The longer I practice physical therapy, the more I come to embrace the skills at our disposal that make us unique as clinicians. We all come out of school with a strong foundation in anatomy, orthopedics, and neurology. In other words, fresh graduates (who, like your friendly Relevation clinicians, all have their clinical doctorates, or DPTs) are pretty darn good at identifying and locating a body structure, describing how it moves, and reciting the nerve (or the “wiring”) that feeds the utilized muscle (or the “motor”). We also take courses in diagnosis and treatment of conditions, but usually experience in the clinic, hospital, or nursing facility is the best way to improve these aspects of the job. However, students often get very little (I’m talking like 1-2 days) exposure to many of the really cool specialties that physical therapists use to distinguish themselves from other professions in the health and wellness field. I know that it is just the reality of the mandatory curriculum, but still, it’s a shame.
Alright, Hot Shot. Let’s try a little quiz: Which of the following are conditions treated by physical therapists (please circle all that apply):
a) Incontinence e) Wound Management
b) Migraines/Headaches f) Osteoporosis
c) Pain with Intercourse g) Breast Cancer
d) Jaw/TMJ Pain h) Zombie virus from “The Walking Dead”
I am sure that it wasn’t difficult to tell which pathology we cannot help with - that’s right, headaches…Just kidding. But every malady listed above (well, almost every one) can be significantly improved with the addition of a physical therapist with specialty training to the treatment team, which may also include physicians, dentists, and psychologists. It is not shocking, but perhaps still frustrating, that the general public still really does not grasp the advanced skills and large scope of services that our field can offer. I really want to lobby the American Physical Therapy Association to change its official slogan to “Physical Therapy: So Much More Than Ultrasound, Hot Packs, and Stretching”!
So in an effort to put my money where my mouth is, I have started to dive into my own treatment specialty over the last year: dry needling. Ever heard of it? Your mind may have jumped right to acupuncture, which would have been a logical leap. Dry needling can be considered a technique of acupuncture, but it can be safely and effectively practiced by several different disciplines, including physical therapists. Westernized needling theory, however, has nothing in common with Traditional Chinese Medicine standards such as meridians, energy flow, and metaphysics. The technique does utilize acupuncture needles, which are “dry” in that they are solid and do not contain or inject any liquid medication. So if you are a fan of keeping as much artificial junk out of your system as possible (as I am), this treatment, if appropriate, could be right up your alley.
Dry needling that pesky upper trapezius muscle.
I use dry needling in my practice to primarily treat something called myofascial pain, which is a term that has gotten grossly overused in terms of giving accurate diagnoses. Myofascial pain specifically refers to symptoms caused by myofascial trigger points. Let us creep further down this rabbit hole and ask, “What the heck are myofascial trigger points (or MTrP from now on…that’s too much typing!). The smart people who study this stuff define them as “hyperirritable spots in taut bands of skeletal muscle that are painful on compression, stretch, overload, or contraction of the tissue which usually respond with referred pain that is perceived distant from the spots.” (Simons et al. 1999)…Huh? Though I am sure that all of my readers are utterly brilliant, let me try to simplify that definition, if just for giggles. A muscle can develop a specific spot in a guitar-string like band of fibers that when pressed on, stretched out, or put under stress can send pain messages to places far away from that original source. This “referred pain” is tricky to recognize because of our innate tendency to think that pain represents a problem exactly where you are feeling that pain. For example, “My elbow hurts, so there must be a problem with my elbow.” However, in the case of myofascial pain, the following is more accurate: “My elbow hurts, and its due to a MTrP in my shoulder.” See how that can be confusing? Don’t worry. This can very often trip up physicians and physical therapists, too. But these MTrPs do come with some pretty specific characteristics to look out for:
1) Duration of Pain: a few seconds to indefinitely (hmm, that one is pretty vague)
2) Pain Description: deep, diffuse, burning, tightening, pressing (ok, getting somewhere)
3) Pain Pattern: can spread up or down, front or back (so pretty much anywhere, which is actually helpful, as pinched nerves, conversely, have specific patterns)
4) Intensity: The more irritated the spot, the larger and more intense the pain pattern (seems logical)
5) Additional Symptoms: numbness, tingling, coldness, stiffness, fatigue, weakness (JACKPOT!)
If you thought the definition of a MTrP was complicated, then the reasoning behind how a muscle can develop referred pain might make your eyes pop out ala Total Recall (I almost put a picture in here from that scene, but I didn't want to give anyone nightmares). In fact, the true mechanism is not even completely understood by scientists. So let’s save ourselves a headache and move on!
There are several ways to actually conduct dry needling. Superficial needling refers to only penetrating the skin and underlying tissue, not the muscle. This can be useful for de-sensitizing scars and treating MTrPs in those particular muscles that could be slightly dangerous to needle (like certain deep neck muscles – no thank you!). But for the vast majority of my treatments, I use deep needling techniques, which actually penetrate the muscle in question. I use body position, needle size, hand placement, and needle angle to make sure that I am not going to poke anything that shouldn’t be poked (like lungs or big arteries. That surely wouldn’t help). Once the needle is in the muscle, I may just leave it there or may move it around in twisting or lancing motions in order to achieve the response I want, which could be either a reproduction of the pain complaints or even an involuntary twitch of the muscle (if I get that, I know I have hit paydirt!). The procedure is usually followed by some stretching and education about what the patient may experience over the next 12-24 hours, including soreness in the needling region (not a surprise, right?) and possible feelings of fatigue (most common), aggressiveness, or euphoria
Though learning a specialty has been enjoyable and also useful for treating my patients, I try very hard to remember that it is just one “tool in my belt” and that every ache and pain that walks in the door does not need to be poked. I think using this skill appropriately and only when true symptoms of myofascial pain are present has been the reason it has been quite successful to this point. So if you see me at a party and dare me to stick a toothpick in your gluteus maximus in order to maximize your euphoria, I probably will not oblige. But if you have been suffering through some pretty aggravating and mysterious symptoms, this specialty might be a bullseye (pun intended).
Dommerholt, J and C. Fernández de las Peñas. Trigger Point Dry Needling: An Evidence and Clinical-Based Approach. Churchill Livingstone, 2013
Simon, D.G., Travell J.G., Simons, L.S. Myofascial Pain and Dysfunction: The Trigger Point Manual. Vol. 1, Lippincott William & Wilkins, Philadelphia.