Dry Needling for Manual Therapists

Points, Techniques and Treatments, Including Electroacupuncture and Advanced Tendon Techniques

Giles Gyer, Jimmy Michael, Ben Tolson

• Publisher: Singing Dragon
• Year: 2016
• ISBN:
  9780857012029
• Topic: Medicina
• Subtopic: Agopuntura

Designed to be a go-to reference for assessment and treatment planning in the clinic, this is a clear and concise handbook for students and practitioners of dry needling, or medical acupuncture. It includes:

· Comprehensive medical illustrations demonstrating trigger point locations and associated pain referral patterns
· Easy-to-follow instructions and photographs demonstrating musculoskeletal dry needling points and electroacupuncture techniques
· Dedicated section on the acupuncture treatment of tendinopathy
· Vital information on palpation and correct needling techniques
· Practical guidance on best practice, safety and treatment planning
· Overviews of the history and key principles of Traditional Chinese medicine and acupuncture
· Up-to-date research on the effect of acupuncture in the treatment of MSK conditions, myofascial pain, trigger points (MTrPS), fascia and pain.

The book will be an essential aid for osteopaths, physiotherapists, sports rehabilitators, chiropractors, massage therapists, as well as traditional acupuncturists wishing to understand a Western approach on acupuncture. Other health professionals incorporating, or looking to incorporate dry needling into their treatment programme, will also find this book an invaluable resource.

Part I

BACKGROUND

Chapter 1

Introduction

This book is primarily for health professionals who are treating musculoskeletal (MSK) conditions and who wish to incorporate acupuncture into their practice. We acknowledge that acupuncture can treat conditions other than MSK, but that is beyond the scope of the book.

Physical therapists see many MSK problems in clinic, which makes them ideal candidates to incorporate acupuncture into their practice. Musculoskeletal problems of various types are often the most common reasons for patients to seek care from acupuncturists, representing one third to one half of all visits (Sherman et al. 2005). In one study of Chinese patients (Mao et al. 2007), patients presented with pain-related musculoskeletal complaints such as back and neck pain (53%), arthritis (41%), neurological complaints such as post-stroke rehabilitation and facial paralysis (23%), and weight loss (10%). In the United Kingdom acupuncture is used in 84 per cent of chronic pain clinics (Woollam and Jackson 1998).

Acupuncture has become more accepted by Western medicine over the last 30 years and has seen an exponential growth in its practice worldwide (Guerreiro da Silva 2013). As the practice of acupuncture has grown, so too has the evidence base. The advantages of using acupuncture are well documented and include an immediate reduction in local, referred and widespread pain, restoration of range of motion and muscle activation patterns, and a normalization of the immediate chemical environment of active myofascial trigger points (Dommerholt 2011). As well as these well-documented effects, acupuncture can have simultaneous widespread effects at multiple sites.

Acupuncture as part of manual therapy is rarely a stand-alone procedure and should be part of a broader physical therapy approach. Other approaches, including soft tissue mobilization, manipulation, therapeutic exercise and functional retraining, should be used in combination with acupuncture. For example, after deactivation of myofascial trigger points, patients should be educated in appropriate self-care techniques which may include specific stretches of the involved muscles and self-massage techniques (American Physical Therapy Association 2013).

As the appetite for acupuncture has grown, there now exist varying standards of training. The requirements for acupuncture training have yet to be provided and vary considerably in practice. Broadly speaking there are two main training routes for acupuncture: courses for lay persons and courses for medically qualified practitioners.

Those courses which are mainly for lay persons are generally very comprehensive and will include a mixture of standard Western anatomy and pathology with a large percentage of traditional Chinese medicine (TCM). TCM theory is extremely complex, takes a long time to learn and includes pulse and tongue diagnosis amongst other techniques.

The courses attended by medically qualified practitioners are usually much shorter. This is because, in the case of doctors and allied health professionals, their knowledge of diagnosis, pathology, anatomy, physiology, microbiology and other treatment techniques that can be used at the same time as acupuncture can be taken for granted.

White (2009, p.33) defines dry needling (also know as Western medical acupuncture) as a ‘therapeutic modality involving the insertion of fine needles; it is an adaptation of Chinese acupuncture using current knowledge of anatomy, physiology and pathology, and the principles of evidence-based medicine. Although Western medical acupuncture has evolved from Chinese acupuncture, its practitioners no longer adhere to concepts such as yin/yang and circulation of qi, and regard acupuncture as part of conventional medicine rather than a complete “alternative medical system”.’ For convenience, however, the term acupuncture will be used throughout this book.

Hong (2013, p.593) describes acupuncture as covering ‘a diverse academic field that spans from ancient medical history to the most advanced contemporary neurophysiology’. He continues: ‘Acupuncture as a treatment for pain encompasses much more than simply needling: it involves a complex interaction and context that may include empathy, touch, intention, attention, expectation and conditioning.’

The term ‘dry needling’ is often used to differentiate this technique from myofascial trigger point injections. Myofascial trigger point injections are performed with a variety of injectables, such as: procaine, lidocaine and other local anaesthetics; isotonic saline solutions; non-steroidal anti-inflammatories; corticosteroids; bee venom; botulinum toxin; and serotonin antagonists (Dommerholt, del Moral and Gröbli 2006).

Many acupuncturists see the use of so-called dry needling/Western medical acupuncture as an infringement of the rights of traditional acupuncture practitioners. It is the position of some organizations that any intervention utilizing dry needling beyond trigger point dry needling is the practice of acupuncture, regardless of the language utilized in describing the technique. Acupuncturists will argue that by using acupuncture in their practice practitioners may inadvertently be affecting the whole organism without realizing it.

Whether acupuncture falls within the confines of a single discipline or should be incorporated into physical therapy remains a question to be answered by individuals and the respective organizations or governing bodies. Currently in some parts of the world this has resulted in a turf war where legislation has been passed banning the use of acupuncture within manual or physical therapy.

At its heart, Western medical acupuncture has a scientific rationale. Acupuncture training programmes must provide students with sufficient knowledge to communicate the science and theories underlying acupuncture in conventional medical language.

Resistance to implementation of broad integrative clinical training has encouraged other professions such as medicine, chiropractic and physical therapy to include acupuncture in their scope of practice, redefined as percutaneous electrical nerve stimulation, transcutaneous electrical nerve stimulation and dry needling (Dommerholt 2011), which explain the modality in conventional medical language (Stumpf, Kendall and Hardy 2010).

One current argument against acupuncture being used within modern healthcare settings in the West is that acupuncture mechanisms (how it works) cannot depend on a philosophical or political debate that transcends clinical practice (Stumpf et al. 2010). Only through a universal way to describe how acupuncture works, along with safe working practices and treatment strategies, will a continued adoption of acupuncture theory and understanding be promoted.

Stumpf et al. (2010) argue that the greatest barriers to integration, however, originate with acupuncture training programmes based on European metaphysical ideas (Kendall 2008) which therefore do not ensure that graduates have a sufficient understanding of quality biomedical knowledge and mainstream medicine, including primary care, or are able to evaluate research competently (Hammerschlag 2006). Without adequate knowledge or exposure to mainstream medicine, graduates are unprepared to (a) function effectively in an integrative healthcare team, (b) provide competent primary care to patients, or (c) make appropriate referrals to physicians and other mainstream providers.

The focus should be on expanding acupuncture to populations that might not necessarily be able to access acupuncture through private practice. Just as spinal manipulation should not be exclusive to one profession, so should the practice of acupuncture. Our hope is that traditional acupuncturists will study the known Western medical theories of how acupuncture works and will give a flavour of the understanding of how traditional acupuncture works from an energetic perspective. Only by ensuring high educational standards for training physical therapists will acupuncture be practised safely, and this book is not intended to replace such training.

Only by integrating different modalities such as acupuncture into our practice will patients benefit fully. The practice of integrative medicine has emerged as a potential solution to solve complex problems seen in our patient population (Maizes, Rakel and Niemiec 2009).

Good medicine is based on good science. It is inquiry-driven and open to new paradigms. It is both practical and pragmatic. Although Western acupuncture has evolved from TCM, we are not dismissing the TCM approach to acupuncture. Western medicine is continually evolving and the explanations given are based on current evidence. As the evidence continues to grow, we may be able to explain more of the mechanisms of acupuncture. There is now much positive evidence to support the use of acupuncture, and this is outlined later in the book.

The techniques in the book are the ones the authors frequently use in clinical practice. Obviously this book is intended only as a supplement for acupuncture training. Perhaps the use of acupuncture should be patient-centred and not driven by professional disputes. It is our hope that by writing this book more health professionals will be able to use acupuncture in their practice and help the many patients who are suffering in pain.

References

American Physical Therapy Association (APTA) (2013) Description of Dry Needling in Clinical Practice. Alexandria, VA: APTA Public Policy, Practice, and Professional Affairs Unit. Available at www.apta.org/StateIssues/DryNeedling/ClinicalPracticeResourcePaper, accessed on 15 July 2015.

Dommerholt, J. (2011) ‘Dry needling – peripheral and central considerations.’ Journal of Manual and Manipulative Therapies 19, 4, 223–227.

Dommerholt, J., del Moral, O.M., and Gröbli, C. (2006) ‘Trigger point dry needling.’ Journal of Manual & Manipulative Therapy 14, 4, E70–E87.

Guerreiro da Silva, J.B. (2013) ‘Integrative medicine, integrative acupuncture.’ European Journal of Integrative Medicine 5, 83–86.

Hammerschlag, R. (2006) ‘Evidence-based complementary and alternative medicine: back to basics.’ Journal of Alternative and Complementary Medicine 12, 349–350.

Hong, H. (2013) Acupuncture: Theories and Evidence. Singapore: World Scientific Publishing.

Kendall, D.E. (2008) ‘Energy – meridian misconceptions of Chinese medicine.’ Schweiz. Zschr. GanzheitsMedizin 20, 2, 112–117.

Maizes, V., Rakel, D., and Niemiec, C.J.D. (2009) ‘Integrative medicine and patient centred care.’ Explore (NY) 5, 5, 277–289. Commissioned for the IOM Summit on Integrative Medicine and the Health of the Public.

Mao, J.J., Farrar, J.T., Armstrong, K., Donahue, A., Ngo, J., and Bowman, M.A. (2007) ‘De qi: Chinese acupuncture patients’ experiences and beliefs regarding acupuncture needling sensation – an exploratory survey.’ Acupunct. Med. 25, 4, 158–165.

Sherman, K.J., Cherkin, D.C., Eisenberg, D.M., et al. (2005) ‘The practice of acupuncture: who are the providers and what do they do?’ Annals of Family Medicine 3, 151–158.

Stumpf, S.H., Kendall, D.E., and Hardy, M.L. (2010) ‘Mainstreaming acupuncture: barriers and solutions.’ Journal of Evidence-Based Complementary & Alternative Medicine 15, 1, 3–13.

White, A. (2009) ‘Western medical acupuncture: a definition.’ Acupunct. Med. 27, 33–35.

Woollam, C.H.M., and Jackson, A.O. (1998) ‘Acupuncture in the management of chronic pain.’ Journal of Anaesthesia 53, 593–595.

Chapter 2

A Short History of Acupuncture

It is important for the practitioner to have an understanding of the origins of acupuncture as it puts current practice into context. Also, it is useful to understand some of the principles and techniques in traditional Chinese medicine (TCM), as it is from these techniques that Western acupuncture has evolved. Some clinical trials and research papers may also use TCM methodology and traditional acupuncture points, so being able to understand and evaluate the treatment protocols and locations is of benefit when forming one’s own clinical reasoning and opinions of such research. This chapter outlines some current thinking in TCM and how that might differ from a Western medical approach.

Before the discussion of the origins of acupuncture begins, it must be stated that acupuncture is just one part of an ancient medical system. Typically there are four main disciplines that form part of TCM:

•acupuncture

•herbal medicine

•Chinese massage/bodywork/physical therapy known as tui na (which means ‘push and grasp’)

•Chinese exercise such as martial arts, tai chi, qi gong and esoteric practices.

These disciplines are still in use in China and other parts of the Orient today and, when combined, provide a powerfu...