Dry Needling Questions Answered

I have been pleasantly surprised by the interest HCC patients have had in dry needling. When applied to the right cases, I certainly think it is a great tool. And when we use it in conjunction with other techniques such as adjustments and rehabilitative exercises, we can get outstanding results.

With the interest have come several questions, which I hope to answer here.

• What is it? Dry needling is the use of needles inserted into the body to create very tiny lesions in the skin, muscles and connectives tissues. When the needle is inserted into a tight muscle it reflexively relaxes the muscle, which decreases tension and tightness. When it cuts through the connective tissue it forces the tissue to heal, lying down new tissue. When cutting through capillaries it creates a very tiny bleed resulting in increased blood flow to the area. This very small amount of bleeding does not create excess inflammation, which can be harmful. Instead, it actually decreases inflammation. Lastly, the needles affect the way the central nervous system processes pain and results in the release of chemicals such as endorphins, the body’s natural morphine. In fact, MRI imaging of the brain has shown a decrease in activation of pain sensing areas in the brain after needling. All of these affects are proven by research, so we know them to be true.
• Is it acupuncture? In the sense of the word—“acu” (needle) and “puncture” (breaking the skin)—it is, but when many people think of “acupuncture,” they think in terms of traditional Chinese acupuncture, which is based on only empirical evidence. This means we are not sure how it works but it seems to help. The goal for traditional acupuncture is to balance “qi flow,” which may or may not exist. However, we do know the physiological effects as explained in the answer above. In the end, I guess the simple answer to this question is: No, dry needling and acupuncture are not the same thing.
• Why is it called, “dry”? A medical doctor was experimenting using different injections to relieve pain, and what he found was that it wasn’t a matter of what he injected but the precise location in which the needle was placed that made a difference. He ended up testing his theory with a dry needle (no substance) and had great results.
• How do you know where to put the needles? When I apply needles, the placement is based on palpating tight muscles, areas where large nerves exist to affect the nervous system and areas with similar segmental innervation. For example, for knee pain, we may needle the spine at the same level in which the nerves that serve the knee enter the spinal cord. Using these basic principles have given me and my patients some truly great results. Below are three cases in which dry needling has proven beneficial.

Case Studies

Patient 1
30-year-old female, recreational volleyball player with long history of shoulder pain when serving and hitting
Techniques: 

• Dry needling of shoulder
• Active Release Technique (ART) to rotator cuff
• Shoulder blade and rotator cuff exercises
• Pectoralis muscle stretching
• Mid-back adjustments

Results: 5 visits and patient was pain-free when serving and hitting

Patient 2
High school male football player with sprained ankle
Techniques:

• Immersed foot in bucket of ice water for 15 minutes
• Dry needled ankle
• Single leg balance on leg with sprain

Results: 3 visits and ankle was fully recovered

Patient 3
45-year-old-female with knee pain especially when bending and walking up stairs
Techniques:

• Dry needling
• Exercises for hip and knee
• Kinesio tape

Results: 6 visits and patient was pain-free when bending and walking up stairs

Patient 4
65-year-old with low back pain and migraine headaches. Experienced migraine headaches about 5 times per week for two years. Had tried physical therapy, chiropractic, massage and pain killers.
Techniques: 

• Dry needling of neck muscles
• Active Release Technique (ART) of neck muscles
• Stretching of jaw muscles
• Advice to stop clinching jaw
• Breathing exercises
• Adjustments to mid back and neck

Results: 10 visits and patient only experienced one very minor headache in two week period

As you can see, dry needling is a great tool that fits in perfectly with the other techniques used in our office. To put it simply, it helps move the healing process along. With a proper examination and when applied to the appropriate situation, great results are achieved. If you have any further questions please do not hesitate to e-mail me or give me a call at (402) 467-5143.

A Functionalist’s Approach to TMD

This week I had the great opportunity to be a guest lecturer at University of Nebraska Medical Center College of Dentistry. I presented to students about how posture and function effect the Temporomandibular Joint (TMJ). In talking with them afterward, I learned that my functionalist approach is not something they encounter during their curriculum as much of their education with Temporomandibular Disorder (TMD) deals with making mouth guards. While these can certainly be beneficial, many patients require postural advice, rehab and soft tissue treatment as well.

I wanted to share some of the information I presented to them with you as well since TMD and related pathologies are something I see commonly in our office.

To start, here are some functional factors that can contribute to TMD:

• Poor breathing patterns
• Forward head posture
• Rounded shoulders
• Stress
• Gum chewing
• Resting chin on hand while sitting

Many of these factors need to be addressed from a rehabilitative standpoint. For example, poor breathing patterns and weakness of the diaphragm leads to weakness in the muscles that hold the cervical spine in its normal position. These things are more common than you would probably think. I would say about 80 percent of people I see need help learning how to breath correctly and strengthening their diaphragm. This is important for TMD because when these areas are weak our head escapes into a forward position. When the head is forward the muscles attached to the chin pull it back, jamming the TMJ. For patients with this issue, if respiration was never assessed, they would not improve.

Another important point I stressed to the dental students is best explained by a famous orthopedist, Karel Lewit, M.D. Dr. Lewit once said: “One who treats at the site of pain is lost, and so is the patient.”

This is a very important concept because if I only treated the site of my patients’ pain, I would not always be treating the cause of the pain and therefore they would not improve. During the presentation, I followed Dr. Lewit’s quote with a research article that showed people with TMD were more likely to flat feet. Now, this doesn’t mean that I am going to just fix the foot and that will solve the jaw problems, but I do know with 100 percent certainty that a muscle imbalance in the body is contributing to both problems. 

Lastly, I touched on the subject of referred pain. For example, a trigger point in a muscle of the neck can refer pain to the jaw and vise-versa. In fact, a study that induced jaw pain increased neck muscle activity by 700 percent. Another cool example of this is a famous golf instructor who has his students swing with a potato chip in their mouth. If the chip breaks he knows they were too tense during the swing. 

So the next time you have jaw or neck pain, I hope you take some of the things I mentioned here into consideration such as posture, stress, gum chewing, breathing and so on. And, as always, if you ever have any questions, please don’t hesitate to come see me (6132 Havelock Ave.), give me a call (402.467.5143) or shoot me an e-mail (tylerideus@gmail.com). 

Resources

• Marco, Antonio. Interrelationships Between Dental Occlusion and Planter Arch.  Journal of Bodywork and Movement Therapies.
• Usefulness of Posture Training for Patients with Temporomandibular Disorders. Journal of American Dental Association.

Continuing My Integration Education @ American Sports Medicine Institute

In late January I had the wonderful opportunity to attend a course put on by the American Sports Medicine Institute (ASMI) in Birmingham, Ala. ASMI was started by Dr. James Andrews, M.D., in order to help with athletic injuries and sports medicine. Dr. Andrews is a famous orthopaedic surgeon who has worked with athletes such as Michael Jordan, Tom Brady and Albert Pujols. ASMI currently conducts research involving evaluation, treatment and biomechanics of athletes. They also perform video analysis of athletes’ biomechanics and conduct continuing education for health care professionals who are involved in sports medicine.

Dr. James and myself at American Sports Medicine Institute Conference in January 2012.

This course was a great opportunity to see the most current treatment approaches available as well as what other professionals are using to benefit patients throughout the entire United States. Topics ranged from orthopaedics, to biomechanics, to performance training and to rehabilitation of the injured athletes and even non-injured athletes.

One of my favorite parts was listening to the current surgical techniques being used on the shoulder and the orthopaedic evaluation of the shoulder itself (the shoulder is one of my favorite areas in the body!). It was very interesting to learn orthopaedics’ state of mind and thought process when looking at athletes, and more importantly, their thought process when it comes to conservative care and rehabilitation. I was really excited because what they do fits perfectly with what we do right here at HCC. This is so important for our patients who are under the care of both us and orthopaedic physicians, as we can ensure we are integrating for the best possible benefits of our patients.

Along the same lines, it was really neat to see the performance professionals and the biomechanists as well. Each is an expert in his or her own field and each sees things slightly differently. Personally, this is why I so strongly believe that an integrated approach serves our patients the best—you have to be able to use the best of everything. I also believe there needs to be cooperation and communication between the groups because then we don’t risk disagreement that results in pulling the patient in different directions.

Another thing I was very excited to see was that several sections were specifically dedicated to exposing practitioners to the concepts of Dynamic Neuromuscular Stabilization (DNS). As the only certified DNS practitioner in Nebraska, it’s great to see the integration of this important technique into MLB, NBA and NFL. It’s also gaining exposure and integration with many of the top orthopeadists and performance specialists in the country.

Lastly, I was really glad to make the trip without being snowed in at any point! Connecting in Chicago always makes me nervous, but I was lucky to miss the blizzard that hit just the week after.

Pain: Is it in the tissue or the brain?

As someone whose job is to relieve people’s pain, understanding the science of pain is obviously very important. But pain isn’t necessarily easy to understand. If tissue is damaged in the body, it sends a signal to the brain and then we hurt, right? So if we fix the tissue located in the painful spot, then the pain goes away, right? While this is sometimes true, there is a big misunderstanding of pain by both patients and even some practitioners who are attempting to treat their patient’s pain.

Let’s begin with a simple explanation of pain, because when we understand pain, we no longer have to fear it. In the introduction of the book, Explain Pain, which I highly recommend, physiotherapist David Butler and Lorimer Moseley, PhD, explain pain as an unpleasant feeling that is essential to life because it protects us and alerts us to danger. When this happens, it changes how our muscles and joints function, our thoughts and behaviors, and it can even affect our immune system.

However, as you will soon learn, the amount of pain we feel DOES NOT necessarily relate to the amount of tissue damage. In fact, many sensory cues come together to form a pain experience.  Unfortunately, it is not as simple as a nerve innervates a tissue, the tissue is damaged, we feel pain, and then we heal tissue and we no longer have pain.

For example, maybe you have heard of a story or experienced first hand a fairly severe injury that didn’t hurt immediately. Maybe you were playing in a big sporting event and after the game you noticed a sore spot. Or maybe you’ve heard stories of soldiers being shot in battle and never realizing it until the battle was over. On the other hand, why do paper cuts hurt so bad when there is barely any damage at all? Obviously, the idea of “damaged-nerve sends signal to brain and then pain happens” doesn’t fit.

What is actually happening during a pain experience is much more complicated. As we know, to begin there is usually damage to a tissue, joint, etc. The nerves innervating those tissues are activated and send a signal. However, once the signal enters the spinal cord and brain, aka the central nervous system, things are a bit different than we assume. At this point it is up to the brain to decide if it is appropriate to construct a pain experience or not. Things that affect this may include: thoughts, beliefs, job situation, home situation, mood, past pain experiences, and so on.

The most interesting example to me is that of phantom limb pain. This often occurs in people who have lost an arm or leg but still get pain in that arm or leg. This alone proves pain is not only in the tissue (Norman Doidge, The Brain That Changes Itself). So for those who believe that there must be damaged tissue to have pain, think again. Pain is in the brain.

Now that we know pain is in our head, please know that I am NOT in anyway saying that it isn’t real because it most definitely is! In fact, a person who says it isn’t doesn’t truly understand pain at all. How can more than one billion people suffering from chronic pain be wrong? (Butler and Mosley).

Another subject that affects a pain experience that I would like to mention is that of imaging such as MRIs or x-rays. While they can be very informative and often necessary to rule out serious diseases such as cancer, it is very important that we do not fear what they show. This means that an x-ray might show some degenerative changes, or an MRI may show a slightly herniated disc, when in reality this is more the norm than the exception. After the age of 25, most of us will have some NORMAL degenerative changes. One study showed that up to 35% of people who have never experienced low back pain had herniated discs (Weishaupt D et al). Instead of dwelling on what was seen on the image, we should be more concerned about dysfunctional joints and muscles. Maybe it’s bad posture, joint restriction, poor lifting habits, or instability that needs rehabilitation. Once these dysfunctions (the true causes of pain) are addressed one will see the pain diminish. And once we realize a herniated disc can be completely functional with normal body biomechanics, we no longer have to fear it!

So how can we relate this to every day pain suffers? Well, imagine a person who sits at a desk all day and gets very little movement throughout the day, has poor posture, and holds a lot of tension in his or her shoulders. While there is no immediate pain, this can actually cause a build up of acid in the muscles (Butler and Mosely) and with enough build up, the nerve sensors open up and send a signal to the cord and then to the brain where it decides if it is a danger or not. If you have had a terrible day, and you are ready to go home the pain will probably be increased, whereas if you are focused on something very important and enjoying the work then it may not be as noticeable. However, if the acid persists, it can definitely become dangerous, and we will experience pain.

Another example is when a person bends over to pick a pencil and his or her back goes out. The person can barely stand and is in excruciating pain. The second this happens our brain begins to process not only signals from the tissue, but all sorts of information. Is it broken? How can I still function? Will I miss the big game? How much will it cost? Etc. According to Butler and Mosely, all of these questions are being processed in the brain without us really even knowing it. All we know is that we hurt!

These last two examples relate to chronic and acute pain. Whenever there is some type of tissue injury, inflammation occurs to help healing, which is a good thing. However, if it persists it becomes a bad thing and our brain continues to sense danger, making it a persistent pain perception or chronic pain. (Following graph from Butler and Mosley).

When it comes to chronic pain, Butler and Mosely compare the brain to an orchestra. A really good orchestra has many different instruments playing many different tunes. They play many different songs and give great performances—like a good functioning body. Now, imagine this orchestra starts playing the same song over and over and over. Pretty soon, it can no longer play other tunes, nor can it be creative, curious, or seek new challenges. Instrumentalists quit, spectators become unhappy, and the tune is no longer a good one. In the brain when the pain perception is constant for too long—and poor muscle and joint function becomes the normal movement—it becomes the only tune we hear even in instances where the tissues are completely healed. Our brain becomes sensitized to pain (Doidge).

Notice the two ways we can fall into chronic pain. (Following graph from Butler and Mosley).

So how do we keep acute pain from becoming chronic, and if it is chronic pain how do we treat it? To begin, lets consider a person who just got into a minor car accident that hasn’t had a history of pain. However, after the accident they have pain in the neck and are sent to the emergency room.  Imaging is done which shows degenerative changes. The patient is given a whiplash diagnoses sent home with some pain pills and never educated on the pain process. Now the person thinks of the imaging findings whenever turning their head and experiences pain because they think they are hurting the tissue. The muscles around the neck then begin to tighten to protect it and results in muscle imbalance and joint restriction. Now we have a system that is set up perfectly for chronic pain with both fear of pain and the muscle and joint problems that keep the pain experience going. However, if this person had a better understanding of pain and taken the appropriate steps to avoid excess inflammation and avoid creating muscle and joint imbalances it would have been quick to heal.

If the pain has become chronic, the answer lies in finding the true break down leading to pain. In this person’s case it is not the degenerative changes in the spine that are the problem, but the fear avoidance beliefs as well as the muscle imbalances around it and joint restrictions likely above and below it. Therefore, the treatment is not directed at the pain site but the beliefs and dysfunctions around it. Most commonly the cause of the pain is far from the site of pain. Karel Lewit, a very famous medical doctor says: “He who treats only at the site of pain is lost.” Therefore, once we treat these dysfunctions away from the site of pain, we will see relief of the pain.

To summarize, here are some basic tools I follow with my patients:

Tool 1: Education and understanding

• No pain, no gain = no good
• Let pain be your guide = no good
• UNDERSTAND PAIN = you don’t have to fear it

Tool 2: Your hurts won’t harm you

• Hurt does not always equal harm
• BUT WAIT! This certainly doesn’t mean go out and run a marathon!
• GRADUALLY increase activity

Tool 3: Pacing and graded exposure

• Movement is essential for health (motion is lotion)
• Find what you want to do more of—find a baseline and plan a progression

Tool 4: Accessing the virtual body

• Imagined movements
• Alter gravitational forces
• Alter environmental activities
• Add distractions

Understanding pain can be a great liberator. We should understand that the phrase, “No pain, no gain,” shouldn’t be our thought process, but we also shouldn’t let pain completely be our guide either. Butler and Mosely have the saying, “KNOW your pain, or no gain!” And aside of traumatic injury that requires direct treatment to the site, understanding the science of pain and treating the true dysfunctions away from the sight of pain have become the standard.

Resources

Butler, David S., and Mosley, C. Lorimer. Explain Pain, First Edition. Australia: Noigroup Publications, 2003.

Doidge, Norman. The Brain that Changes Itself. USA: Penguin Books, 2007.

Weishaupt D et al. “MRI of the lumbar spine: Prevalence of intervertebral disc extrusion and sequestration, nerve root compression and plate abnormalities and osteoarthritis of the fact joints in asymptomatic volunteers.” Radiology 1998, 209:661-666.