Dry Needling Pre & Post Considerations

Following some recent questions about trigger point treatment and associated documentation, I have developed these themes for others interested in dry needling and acupuncture.

Technique to Desensitise Trigger Points

After tapping needle into skin, initial needle depth penetration is achieved slowly (1-2 mm per second)
Just before entering a specific trigger point, an increased tissue resistance can often be felt and pain is reported. As you 'drop' into the muscle, then sensation can diminish. It is interesting to note that an in vivo experiment by Kessler and Streitberger, 2008, found greater parathesia just before and just after impaling their own median nerve. Similar clinical finding - related? More detail is covered in the Advanced Upper Quadrant Course as we examine in detail the forearm flexor muscle group
A visible/palpable twitch is commonly noted just at resistance and pain
Following needle insertion, the goal is to use the minimum amount of stimulation to achieve a relaxation effect

Regardless of duration of complaint, the effect can be near immediate and long lasting, but this is variable.

A Suggested Grading System

This grading system was developed with two specific goals in mind.

The first was to encourage accurate note taking. For example when a 'strong reactor' received acupuncture or dry needling, it would be noted, and in a multi-practitioner clinic, if this client was treated by another practitioner, they would know to use no extra stimulation
The second was to encourage practitioners to consider the degree of stimulation that was required to achieve positive outcomes, without over stimulation a client's body and increasing the likelihood of adverse side effects

Grade 1 (Insert & Remove)

Use this if after the initial treatment (Grade 2), the client returns having had an excessive reaction.

Grade 2 (Up to 1 minute)

Insert needle and leave for up to 1 minute. Initially I wouldn’t stimulate a point at all. On removal of the needle, I then manually re-test the point. If not 50-75% reduced, reintroduce a needle, and proceed to Grade 3.

Grade 3 (Up to 3 minutes)

Use some gentle stimulation. e.g. fanning, twisting, flicking.

Grade 4 (Up to 10 minutes)

Use more gentle stimulation. e.g. fanning, twisting, flicking.

Grade 5 (Electro-acupuncture stimulation)

This technique is covered in the Advanced Lower Quadrant Course.

After Needle Insertion Care

Slow removal, without direction change
The application of digital pressure (no blood present) or cotton bud/alcohol swab (blood present) will minimise muscle bleeding. This is particularly important in the neck where small amounts of blood produce after pain. If a haematoma is formed, usage of local cooling will minimise bruising
Often 1 minute after needle removal, the exquisite tenderness and spasm in the muscle has disappeared
Application of heat is useful for post treatment pain
If treating a particularly painful trigger point (upper trapezius), perhaps suggest an afternoon appointment so they are heading home and can manage post treatment soreness, rather than in the morning, when they will then need to be at work all day

Some Other Considerations

During the initial treatment, it is better to under stimulate than over stimulate
In conditions that have been present for greater than 3 months likewise minimise the stimulation
10% of the adult population and most children are ‘strong reactors’; meaning they only require transient insertion for pain relief
The number of points treated, depends upon client comfort, past reactions and intensity of presenting trigger points
Points should be palpated before and after treatment and objective signs reassessed to guide clinical direction

All the best,

Doug Cary FACP

Specialist Musculoskeletal Physiotherapist

email doug@aapeducation.com.au

ph/fx 08 90715055

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