01 Sep Dry Needling vs. Acupuncture
What is Trigger Point Dry Needling?
Trigger Point Dry Needling is a technique used mostly by physical therapists and increasingly by chiropractors, medical doctors and, dare I say, acupuncturists. You may be asking “is this not the same as acupuncture?” There really is no short answer to this question but, generally speaking, they are not the same. Acupuncture is based on traditional Chinese medicine and the belief that our bodies are fed by a variety of energy channels which have “Grand Central Stations” of flow or “qi” (pronounced “chi”). A needle is inserted into those central stations to increase the amount of energy to a given system (e.g. the low back). There are many different types of acupuncture including a more modern technique that involves needling into motor points with the intention of relieving dysfunction. It is important to recognize that trigger points and motor points are not the same; motor points are essentially superficial areas overlaying an area where nerve enters muscle whereas trigger points are taut bands located in a muscle. There is less than 30% overlap of motor points and trigger points. Acupuncturist training varies by school but typically includes 3-4 years of study including internship. Physical therapist are equally trained, with four years of undergraduate study, a background in sciences, three years of doctoral training including internship and post-graduate education/training to perform the technique. The amount of training required to perform Trigger Point Dry Needling varies widely by state which, in my opinion, contributes negatively to the perception of the practice due to the wide variation of the skills of practitioners.
(Dry Needling of the Upper Trapezius)
History of Trigger Point Dry Needling
Trigger Point Dry Needling emerged in the United States as a practice for physical therapists in the early 1980s as a result of studies performed by Dr. Janet Travell, a cardiologist at Beth Israel Hospital in New York and the first female physician to the President (President John F. Kennedy, 1960). Dr. Travell observed a trend in her patients presenting with cardiac symptoms however, upon testing, those symptoms were not found to be coming from the heart. Further examination found that when she pressed on a spot between the 5th and 6th rib on the right side of the body of these patients she could reproduce their cardiac symptoms. Ah ha! Already a believer in referred pain this was the evidence she needed to develop her hypotheses. Dr. Travell partnered with Dr. David Simmons, an aerospace physician who studied the physiologic response of stress to weightlessness, and contributed to Myofascial Pain and Dysfunction, The Trigger Point Manual (LWW, August 2018). This book has become the primary teaching tool for medical professionals on the diagnosis and treatment of myofascial pain.
What does this have to do with Trigger Point Dry Needling? With this knowledge of the impact of myofascial trigger points, Dr. Travell convinced some unbelieving physician friends to begin treating trigger points with pain medication. Initially the treatment of choice was procaine, an injectable analgesic. Over time less invasive options like topical spray analgesics were used but both provided only temporary relief of symptoms.
Analgesics vs. Anti-Inflammatories
Further studies found that inflammatory chemicals inside the taut band (the “trigger point”) were the contributing factors to ongoing dysfunction of the muscular fiber and, subsequently, pain. This new information led investigators to the use of steroids (anti-inflammatories) as a treatment option. Comparison studies were performed to find the better outcome between use of an analgesic (pain medication) versus steroids (anti-inflammatories). Such studies required the use of a control group (saline solution) that would also be injected into the trigger point of certain subjects. Upon follow up at six and twelve months the subjects who were injected with saline had the better outcomes. Why? The answer is easy: the needle. Jan Dommerholt, founder of Myopain Seminars and understudy of Dr. Travell wrote a great article summarizing the clinical evidence for Trigger Point Dry Needling that can be found here.
We have known for hundreds of years that muscles respond to mechanical pressure which is why for that same period of time people have sought out massage therapy for relief of muscular pain. It’s also why for years physical therapists have dug their elbows into your buttocks to get rid of nagging gluteal pain. It’s why CrossFitters lay over lacrosse balls and why others use foam rollers and any other device to cause ourselves physical discomfort for the sake of relief. A needle is a noxious stimulus that causes a local twitch response. This response subsequently causes a “dump” of the inflammatory agents that accumulate in your muscles thus impeding the ability of the brain to tell the muscle what to do and when to do it. Instead of using the hypodermic needles that were required with injections, research leaned toward the idea of using thin, mono-filiform needle that would not cause any tissue shearing or damage an implement similar to the well-known acupuncture needle.
So Why is it Not the Same as Acupuncture?
How then is Trigger Point Dry Needling really any different from acupuncture? Trigger Point Dry Needling is a technique through which a well-trained practitioner (preferably one who has been through comprehensive education and testing) completes a thorough examination and determines the etiology of symptoms arises, in whole or in part, from the presence of myofascial trigger points. The dry needle is inserted into the taut bands of muscle in lieu of pain relief medication. We, as trained professionals and Certified Myofascial Trigger Point Therapist (CMTPT), determine the most appropriate points to treat based on knowledge gained through research, training and clinical experience. It is also the job of the practitioner to determine whether Trigger Point Dry Needling is the best option for you as it is certainly not for everyone.
Indeed, there are other ways to treat trigger points. Trigger Point Dry Needling is an effective tool in the toolbox for a lot of medical practitioners, especially physical therapists, who have a vast knowledge of the musculoskeletal and neuromuscular systems. Trigger Point Dry Needling can be highly successful in the treatment of a variety of common conditions including headache, low back pain, plantar fasciitis, carpal tunnel, frozen shoulder, IT band syndrome, and more.
Venn-Diagragm of Medical Practitioners
I think it’s important to talk about the overlap in medicine. Physical therapist are thought to be the musculoskeletal specialist of the medical arena. Physicians, athletic trainers and physical therapist all perform similar testing to diagnose musculoskeletal conditions. Physical therapists and massage therapists both utilize soft tissue mobilization to address deficits in muscles. Chiropractors and physical therapist both perform manipulations of joints. Physical therapists, athletic trainers, chiropractors and personal trainers all apply therapeutic exercise to rehabilitate injuries. I think when a patient is deciding who to see for a given condition it’s in their best interest to evaluate the skill level of any prospective healthcare provider. You should seriously consider whether any provider has extensive diagnostic skills, a wide variety of interventional skills, and ultimately the knowledge required to prevent future injury/re-injury?
About the author:
Dr. Sarah Cash Crawford, PT, DPT, COMT, CMTPT, is a physical therapist and certified myofasical trigger point therapist through Myopain Seminars ®, the only certifying body of Trigger Point Dry Needling in the US. Dr. Crawford trained under Jan Dommerholt, PT and founder of Myopain Seminars ®, who worked directly under Drs. Travell and Simmons in his pursuit to bring dry needling to the U.S. Dr. Crawford has been performing Trigger Point Dry Needling the Cincinnati area for over six years and was the first CMTPT in the state of Ohio. She has been a practicing physical therapy for eight years. With a background in neurologic rehabilitation, manual therapy and a specialty in treating chronic pain, Dr. Crawford began studying dry needling to further expand her treatment options to help patients overcome the influence of myofascial restriction. Dr. Crawford is the founder of Anchor Wellness, Inc., an integrative health practice that specializes in physical therapy, pilates and health coaching.