothesis but rather considered it a mere. has adapted Gunn s radiculopathy model in that she description of clinical findings that can be found by. has recognized that MTrPs are frequently the result of anyone who examines a patient for radiculopathy 34. cervical or lumbar radiculopathy16 18 22 23 However without scientific validation the radiculopathy. Gunn13 maintained that the most effective treatment model was never developed beyond the hypothetical stage. points are always located close to the muscle motor points Gunn s conclusion that relative minor injuries would. or musculotendinous junctions which are distributed in not result in chronic pain without prior sensitization. a segmental or myotomal fashion in muscles supplied of the nerve root is inconsistent with many current. by the primary anterior and posterior rami Because the neurophysiological studies that confirm that persistent. primary posterior rami are segmentally linked to the para and even relatively brief nociceptive input can result in. spinal muscles including the multifidi and the primary pain producing plastic dorsal horn changes36 42. anterior rami with the remainder of the myotome the. treatment must always include the paraspinal muscles Trigger Point Model. as well as the more peripheral muscles Gunn found Clinicians practicing from the perspective of the. that the tender points usually coincided with painful trigger point model specifically target MTrPs The clini. palpable muscle bands in shortened and contracted cal manifestation of MTrPs is referred to as MPS and is. muscles He suggested that nerve root dysfunction is defined as the sensory motor and autonomic symptoms. particularly due to spondylotic changes According to caused by MTrPs 1 Myofascial trigger points may consist. Gunn relatively minor injuries would not result in of multiple contraction knots which are thought to be. severe pain that continues beyond a reasonable period due to an excessive release of acetylcholine ACh from. unless the nerve root was already in a sensitized state select motor endplates and can be divided into active and. prior to the injury13 latent MTrPs1 43 44 The release of ACh has been associated. Gunn s assessment technique is based on the evalu with endplate noise a characteristic electromyographic. ation of specific motor sensory and trophic changes discharge at MTrP sites consisting of low amplitude. The main objective of the initial examination is to find discharges in the order of 10 50 V and intermittent. characteristic signs of neuropathic pain and to determine high amplitude discharges up to 500 V in painful. which segmental levels are involved in a given individual MTrPs45 47 Active MTrPs can spontaneously trigger local. The examination is rather limited and does not include pain in the vicinity of the MTrP or they can refer pain. standard medical and physical therapy evaluation tech or paraesthesiae to more distant locations They cause. Myofascial Pain Trigger Point Acupuncture Injection Physical Therapy T rigger point dry needling TrP DN also referred to as intramuscular stimulation IMS is an invasive procedure in which an acupuncture needle is inserted into the skin and muscle As the name implies TrP DN is directed at myofascial trigger points MTrPs which

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