Trigger Point Dry Needling (TDN) is Not #Physicaltherapy

Don’t be deceived by this title.  Yes, trigger point dry needling (TDN) is within the scope of physical therapy.  Yes, while there is a paucity of evidence, TDN probably works in some instances-likely more to “meaning effect” and  placebo than anything else (which of course is fine but in states with informed consent forms it probably works as a  nocebo).  My concern is the nocebo effect of TDN on our profession.

The irrational exuberance around TDN within the #physicaltherapy profession is ironic if not downright damaging.  We fight and defend for direct access, expanded scopes of practice, evidence as the core basis of our interventions, and being recognized in the healthcare chain as force multipliers within the musculoskeletal world yet state legislators in many states are hearing PT’s fight for the right to stick needles into patients. TDN is hardly a transformative intervention and regardless it does not define #physicaltherapy.  The trouble is the neuromarketing image that many are getting right now suggests that physical therapists are defined by repeatedly sticking needles into patients regardless of diagnosis rather than “neck up” skills of clinical reasoning, examination, and strong interactional skills.  While the comparison to acupuncturists is the most FAQ to differentiate TDN vs. acupuncture, we jump into the “needle” and “philosophy” differences and conveniently forget that the acupuncturist is totally defined by one intervention and that TDN is but one tool in an arsenal for PT’s to consider.

Some other observations about TDN that I find troubling.  We have PT students seeking  TDN clinical instructors and consumed with the technique at the expense of basis skill sets.  We see brash PT’s (ok arrogant PT’s) ignoring many pleas by physicians to NOT use TDN on their patients and yet the PT’s go on anyhow since they have an anchoring bias to TDN and an ignorance to referral sources demands and then we talk about a branding problem in PT!  I get that many MD’s need briefings on TDN, its application for the right patient, with the right diagnosis, at the right time yet even after those briefings physicians are entitled to demand that their patients don’t get TDN as many of them can’t get past the “do no harm” edict and view TDN as “harm”.  The marketing of TDN is becoming quite comical as PT practices try to get a leg up on their competitor by going to a weekend course and then declaring them experts (full disclosure-EIM where I am a founder/partner provides TDN training!!).  This is so reminiscent of the days where some PT clinics bought an isokinetic devices (e.g. Cybex) and marketed their “differentiation” to the MD’s which then compelled the competitor to purchase the same (and boy were the equipment manufacturers happy).  My last observation is the idea that sticking needles into patients is not anything new for PT’s.  I have been board certified ECS and did EMG’s for 20+ years and never saw PT’s wanting to adopt this technique to the degree that they want to adopt TDN for clinical use.  Keep in mind, we have had and continue to have our battles to perform EMG/NCS but we never defined ourselves as PT’s by the ability to perform the studies and neither should we define our practice by this one currently in vogue intervention.

My hope is that the pendulum of TDN will swing back to some sense of balance and realize it is one of many and not THE intervention that PT’s can access.   At some point and with evolving evidence, (which I am confident will come), TDN will likely be an entry level skill and some other intervention or machine in PT will then have its day of an overly enthusiastic adoption-let’s hope though that its image doesn’t have the same neuromarketing impact.  

Thoughts?

@physicaltherapy

184 responses to “Trigger Point Dry Needling (TDN) is Not #Physicaltherapy

  1. Sandra Norby says:

    Well said, Larry. Another tool in the tool kit. this is going to date me, but reminds me of Neuroprobe.

    1. Larry W says:

      I agreed to “Dry Needling.” In my opinion, anything that causes me excruciating pain, is not therapeutic. NEVER AGAIN !

      1. L. Cauthen says:

        Sorry you had that problem with pain. I just had that treatment today. 12 in my right hip some in my left hip, some in my lower back where I have had two surgeries. Pain meds have had no affect on me and neither has anything else. I had very little discomfort from my procedure. I went grocery shopping on the way home and for once in a long time, my back didn’t feel like it was going to break, I look forward to more treatments in hope that I can return to normal life after five years of pain.

  2. Great post, Larry.

    First of all, I must profess total ignorance about TDN; I have never done it, haven’t even really read much about it, I am not all that interested in it, and don’t understand what the proposed therapeutic effect might be.

    But, I have been struck by the overwhelming enthusiasm for the technique accompanied by claims of extraordinary results.

    I also think it would be pretty easy to argue that it is outside of our scope of practice. Needle EMG is a diagnostic technique that has been within the scope of practice for a long time. TDN appears, from my admittedly uninformed view, to be a different name for acupuncture.

    I could be horribly off base, but I am a bit troubled any time I see extraordinary claims for any intervention, even those that are used more traditionally in our profession: muscle energy, trigger point therapy, myofascial release, and manual therapy from multiple schools of thought come to mind.

    Remember that frontal lobotomy was used routinely and enthusiastically in psychiatry not all that long ago. I am not saying TDN is in the same league, just drawing a parallel with the same level of enthusiasm for a panacea.

    Just my 2 cents. Thanks for bringing up the concern.

    Jerry

  3. Bryan Nichols says:

    Basic skills with a bevy of evidence behind them should be the first line. With a small percentage of PTs using HVLA techniques I wonder will we have a greater number of PTs needling than using manipulation in the very near future?

    I’ve gone through EIMs TDN courses, with the first nearly a year ago. My clinic wants me to hold off with utilization on patients due to being in a “grey area” state. Our newest practice act includes the technique. I’ve been staying sharp while continuing to practice with friends/coworkers but my clinical practice has benefited, mainly from my ortho residency but that’s beside the point. I have had to utilize other, more researched, skills first and have come to better identify patients who would benefit from TDN.

    Looking at the entry cost being 2k plus travel at minimum TDN is an expensive skill to not use and boy is it sexy. I’ve come to better identify patients who could use it and hope, unless someone beats me to it, to attempt to study responders vs non-responder characteristics.

  4. Kevin Wait says:

    Great post. Right or wrong, TDN is the “sexy” intervention in our profession right now. Licensed PTs using TDN are skilled at the fine motor skills and requisite foundational knowledge related to using this technique, but motor skills and anatomical knowledge are not enough to maximize patient outcomes. Do clinicians know when to use this technique, and perhaps more importantly, when NOT to use this technique? These are important questions as you point out, and I agree, it’s possible we are doing more harm than good in many cases. Many things should be considered when electing to use TDN. Patient positioning, meaningful comparable signs, and intentional/strategic patient language should all be emphasized to maximize functional outcomes. There is still much to learn, but I think all clinicians would do themselves (and patients) a tremendous favor if a “less is more” approach becomes more popular when using TDN.

  5. Theodore Croy says:

    Larry wrote: “We have PT students seeking TDN clinical instructors and consumed with the technique at the expense of basic skill sets.”

    As an educator, this is what concerns me. If DPT students get a taste of TDN without learning and pursuing other interventions, that should concern us–because the NPTE licensure exam (and clinical practice) requires us to know/practice many other interventions beyond TDN.

    PTs should learn and practice TDN, but I have to wonder if the “irrational exuberance” as Larry put it is just another season in the profession like other treatment modalities once enjoyed. Conversely, is it the proverbial “nail” that the provider who only owns a “hammer” has been searching for?

    Thanks for posting, Larry. Interesting perspective on this intervention.

  6. Liza Bayley says:

    I read this with great interest! After various awakenings from quietly watching heated discussions unfold on Twitter and realising that a lot of the things I questioned as a student I was probably right to question, I was starting to become a little disillusioned with manual therapy and a lot of the claims made by the physical therapy professions. There’s no doubt that fashions come and go in interventions and theories and I’m sure you’re right, in that part of the reason for this is trying to stay ahead, remain a competitive name in the business and offer something new to our hungry clients. Kinesio taping is one of the band wagons that I jumped on a few years ago. While I find it useful in certain circumstances, some of the claims made about its effectiveness were clearly unscientific and I was squirming in my seat at ridiculous demonstrations of ‘look how much stronger this perfectly healthy specimen – with no participant or practitioner bias – is when we wack some tape on his thigh. Look how much higher he jumps!’ *Rolls eyes.

    Yes we need various tools at our disposal, which will help us treat our highly individual patients in the best way possible, but let’s keep it realistic, evidence based and as simple as possible. Let’s stop focusing on high tech, relatively expensive (because of training etc) interventions and start looking at our basic clinical reasoning and associated theoretical outcomes. There’s too much rubbish going around, and in my opinion patients aren’t stupid! They can see right through someone plastering them with tape or using them as a pin cushion because they’re not sure what else to do.
    Liz.

  7. Kevin Wait says:

    While we should use TDN with caution, I also think it’s worth emphasizing the positive treatment effects happening every day with this technique when used appropriately. TDN is absolutely in our scope of practice and has been established as a very safe intervention. I have seen dramatic and life changing improvements in many of my patients which should not be ignored. Some patients are able to lift their head again to eat dinner or play cards with their friends without having to lie down and take a break. These people have cried tears of joy because of this tool. These effects are in the Neuro population as well as the MSK population. Does it work every time? Absolutely not, but I would not equate TDN with a “fad” treatment. I believe it’s here to stay, and I’m excited to contribute to the evidence base and enhance my own clinical reasoning skills with this tool as more clinical research is published.

  8. Dave Walton says:

    Nice little post here Larry, and reminds me of so much I’ve seen in PT practice over the 14 years of my career (first as clinician, now as academic). When I broke into the profession in the late ’90s, everyone with back pain was getting extension exercises. Everyone. That’s and postero-anterior mobilizations was what I had learned as a student to treat back pain. Shortly thereafter it was Sahrmann-type exercises. And we all did it. I know I’m missing some, but I remember more recently capnography was en vogue at least here in Canada, then real-time ultrasound (at no small overhead I should add), Gunn IMS and ‘dry needling’ is now burgeoning. As a student of the profession for many years now, I’m left wondering – why is it that PTs (very broad brush I admit) seem so quick to jump onto the next ‘new thing’? Is it for the competitive advantage? Marketing? Fear of obsolescence perhaps? I’ll offer one insight that perhaps not many have thought about, and that’s fear of being challenged on treatment decisions. As an educator of 12 years, I’ve observed that many of our bright young minds have made it this far because they’re very good at finding the ‘right’ answer. And I’ve also realized that many struggle mightily when learning to deal with humans, for whom there is very rarely an absolute ‘right’ or ‘wrong’. The psychological construct of tolerance for ambiguity or intolerance of uncertainty seems particularly relevant here. My perception, sometimes arm’s length, sometimes personal experience, is that on average many PTs are fairly intolerant of uncertainty or ambiguity – they need someone or something (book) to tell them what to do, and then many are very capable in application of the skills technically. Truth is thought that in reality there are very few techniques we have access to in PT for which we can open a book or listen to an ‘expert’ and know ‘OK, for low back pain, I stick this here’. And then, if anyone challenges our decisions, we point to the book and say ‘see, this is what I did’. We don’t even enjoy that level of pseudo-direction with how long to put a patient on a stationary bike. So, no wonder especially young or new grads gravitate in these directions – it’s a technical skill with a bit of reasoning sprinkled in, rather than a reasoning skill with a bit of technical know-how sprinkled in. I think it’s just more comforting.
    I’ll say this in closing – when I tell people that my expertise lies in chronic pain assessment and management but that I don’t do dry needling, many say with quizzical looks ‘then what else do you do?’. Really? Is that what we’re teaching our students regarding pain management? Now that makes my skin crawl.

    1. Kim says:

      You never even had time (2 yrs) ???? To even practice your “skills” as a PT. just stay in the schools and let the rest of us do our jobs…” those who can’t……..teach” sucker

  9. Larry says:

    Terrific comments and insights. Dave, I think they should make your comments mandatory reading in entry level PT program.

  10. Guy Terry says:

    There is a growing number of courses that I end up taking so that I can say “yes, I can do that” when a referral source is keen on referring for that specific intervention. That’s a slippery slow in of itself, and I get annoyed spending money for courses so that I can critique the treatment techniques more than I use them…but I guess I’m paying to compact the amount of time I may or may not be wasting, lol.

    EIM’s TDN course was exactly what I was looking for, and decidedly not a waste of money. I can now say that I offer it, and I used it on a problem patient who was satisfied, and showed improvement that she did not obtain with other means.

    Now if you could just wrap up an MFR/Graston/Kinesotape course all in one 2-3 segment, I’d get it all over with in one weekend, and not feel that my money went to some idiot to spend on lots of bogus marketing claims.

    In fact, EIM could host an “Investigative Reports” series of courses on pseudo-bogus treatment techniques with cache, that might happen to benefit a patient from time to time.

  11. Guy Terry says:

    There is a growing number of courses that I end up taking so that I can say “yes, I can do that” when a referral source is keen on referring for that specific intervention. That’s a slippery slow in of itself, and I get annoyed spending money for courses so that I can critique the treatment techniques more than I use them…but I guess I’m paying to compact the amount of time I may or may not be wasting, lol.

    EIM’s TDN course was exactly what I was looking for, and decidedly not a waste of money. I can now say that I offer it, and I used it on a problem patient who was satisfied, and showed improvement that she did not obtain with other means.

    Now if you could just wrap up an MFR/Graston/Kinesotape course all in one 2-3 segment, I’d get it all over with in one weekend, and not feel that my money went to some idiot to spend on lots of bogus marketing claims.

    In fact, EIM could host an “Investigative Reports” series of courses on pseudo-bogus treatment techniques with cache, that might happen to benefit a patient from time to time.

  12. Tracy Sher says:

    Thank you for posting this article! I’m sure this will continue to lead to great discussions. I am in Florida and cannot do dry needling. However, even if I could, I may not rush out for the training. I certainly realize that this is just one form of treatment as you discussed; and as some have stated may help patients.

    It would be great to have another skill or application to add to the armamentarium, but what often gets lost is sound clinical reasoning, critical thinking, patient preferences, social skills, and science based on the patients’ presenting issues (these definitions usually lead to further debates, but I hope my intent here is generally acknowledged).

    I see patients who tell me “PT likely won’t work because I’ve already had lots of trigger point therapy”. I have to do a lot of education to explain that the TP therapy is just one small aspect of a much larger treatment plan available.
    Dave Walton’s comments resonated a lot with me: “So, no wonder especially young or new grads gravitate in these directions – it’s a technical skill with a bit of reasoning sprinkled in, rather than a reasoning skill with a bit of technical know-how sprinkled in. I think it’s just more comforting”

    It’s not about a cookbook of exact treatments. It’s combining the best approaches based on individualized factors – ultimately getting the patient moving (in the case of pain) and functioning at a level that helps quality of life.

    Tracy Sher, MPT, CSCS
    http://www.sherpelvic.com
    http://www.pelvicguru.com

  13. Jon says:

    Timely post Larry. See too many interns and young PT’s jumping into TDN as first treatment of choice, practicing TDN at lunch over other things and seemingly forgetting other treatment options with more proven effectiveness. I think it’s a great addition, but we need to not forget the other tools in our bag. Thanks for the reminder.

    1. Darren Beilstein says:

      Great point Rich. In my opinion, DN is a tool and a skill that should only be implemented once a strong foundation of anatomy, physiology and functional rehab skills have been developed and implemented through a reasonable time of clinical practice.

  14. Nice post!

    “At some point and with evolving evidence, (which I am confident will come), TDN will likely be an entry level skill . . .”

    One of my concerns is the push to incorporate DN into DPT programs . . . before there is really much evidence to support it.

    1. Darren Beilstein says:

      Great point Rich. In my opinion, DN is a tool and a skill that should only be implemented once a strong foundation of anatomy, physiology and functional rehab skills have been developed and implemented through a reasonable time of clinical practice.

  15. Again, Nice post Larry. I second Dave Walton’s comments above. He stated, ” on average many PTs are fairly intolerant of uncertainty or ambiguity – they need someone or something (book) to tell them what to do, and then many are very capable in application of the skills technically.” This statement encapsulates the issues that face us; the inability for many to accept a bit of clinical uncertainty (and that it’s ok to feel this way).

    There are a large multitude of variables which may confound a patients ability to move more efficiently or with less pain. The needle appears to simply be another variable, added to a complex equation, that in my small knowledge of pain science, would lead to a further reduction in a patients internal locus of control. I am not quite sure we need another intervention that does this (at least in the treatment of painful conditions). It appears we are quick to applaud studies which demonstrate “we are just as effective as surgery”, but often lose site of why this may be? I suspect its because we interact intimately with our patients and I am not convinced that adopting another modality and moving towards an operational role, is the right direction.

    I truly hope this post will invoke discussion from proponents of the concept (beyond the common arguments “It works for my patients” or “its another useful tool in my toolbox). From a basic understanding of pain neurophysiology, I would like to see a discussion of why an invasive intervention is more effective or even necessary (when compared to non-invasive intervention)?

  16. I completely agree that TDN isn’t #physicaltherapy any more than it is home exercises or cavitating joints. As limited evidence accumulates pointing toward TDN effectiveness and even some very basic outline of mechanism of action, we certainly are right to fall back on our clinical experience and expert opinion. My clinical experience would lead to a much different conclusion than what Larry posted: “TDN probably works in some instances-likely more to “meaning effect” and placebo than anything else”. In my clinical experience and personal opinion, meaning effect and placebo are certainly amplifiers, but there is something of significant influence and power within TDN. In fact, I can only recall one other time in my professional career where my personal practice and thinking has shifted so dramatically: in my fellowship when I began to chose thoracic spine thrust manipulation as my first level intervention for shoulder impingement. Mind you this was several years BEFORE even the first lumbar spine clinical prediction rule for manipulation was even being considered. The effect, both immediate and sustained, that thrust manipulation could produce began to have course changing impact on my thinking. Just as I cannot not return to treating shoulder impingement patients without a T-spine HVT and fully expecting change, I cannot responsibly pass off TDN as another Cybex machine that will be replaced after the allure (or reimbursement) passes.

    NOW –> on to my point

    It is BECAUSE of my disagreement with Larry’s opinion on the clinical effectiveness of TDN that I wholeheartedly agree with his call to avoid irrational exuberance around TDN, particularly when the effects are as he points out are: “downright damaging”. My personal bias is that both highly trained critical thinking PTs and weekend CEU junkies who stumble onto TDN by dumb luck become irrational around TDN because of the significant influence and power of TDN. Power is dangerous and must be discovered and wielded responsibly, with due pause. The exuberant PT who begins to abandon reason, logic, and sound rationale while ignoring any larger consequences on referral relationships, patient values, and impact on the profession in exchange for the pursuit of a feeling of power over human suffering is headed down a slippery slope. Reminds me of one of the characters from one of my favorite books of all time: http://www.youtube.com/watch?v=DLvIFRNbqOs

    Am I being dramatic here? Of course. This is a blog after all.

    But there are personal experiences behind every drama. Having seen first hand the power TDN affords to effect chronic pain, post immobilization strength and stiffness, and even reproducible and predictable influence on abnormal neurologic tone such as cerebral palsy or CVA patients, perhaps I am just keenly aware of what that sense of power feels like. And like another one of my favorite books (Proverbs) points out, I am well aware of the warning not to get drunk on my own abilities or to fall prey to the tendencies to use my knowledge and skill for selfish gain.

    So what’s my bottom line here??

    TDN is a powerful tool in the hands of a seasoned clinician but can wreck havoc in the hands of a selfish and ignorant one.

    …….which one will YOU be?

    ab
    (co-author of EIM’s TDN course series)

  17. John Ware, PT says:

    Andrew,
    Is it possible that TDN and HVT just have stronger placebo and meaning/expectation effects than the non-specific effects of some other interventions? You seem to be assuming that there’s “something of significant influence and power within TDN” distinct from these potentially very powerful non-specific effects. Given the shaky ground upon which the myofascial trigger point concept rests, and given that the higher quality outcomes studies on needling indicate very modest effect sizes, I’m wondering what you’re basing this assumption on.

    I think the most reasonable assumption based on the current evidence is that TDN’s effects are driven, similar to HVT, primarily by non-specific effects, just as Larry stated. Just the fact alone that it makes us feel so powerful over the patient’s pain experience has the potential to add a profound layer of patient confidence in the practitioner.

    I’d rather that confidence stay with the patient than be projected onto me.

  18. Derek says:

    The actual point that PT’s should focus on developing sound clinical reasoning and a strong skill set should be the emphasis of this article. It’s 100% true and accurate. However, DN has some exciting potential clinically. Like all other tools, patient selection and incorporation of education etc is essential.

  19. Trevor Dorius says:

    TDN offers a way to target and provide input to the neuromuscular system in a more specific way than any other tool that we have. It is a powerful way to intervene at the site of treatment as well as in the mind of the pt (as has already been mentioned). Upon learning TDN, I was guilty with more than one patient of trying to use the intervention when it wasn’t indicated and the negative effect on treatment was just as immediate and profound as were my successes with the proper patients. No question that TDN is an effective tool when applied with correct critical reasoning. The problem that Larry alludes to comes when we are holding the hammer and everything starts to look like a nail.

  20. Larry says:

    Andrew:
    Your belief in the transformative power of TDN is powerful. I would suggest that in part its effectiveness is based on your belief. Keep in mind that MFR PT’s and craniosacral PT’s believe just as much in those techniques as the orthos do in knee arthroscopy (which as it turns out has mostly placebo effect as well). I certainly do not doubt the results but we have to be very careful of the over zealous use of TDN has also profound impacts on students and interns in their impression of PT. While TDN might not be fad, keep in mind “spray in strech” was likewise seen as the savior technique and while it continues to be used, it isn’t to the extent it once was. In my opinion, TDN will go in a likewise direction.

  21. Trevor states: “No question that TDN is an effective tool when applied with correct critical reasoning. ”

    This is where I was hoping this discussion would go (the term is “clinical reasoning”). When does a practitioner determine, the patient in front of them, could benefit from TDN (over non-invasive interventions)? And how is this “input” different then simply “pushing” over the same region? Why is a needle necessary? As John and Larry eluded to, could it simply be the non-specific effects elicited from the practitioner-patient interaction? I am hearing the term “powerful” quite a bit from the proponents here—which indicates there is a strong belief in the intervention. Would the effects be the same if you provided TDN, in absence of emotion or interaction? When some of you discuss the importance of patient selection, are you discussing the choosing of patients who “believe”?

  22. Perhaps my assumption that solid clinical reasoning to include the use/dosing/methods as the basis of our decision to use TDN were not implicitly stated very well….. The need for intentional thinking here are quite high and are the foundation of how we teach and practice TDN. In fact, that’s the backbone of the TDN courses and the multiple research projects that I’m a part of in the TDN arena. Joseph – your questions are exactly what I’d like to know. My hypothesis is that we will find in some cases the needle does matter but not in all (similar to thrust non thrust debate). The provider’s belief and the patients projected belief is a big variable here no question and why we’re using sham techniques in the studies that hopefully control for the “emotional/belief” in the providers (i.e. not blinded). And yes, one of the items we’re considering is a fear or needling or absence of such a fear. While not quantifying the level of belief in the intervention, it is a good start to helping to identify folks who might not benefit. The clinical curiosity is high here and has signs of some promising findings. The research is underway to help with the generalization of clinical patterns to the larger population. My (and sounds like OUR) biggest concern is the provider who chases curiosity or “winning” at the cost of the very patient in front of them.

  23. Just chiming in quickly. Yes it is a tool in the tool box. As therapists, we must be able to treat muscle, fascia, joint, and nerve. There aren’t many good techniques that a skilled manual therapist can use for nerve. As a therapist always looking to improve my care, I turned to IMT/IDN. I struggled with patients who continued to have a constant underlying ache pain. I would correct muscle/fascia imbalance, joint stiffness, posture, ROM, strength, etc., but patients would still have a constant underlying acheness. This, I determined, was/is nervous system irritation. Again, trying to be brief. IMT/IDN works. Bottom line. I took more than a weekend course. Was treated with needling throughout the course, and felt better than I had in a long time. IMT/IDN allows the therapist to treat/settle nerves, affect muscle belly trigger points that are too deep to effectively “push” on without killing your patient, work on joint capsule (besides MOBS) and helps to relax and deactivate an overactive nervous system. It is especially effective for the geriatric population, who may not be able to tolerate some other manual therapy approaches. It is definitely an effective tool. I am able to needle myself, and it is not placebo. It helps unlock or deactivate deeper tissues that cannot be “pushed” on. Helps settle nerves, improves blood flow to an area that has not had good blood flow, which improves nutrition and oxygenation to that area, and promotes and speeds healing. I have added this to my ankle sprain protocol and cut that healing time in half, getting athletes back on the field quicker and more safely (combining it with joint, fascia, muscle work, stretching, and strengthening). It is a great tool to have. It is an essential in my book. A must have. It is unfortunate some states do not allow it. If I were a nursing home owner, I would insist on it’s use. It is just so helpful, and relatively painless, for the geriatric population. I use it on all ages, as needed and as indicated, but not every patient gets treated with IMT/IDN. I would guess 1 in 6-8 patients get IMT/IDN, and that is only after they have been educated and agree to try it. After that, it is their call (typically, they want more). Thanks!

  24. Jeff Daly says:

    Excellent post as usual, Larry. In response to the first reply, Sandra we still have a fully functional Neuroprobe device and a few in this clinic use it regularly! So no apologies needed for sounding dated. In fact we will purchase any units that one may no longer be using. I fully acknowledge the belief of the provider drives the treatment when we use this modality, however we have created quite a culture around it by referring to it as The Black Box, and applying tag lines such as “Resistance Is Futile”. The athletes tend to respond positively when applied to their accute injuries, hokey tag lines aside.

  25. Todd says:

    It pains me to see so many in our profession continue to chase secondary symptoms/pain and ignore the primary cause of a patient’s ailment. I really don’t care if you practice craniosacral, MFR, or something likeTDN but please don’t call or promote it as physical therapy. I truly believe it’s things like these as to why we are viewed by many as ancillary service providers and not worthy of direct access.

  26. Nathaniel Hoover says:

    As a current PT student I would like to weigh in with a student’s perspective on TDN. I think it goes without saying that students are excited and eager to learn “the new technique”, but I feel students seek out TDN clinicians for different reasons.

    Students are excited to be mentored by clinicians utilizing new, up and coming techniques, because they associate this with clinicians who are also keeping up with the evidence, utilizing manual therapy techniques and do not have a “cookie-cutter approach” to treatment.

    For me, school is a time to absorb as much as possible and familiarize myself with what the field of physical therapy has to offer. We are taught techniques in school with very little supporting evidence (MFR, ART, Ultrasound, etc), and I feel TDN should be introduced due to the potential treatment benefits. The two case reports in this month’s publication of JOSPT further highlight the need for more research on TDN but are an example of promising results that favor its use.

    Upon graduation, and planned completion of a residency, I want to be a clinician able to utilize sound clinical decision making while providing my patients with a variety of treatment options. At this point in my career, if I don’t consider the potential of TDN I may be selling my clinical skills and future patient’s outcomes short.

  27. Ryan Grella says:

    Thank you Larry for this thought provoking post. I think you bring up valid points that many in the profession are thinking, but afraid to say out of fear of jumping in front of an out of control freight train.

    As a physical therapist practicing in Florida I must admit I have paid little attention to dry needling, and in terms of implementing legislation have let others more versed in the topic handle the issue. I do need to read up more on the topic. As someone in the legislative trenches I can tell you that the acupuncture groups are saying dry needing is nothing more than a silly name for acupuncture. I am familiar with the evidence surrounding this procedure. We have all heard the saying, if it walks, acts, and quacks, like a duck, it’s a duck. I’ve always wondered how is dry needling unequivocally and fundamental different from acupuncture?

    Now the mere fact that dry needling is similar to acupuncture does not exclude it from the physical therapist’s scope of practice however, unless something has recently changed controlled studies seem to indicate that acupuncture is nothing more than an elaborate placebo more powerful than a sugar pill. Studies find that if you believe acupuncture will work you will get better, if you don’t you won’t. In fact If you believe acupuncture will work it does not matter if you get real or sham acupuncture, you will still get better. So the clinical prediction rule is: Do you believe acupuncture will work? Hardly befitting of 7 years of education and upwards of 150k in debt. Again, so I can better understand the topic, how is this fundamentally different from acupuncture and I’m not sure if underlying philosophy is an adequate response.

    The second question then becomes, given our uphill battles in the legislative arena and lack of awareness of what physical therapists actually do; can we afford to be playing in this grey area as Larry points out?

  28. Jason Silvernail says:

    We should all – every one of us – be nothing but disturbed by our colleagues’ use of emotional anecdotes. I look forward to the day when mentioning an anecdote automatically makes our students shake their heads and turn away. Great post, Larry and a tremendous comment from Dave Walton. Highly recommend people look into MJ Simmonds’ work on intolerance of uncertainty in our profession and how that anchors practitioners beliefs into concrete and wrong explanatory models loaded with nocebo and external loci of control.
    Example: http://mobile.journals.lww.com/clinicalpain/_layouts/oaks.journals.mobile/articleviewer.aspx?year=2012&issue=07000&article=00002

  29. It’s good for us to be very vigilant of any technique that sends the message, “health and healing happen to you,” and not from within you.

  30. Matt says:

    This all sounds too familiar. More “tools” for the individual in pain to have used on them. More billable options and fliers to market services. More theoretical discussion with ‘neuro’ to justify use. More peripherally focused interventions. All of this and we continue to see a rise in chronic pain.

    This is no different that McConnel taping, kine$iotaping, $craping $kin with in$truments, myofa$cial release, cranio$acral ,rieki, rolfing, mobipulation.

    A hypothesis for TDN that will sound similar to many other ‘tools’ from the profession:

    Repackage/rename an intervention, overstated anectdotal claims, perform pseudoscientific/tooth fairy research and label as ‘evidence,’ follow up with expensive courses, clinical world finds more non-responders than responders, expensive research to find the responders, more research to identify psychosocial factors reign supreme, start over again while those suffering search for next holy grail…

    It’s almost time to add one more to this list….

    http://www.bodyinmind.org/jointhead-diskhead-musclehead-fasciahead/

  31. John Ware, PT says:

    I encourage readers to take a look at the extensive systematic review by Derry et al (http://www.ncbi.nlm.nih.gov/pubmed/16956145) of the 35 systematic reviews that had been performed on acupuncture/dry needling trial from 1995-2006. The evidence is compelling that once bias was accounted for in these reviews that there is no robust evidence that acupuncture/dry needling is effective for treating any condition, including persistent pain.

    What’s more is that there’s no plausible scientific basis for acupuncture/dry needling. I challenge anyone who uses this modality to clearly state the scientific premise upon which it is based.

    Have we learned nothing from the days of mindlessly applying ultrasound, spray and stretching, and acupressure to trigger points? When are we going to grow up as a profession?

  32. Wyatt says:

    Well said Matt and Jason. It appears to me that TDN is most likely a pseudo-scientific treatment that leads to pain relief if it is used in alignment with provider and patient beliefs and expectation, which emphasizes an external locus of control.

    Our profession needs to combine more science-based reasoning with the common current practice of evidence-based medicine, and we can then stop chasing “tooth-fairy” science.

  33. I also recommend we pay attention to studies such as this: (http://www.dcscience.net/white-2011-acupuncture-placebo-rct.pdf).

    The authors state: “The individual practitioner and the patient’s belief had a significant effect on outcome. The 2 placebos were equally as effective and credible as acupuncture. Needle and nonneedle placebos are equivalent. An unknown characteristic of the treating practitioner predicts outcome, as does the patient’s belief (independently). Beliefs about treatment veracity shape how patients self-report outcome, complicating and confounding study interpretation.”

  34. John Ware, PT says:

    Another very well-done study in this area- actually a pair of studies-was done by Nadine Foster’s group out of the UK (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2856919/). They first found that acupuncture for knee OA combined with advice and exercise was not better than advice and exercise alone. And, they included a sham arm. The companion study investigated both patient and therapist expectations and preferences for treatment. They found that neither patient nor therapist preference or expectation had an impact on the primary outcome, which was the pain subscale of the WOMAC at 6 and 12 months. However, on the secondary outcome patients who had high expectations from their treatment were nearly twice as likely to be a treatment “responders” at both 6 and 12 months.

    I think the take home is that it’s very difficult to determine all the factors that can influence patient and therapist expectation in a formal clinical trial. Foster et al do a good job of laying out how mixed the current research is in this regard. What I found most interesting from this trial was that the non-participants of the study from who they were able to get treatment preference information, these non-participants had a significantly lower expectation of acupuncture. That finding suggests that trials on needling, and perhaps other complementary interventions, may be more likely to include participants with a bias in favor of the experimental intervention. If this isn’t controlled for during participant recruitment in the trial, then it needs to be considered a factor in any positive outcome.

  35. Glen says:

    Andrew,

    I would encourage you to consider EBM’s blind spot discussed in this excellent presentation:

    http://www.youtube.com/watch?v=XHkHB1i0Ss0

    I am afraid our profession will never ever move forward until we develop a solid premise by which to proceed with actual research.

    The notion of needling being anything more than an elaborate placebo is laughable based on the best available evidence we currently have. I know it’s “sexy” but I am with Todd with his comment:

    “I truly believe it’s things like these as to why we are viewed by many as ancillary service providers and not worthy of direct access”.

    We really need to move on from this passive modality “flavour of the month” merry-go-round we seem determined to stay on. Let’s get serious about the “science” behind what we do shall we?

  36. sean says:

    I recently sent one of my clinicians to the first in a series of 3 DN courses. We’ve seen the full scope of results from the miraculous to no effect. The decision to acquire the training and knowledge to use these techniques was borne out of a need to help people we seemingly could not with the more traditional treatments like exercise and manual therapy.
    I have to say, that the neuroscience refresher/update was as equally as beneficial for our clinicians as the ability to have their patients receive TDN. For us, it is a great option, but we haven’t used it on more than maybe 5%-10% of our clientele. The one thing I tell everyone I offer the service to is that there are no magic bullets, but based on the symptoms, etc., I believe they may benefit.
    Any clinician who TDN’s virtually everyone in the clinic would probably be the same PT who did HUMS on every patient back in the 80s and 90s (and unfortunately 2000s).

  37. Bobby says:

    odd says:
    March 18, 2014 at 2:31 pm

    It pains me to see so many in our profession continue to chase secondary symptoms/pain and ignore the primary cause of a patient’s ailment. I really don’t care if you practice craniosacral, MFR, or something likeTDN but please don’t call or promote it as physical therapy. I truly believe it’s things like these as to why we are viewed by many as ancillary service providers and not worthy of direct access.

    Comments on Todd’s Comment,

    Kind of offensive to those those Therapist’s who has spent near 40 years helping patients using unique and cutting edge approaches that we have studied for years when some of the finest PT’s in the Nation could not make a difference in these patients lives when our clinics have. Physical therapy is an ART as well as a SCIENCE. It is not a pure SCIENCE. Patients are not machines. You cannot look at the human body in bits and pieces but rather as a whole or you will miss some of the important details. Had Dr. Amen thought like this, well, he would have never surpassed the limits of his profession at that time. Now he is recognized as a leader in his field of psychiatry and has provided tremendous tools to help patients. PT’s are viewed as Ancillary by physicians because that’s the way it was for a long time. So it changing which is good. We have strongly cashed based clinics where our patients seek our services and go to their physicians asking for a referral to our clinics. We don’t have to persuade a physicians office but rather let the patients teach their physician and we gain their respect. Little off topic but I felt compelled to comment as there are lots of Great PT’s who utilize cutting edge methods that may be considered by some as non-evidence based but in 10 years may be the way of the future. Don’t throw the Baby out with the bath water.

  38. John Ware, PT says:

    Bobby,
    The qualities of being “unique” or “cutting edge” are fine if you’re selling fashion accessories, but I think professional health carers- certainly those who aspire to be members of a doctoring profession- should be held to a more rigorous standard. Fortunately, the scientific method affords us the opportunity to advance in our understanding in a rational and systematic way rather than adopting interventions because they are trending in the culture, or, as some have characterized needling, they are “sexy”. Unfortunately, we often choose to ignore how the science informs us.

    For once, I’d like to see the profession of PT formally stand up and say, “We’ve studied the research on this intervention, and we’ve decided that it doesn’t meet the scientific standards that we consider advance the best interests of our patients and indeed the public health writ large.” We seem to embrace just about anything and everything that comes down the pike because “it works”. We won’t be taken seriously until we start taking more principled positions on what constitutes professional practice and what doesn’t.

  39. Kevin Wait says:

    Patient outcomes and EBP is driven by three things. We can’t live in an idealistic, “the evidence and science is perfect” world 100% of the time. It simply isn’t possible. Life in the clinical setting is difficult. Patients present with a host of physical and emotional problems contributing to their pain. I will try to take some time to describe the theoretical models put forth as to the “why” TDN may work later this afternoon so perhaps this will help inform some of you who are unfortunately equating acupuncture to TDN. I am not an acupuncturist, so I don’t know exactly what their practice entails, but I have spoken to a few of them, and what we do from a TDN (western medicine, muscle physiology) perspective appears to be different. Obviously some level of placebo exists, as it does with everything, and I will absolutely use everything in my power to ethically manipulate my patient outcomes. If I can get someone better by maximizing the placebo effect and still staying focused on the other three pillars of EBP, I don’t see anything wrong with that. My job is to get people moving better with less pain, if I need to bring a “needle to a gun fight” to do that, then I will.

  40. Larry says:

    I appreciate the threads and comments-insightful and very interesting. One area that has not been addressed per se is the notion of “no harm”. If I was putting together a CPR for TDN, my first pass would be if you are in a state where the informed consent forces you to list the potential adverse effects, the prediction rule would say don’t do it (strong research on nocebo). Patient with fear avoidance issues surrounding needles? Don’t do it. Referral source wanting TDN on their patient and sending it to a practitioner who is well trained” Do it!

    Does TDN harm some referral relationship (it does in my recent experiences). Does it harm our credibility (yes in my opinion when a patient returns to a doc who gets ticked off and then discounts what we do as faddish). I am not suggesting don’t utilize TDN but am suggesting that it comes with trade offs and unintended consequences both to patients, referral sources, and the profession.

    One area that I think everyone agrees with is that TDN is not #physicaltherapy.

  41. Bobby says:

    Just curious Larry and to the others on this topic. Then would you suggest that the Feldenkrais Method, CranioSacral, Visceral Manipulation, MFR and some of the other methods identified by Jerry H above is not Physical Therapy. Many PT’s don’t know what these are in the Ortho World and are lumping them into your discussion her on Dry needling and suggest them as fades. In our State we cannot perform Dry Needling as it is not yet approved to my knowledge so of course we don’t do it. This is how the first part of our License reads,

    2620. (a) Physical therapy means the ART and SCIENCE of physical or
    corrective rehabilitation or of physical or corrective treatment of
    any bodily or mental condition of any person by the use of the
    physical,…………………………………

    Did you know that the Feldenkrais Method is actually stated in the Medicare Manual as a form of treatment or procedure (although spelt wrong)?

    We are just touching the surface of understanding the human body where pure science doesn’t answer all questions. So why as professionals should we stifle creative and cutting edge approaches that have merit and are trying to be better understood why they work as time goes on. We actually take very seriously the words DUE NO HARM. We have never been excused of breaking an arm, a leg, ripping apart a surgical region etc etc. etc. yet we have known many Ortho PT’s that have done just that in conjunction with questions posed to our Malpractice Insurer why rates go up. I cannot say physicians have been all that successful with their approach to the human body. 7 min visit or less, medication, medication, medication and all excepted as evidenced based so why do we want to become that rigid. Personally speaking I don’t practice Physical Therapy to impress physicians, I do it to help patients and the rest generally follows in our clinics back to the physicians which is generally good with the strong cash based clinics that we run.

    Just my 2 cents amongst friends!

  42. John Ware, PT says:

    Bobby,
    I could easily come up with a plausible premise to explain why moving in a novel and thoughtful way, as is taught in various movements schools including Feldenkrais, yoga and Somatics, would be beneficial for someone with a MSK-related pain problem. However, I’ve been involved in several in-depth discussions in recent years regarding needling, and I’ve yet to hear anyone articulate a premise that they could defend to explain why inserting a needle into a patient makes sense. Invariably, I hear excuses about how complex humans are, about how imperfect science is, and finally that we need to keep doing TDN because “it works”. I think a doctoring profession should have much higher standards than empirical, anecdotal evidence.

  43. Larry says:

    Bobby: that’s a lot of items to bundle together and frankly some of them I have only heard by name and won’t even try and spell (and definitely agree that many are beneficial). I think there are generally 2 approaches to “what is physical therapy?”. The first is what we are defined by our state practice act (since I personally disagree vehemently when APTA superimposes or restricts our very own practice act I can’t in good conscious use any of their definitions or positions). In my view, the other litmus test is what is physical therapy from a patient’s perspective outside of much of the legal speak of a practice act. In that regard, I prefer to avoid any specific technique, intervention, or piece of equipment whether it is in vogue or not as that takes away from the very “neck up” skills coupled with hands on and strong interactional approach that I believe more readily resonates with a patient and which strongly differentiates us in the market. Admittedly, that is my bias.

  44. Bobby says:

    I could speak from the perspective of Acupuncture and all of the support around that treatment approach from professionals that provide that treatment for their patients which in fact is very helpful, however, TDN comes from a different perspective one that I’m not as equipped to speak about as our state doesn’t allow for TDN. My point is that the body is not simple like a machine. We don’t have all the answers and Science is yet to answer what we don’t always understand. So because we don’t understand it, that doesn’t mean it doesn’t have value and merit in the world of Physical Therapy. I do think good training is important and I do think that TDN is not for every patient but it can definitely help a few based on the experience of those that use the method. If it helps a few patients, well, that’s great, so long as NO HARM is done to any patient that is treated with the method. You have to know that there are standard methods that Ortho PT’s use all day long that are considered evidence based where they have done harm. This doesn’t mean the treatment method was inadequate but maybe the clinicians training was poor in that method. Good training would strike me as being very important with the TDN method and awareness of where it could help and maybe where it is not an appropriate method and used less.

    If physicians standards of doctoring is what we are aiming for in physical therapy, count me out, because mostly I’m unimpressed by the model that they have adopted. Cannot saw I’m all that impressed with the APTA either with some of they propose.

    There is my 1 cent comment. I spent 1 cent on my last comment!

  45. Bobby says:

    I spent my last cent Larry. Good points. I’m out of money……………… lots of great comments!

  46. Nick Rainey says:

    I definitely agree that this isn’t the “end all” treatment. Clinical reasoning is why we get paid. I pride myself in clinical reasoning much more than any skill I may have.

    One are I disagree is that there isn’t evidence to back up dry needling. A quick search on google scholar for “trigger point acupuncture” gives the following articles as 3 of the top 4 results.

    http://aim.bmj.com/content/22/4/170.short
    http://aim.bmj.com/content/24/1/5.short
    http://www.complementarytherapiesinmedicine.com/article/S0965-2299(06)00060-4/abstract

    While we don’t call it “acupuncture” the article compare sticking needles in trigger points to control groups. There are control groups and blinding to protect against threats to validity. While I haven’t read through each of these studies their findings should be of interest to everyone who performs trigger point dry needling.

    1. Nick Rainey says:

      Good point John. I didn’t look too much at those studies. My point was more that there is research in this area. Some (like all areas) is better than others, but when we use “best available evidence” I think we need to see what is already out there. Here are a few more.

      http://www.ncbi.nlm.nih.gov/pubmed/20213036
      http://www.ncbi.nlm.nih.gov/pubmed/10807110

      The area that I think we are most lacking is the efficacy of needling 20+ mm depth in patients. There is a lot of literature of the benefits of acupuncture of local and distal points to treat musculoskeletal conditions. However, the deep needling studies are normally 20mm or less. I, as do most physical therapists, often needle much deeper. Acupuncturists needle deeper as well, they just haven’t put it in the research that I’ve seen.

  47. John Ware, PT says:

    Nick,
    I think your argument by citation in this case is not very strong. All of those trials you found through Google Scholar are by the same research group, and the lead authors are licensed acupuncturists. The samples are all drawn from their clinic, and the participants come from the Asian culture where acupuncture has a very long and embedded history. The sample sizes are small. The potential for bias is very high. Also, the outcomes are very short term.

    I’m not arguing that there’s no evidence. I’m arguing that the positive evidence is of low quality, while the high quality evidence suggests that needling is probably no better than placebo. I’m not against harnessing placebo, but I can’t fathom why I need to stick a needle into my patient to do that, particularly when I can’t explain to them in a coherent and defensible way why this intervention might provide them enduring relief from their pain.

  48. Jennifer Kish says:

    Well said, Larry, especially with respect to neuromarketing and the perceptions of the public, legislators, and referral sources!

  49. sean says:

    Can someone explain to me why so many of the comments are negative about a not-so-well researched treatment? There’s a comment I’ve seen on this site before which goes something like: “If we only performed interventions that are backed up by multiple RCT’s, we would be doing very little.”

  50. John Ware, PT says:

    Sean,
    I can explain my comments. TDN lacks a plausible theory.

    Can anyone explain to me why so many in our profession are willing to accept interventions that lack a logical, defensible premise?

    Jason Silvernail wrote the following piece about the importance of theory at this very blog nearly 6 years ago. I think it’s worth another read in the context of TDN. https://www.evidenceinmotion.com/about/blog/2008/05/ebp-deep-models/

    1. Andrew Sotirokos says:

      So just to be clear, when my patient has pain under his patella with squatting, and I can reproduce that pain exactly with palpation of an area of his quadricep muscle, I should talk to him about the theories of pain and how it is all in his head and he will get better? That sounds like what is being advocated on here. Or I can treat his quadricep with TDN and have him squat pain free immediately after, discuss with him how he developed his pain and teach him strategies to prevent it from recurring. I think I will take the latter thank you.

      1. So your patient’s comparable sign was “pain felt under the patella while squatting”, and you were able to reproduce this exact pain through palpating the quadriceps (palpating the quadriceps reproduces pain under the patella). You then stick a needle into the quadriceps, which then resulted in no pain, under the patella, during squatting? Am I correct with this analysis? I am not denying that this happened and I’m glad this patient had a great recovery. I simply want to understand why this approach was taken? Can we discuss potential plausible theories, based upon our best understanding of pain neurophysiology and tissue physiology, to determine why this might have happened?

        Let’s also consider the clinical approach. Did you set realistic expectations that sticking a needle into the quadriceps would result in less sub-patellar pain or do you quietly insert the needle? What is the patients belief’s about what this type of treatment? Does this patient believe this will help or harm them? Is the treatment area open or closed, to others (did he observe the treatment of others while you performed this?)

        1. Andrew Sotirokos says:

          Patients beliefs and our beliefs always play a role in the treatment we provide, regardless of whether it is TDN, HVLAT, pt education, or Graded Motor Imagery (yes I utilize a cognitive approach with my patients sometimes as well. NO TREATMENT works on everyone for every condition. That is where clinical reasoning comes into play. If you choose not to use TDN as part of your treatment, so be it. But don’t be condescending to those who do simply because you don’t understand it and it is different from the way you practice. If you want RCT’s, let me submit to you that there were NO RCT’s supporting HVLAT prior to the early 2000’s and clinicians still used it with great success in some patients. For me to deny using a treatment with superior effectiveness as part of a comprehensive PT program when my clinical experience (one of the 3 parts of EBM last time I checked) suggests it would be beneficial would be a disservice to my patient. That is what we are here to do, partner with our patients to help them achieve their goals, not stand on our high horses while denouncing anything we don’t agree with as not evidenced based and not useful.

          1. I had no intent of being condescending and apologize if my comment came across as sounding that way. I am not looking for RCTs, either (we have a pretty good suspicion that parachutes save lives when jumping out of planes, without any RCTs to support: (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC300808/?utm_source=dlvr.it&utm_medium=twitter ). I simply wanted to discuss the “why” behind it (other than “it works”). Taking into account all that we know, why do you suspect TDN is “a treatment with superior effectiveness”?

      2. sean says:

        Andrew, I think we either missed something he wrote/implied or he just left it out.

        In response to John’s question:
        Because they work. My job as a PT outside of treating patients is learning how to get higher quality outcomes in less time. I sent my PT to the class after a former co-worker (who is not some fad-chasing, Barnesian nutball) told me what great results she was getting doing TDN. I feel the refusal to provide, or at least attempting to learn how to provide such a technique would make me a bad PT and clinic director.

  51. Chris Baker says:

    Very good read. Enjoy this dialogue very much. For me coming out of the chiro background this is so much Déjà vu. I left a profession where I practiced manual (adjustments) since 1991, am certified in Acupuncture in State of Texas since 1991, utilize MFR, and was exposed to many ancillary treatment methods to put in my chest……and have always been driven to evidence based thus my transfer over to PT several years ago. My life centers around every patient getting hands on as I am an Outpatient Ortho doc (just to clear the air for those who may feel that I utilize manual for neuro patients to cure them LOL)……while many of these ancillary treatment choices were and are effective for their specific uses and diagnosis…I was of the belief way back then that those who were not efficient in manual tended to gravitate to these other methods. Ouch…I know I just stepped on some toes…..but…….while it is nice to have all these tools let’s not forget what our primary treatment choice is. And I go so far as to say that the primary treatment choice for each of us will be what we do best…..which I think is different for each of us.
    So let’s fill our chest with all of these tools that are proven and are known to work (from CPR to case study). For me… it is the manual. Best regards – Chris

  52. Evan Raftopoulos, PT says:

    Larry, thank you for posting this. The same/similar criticism can be applied to “manipulation” (“manipulation” is NOT physical therapy)I could be wrong, but it seems to me that the pendulum of manipulation has yet to swung back to some sense of balance. In this context, I don’t see how DN can do any better.

  53. Evan Raftopoulos, PT says:

    Sean says
    “My job as a PT outside of treating patients is learning how to get higher quality outcomes in less time. ”

    And how is inserting needles in patients achieves the above?

    1. L. Cauthen says:

      Well Evan, as a patient, I’ve had two back surgeries in the past five years. Nothing has worked to help with the pain until today. I have been on pain meds for the last five years, and I am fed up. I had pt before the surgeries and they didn’t help. Then I had the two surgeries, pain meds didn’t help. Had more pt , not helping. Then today I tried the needling. It has helped. It feels better to not have to practically crawl up stairs. It may not last, but i will take it while I can. When you can’t clean your house, grocery shop, do the things you used to do, It’s hard. I am speaking from a patient’s point of view, and isn’t it your jobs to help us feel better?

  54. John Ware, PT says:

    So I think Sean has confirmed my suspicion that PTs are willing to rely on empiricism over a plausible and defensible theory. I appreciate his honesty, but I’m somehow not encouraged by this frank admission.

    I am mystified, however, by the suggestion that failing to embrace a method that lacks a sensible explanatory model would make one a bad therapist.

    Chris’s suggestion on the other hand that we should just do whatever we feel most comfortable with because it’s what we do best is downright depressing.

    1. sean says:

      John Ware, you misrepresented my “admission.” As has already been stated, personal experience (empiricism) is part of EBP. But I do not exclusively practice only one part of EBP, as you admitted above. When I read a research article, on for instance thoracic manipulation for cervical patients, I’m not snobbishly looking for some deep theory that will allow my ego to incorporate it into my skill set. I’m looking at the effectiveness of the treatment. I’m looking at the responses to the study that may point out flaws in study design. etc. etc.
      Most of us did not become PTs to practice philosophy. We did it to help people and to make a decent living doing it.

      1. John Ware, PT says:

        So now it’s “snobbish” to ask for a cogent explanation for how our intervention work?

        You haven’t quite got the definition of empiricism correct. You’ve defined anecdote, which is just one low level of empirical evidence. RCTs can be just a high level of empirical evidence. When they are based on a plausible, science-based theory that describes mechanisms that are consistent with known physiology (acupuncture meridians fail here) and possess diagnostic criteria that are reliable and valid (trigger points fail here), then RCTs provide compelling evidence in favor of the intervention. Otherwise, all we’ve got in RCTs, as Dr. Harriet Hall explained, is “tooth fairy” science.

        I think I could argue much more convincingly that it is ego that drives those to embrace an intervention that lacks a defensible theory. This allows therapists to justify the contents of their “toolbox” based on its clinical effectiveness alone. In therapy, these tend to be the interventions that place the therapist in a position of authority over the patient, like manipulation and needling. These are the interventions that, as someone mentioned above, possess some “power”- the source of which is yet to be discerned. There therapist thus wields this power simply by virtue of possessing a license, but not necessarily by understanding how it works.

        I think as professionals we owe our patients more than that.

    2. Chris Baker says:

      John – don’t misrepresent me here. Has nothing to do with “whatever we feel comfortable with b/c its what we do best.” Somehow you missed the point about what the evidence supports. We all use tools that we are most comfortable with, tools of treatment that I have assumed on this blog we all have understand to be supported by these “plausible and defensible theories” to achieve best patient care in the clinic. My point above is that many clinicians criticize techniques that they have not mastered or learned, or are drawn to techniques that they have mastered, or are simply scared and intimidated with new change.

      1. John Ware, PT says:

        Chris,
        I haven’t mastered Reiki. Does that mean I’m not allowed to criticize it?

        I think your assumption that PTs are considering a defensible theory is unjustified, particularly in this conversation. I’m still waiting for someone to provide a plausible premise for sticking needles into patients.

        The evidence indicates that the insertion of the needle is no more effective than sham. Shouldn’t this give us pause before subjecting the patient to real albeit small risk of harm?

      2. Evan Raftopoulos,PT says:

        Chris you say ” My point above is that many clinicians criticize techniques that they have not mastered or learned,”

        And why is this a problem? Wouldn’t this reduce the cognitive bias from NOT spending time and money learning an intervention that nobody actually knows if and how it works? Look at Marino’s post below. IMO his view seems so distorted to the point that it has no basis in reality.

  55. Todd says:

    Larry,

    Great thread, a very interesting read to say the least. I would add that this thread helps to support the notion that Physical Therapy “as a profession” has a long, long way to go before we can truly be taken seriously. I may not be around to see it but hopefully that day will come.

  56. Wyatt says:

    My biggest concern regarding TDN is basically this: From the research I’ve come across, it appears that the underlying mechanism for pain relief from this treatment is essentially through patient and provider expectation – an “elaborate placebo” as Neil O’Connell would say. That being said, a patient has the right to informed consent, and it would be my responsibility as a provider to inform the patient that it appears the most likely mechanism for pain relief from this treatment is through placebo-type mechanisms. This is a matter of the ethics of a placebo. My personal opinion is that I would choose not to use a treatment that is based around a placebo mechanism. Other providers could use TDN, as long as they inform the patient that pain relief is most likely achieved placebo mechanisms, and the patient is agreeable (but you probably undermine your placebo effect to do this!). That being said, I have a feeling very few providers actually give this explanation. If my understanding of the mechnism is wrong, I’d love to see the science and evidence supporting it, and I might change my feelings about it.

  57. John Ware, PT says:

    Wyatt,
    I think the problem arises with the promotion of placebo when it exploits a patient’s erroneous or incomplete beliefs about why they hurt and what they need to recover. I think we should re-frame this debate in terms of maximizing internal locus of control. The literature is becoming increasingly clear on the role of self-confidence- or lack of it- in delayed recovery from a musculoskeletal injury. Anything that reduces the threat associated with movement is likely to produce a beneficial outcome for these patients. However, we should choose interventions that keep agency with the patient. Being invasive, I can’t see how needling conforms with this criterion. Also, the fact that the existence of trigger points- the supposed treatable “lesion” addressed with TDN- remains highly debatable should give additional pause to providing this intervention. For those who argue that de-activating trigger points isn’t necessary for a patient to benefit from TDN, then I ask again, what is the purpose of the needle?

    These are fundamental questions that those who needle need to answer, but they invariably resort to, “It works, so I’m gonna keep doing it.”

  58. Wyatt says:

    Well said, John. You brought up a very good point regarding hurting the patient’s internal locus of control. I also feel I spend a significant portion of my day doing my best to explain pain and address incomplete or erroneous beliefs about why they hurt. I believe our understanding of the science and literature in this regard is quite in agreement.

    Even if a patient notes a reduction from pain from needling in the short-term, it is possible that the patient’s belief that he or she needs to be “fixed” when in pain, coupled with a tissue-based biomedical understanding for why they are in pain, could potentially promote chronicity.

    This may make people look at me like a heretic, but a lot of these points we are making in regard to dry needling also could apply to manual therapy interventions.

  59. Evan Raftopoulos, PT says:

    Wyatt, you say” My personal opinion is that I would choose not to use a treatment that is based around a placebo mechanism”

    The problem here is that in the context of pt reported outcomes like pain relief and perceived pain resolution we cannot really separate placebo from other effects. This applies to all interventions.However, a treatment of higher biological plausibility is more likely to deliver other effects along with placebo (Eg. active approaches like exercise/movement).

  60. Mikal Solstad says:

    For those who use dry needling “because it works”, are you eager to learn cranio-sacral therapy? Some say that “just works”. How about healing? Reflexology?

    If our only criteria for acceptance of a treatment technique is empirical evidence, then we have a long way to go.
    Everything we do must have a defensible premise behind it.

  61. Glen says:

    This entry will be terse for sure.

    Quite literally, I am a little shocked at how the supporters of TDN have little more to offer than anecdote as a basis to validate this invasive treatment approach.

    The premise here is deeply flawed for those out there who wish to read the relevant literature. The notion that trigger points even exist is debatable at best and mythical at worst. The further exacerbate the problem…even if they did exist as a clinical entity, the plethora of readily available literature clearly suggests that we can simply NOT reliably locate them. And then to even further exacerbate the situation…even if we could, the available literature is inconclusive at best to determine if jabbing needles into them does anything beyond placebo. All this knowing that it’s a crap-shoot as to where the darn needle is going anyway.

    To Sean above who seems to believe that he would be a bad clinical director by not offering this continuing education to his staff. I think the opposite is true.

    This treatment paradigm lacks sufficient evidence. I’ve so far not read one single defendable theory (based on known and established biological and physiological principles). And worst of all…it’s invasive. Not to mention it removes locus of control.

    When on earth did our profession stoop to “it works” to form a rationale and basis by which to treat patients?

    There is a plethora of providers including Reiki masters, herbalists and homeopaths out there that use “it works” to defend what they do. Is this what we strive for as a profession? Are we not recruiting critical thinkers capable of a more structured and reasoned defense into our programs these days?

    Carl Sagan is known for the quote “extraordinary claims require extraordinary evidence” and this could not be more applicable when supposedly providing professional services to patients in pain.

    Plenty of things “work” for patients however what that patient walks away with in terms of understanding and locus of control is paramount. Many of the pseudoscientific treatments that “work” are short lived and serve no purpose in helping people deal with future painful episodes which will inevitably occur in their lives.

    This culture of “it works” we seem determined to align ourselves with alongside a boat load of other providers might well explain why we have an epidemic of persistent pain in the developed world.

    Are we often providing placebo short term and then subsequently blinded to the fact that we may have created a walking nocebo away from the clinic?

    State your premise, defend it and let the discussion unfold. If you want to provide care without a scientifically defendable start point and wish to lean on “it works”, perhaps it’s time to cash in that science degree you earned?

  62. Glen says:

    Just to add, I was not going to comment on Andrews comment above but I just felt I had to.

    This comment:

    “..but there is something of significant influence and power within TDN”.

    Made me cringe. I believe when I was younger I met with a local chiropractor that used an eerily similar phrase to describe the influence of adjusting for a subluxation.

    Honestly, we need to be careful here.

  63. Matt says:

    “We fight and defend for direct access, expanded scopes of practice, evidence as the core basis of our interventions, and being recognized in the healthcare chain as force multipliers within the musculoskeletal world…”

    Yes, we’ve bulked up the education (and educational debt for students), researched until blue in the face and, so righteously armed, have gone off to fight the good fight….

    But recent direct access victories read like Alabama’s:

    May perform physical therapy services without a prescription or referral under the following circumstances:
     To children with a diagnosed developmental disability pursuant to the patient’s plan of care.
     As part of a home health care agency pursuant to the patient’s plan of care.
     To a patient in a nursing home pursuant to the patient’s plan of care.
     Related to conditioning or to providing education or activities in a wellness setting for the purpose of injury prevention, reduction of stress, or promotion of fitness.
     To an individual for a previously diagnosed condition or conditions for which physical therapy services are appropriate after informing the health care provider rendering the diagnosis. The diagnosis shall have been made within the previous ninety days. The physical therapist shall provide the health care provider who rendered such diagnosis with a plan of care for physical therapy services within the first fifteen days of physical therapy intervention.”

    So disabled kids, home health, nursing homes, wellness… and 15 days if the patient has already been seen…in the last three months.

    Recognition as a health care MSK expert or force multiplier? Hardly.

    No, quite frankly, that’s pathetic. The only thing worse is that some count it a “fight” and a “victory”.

    Until direct access changes start reading like Arizona:

    “No Restrictions to Access
     A physical therapist shall refer a client to appropriate health care practitioners if the PT has reasonable cause to believe symptoms or conditions are present that require services beyond the scope of practice and if PT is contraindicated.”

    then there hasn’t been a direct access fight or victory worth talking about. And it still won’t be worth a second breath until the 3rd parties start reimbursing for direct access care.

    Fighting to expand scope? PTs in most of the world, whose entry-level education is well below ours, enjoy unfettered direct access, and some have achieved or are fighting for expanding scope into performing injections and prescribing oral medication for NMSK conditions, issues not even on the radar in our scope of practice fights (military aside). Meanwhile, outside of giving up existing scope for conditional direct access (looking at you Indiana), the only recent fights and victories do seem to be when “…state legislators in many states are hearing PT’s fight for the right to stick needles into patients.”

    So I’m not quite so fast to bemoan these DN legislative efforts.

    “The trouble is the neuromarketing image that many are getting right now suggests that physical therapists are defined by repeatedly sticking needles into patients regardless of diagnosis rather than “neck up” skills of clinical reasoning, examination, and strong interactional skills.”

    Per google I’m fairly sure the current, mainstream “neuromarketing” image still consists of combinations of polo shirts, khakis, smiles, beach balls and hamstring stretches. Honestly, indistinguishable from personal training.

    How does one market/image internal “neck up” skills in health care to the public? Lab coats and stethoscopes… taken (though it still shows up on PT magazine covers) and hackneyed anyway. A therapist sitting next to a pile of charts as she documents during a lunch hour… boring and too realistic. Maybe the image of a hands-on skill that isn’t a passive stretch (read: part of a middle school PE warm-up) isn’t such a bad way to go?

    “We have PT students seeking TDN clinical instructors and consumed with the technique at the expense of basis skill sets.”

    If at the expense of basic skill sets, yes that is a problem. However, basic skill sets should be acquired by the end of the 2nd year, so if a 3rd year student wanted to learn why not? They have payed substantially to be educated.

    “We see brash PT’s (ok arrogant PT’s) ignoring many pleas by physicians to NOT use TDN on their patients and yet the PT’s go on anyhow since they have an anchoring bias to TDN and an ignorance to referral sources demands and then we talk about a branding problem in PT!”

    I wonder… not to long ago when PTs deviated from the physician’s clearly written orders for Hot Pack, Massage, Ultrasound, E-Stim… did they get called brash and arrogant when they deviated from the script? Was pushing exercise and activity violating “do no harm” vs the feel good shake and bake?

    “I have been board certified ECS and did EMG’s for 20+ years and never saw PT’s wanting to adopt this technique to the degree that they want to adopt TDN for clinical use.”

    EMG a diagnostic procedure vs. DN a interventional procedure. The applicability as a treatment is likely why.

    “My hope is that the pendulum of TDN will swing back to some sense of balance and realize it is one of many and not THE intervention that PT’s can access.”

    I agree. It is often used too soon and too aggressively.

    Now onto the discussion…

    Manual interventions demonized. Let’s be blunt. While the hardcore biopsychosocial crowd pines for the eventual death of SMT, DN and all things manual, athletic trainers, personal trainers, kinesiotherapists, dance therapists, etc. encroach on exercise/movement interventions and massage therapists on all things soft tissue. And what does that leave us?

    Are they physical therapists? No.
    Do they have our exact skill set? No.
    Can they afford to offer their version of our services for a fraction of the price all day long? Hell. Yes.

    And if you, John Q Public, are paying out of pocket or looking at a massive deductible/co-pay who are you going to see? The bottom dollar wins.

    “But they don’t have our unique—” Doesn’t matter. Bottom dollar wins.

    I’m not advocating blind thoughtless practice, but cautioning folks to not, in their zeal, debate themselves out of NMSK practice.

    1. Larry says:

      Some excellent points and thanks for the thoughtful response. I agree on the googling images of PT and find find some even worse than you mention. Neuromarketing and past images though are 2 different constructs.

  64. Sean says:

    Just to reiterate, I did not attend the TDN course, and I am not personally practicing it. However, when every method my therapists and I employ fails a patient, I start looking for alternatives. That is my responsibility to my staff as well as my clientele. I had the opportunity of doing a clinical with a craniosacral PT and felt it was total BS. Later some studies showed it was. I felt vindicated that I wasn’t a horrific PT and just couldn’t feel something that was not there.
    Studies show there is definitely some benefit from acupuncture as well as sham acupuncture. Studies also show that cortisone injections for hamstring strains provided a significant benefit to the Cleveland Browns in the 80s. ESIs also seem to provide some benefit to some patients. There is a therapist I trust who told me she is getting results from dry needling. So I sent one of my most intelligent therapists with BS radar to a CE class. She came back saying it seemed legit. We have gotten some great results as well as non-response.
    Yes it is invasive. But what is more invasive, an anterior/posterior approach spinal fusion, or a couple of needles? I’m going to try everything reasonable to help a patient avoid the fusion.
    Since the FABQ came out, I’ve been searching for something that tells us what to do besides hand out “The back book” to people. I’m not sure how many years ago that came out but it didn’t do a damn thing to help my FAB patients. Now i’m hearing “locus of control”, a nice catchy phrase, but similarly, no actual way to achieve the goal of getting our patients better. Please post some links to CE courses accredited in the state of Texas for PTs to assist our patients in healing themselves.

  65. Nate says:

    I agree with your assertion we need to be careful here, Glen. I do think some of us are quick to throw TDN out as a reasonable intervention simply because it’s not well researched yet and compared strictly with Acupuncture. I don’t use TDN, but I have no problem with Andrew using the words ‘power’ to describe its effect. I think there is great power in what we do many times, and I believe the sensation from having significant pain relief from a noxious stimulus would likely be quite powerful. Subluxations have been disproven, and trigger-points have not. There is still a lot of work to be done in this area, so I think caution is an appropriate word to use here, but I am similarly concerned with those who are taking a seemingly ignorant stance on this subject. If you are not performing TDN on patients, and your knee-jerk reaction is it doesn’t work, that is ignorant and unfair. If TDN is producing positive outcomes, why would we not continue using it and researching it to enhance our clinical decision making skills to lessen the “nocebo” effect? Please explain this to me. All of us have had those tough patients where we simply can’t get them better. What if this can help some of those people? Some are better than none, wouldn’t you agree?

  66. Larry says:

    Regarding informed consent regarding transparency or plausibility of “placebo effect”. Interesting-perhaps a slippery slope as there many things we do in PT that likely influence such effect. However, there are studies that suggest that even telling patients that the effect is placebo doesn’t hinder its effect (even in sham acupuncture). If that is in fact the case, is their a role for sham TDN?

    1. Evan Raftopoulos, PT says:

      Larry, what is “sham TDN” by definition? One could argue that trigger point dry needling = sham intervention as it is based on a construct of poor validity and reliability. So why differentiate sham TDN from TDN?

      In addition, we should not need “sham TDN” to deliver placebo responses. The counter argument here is that “not all placebo is created equal” , but until we have evidence that suggests that needling generates more placebo than other interventions, then it is unwise IMO to assume that it actually does.

      1. Larry says:

        Good point!!

  67. Wyatt says:

    Larry, interesting and valid point. if I had to choose between TDN vs. sham TDN, I would vote sham TDN.

    However, in the real world, I choose none of the above. In agreement with Evan, if meaning and belief are what lead to pain relief, a skilled PT could generate that response without needing needles. High quality pain science education and exercise/movement, delivered by an empathic, passionate provider – without the need for needles.

  68. Eric says:

    Practice leads research. If you are a clinician, pick any intervention you use. Our profession has been using it BEFORE powerful definitive RCTs existed.

    I don’t necessarily agree about a paucity of evidence regarding dry needling. More and more has been trickling out. A simple pubmed search will show this. It’s just a matter of time before those big quality RCTs are here justifying what many have known all along.

    In addition to the Joint-Head, Disc-Head, Fascia-Head, etc, I’d like to add a few more labels to Jason Silvernail’s above linked post from a few years back:

    One is the Pain-Head. While the neuroscience of pain is filling a big void and really helping us connect the dots with many complicated / chronic pain patients, it is by no means a panacea. Yet, a number of self-righteous individuals seem to think so. Pain education, graded motor imagery, and mirror boxes certainly aren’t useful for every condition.

    Another is the Evidence-Head. If powerful RCTs don’t exist justifying an intervention to their satisfaction, it is useless, damaging, or potentially dooming our profession forever. No treatment is 100% effective, even if evidence suggests its benefits are statistically significant. You will be limiting your options, and missing the opportunity to help many patients.

    Eric

    1. Joe Brence says:

      You forgot “Plausibility-Head”. Those who attempt to determine the scientific plausibility of a proposed intervention, based upon the best available understanding of science and evidence.

      And “Logical-Fallacy Head”. Those who are unable to overcome an incorrect argument of logic. This may lead to reinforcement of their own confirmation biases.

  69. Glen says:

    Eric,

    Your commentary made no sense (sorry). Knowledge of how recent advances in pain physiology should guide practice is not a “treatment” approach.

    This is not new of course. It seems the Physical Therapy profession is churning out graduates who fail to understand the concept that prior plausibility should proceed a treatment. In particular when the proposed treatment is invasive.

    It’s why I discontinued utilizing manipulation…and I took the manipalooza in 2010. After near 20 years of practice…my results are at least equal now to what they where 8 years ago when I started to pay attention to the science behind what we do.

    The problem is, the emerging pain literature is expanding exponentially and leaving many behind…including those in charge of educating students. But guess what? As supposed professionals, it’s our job individually to keep ourselves up to date.

    Nate: Until recently…the subluxation was maintained as a real clinical entity by chiropractors and others. The evidence for the existence of a trigger point is approximately as robust as that.

    Those that believed in subluxations suggested they could specifically correct them. Until recently…specificity in manual therapy was believed (in italics if I could). Well…that ship has since sailed.

    Just as the questionable (?mythical) trigger point that those who defend it’s existence claim they can specifically isolate them and eradicate them with needles. Well guess what? They ability to be specific into supposed trigger points turns out to be false as well (Lucas et al I believe..without having my papers before me.).

    And what makes you think that because “it works” there must be some “power” within? I cannot get over how absurd that sounds in total.

    Thousands upon thousands of people swear by the relief they get from having their subluxations corrected. I suspect the relief obtained by TDN is absolutely no different.

    The parralles between the subluxation and it’s “correction” and trigger points and the ability to treat them by jabbing needles into them is alarming.

    I just do not see how a good clinical reasoning process at this point in time, would include TDN.

    I haven’t even touched on perhaps the most glaring problem with TDN (locus of control).

  70. John Ware, PT says:

    Joe,
    I was more specifically thinking “Straw Man-Head” when I read Eric’s post. But mostly I’m with Glen- I find Eric’s comment generally inscrutable. But what do I know, I’m just a self-righteous “Pain-Head” who does mirror therapy on every patient who walks in the clinic door with a primary complaint of pain. And I apparently do that even though I only use interventions that are 100% proven effective by RCTs. Hmmn, that doesn’t quite add up, does it?

    Here’s what a couple of “Pain-Heads” had to say fairly recently about the evidence for dry needling: http://theconversation.com/acupuncture-research-the-path-least-scientific-10273

  71. Marino Moutafis says:

    As a trained, licensed and certified acupuncturist in Michigan, I am insulted in the movement of “dry needling” in the field of physical therapy.

    First off, I would like introduce myself. I come from a mechanical and scientific background. My undergrad is in engineering. I worked in healthcare as project manager in IT, Risk and Quality Management for over 5 years (Oregon Health Sciences University).

    Since I finished my 4 YEAR Master’s Program in Oriental Medicine, I worked in a hospital group in Nan Jing, China and have practiced this medicine in research and hospital settings (Henry Ford Health Systems of Detroit).

    Acupuncture is a wonderful medical technique, that even after 4 years of study and 8 years of professional practice, I am constantly learning new skills related to this technique.

    This a a very difficult technique to master. Most professionals in my field state it takes a good 4-5 years to truly be comfortable in profession.

    First off, let me call it what this is: A C U P U N C T U R E.

    It is the insertion of an acupuncture needle (that is what they are called, that is what manufacturers make, that is what I have heard PT practitioners refer to them) into specific connective tissue area (which have been called acupuncture points in both medical text books and research prior to the development of “dry needling”) is acupuncture. Changing the name of the technique is misleading to the patient and to the general public.

    Granted, Oriental medicine is the application of certain theories based on observations and historical applications. It can be utilized to treat pain, neurological, digestive, reproductive and other medical conditions. It seems that PT’s are trying to use acupuncture for only pain relief/repair muscle function. It is this reductionistic approach that can threaten the safety of an patient getting acupuncture from a non-licensed health professional.

    Old traditional way of explaining the mechanisms of acupuncture used terms of “energy’ or “qi”. These terms are out of date and do not represent the scientific research that have been able to explain some of the biomechanical mechanisms of acupuncture in the past 15 years. I can exhaust this comment section with viable research. Here is a brief start.

    http://yinyangpodcast.blogspot.com/2014/03/the-science-behind-acupuncture.html

    The intent of some one who would like to “add a tool to there tool box” is admirable. But one must truly understand the risks involved when stepping into something without the proper training. I do not see this with the utilization of “dry needle techniques”

    Physical therapists that utilized acupuncture, in the guise of “dry needling”, is a specific trigger point or Sport medical acupuncture techniques. This style is prevalent in Tradition Chinese Medicine (a specific style of acupuncture that is taught in the majority of acupuncture school in the USA and Europe).

    Trigger point release techniques have been utilized for many years in Traditional Oriental medical acupuncture. It is a branch of acupuncture styles. This is ask the most dangerous style of acupuncture. The risk of bleeding, bruising, pneumothorax, and nerve damage increase significantly with this style WITH A LICENSED PRACTITIONER. What does one expect with a individual that takes less than 100 hours of clinically supervised training.

    Trigger point therapy is also utilized by massage therapist, DC and PTs. The difference between acupuncture an trigger point therapy is the NEEDLE.

    Trying to pass off this as anything more than acupuncture is misleading to patients and the general public.

    Little training, with poorly educated instructors, and no national or state licensing body to regulate any educational standards speaks poorly for those who try to push this techniques as anything other than acupuncture.

    We can all understand why some individuals want to expand their knowledge of medicine. But we should “know our roles” and “stay in our lanes”.

    We, as a group, should instead reach out to one another for help. Seeking skilled licensed practitioners in our area to refer our difficult case.

    Let’s work together to help those in need.

    Feel free to contact me with an question or concerns.

    1. Marino Moutafis says:

      Evan,

      That is not the easiest question to answer in a short forum.

      1. I use a blend of physics, physiology and meridian theories. First I look at structure and try to determine of the pain/dysfunction area is either the cause or effect (root vs. branch). I then overlap the meridian theory pathways (which are connective tissue/fasceal plains). From there, I feel the patients radial pulse (Japanese diagnostic technique-similarly found in most traditional medical techniques), from there I palpate the acupuncture points, and if the pulse pattern changes (see hard to explain in a short form) I will use that point as part of the protocol.

      I use a holistic structural model (again, former engineer), and really focus on relationships from the cervical curvature, thoracic and lumbar arch. For example, patient come to me with elbow pain, I rarely treat the elbow directly. I look that the neck, shoulder joint and wrist first. From there, dependent on the immediate result of the my initial point protocols, I will determine if I needle the elbow tissue at all. It complex to explain, but I use a variety of acupuncture techniques based on Japanese, Taiwanese and Chinese traditions.

      2. Evidence, there is a ton out there. Is it perfect research, no. Does it give us a clue on why/how these techniques work. Yes. Is it perfect in a nice neat package, no. This is an exciting time to work in this field, because we don’t have to explain things in terms of “energy” and “Qi”. Modern research techniques and protocols are evolving to help explain this technique.

      For example, http://jco.ascopubs.org/content/28/4/634.short. I worked on the back end of this study after its completion out of Henry Ford Health Systems. This study shows the effects of acupuncture vs. drug therapy. In my opinion, this study was flawed because it is “cookie cutter”. I never use the same points over and over again for 12 visits. Each therapy should be individualistic. Some patients did not exhibit the same symptoms (intensity/frequency/areas) but where given points that where not needed. Clinically, any good practitioner tailors the care protocols per individual needs.

      This is a wonderful medicine. I immensely enjoy my practice. There is a depth to this medicine that I am only scrapping the top of. I was lucky to have had trained with some of the best practitioners in the USA/China.

      I am able to help 85-90% of my patients that walk through my doors. But my success rates do not prove how this medicine works.

      It is an exciting time to be in this field.

      That being said, the musculotendonal pathways/fasceal plains, are unique and require over 1000 hours of practical supervised practice to do needle correctly. If not, one can cause harm to a patient.

      There are document case of acupuncturist doing harm to patients. Like all fields, there are individual that are not as dedicated or well-train. One apple should not ruin the bunch.

      I believe that a PT, MD, DO, DC or other highly educated practitioners can learn to do acupuncture correctly. The problem is it take time, proper training and technique. This cannot happen in 100-200 hour course.

      Thank you for your response. I hope to add more, but I started this reply @9am and just finishing it [email protected]

      There is research behind this practice, there is evidence of its effectiveness. Science and medicine will show the true effects of this modality in time. I am excited to share this medicine with my community.

      Be well

      Marino

  72. Evan Raftopoulos, PT says:

    Marino thank you for your post.

    1. As an acupuncturist, what construct do you use for deciding where to insert the needle if not the pseudoscientific meridian theory?

    2. show us the evidence that demonstrate the validity and reliability of your construct of choice

    For the record, at this point in time I agree with you that PTs should stop needling pain patients but for different reasons.

  73. Glen says:

    Evan,

    Well stated. Except I would change your last sentance to:

    ” At this point, I would agree with you that PT’s and all providers should stop needling patients…unless you can answer the above inquires”.

    To date, not one needler has been able to adequately provide a plausible mechanism. I don’t suspect Marino will be the saviour either.

    1. Evan Raftopoulos says:

      Glen, I don’t expect from Marino to come back. It shouldn’t take days to answer two very basic questions, should it?

      People will continue pursuing needling for their pleasure and their own motives and I’m OK with that, that’s not my business. What is my business is providing a critical analysis of any intervention that my profession (and medicine in general) chooses to embrace for the treatment of painful msk manifested conditions. Also, I’m asking from people who use needles to stop making unsubstantiated claims and be honest with their clients and colleagues. As Doctor Skeptic wrote recently here http://doctorskeptic.blogspot.com/2014/02/the-hope-peddlers.html ,”Doctors should be fact peddlers, not hope peddlers. “.

      1. Marino Moutafis says:

        Evan,

        That is not the easiest question to answer in a short forum.

        1. I use a blend of physics, physiology and meridian theories. First I look at structure and try to determine of the pain/dysfunction area is either the cause or effect (root vs. branch). I then overlap the meridian theory pathways (which are connective tissue/fasceal plains). From there, I feel the patients radial pulse (Japanese diagnostic technique-similarly found in most traditional medical techniques), from there I palpate the acupuncture points, and if the pulse pattern changes (see hard to explain in a short form) I will use that point as part of the protocol.

        I use a holistic structural model (again, former engineer), and really focus on relationships from the cervical curvature, thoracic and lumbar arch. For example, patient come to me with elbow pain, I rarely treat the elbow directly. I look that the neck, shoulder joint and wrist first. From there, dependent on the immediate result of the my initial point protocols, I will determine if I needle the elbow tissue at all. It complex to explain, but I use a variety of acupuncture techniques based on Japanese, Taiwanese and Chinese traditions.

        2. Evidence, there is a ton out there. Is it perfect research, no. Does it give us a clue on why/how these techniques work. Yes. Is it perfect in a nice neat package, no. This is an exciting time to work in this field, because we don’t have to explain things in terms of “energy” and “Qi”. Modern research techniques and protocols are evolving to help explain this technique.

        For example, http://jco.ascopubs.org/content/28/4/634.short. I worked on the back end of this study after its completion out of Henry Ford Health Systems. This study shows the effects of acupuncture vs. drug therapy. In my opinion, this study was flawed because it is “cookie cutter”. I never use the same points over and over again for 12 visits. Each therapy should be individualistic. Some patients did not exhibit the same symptoms (intensity/frequency/areas) but where given points that where not needed. Clinically, any good practitioner tailors the care protocols per individual needs.

        This is a wonderful medicine. I immensely enjoy my practice. There is a depth to this medicine that I am only scrapping the top of. I was lucky to have had trained with some of the best practitioners in the USA/China.

        I am able to help 85-90% of my patients that walk through my doors. But my success rates do not prove how this medicine works.

        It is an exciting time to be in this field.

        That being said, the musculotendonal pathways/fasceal plains, are unique and require over 1000 hours of practical supervised practice to do needle correctly. If not, one can cause harm to a patient.

        There are document case of acupuncturist doing harm to patients. Like all fields, there are individual that are not as dedicated or well-train. One apple should not ruin the bunch.

        I believe that a PT, MD, DO, DC or other highly educated practitioners can learn to do acupuncture correctly. The problem is it take time, proper training and technique. This cannot happen in 100-200 hour course.

        Thank you for your response. I hope to add more, but I started this reply @9am and just finishing it [email protected]

        There is research behind this practice, there is evidence of its effectiveness. Science and medicine will show the true effects of this modality in time. I am excited to share this medicine with my community.

        Be well

        Marino

  74. Marino Moutafis says:

    Sorry for the long delay. I am not in the office on Wed, and I am so busy during my workday to replay.

    I did get a chance to replay back in the previous post.

    You can always contact me via email for a honest and educated response if you have any questions.

    [email protected]

    Be well

    1. Evan Raftopoulos says:

      Marino, thank you for your response.

      about #1

      you say “I use a blend of physics, physiology and meridian theories.”

      It sounds like you created your own construct which is a blend of “science” and pseudoscience. Unfortunately for your ideas, in science you can’t have it both ways. You cannot use science when it seems convenient and reject it when it doesn’t support your ideas.

      “holistic structural model” does not mean anything. If it’s a model, what is its prediction? Is it testable? where is the evidence?

      you say “It complex to explain, but I use a variety of acupuncture techniques based on Japanese, Taiwanese and Chinese traditions.”

      that’s pretty much NOT science.

      about #2
      you say “Evidence, there is a ton out there.”

      Where? I asked for references indicating validity and reliability of your construct of choice. The only study that you referenced is about reducing vasomotor symptoms in menopausal women. I don’t see any relevance.

      you say “Does it give us a clue on why/how these techniques work. Yes”

      Not really. It’s a mistake to accept speculations as conclusions.This is a common mistake in medicine.

      you say “That being said, the musculotendonal pathways/fasceal plains, are unique and require over 1000 hours of practical supervised practice to do needle correctly.”

      I must disagree. Show us the evidence that indicates that these pathways exist, evidence that demonstrates relevance to the patient’s pain experience, and evidence that examines interrater palpation reliability.

      you say “There is research behind this practice, there is evidence of its effectiveness. ”

      Only if we cherry pick research studies. There is also evidence of its non effectiveness.

      Thank you for your time here.

      Evan

      1. Marino Moutafis says:

        The physics I spoke about are in regards the to physics I learned in college: Vector, friction coefficients, lever and pulley systems…you know physics…Holistic means “whole system”, so again, if a patient comes in with plantar pain do you just look at the foot. The majority of my plantar patients get better results when we treat the lumbar curve and hip structure.

        Also, in terns of pseudoscience…It sounds to me that you haven’t had time to do research on the field. Check out that first link I posted, that is just a start. I really wish I had the time and the energy to go point-counter point with you Evan, but I don’t. I started this email at 9am again (and its 11am now)

        I do want to help open your eyes an experience this medicine. It flat out works. In ways that even surprise me.

        I was exposed to natural health (meditation and herbs) from my MD’s in dealing with my pediatric migraine patterns.

        I never tried acupuncture for my pain, I only look toward it as a career well after I learned to manage my condition.

        I had no reason to go in this field other than my desire to understand life. My choice to select Oriental Medicine vs. MD/DO/PhD was from the direction of my MD, professors and family.

        Take if from a Greek kid from the suburbs of Detroit. I have no reason to B.S. anyone.

      2. Chris Curley says:

        Evan, if your line of interrogation is indeed searching for truth and not merely holding ones feet to the coals, then the book I would recommend you read for “scientific” answers to your questions is The Tao of Chinese Medicine by Deke Kendall

        1. Jayse Brock says:

          Excellent post! Lots of comments and great insights will help PT programs for sure.

  75. Glen says:

    I will read the article you provided and get back to you. In the meantime…I would live your comments on this:

    http://theconversation.com/acupuncture-research-the-path-least-scientific-10273

    1. Marino Moutafis says:

      quick response, I have seen this. Again, placebo acupuncture is not easy to pull off.

      Needling “non acu points” is a matter of perspective. Taiwanese, Korean, Japanese styles have over 400 more additional points than Chinese. Some non-ac-points are really acu-points, but not in some traditions.

      I will try to follow up more in the future. If you have more questions you can email me [email protected] or call my office 248-432-2846

      be well

      1. Chris Curley says:

        Yes, the concept of Points was invented at a later date then the first acupuncture model. Many of the first models were aimed at “reflex zones” and within those zones points of tenderness were used. However the needles were inserted often far away from the areas of pain. As in….points on the scapular fossa can treat lower coccygeal pain, as an example. There are no such thing as definite “points” merely areas of correspondence, influence, and reflex.

  76. Marino Moutafis says:

    I hope you guys/gals get a chance to look at the first link I posted.

    Listed below are a significant amount of good research about acupuncture.

    It is my belief that science will be able to explain all the mechanisms involved with acupuncture.

    My points in earlier post were to show that it isn’t explained scientifically currently. Having clues is a start. I don’t have the time or $ to do the research, but there are groups of highly educated people that are dedicating their careers to this. I am lucky enough to “ride the wave of research” with them as a practitioner.

    I think that all physicians should be open to understanding all aspects of health care. Medicine changes with the times. Research (both drug therapy, lifestyle, diet and nutrition) can be bias. We can all think of a “hot new drug” that gets pushed into a market due to great research that gets pulled because it can cause more damage than good. Unfortunately, these finds are seen years down the line, and at the cost of the patient health and wellbeing.

    The difficult thing to explain with acupuncture and Oriental medicine is why it works. How does a #46 wire inserted into an area on the wrist open the sinus passages? How does massaging a area on your ankle resolve reproductive related cramps?

    My last question to the group: what work better and why: Ice or Heat on area of injury? Why?

  77. Marino Moutafis says:

    Last point: safety of acupuncture.

    How many complaints are sent in per year, per state for this practice of acupuncture?

    Can anyone guess my malpractice insurance per year cost ($1mill/$3mill coverage)?

  78. John Ware, PT says:

    “My last question to the group: what work better and why: Ice or Heat on area of injury? Why?”

    Whichever one produces a sensation that reduces the perceived threat associated with the particular region of the body that hurts. Why? Because pain is a multidimensional output of the patient’s neuromatrix. Try applying a cold pack to a patient’s sore, swollen knee while the patient sits shivering under an air conditioning vent with cold air blowing. Do you think that cold pack is more or less likely to increase the patient’s pain?

    It’s the same kind of thing with your needles: you’ve learned how to engage in an elaborate ritual that meets the patient’s expectations while sounding very confident and assured that your intervention is effective. However, the evidence from the systematic reviews and meta-analyses on acupuncture compellingly show that real acupuncture is not meaningfully more beneficial than sham.

    The jury is out. Not one more dime should be spent on acupuncture research. At least not my dime.

    1. Chris Curley says:

      John come on, easy on the tone my friend. You are inferring that acupuncture is nothing more than placebo based Voodoo? Then tell me friend why are P.T.s signing up in droves for voodoo lessons?

  79. Marino Moutafis says:

    To answer the ice question, I find that ice (cold) slows down the healing process. It is in my experience that heat expands, cold contacts. My education show me that pain is a stagnation of blood, lymphatics and other tissue. Cooling it may numb the sensation, but never “takes away the pain”.

    I prefer heat for most injuries, and the PTs whom I share patients with agree. However, many of their peers disagree. I work with many professional athletes in the area. I work closely with their trainers and we agree that R I C E is an outdated practice. Heat, movement and normal activity works best in my experience. I believe an study came out in 2013 showing cold does not work as well as heat.

    FYI, you can look into TDP heat lamps, they really work great for indirect heat on areas of pain or swelling. Billable under heat therapy.

    I was hoping for a better exchange of information within this forum. It doesn’t seem that anyone who has responded to me has view any of the over 40 cited research studies list in my first link. Listed below is the link for the Society for Acupuncture Research. I encourage you all to take some time to look through the site.

    http://www.acupunctureresearch.org

    As a practitioner, my efforts are to be an honesty resource for my patients. The first thing I tell patients is that we don’t know exactly how acupuncture work, the scientific community is figuring it out, this is what we know now, things can change as the research come forward with some new answers.

    Research is a tool, not always perfect, but a tool none the less.

    I’m not here to prove to your group the medicine works, I am a practitioner not a researcher. I wanted to share an opinion from the acupuncture perspective on training and protecting the general public.

    Again, I was hoping to share information, and you can make up your own minds. I respect this type of forum, but I don’t feel that one can write off this “pseudoscience”.

    Blanket statements of my “rituals” are close minded. If my “rituals” have that kind of power, than why do I even work on a daily basis. Is there a “Secret” on tricking patients to believe the pain went away, or their chemo induced nausea just got better. Is this because I have a better bed-side manner than an MD or nurse practitioner?

    Are they mesmerized with my terminology and philosophy of wholeness? Is my aura so great, that just being around me makes people feel better? How did you know that I just line people up in a row, and I start to speak in tongues and people remarkable stand up from their wheel chairs and walk out the office?

    Please, respect my perspective as I have yours.

    My next question is has anyone shadowed an acupuncturist or received any acupuncture therapy? If so how were the results. Again, I’m not here to B.S., not all professional are created equal. But someone must have an experience that can share.

    Again, I carry the upmost respect for the PT/OT professions. One of my best friends is a PT. We work closely together to help our individual patients. The majority of our shared patients do find better result when the therapies are combined.

    This will be my last response. I wish you and your patients well.

  80. Evan Raftopoulos says:

    Marino, thank you for sharing your stories and anecdotes. Anecdote =/ data. Also, pseudoscience has to do with claims and constructs founded on wishful thinking vs. facts. Please don’t tell me the meridian theory is scientific. I recommend looking up post hoc error , confirmation bias, cognitive dissonance, and what is science. Take care.

    Evan

    1. Marino Moutafis says:

      I have to add a few last things:

      When I got to my voicemail box this morning. I received 4 different messages from PT’s who have been following this thread. They ALL expressed their support of acupuncturist doing acupuncture.

      All 4 individuals also stated the reason they did not respond in this thread is that certain individuals “cough cough” make it difficult to share openly. I understand, we have the same type of trolls on some acupuncture forums.

      I want to thank you all for the forum, you are all true physicians.

      Have a great spring all,

      MnM

    2. Chris Curley says:

      The term “meridian” was invented by a frenchman in the 1800’s. The Chinese medicine doctrine was based on VESSELS . Blood Vessels. The pricking of the skin with needles stimulates a neuro-vascular response which restores proper blood circulation to the affected area, organ, or tissue and voila you have the healing response. Meridian is an outdated, “energetic medicine” term that has no valid scientific proof and no corroboration in the foundations of Chinese Medicine. It is a misnomer and will hopefully go the way of the dodo. Bird.

      I am an acupuncturist.

  81. Mikal Solstad says:

    Trolls? All that is being asked is that you operate within a defensible premise. You don’t, hence this discussion.

    1. Marino Moutafis says:

      Defensible premise: I didn’t find that anyone even discussed one study that I shared.

      Again, when you look at the first link I attached, there are over 40 studies listed. Go over those and come back to me with something other than using passive-agressive terms.

      I can sit here everyday an study after study, but like I stated I don’t have the time and YOU HAVE THE RESOURCES IN FRONT OF YOU.

      much love all

  82. Mike Kohm PT says:

    Having read Larry Benz article a second time, his “article” is a biased opinion devoid of apparent experience with the technique of TDN. This article with a true lack of investigation is representative of EIM’s tired, argumentative, dare I say paleolithic stance. The comments of I have no experience with this technique, but will comment anyway are comical to say the least. The comments are the equivalent of Johnny “try the broccoli”, “I dont like broccoli”, “Did you try it”, “No”, but will say, “I dont like it anyway”. The old “dont argue with fools, they will drag you down to their level” comes to mind.

    re Larry benz “failure of clinical reasoning” TDN requires a practitioner to tie together special tests, systems such as neural pathways, joint mechanics, musculoskeletal dysfunction are all incorporated. Connective tissue restrictions are considered and incorporated. Movement screens such as the FMS, and SFMA screens are also integrated into clinical reasoning prior to needling.

    Mr. Benz, maybe the reason that TDN is popular as of now, is that for the right patient, it works. Slamming your own profession or another’s profession if you are not a PT is not really the way to generate a dialogue.

    1. Larry says:

      Wow Mike, impressive response. Great ad hominem response-how about trying to defend your position with evidence and clinical reasoning?

      1. Mike Kohm PT says:

        Larry,

        Apologies thought that this did outline clinical reasoning.

        TDN requires a practitioner to tie together special tests, systems such as neural pathways, joint mechanics, musculoskeletal dysfunction are all incorporated. Connective tissue restrictions are considered and incorporated. Movement screens such as the FMS, and SFMA screens are also integrated into clinical reasoning prior to needling.

        Are you familiar with the Canadian physician Chann Gunn’s work? How about Janet Travell MD and David Simons MD? Chris Centeno MD? Years of treatment and research of trigger point work. What about Jan Dommerholt. Here is an informative article he wrote on TDN.

        http://www.bethesdaphysiocare.com/professionals/pdf/qi-unity_dryneedlingissue08.pdf

        There are references of evidence based practice at the end.

        Re research, here is a new book by Jan Dommerholt and Cesar Fernandez de las Penas re clinical evidence and TDN, IMS etc.

        http://www.us.elsevierhealth.com/product.jsp?isbn=9780702054525&sgCountry=US&isbn=9780702054525

        Maybe you should read your own website re what your company is teaching. You should be able to find the evidence based practice you need there. Thought the name of your company was “Evidence in Motion” If you can not provide your own evidence then why is your own company teaching the course?, a bit hypocriticial is it not?

        here is the link in case you need it. Maybe you should take the course.

        https://www.evidenceinmotion.com/educational-offerings/course/integratedtriggerpointdryneedlingforthelowerquarter-level1-3-day/

        I looked on your website and do you practice TDN? It does not appear to be listed. Are you speaking out of practical experience or theorectical pretense?

        As far as “ad hominem” response “based in emotion”, your article did nothing less then throw stones at some very qualified practitioners. Including your own staff!

        Lastly your clinic appears to do great community service, not sure why you chose to argue so vehemently against a service that has clinical benefit to a vast number of patients in your own profession.

        Sincerely,

        Mike Kohm PT

        1. Larry says:

          Mike,

          the original blog post and my contention is not on the use of TDN per se or for that matter its evidence (I standby my contention that there is a paucity of evidence right now on TDN). My issue is really more the irrational exuberance of its use (perhaps overuse?) and how ironic that many are (and continue to be) marketing it like it is a huge marketplace differential. I really believe that TDN is not #physicaltherapy (nor is any specific intervention ) which was the main driver and motivation of the blog post-certainly comments go in other directions and many have been helpful-including yours. I don’t believe that the post “threw stones” at any practitioners unless of course they are sacrificing clinical reasoning or decision making for the expressed purposes of using TDN because it is new and different-and even then I consider it more of a challenge than a denigration.

          1. Mike Kohm PT says:

            Thank you for your reply. I do agree that people should not jeopardize their clinical reasoning skills with any intervention/treatment. One of the basis for neuro marketing is influenced by Dr. Gunn’s work. I have previously stated my other opinions and given your reply were read with respect.

            I do think pracitioners are excited, because they see their patients improve when incorporating TDN into their skill set. Your point is valid re as any new technique being potentially over utilized.

            How many lateral releases have we seen that made a patients knee worse?

            The research is small as a result of TDN being a relatively new technique in PT. I think back to the days of “manual therapy” and “neural dynamics” and those techniques were challenged and improved upon.

            My hope is the same for TDN

            And yes even remember the days of the Cybex and “isokinetic” training being all the rage!

            Sincerely,

            Mike Kohm PT

    2. Evan Raftopoulos, PT says:

      Mike, you only succeeded in creating a straw man argument, the comments here are not equivalent to the nonsense broccoli example. I’m interested in hearing from you how is a needle addressing “neural pathways, joint mechanics, musculoskeletal dysfunction are all incorporated. Connective tissue restrictions are considered and incorporated”

      You say “the reason that TDN is popular as of now, is that for the right patient, it works.”

      Change that to “ the reason that TDN is popular, is that for the right patient, it SEEMS to work” It seems to work does not necessarily mean that it actually works.

      1. Mike Kohm PT says:

        Evan,

        As far as the broccoli example, do you practice TDN?, If not then what makes you qualified to imply it is a placebo? If you do practice TDN then why is it a placebo? If you want to have a rational discussion, then maybe you can bring practical clinical experience as to why TDN does not work?

        I apologize in advance but are you speaking out of practical clinical experience or theorectical pretense?

        I do agree with Mr, Benz in that we should not “throw out all our clinical reasoning skills and go straight to TDN” Honestly that is not how I was taught nor is it how I treat.

        Clinically speaking why do patients, come back and thank me for helping them with pain? Then they go on to write testimonials based in part, on TDN helping to restore their function. I have had patients come in with a laterally shifted pelvis and when TDN is performed on the multifidi and erector spinae, and the shift is significantly better at the end of the session?

        Maybe you could read some of Dr. Chann Gunns work on his “radiculopathy model”? Dr. Gunn has been teaching IMS for quite a while in Canada.

        here is his research link

        http://www.istop.org/research.html

        Here is Kinetacore’s research link.

        http://www.kinetacore.com/physical-therapy/Trying-to-keep-you-up-to-date-with-the-most-recent-research-for-Functional-Dry-Needling/page200.html

        Not sure why PTs are against a newer technique that is state board approved?

        I agree more research needs to be done, and is being done presently.

        One thing to ponder is ultrasound still performed in your clinic? Lots of pro/con research on that modality.

        Sincerely,

        Mike Kohm PT

  83. Evan Mahoney says:

    Acupuncturist have been practicing a form of dry needle for 2,000 years. in Chapter 9 of Linggu Shu (Miraculous Pivot), Trigger points were defined as “Ashi” points. The patient says “ah” when the point is palpated. Trigger points are identified by pain upon palpation. In the same book they identified muscle knots, muscle shortening, loss of range of motion identified with “ahshi points”. They also identified exposure to cold as a triggering event of what we call today “trigger point” pathology. I respect Dr. Travell, even she identified trigger points as using acupuncture points. It must be understood that PT’s practicing dry needle, are actually practicing acupuncture.

  84. Wade says:

    PT’s are just glamorized Chiropractors.

    1. Marino Moutafis says:

      Not true, PT work is extremely important.

      A well rounded and compassionate practitioner can change someone’s life.

      Please do use this forum for mud slinging.

  85. Mikal Solstad says:

    “My education show me that pain is a stagnation of blood, lymphatics and other tissue.”

    I don’t think much else needs to be said. Your education is wrong. Educate yourself, for both you ownr and your patients sake.

    1. Marino Moutafis says:

      Please keep your insults to yourself, or just call my office.

      1. Marino Moutafis says:

        I can also assume that my education is far beyond yours with the tone of your response.

  86. Mikal Solstad says:

    I have not insulted you, I have insulted your education, which apparently doesn’t include up-to-date knowledge of neuroscience.

    The fact that you think that your education = you, tells me a lot.

    You could have a ten-year degree and still be misinformed. I’m hoping that you will seek out the necessary information that should be required knowledge for someone dealing with patients whose primary complaint is pain.

    1. Marino Moutafis says:

      Agreed, a 10 year degree can lead to a lot of misinformation.

      The point of my involvement in this topic is express my opinion that PT’s should not be licensed to do acupuncture with limited training. Your argument is the trigger point acupuncture doesn’t work. So that is great, that means you won’t be trying to acupuncture on your patients. Wonderful.

      I have yet to hear from ANYONE debating the research links I provided previously. Read of a few of those, do yourself and your education a favor.

      I am not a neuroscientist. Nor have I claimed that. I would say that I have average knowledge of neuroscience compared to some in healthcare. Not even close to my area of expertise. My view of pain and pain management however is advanced. I shared a brief and basic explanation of pain/inflammation. You attacked it because it was short, concise and not expansive enough.

      I don’t think I have confronted your ideals or insulted your education. But you seem fit to TRY to attack mine.

      In the 3rd grade they call that being a bullying.

      I guess where you went to school they call it being well-mannered.

  87. Evan Raftopoulos, PT says:

    Marino, I have not personally argued that positive trials of acupuncture do not exist, but show me one RCT that indicates that “needling” using your construct of choice has contributed to significantly improved outcomes compared to “sham acupuncture” i.e. just inserting needles wherever in the region perceived as painful and acting confident that the points are very specific. The outcome of interest is “pain resolution” for MSK manifested painful conditions. I look forward to your study.

    In addition, any studies suggesting positive outcomes following needling do NOT validate the pseudo-scientific constructs presented here. IMO and my interpretation of the literature, the ritual of needling in a therapy context has the capacity to work as a form of temporary relief, however 1. nobody knows why (speculations=/conclusions), 2. it only offers temporary relief which does not seem to be superior to any other forms of temporary relief. 3. we do not know if it does much beyond placebo (or % contribution of placebo). 4. it doesn’t matter where you insert the needle as long as you assign meaning to what your doing and verbalize it to the patient.

  88. Mike Kohm PT says:

    With all due respect, just as acupuncture has a “lineage of teachings” as does TDN/IMS. Travell and Simons, then Gunn, Dommerholt, Christopher Centeno MD in Colorado and numerous others have contributed to the body of work that encompasses TDN.

    Mr. Benz has a great point in that we should not throw out clinical reasoning skills and needle straight away. The training I have received is actually that.

    Re acupunture, I firmly believe in acupuncture as a profession and a treatment. I have seen great results personally and professionally.

    This is not a new “discussion”. Yes, TDN is in its relative beginning as a clinical practice in the United States. There is research being done presently. Clinically patients do receive a benefit. Having received both acupuncture and TDN it is my experience that the practices share an acupuncture needle, yet they are different in their application. just my opinion.

    Maybe when the “turf wars” are over, PTs and acupuncturists will collaborate and foster a better understanding and application of each respective practice. The benefit will be to the patient, that is why most of us joined our respective professions, to help patients is it not?

    1. Marino Moutafis says:

      Mike, I respect your perspective and reasoning.

      I really think that needling acupuncture points is a very complicated technique to master. It is not that I don’t think PT’s couldn’t master the techniques. I think the hours and dedication to the technique take time and the correct teachers. Again, graduates from the same school can very in skill and technique. I suggest taking the standards of NCCAOM (national commission/board) and/or California (separate harder board exams, PCP).

      I just don’t understand why PT’s can/would want to penetrate the skin. Looking at the scope of practice and history of the field, I don’t see how this organically fits.

      Thank you for the positive response. Much respect.

  89. Mikal Solstad says:

    Marino,

    Why are you so in love with your education?

    1. Marino Moutafis says:

      To quote the great verbal acupuncturist Dave Chappell “Haters goin’ to hate, lovers goin’ to love…”

      love you my brother

      1. Mike Kohm PT says:

        Awesome!

  90. John Ware, PT says:

    Here in Louisiana, all PT licensees just received a notice from the State PT Board that the Board of Medical Examiners is challenging the practice of TDN by PT arguing that it is beyond our scope of practice.

    They’re bracing for a battle. Lawyers have been hired. I can see my licensure dues dwindling away as I write this.

    This is what invariably happens in our profession. We latch onto the latest treatment fad, make it sound “sciency” and then end up fighting expensive turf wars with other professions who want a piece of the action. I’m sure many more grants will be awarded to PT researchers to investigate TDN. A CPR will be developed. Some group looking to distinguish themselves in PT research circles will insert TDN into a classification scheme. Out in the blogosphere arguments will rage incessantly about the need to apply sound clinical reasoning in practice.

    Meanwhile after 90 comments no one has been able to articulate a clear and defensible premise for inserting needles into patients with a persistent pain problem. They proclaim their amazing results, they provide links to dozens of articles, they appeal to authority and ancient history, but they can’t explain why or how this intervention works in a clear and concise way.

    And the beat goes on…

    1. Evan Raftopoulos, PT says:

      John, good points. From these discussions and in the absence of good evidence of plausible mechanism and effectiveness beyond placebo, what becomes obvious to me is that people practice needling simply because they enjoy doing it and (hopefully) because the patient enjoys having it. Oh and also because it seems to work. I don’t see any other reason. Having said that, I understand why an acupuncturist would say hey this what I do and these reasons are good enough for me, but I personally hold PTs to different standards.

  91. Evan Raftopoulos, PT says:

    Mike,

    Don’t attempt to argue from authority just because you practice needling. Anyone who is scientifically literate is qualified to contribute to a scientific discussion. If you think that experience in needling is necessary, then I’d like to see you arguing with Edzard Ernst MD, PhD, FMedSci, FSB, FRCP, FRCPEd who used to practice acupuncture and was the Chair in Complementary Medicine at the University of Exeter.

    http://edzardernst.com/2013/12/acupuncture-its-a-placebo-isnt-it/

    All interventions in the context of therapy deliver placebo to some extend. This is due to the patient and practitioner anticipation of a favorable outcome. For us to know that needling is much beyond placebo in the context of pain resolution we need (a)good evidence that supports a biologically plausible mechanism why needling can work beyond placebo, and (b) good evidence that suggests that needling is significantly better than “sham” needling.

    So where is the evidence Mike?

  92. Mike Kohm PT says:

    Evan,

    The evidence is in the clinic (acupuncture or PT) and actually practicing the technique, seeing patients improve.

    Have you actually experienced acupuncture or TDN personally?

    I agree that there is a “placebo effect” with a practitioner patient interaction.

    Malcom Gladwell rites about it very eloquently in his book “Blink”.

    I would rather call “the placebo effect” having compassion or emapthy, something you can not measure with research.

    1. Evan Raftopoulos, PT says:

      Mike,

      We are now talking in circles. Seems to work does not mean that it actually works. This is why we need good evidence and not anecdotes. Also, “works” implies more than placebo, at least in research, so improvements in pain reported outcomes within a session of needling do not necessarily suggest that it is more than placebo. Moreover, in the clinic alone we cannot know the contributions of contextual factors (empathetic practitioner that seems knowledgeable, resting supine in a nice warm room, relaxing environment etc) from needling itself.

      And yes, I’ve experienced needling personally.

  93. Mike Conlin, PT, DPT says:

    Larry,

    I would like to share my personal and clinical thoughts regarding the use of dry needling (ie. TDN, DN, IMT). Just as performing craniosacral therapy or NDT techniques for that matter doesn’t intrigue every practitioner, some would argue that they are great techniques and help their patients. In regards to the research, there have been some fairly good studies performed in recent years and you can bet there will be more to come because of the popularity of dry needling. A lot of the research regarding TrPs and/or dry needling to TrPs has been done by Fernadez-de-las-Penas, Jan Dommerholt, Karel Lewit, along with several others. Most of these have been published in The Journal of Pain, J Appl Physiology, Manual Therapy, Clinical Journal of Pain, etc. I would argue that most of the people against dry needling have not thoroughly looked for the research. I will agree that not all of the research is just about dry needling but many of the studies give some justification as to why dry needling may work. This may include mechanical changes to tissues, changes in peripheral or central sensitization, chemical changes (Substance P, Bradykin, Serotonin, etc.), biomechanical response, or even placebo.

    I am not advocating that we use dry needling on all patients just as I am not suggesting that we perform spinal manipulation on all patients. I am suggesting that we as a profession should not jump to conclusions either way until we are able to provide additional research as well as clinical evidence that this specific type of treatment is best for our patients condition. Clinically, I have found that dry needling works best when used as “another tool” and not the only treatment. I do perform dry needling on a daily basis in my clinic but not all of my patients receive this treatment. Also, I always use it in conjunction with some other “tool” including STM, exercises, manipulation, etc. I would agree that it takes a lot more than a weekend course to gain the appropriate experience and knowledge to perform this treatment. I have found that those who are well versed in manual therapy tend to get better and more consistent results with this type of treatment but this is just my personal opinion. I would advise our profession as a whole not to put it up on a pedestal either. PT’s are expected to be able to perform sharps debridement upon graduation but most schools do not attempt to sharpen (pardon the pun) their skills to be experts at wound care during the course of their education in PT school. Some schools do and I applaud them for doing so, just as some schools are concentrating more on manual therapy. My point is that as a profession that emphasizes the muscular system and actually requires more anatomy than most others in the medical field, we should at least be investigating the possible benefits of dry needling. History has shown (See systematic review of diagnostic accuracy of VBI, Man Ther 2013, Jun;18) that some early theories actually have no validity.
    The training is very expensive but I would recommend learning from not just one instructor if you are interested in learning and understanding this “tool”. If we want to be treated like the experts, we should all try and gain as much knowledge as possible. Also, without getting too political on this subject, I do think that physical therapists, acupuncturist, and MD’s should work together and stop this “turf war”. While DN is relatively new in the US, several professions have been practicing dry needling or acupuncture in other countries for years without fighting each other so much.

    Larry, as a graduate of EIM, I truly respect you and thank you for all that you have done for this profession so please don’t take this the wrong way. It is just a question. If you are against the use of dry needling or the fact that everyone seems to be jumping on the bandwagon, why is EIM teaching it?
    I look forward to your response.
    Mike

  94. Mike Conlin, PT, DPT says:

    For those who are interested there is a systematic review and meta-analysis titled: Effectiveness of Dry Needling for Upper Quarter Myofascial Pain, JOSPT vol 43, Sept 2013: 620-634.

    This was a level 1A as far as level of evidence is concerned.

    Mike

  95. John Ware, PT says:

    Mike,
    I’ve looked closely at the Kietrys meta-analysis that you cited. There were several fundamental problems with that review. The largest study had only 40 participants. The study that had the largest effect sizes from TDN (Hsieh) had a low quality score (26/48 versus >37 for the other reviews), this suggests that those results are likely biased. The heterogeneity analysis found that these studies differed a lot indicating that they were not measuring the same things, which also suggests a high degree of bias.

    I asked Neil O’Connell, a PT/PhD about this review and an expert in meta-analysis, and he indicated that they should have used mean difference of the VAS scales rather than Std Mean Difference (SMD) because the pooled effects on this scale will be more meaningful to interpret. When this is done, the scatter plots show very modest effects sizes of TDN for pain and the confidence intervals are close to 0.

    Combined with some of the other high quality reviews, such as Derry et al (2006) and the recent Corbett meta-analysis (2013), the evidence suggests that needling is no more effective than sham.

  96. mike conlin says:

    John,

    Thanks for your input. I would also suggest reading the following. I am certainly not the authority on research and data collection but this study below did have over 200 participants.
    Pain. 1979 Feb;6(1):83-90.
    The needle effect in the relief of myofascial pain.
    Lewit K.

    Again, I am not trying to make others “see the light” as far as dry needling goes and I agree that it is not for everyone. I do not think that either side should jump on the bandwagon, especially with all the “sham” talk. If you are a “manual therapist” that performs spinal manipulation (full disclosure-I do) you may want to read up on spinal manipulation vs. sham as the jury is still out on this as well for lumbar pain and it is still being performed. From a clinical standpoint I would argue that I have seen dramatic, almost immediate changes in some patients that I can guarantee were more effective than sham, soft tissue mobilization, joint mobilization, and modalities. However, I will agree that this is not always the case just as manipulations aren’t the end all be all for all patients with spinal dysfunctions. As far as the quality of the review for JOSPT, I am surprised it got in if the review had so many fundamental flaws. That is something to be discussed with the editorial board but I thank you for alerting me to that.
    Mike

    1. Evan Raftopoulos, PT says:

      Mike C,

      I personally do not think that spinal manipulation makes much more sense than needling in the context of PT practice. Looking at the evidence that we have today it seems to me that we can replace “needling” with “manipulation” in the arguments above and leave everything else the same. Lots of anecdotes, post hoc rationals, cognitive biases, cherry picking studies, you know how it goes.

  97. John Ware, PT says:

    Mike,
    I was surprised, too, after discussing it with Dr. O’Connell. They should have at least had the authors remove that remark in the conclusion about this meta-analysis demonstrating grade A level evidence for TDN. Based on the potential for bias and the very wide CIs, they should have been more circumspect.

    That reference from Lewit is not a randomized controlled trial. It was purely observational and therefore does not constitute evidence upon which to base a clinical decision. It merely shows that sticking needles in some people in a clinical setting has some effect on tender spots. This is very low level evidence. It might serve to promote further research into investigating mechanisms of needling and perhaps it prompted some of the more recent clinical trials under rigorous experimental conditions. By itself, however, it shouldn’t be used to justify using TDN in practice.

  98. Mike Conlin PT, DPT says:

    John,

    I’m definitely not trying to justify DN with my reference to Lewit. Just passing on some information. Hopefully there will be more valid research to help us all in our decision in the near future.

    Note to Evan: Although I do not agree with your statements regarding DN and Manipulation I respect your decision. The practice of Physical Therapy has been and should be an always evolving profession that challenges us as professionals to seek the best treatment options for our patients. Everyone will have their opinions but we should not disregard clinical observations and outcomes. Sometimes we just don’t know exactly why it works but I believe that thinking outside the box encourages us to continue expanding our knowledge.

    1. Evan Raftopoulos,PT says:

      Mike, what is it that you don’t agree with me about DN and manipulation? It’s not clear from your post. Also, it seems to me that we have different definitions of “thinking outside the box” (in the context of health care). My definition does not include let’s do “whatever seems to work no questions asked”. IMO this mentality is thoughtless and irresponsible when it comes to dealing with someone’s health.

  99. John Ware, PT says:

    Mike,
    There *is* valid research in the form of meta-analyses and it shows that needling is no more effective than sham. The Kietrys review that you cited inadvertably it seems provided additional proof of this. This high quality empirical evidence combined with the lack of a sound, defensible explanatory model should have PTs seriously questioning the utilization of this intervention in clinical practice.

    And I think we should disregard clinical observations and outcomes when the results are attributable to effects other than the ones we think or have been led to believe produce them. In fact, as a profession grounded in the principles of scientific discovery, we are obligated to do so. In this way, we acknowledge our susceptibility to confirmation bias.

    That is what differentiates a true profession from a wannabee profession.

  100. Wyatt says:

    John – you can’t see it but I’m giving the computer a standing ovation right now. Well said! I have gradually come to the same point in my young career regarding the use of manual therapy and TDN. When high-quality systematic reviews show that they don’t outperform sham treatments, and when other studies show that the patient and provider’s expectation and belief determine outcome, it tells me that we’re dealing with little more than placebo. Thanks for your continued work in promoting commitment to science and critical reasoning. I hope that everyone reading this discussion commits to critically appraising the available evidence for TDN (and other PT interventions) with an unbiased eye. I also hope that people take a strong look at evidence for the ethics of placebo – it is much needed.

  101. John Ware, PT says:

    You can download a very informative and free e-book by Seth Godin on the ethical issues surrounding placebo. It’s only about 25 pages.
    http://sethgodin.typepad.com/seths_blog/2014/03/thinking-about-placebos-a-new-ebooklet.html?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+typepad%2Fsethsmainblog+%28Seth%27s+Blog%29

  102. mike conlin says:

    John,
    Nice article. Here is a quote from Seth Godin:

    “Let’s start with just one clear scientific study
    to dispel anyone inclined to be skeptical: In not one, but two extremely rigorous studies of lower back pain
    (one of the most expensive and pernicious ailments of an aging population),researchers found that acupuncture
    was twice as effective as traditional Western medical techniques. Interesting. More fascinating:
    fake acupuncture was statistically as effective as real acupuncture.”

    Looks like you should stop traditional western medical techniques (ie. traditional physical therapy). This study also looked at PT and/or traditional
    medications used for back pain. You stated above: “In fact, as a profession grounded in the principles of scientific discovery, we are obligated to do so.
    In this way, we acknowledge our susceptibility to confirmation bias.

    That is what differentiates a true profession from a wannabee profession.”

    I resent the fact that you seem to be implicating that I should disregard clinical observations and outcomes. Do you or Wyatt want patients to get better?
    If so, stop treating back patients because what you are doing treatment wise may not be the best treatment. Leave it to us “wannabees”

    Wyatt, with that type of bias against certain treatments so early on in your career I would suggest that you get out now or send your patients to those of us who have been in the profession for 20+ years that actually take into account our clinical findings ( this includes clinical reasoning) Stay inside the box and let those who think outside of it get your patients better.
    This is why I usually don’t comment on blogs like this. Everyone just bashes everyone else. I tried to be considerate and understanding of others thoughts in my past
    comments and actually tried to just pass on some info along with some positives that I have seen from a clinical standpoint. I still very much respect others thoughts
    regarding new or different techniques but obviously this is not the site to address this. I’m done.

    1. Evan Raftopoulos,PT says:

      Not another appeal to emotion. Please provide with logic and facts, otherwise you are right, blogging might not be very good for you.

  103. Wyatt says:

    Mike,
    Let me make a clear point. In my opinion, if you use acupuncture or dry needling, that is fine, as long as you inform the patient in a few ways:
    1. Inform the patient that acupuncture can treatment can reduce pain, but it performs no better than sham acupuncture, and most likely causes pain relief through placebo mechanism – based around the patient and practitioner’s belief in treatment.
    2. You inform the patient of potential side effects: “there is a small risk of infection, pain, and in extremely rare cases, life-threatening complications”.

    If you do this for every patient, and the patient agrees to treatment,I have no problem with someone using acupuncture. If you don’t do this, based on current evidence, you are deceiving your patient. If i were a patient and given misleading information about how a treatment works, only to find out later it works through placebo mechanisms, I would be irate with my practitioner and would start to distrust PT’s in general.

    And Mike, I’m sorry you are offended by my bias for science-based medicine and critical thinking. It is these elements that I feel are extremely important for the future of our profession.

  104. Robert says:

    Gee Whiz, this is just enough time spent on this topic. There are 2 new topic’s posted.

  105. Mike Conlin PT, DPT says:

    Wyatt,
    Thanks for your reply. I do have a patient sign a consent form listing possible side effects, contraindications, etc before I ever stick a needle in someone. It is actually a requirement in the state. I also try other treatment techniques first and I do not try and expain the exact mechanisms. I give them theories and let them know up front that no one actually knows for sure the exact reason as to why it decreases pain. I know about the placebo effect but most people are not that excited about having needles put into them and I do not sugar coat it at all with my patients. Most of the sham studies actually did insert needles in other areas of the body. This is why there are some theories regarding either peripheral or central sensitization and possible changes that occur. Like I have stated before hopefully more valid studies will be published to either prove or disprove these theories but the jury is still out. A lot of the studies favoring or not favoring were not that good or didn’t have enough numbers to validate them. I totally agree that more studies are needed but I don’t feel the need to stop using it as “a tool” at this time. I believe in evidence and science too but I am not going to discredit clinical observations and changes in function (not just pain). If other PT’s don’t feel that way I am perfectly fine with that. Just remember some studies that seem to be correct (ie. VBI study) are later disproven with additional research.

    1. Larry says:

      Mike: I realize that is within your state requirements and that is unfortunate. There are some very interesting studies on informed consent (non U.S.) whereby they allow a person to sign a form saying that they don’t have to read the potential adverse effects because studies have shown that just merely reading them induces a nocebo effect (the explicit side effects that they are signing off of). I wish it was that way in the U.S. Informed consent, unfortunately causes more problems (effects) than it attempts to remove!

    2. Evan Raftopoulos, PT says:

      One could also argue that “the jury is still out” for fire cupping, Reiki, or any other laughable intervention. What do you have to say to that Mike?
      Also, I don’t understand when people say “more studies are needed” and then practice the modality anyway. What are you hoping? that studies will suggest that you are doing a good job? And if the studies suggest otherwise (see examples above) then what, you just reject them?

  106. John Ware, PT says:

    Mike,
    I don’t “implicate”. I don’t imply either. The burden is on those who insert needles into patients for the purpose of reducing pain (and then improving function- has needling been shown to improve function in patient without pain?) to demonstrate that the clinical results are explained by some active effect of the needle insertion itself and not just non-specific effects that are attributable to patient expectation, the ritual, the confidence of the practitioner, etc. Thus far, the highest quality evidence suggests that the needling, whether based on an acupuncture approach or a TDN approach, is no better than sham- that’s a real sham where the needle does not penetrate the skin. A science-based practitioner is obligated to inform his patient just as Wyatt has described above. He is obligated to guard against confirmation bias based on outcomes alone.

    When I rarely perform spinal manipulation, that is exactly what I tell my patients. That based on current evidence there is likely a short term analgesic effect that can be explained in part by DNIC, but also by the patient’s expectation that the manipulation will be effective. I also mention however that self-efficacy can be impacted negatively because the patient may even subconsciously come to rely on this intervention even though it has not been shown to be more effective than more active interventions, which are more likely to build self-confidence and self-management, and therefore less reliance on the health care system.

    I can defend my approach to treatment of patients with chronic low back pain, and I’m confident that my approach would not be confused with “traditional Western medical techniques” as defined in that study.

  107. I have just read through the posts on this site. I often read across many Forum topic debates and it is interesting to see many of the same names cropping up – with very defined attitudes and ways of expression.

    I have also witnessed bullying, been a victim of same, and contributed to a thread where one contributor actually made a difference to the debate by requesting civility in responses. That thread became quite a bit more pleasant to read.

    The responses to arguments in this thread re dry needling are really a rehash of many debates – is the practice (whatever it is) scientifically validated?

    The problem, as I see it, is that even science has a bad history when it comes to validation. I totally agree that the scientific methodology of testing and retesting is better by a mile than no methodology at all.

    However, just about every ‘special test’ I was required to learn during my Physio training has been proven to lack specificity. Clinicians will always create bias in a one on one consultation with patients. Patients will always present with belief systems that will alter the outcomes of any therapy applied. Placebo effects are real but undermine our confidence as to what is real or imagined via our interventions. What is reproducible?

    I can (and often do), go on. Our system of interactions, whether it be high velocity manipulation, dry needling, or anything else remains in a state of constant evaluation. What may be accepted today could be debunked tomorrow and reaccepted at a later date in a varying form (eg Ultrasound). Yes, the debate re ultrasound continues. I accept that – but the message is that we treat in an imperfect world and science, if it teaches anything, teaches that nothing is perfect.

    You only have to disprove something once.

    Look at Cochrane reports – Hundreds of research articles are assessed, throwing out the majority of these as they do not comply with existing Cochrane standards, with the few that are left heavily criticised, leaving a very few to actually be rated : often with no conclusion able to be drawn.
    How does this advance the argument, other than to make us all doubt our skills? Who is to say Cochrane protocols are correct?

    I can feel the attack being prepared against my post here. Before it hits me full on, I should say that I retain a cynicism in everything I do, read and hear, but plough on trying to keep an open mind.

    Throwing out science would cause anarchy and remove any necessary assessment framework, but slavishly accepting everything put forth by an imperfect framework is also dangerous.

    My way of dealing with all this is to read the opinions of others, both research findings and clinical experience, compare it to my own experience as biased as it probably is, then mix it all together whilst practicing cautiously and within the law, without jumping onto any of the latest fads until they have gained a little maturity.

    Hopefully, my way softens the mistakes we all make and leaves a little space for the growth of skills and knowledge.

    My head is now ready for the kicking – primarily due to my failure to provide the ‘evidence’ at a level to appease professional forum critics.

    Regards to all that attempt to help their patients within the uncertainty
    of our limited understanding of the human body and its intricacies. We should all be humbled.
    Mark Quittner MrPhysio+ Healesville Australia

    1. John Ware, PT says:

      Mark,
      At the risk of being accused of “attacking” you, I don’t get the point of you comment. How would you define “slavishly accepting” scientific evidence? What does it mean for a treatment fad to achieve “maturity”? Would lumbar fusion surgery for chronic low back pain qualify as a treatment fad that has reached maturity? What about bloodletting? It survived well into the 19th century- in fact it was used on George Washington and may have caused his death- therefore it existed as treatment for a variety of diseases for hundreds of years. Would that meet the standards of a “mature treatment fad” by your definition?

      I’m curious what you think the purpose of critical analysis of the available evidence is. Is there a specific interpretation of evidence suggesting that dry needling is no more effective than that has been cited in this thread with which you disagree?

      I don’t participate in online discussion forums to have a pleasant experience; rather, I participate in forums like this to challenge myself and my thinking. I also would like to see more PTs question what they do, and perhaps see a shift towards more rational and defensible practice. I don’t think that TDN possesses a defensible deep model. I’ve asked repeatedly in this thread for someone to provide a premise upon which they base this practice, and I’ve yet to hear anyone provide one. Here’s an example of a defensible premise for movement/exercise for patients with persistent pain:

      “Non-painful movement can reduce isometric motor output and thereby reduce ischemia, tension and/or compression on local nervous tissue. Movement can also promote descending inhibitory control through the CNS. These peripheral and central effects can produce analgesia and assist in resolution of persistent, non-pathological pain.”

      Notice that I didn’t refer to increasing strength, improving posture or improving muscular balance. I don’t think those concepts are defensible either.

      Can you- can anyone- surmise in a concise statement what is the premise for inserting needles into patients?

  108. Mike says:

    Evan,
    Have you ever performed a VBI test on a patient? If so, why? The evidence wasn’t clear and was biased against manipulation in the original sudy but everyone including AAOMPT adopted it until it was debunked. The thoughts on this changed over time. Open your eyes and your mind!!!

    1. Evan Raftopoulos, PT says:

      Mike, I’m not sure if I’m following your point here. And with or without arterial dysfunctions hvla thrusts are 1. more risky than less forceful manual therapies and 2.generally not superior to other interventions for msk manifested pain.

      http://www.ncbi.nlm.nih.gov/pubmed/21593658

      http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008880.pub2/abstract

      http://www.ncbi.nlm.nih.gov/pubmed/22621391

  109. John Ware, PT says:

    Has anyone seen the latest clinical trial published this month in JOSPT on dry needling for neck pain? It’s followed by a full-color “Perspective for Patients” piece entitled “Neck Pain- Dry needling Can Decrease Pain and Increase Motion”. Is the profession really officially prepared to start publishing consumer-directed recommendations for the use of a very contentious intervention? Larry mentioned “irrational exuberance aboutTDN” in his original blogpost. I think this certainly qualifies.

    Oh, and the article by Mejuto-Vazquez et al that prompted JOSPT to publish this “public service” document effectively trivializes the scientific debate over the existence of trigger points. They even mis-state the kappa values that were reported in the cited Gerwin et al (1997) reliability study.

    Where’s the rigorous peer review? If authors are able to get articles published in JOSPT that contain inaccurate citations of statistics and provide lip-service to a contentious scientific debate upon which the studied intervention hinges, then I have to wonder who is providing the peer review and where their personal interests lie. Is the peer review process at JOSPT corrupted by conflict of interest in the area of TDN? When they publish stuff like this, it begs the question.

  110. Nate says:

    John:

    I did see the JOSPT RCT. There’s another one next month in PTJ for plantar foot pain. I agree more debate and evidence should exist before hailing this intervention as effective. I use TDN daily with my patients and have had success with decreasing their pain and improving ROM. Some studies point to decreased myogenic activity following needling and this seems to connect well with what I’m seeing clinically. Do we have perfect evidence? No. Do we with anything? No. I don’t smell a rat at JOSPT. While I agree more debate should take place, I am much more concerned with other pseudoscientific interventions being peformed by PTs and recommend you turn your attention here. While two wrongs don’t make a right, there is a plausible mechanism behind TDN, which is something I can’t say for craniosacral, visceral manipulation, etc. I would rather pour resources into banishing these types of voodoo treatments from being performed than continue to rip apart an intervention showing promising results but needs further investigation before declaring it voodoo vs. let’s do.

  111. John Ware, PT says:

    So, Nate, you’re ok with JOSPT publishing an article that mis-cites reliability statistics? Did you read the paragraph on p253 that stated the argument- such that it is- for trigger point diagnosis. It’s laughable. A freshman biology student couldn’t get away with such a poorly constructed and defended argument. The reference to the Lucas et al review is borderline disingenuous in its omissions. That review identified some very salient problems with identifying trigger point location, study quality, and consistency of operational definitions of the diagnostic criteria for trigger points. The authors don’t mention any of that. Does it matter that the Myburgh et al review that they cite didn’t even use the same diagnostic criteria for trigger points as those used in this study?

    Perfect evidence? I don’t even know what that is, much less would I ask for it.

    Myogenic activity?

    I’ve been a vociferous critic of “voodoo” in PT for many years. In fact, I, along with several others, was threatened with a lawsuit for criticizing a certain controversial method widely used by PTs. I can walk and chew gum at the same time.

  112. Nate says:

    John:

    I didn’t say I was okay with it. Step back from the ledge and take a deep breath. I appreciate your passion here, and I do agree with your concerns and assertions related to the review, but I’m not prepared to denigrate the leaders of our profession and suggest corruption. I’m in the clinic all day long, so I don’t have time to sit in my office and review these things in tremendous detail, and I’m not ready to go on a witch hunt for needle lovers. We’re all trying to help people and make people better, so perhaps you could frame your criticism a bit differently in the future. It appears you are on faculty at LSU. What kind of clinical research are you contributing over there? Perhaps it isn’t enough to be condescending and call ‘myogenic activity’ ridiculous by simply stating the term again with the addition of a question mark. I’m reminded of a famous quote from Col. Nathan R. Jessup:

    “I have neither the time nor the inclination to explain myself to a man who rises and sleeps under the blanket of the very freedom that I provide, and then questions the manner in which I provide it. I would rather you just said thank you, and went on your way, Otherwise, I suggest you pick up a weapon, and stand a post…”

    To summarize the point briefly, please continue to question and be critical, but please also be respectful and make positive contributions rather than hail endless assaults. I’m glad the gum is going well, but can you start a new path or simply twist and turn on the existing footprints?

  113. Nate says:

    The study I’m referring to looking at EMG activity in the muscle is from Chen et al in the American Journal of Physical Medicine Rehabilitation in 2000. They measured EMG activity pre-needling and post-needling and measured a significant reduction in myogenic activity. Granted, this was done in rabbits, but I think it contributes to the plausibility of a mechanism.

    Check out another study from 2011 (Hsieh et al, Archives of Physical Medicine and Rehabilitation) looking at muscle activity with actual needling vs. sham needling, There was a difference. Many of the available systematic reviews appear to question the effectiveness beyond placebo but this study actually shows a difference. Again, I’m not saying this is definitive, but it points to a possible mechanism. I think these mechanisms, combined with managing placebo vs. nocebo, and supplemented with PT and not done in isolation can provide positive clinical outcomes. Why is this not plausible? Why not investigate this further?

  114. John Ware, PT says:

    Nate,
    I think you missed the point of my critique of the article in JOSPT. I was referring to the authors’ carelessness in presenting their argument about the existence of trigger points, which is what trigger point dry needling hinges on. This article should not have been published with the citation errors and superficial treatment of the deep disagreement among scientists over the existence of trigger points. If you have the time, I encourage to take a look at the review by Quintner and Cohen from 1994 (http://journals.lww.com/clinicalpain/abstract/1994/09000/referred_pain_of_peripheral_nerve_origin__an.12.aspx). Most of the points they make in this review regarding the problems associated with the trigger point hypothesis have not been addressed in the last 2 decades. Could it be that the hypothesis is wrong and cannot overcome these problems? I think so. And I think the weight of the evidence is on my side. By the way, that’s what we’re supposed to do- not find or achieve “perfect evidence”- that’ll never happen. We’re suppose to analyze and discern the quality of the evidence, weight it up, and then make informed decisions about how it should impact practice. This is what defines being a professional.

    I don’t see how the presence of altered muscular behavior associated with needling contributes to a plausible mechanism for a meaningful reduction in persistent, non-pathological pain. Why wouldn’t EMG detect something different when a needle is actually inserted into muscle versus a sham treatment where the likelihood of creating nociception is minimal? I would be amazed if there were no difference. And since the management of nocebo and placebo accompanies every intervention provided by PTs, that adds nothing to an argument in favor of treating trigger points with needles.

    To refer to my efforts to keep our process of research publication honest as a “witch hunt” is insulting, and I think you should reconsider that position. The quote from “A Few Good Men” is strangely out of context. I should be thanking you for what exactly? Wasn’t Jessup convicted of conspiring to murder a recruit? No, I don’t get that at all.

  115. Bruce says:

    When the Olympic athlete Torin Yater-Wallace suffered a pneumothorax due to dry-needling at the hands of a physical therapist, that’s when I decided we as PT’s not only need to wave the white flag on the whole dry-needling issue, but ACTIVELY CAMPAIGN AGAINST IT. The public is starting to find out that our standards, state by state, are far too low as compared with acupuncturists. Granted, we probably know anatomy, or at least surface anatomy, better than they do, but I don’t care to convince the public nor the legislature of that. It’s a battle not worth fighting and if we keep fighting it, it’ll only cheapen our profession and weaken us in the battles we really need to pursue. One more dry needling accident to a prominent person, and it could ruin our profession.

  116. Hello, I googled “trigger point evidence” and found this page. I’m not surprised that there is a lot of confusion in the world of traditional medicine, Complementary and Alternative Medicine, physical therapy and pain management. Chronic pain, neuromuscular + neurovascular dysfunctions are wreaking havoc on the cost of medicine and on people’s lives and we need to clarify key points.

    I started in ‘97 to figure out how to treat fibromyalgia with acupuncture because one of my patients had some improvement with the therapy. I wanted to know why! Well I found a lot of information that has been marginalized and a key data point. This key data point is so innocent it is easily overlooked and contributes to confusions;
    Chronic pain is in the tissues of locomotion or neuro-muscles so the treatment as to aimed at these tissues.

    Chronic pain will not go away all by itself so it should be effectively treated.

    This type of pain will evolve/devolve by spreading into adjacent tissues, broader across to other body parts, migrate deeper towards the bone and more dense. So early and aggressive treatment is necessary.
    Because of the above the longer you wait the longer it can take to reverse the damage.
    This damaged tissue can not be seen with technology so it cannot be fixed with high-technology. So called step or event therapy like Epidural Inject, Arthroscopic procedure are less effective than cumulative type ongoing physical therapy.

    This damaged neuro-muscular tissues can only be effectively treated with movement or agitation in the form of massage, stretching, twisting, kneading and heat.

    If the tissues are very affected than hands-on and leverage will not be enough to ignite the healing process enough to reverse the damage. So an additional tool has to be used in the form of a wire probe (needling) that can penetrate through the skin (doing no harm) to stimulate, agitate and stir up the healing cascade. The needle will also “reset” these densely contracted muscles to short circuit the muscle bundles as per Cannon’s Law of depolarization. Then the muscles will relax into a better resting state which will allow the environment to be in a better state for healing.

    Stale tissues can become stubbornly dense, stiff and will not allow a non-traumatic needle to penetrate, so therapy will stall. In these cases the next available tool would be a needle with a cutting beveled tip as in a hypodermic needle. This is where biopuncture, prolotherapy and TrP injects comes into play.

    Cannon WB, Rosenblueth A. The Supersensitivity of Denervated Structures: A Law of Denervation.New York: MacMillan; 1949.

  117. Cynthia says:

    I am not a PT but, a patient who was looking for some objective information on TDN as it was suggested by my PT as a tool in my treatment. I have to say that he is only suggesting it as a tool and not total treatment so, I was glad to come across this blog and see all the comments here about the use of it. I now believe he is making the right decision, in using it with other treatments to get me back on track. I’m very glad to have stumbled across this blog.

  118. Jayse Brock says:

    Thanks for sharing your post and there are lots of great comments as well from members.

  119. Berlene Vodicka says:

    Where can I get dry needling, in Clearwater FL?
    Do I need a referral?
    Please reply!

  120. Reenie says:

    I am just glad dry needling is legal in GA. I have suffered from migraines for years and my neurologist could not do anything except give me meds. I had limited PT to my neck about 8 years ago but it did not really help. I recently changed my neurologist and this doc referred me to PT and was open to dry needling for me. It has worked and for the first time in years I have not been getting the migraines. Mine actually start out as tension headaches from issues in my neck and traps, and then they progress to a full blown migraine with the nausea, light sensitivity, etc. My therapy has been combined with exercises for the neck and upper back, and cervical traction. So I realize it is a combination of therapies, but I’m glad the needling is available because my results were pretty quick, unlike years ago when I ONLY had the PT without needling where i had no results. I will be continuing the exercises at home and hopefully this will keep those headaches away.

  121. Acupuncture Vengeance says:

    Calling Bullshit on this. You guys are simply trying to practice acupuncture without the necessary safety training and knowledge of acupuncture physiology. Doing so makes you dangerous to your patients. Your overzealousness also leads you into unethical behaviors as you mislead your patients into treating things which you are unqualified to practice.
    FYI – Thank you for proving a couple points while you try to pre-empt acupuncture for yourself. Point #1 is that your current physical therapy techniques must be ineffective if you have to reach beyond your scope of practice. Point #2 you are admitting that acupuncture is superior medicine.
    Now, if you want to learn real acupuncture go to a real acupuncture school, and learn the real deal.

  122. Kory Zimney says:

    Physical Therapy is a defined profession by what we as physical therapist know, not by what we do. There will always be overlap between professions on what they do, but there is no overlap in the distinct set of knowledge that a physical therapist has.

    Someone’s profession is defined by knowledge not techniques.

  123. Larry, thank you for a thought provoking post. And kudos to all the comments and discussion. I just finished a post detailing my concerns and assessment of needling. I’ve outlined 9 considerations. Comments and discussion welcome:

    http://ptthinktank.com/2015/08/03/what-are-the-issues-with-therapeutic-or-trigger-point-dry-needling-9-considerations-to-ponder/

  124. Lisa G says:

    I am a PTA and an Acupuncturist, I have deep concerns about practice infringement, and the potential damage this can do to Acupuncture as a profession. When I look at youtube videos of dry needling, especially dry needling with electrical stimulation, it is indistinguishable from electroacupuncture. The disclaimer that this is not Acupuncture because dry needling is based on Science and Neuroanatomy and is not attempting to move qi and blood in the meridians is truly flimsy. It is dismissive to the significant body of good research based on Acupuncture. It also diminishes the knowledge and training of Acupuncturists.

    How many Physical Therapy tools have been derived from Acupuncture? When I started work in the 1980’s the use of TENS was based on research with Electro-Acupuncture. How many practitioners are using Acupuncture- like TENS for chronic pain and myofascial trigger points? Is there an appreciable difference in Acupuncture like TENS compared to electro-dry needling? I don’t know, but that might be a good research topic to explore.

    Laser and Ultrasound cause tissue changes, relieve inflammation, improve circulation and address trigger points, intramuscular points, and acupuncture points as well. The problem is insurance has minimal to no reimbursement for modalities, which is a shame, because these do work.. Possibly because of practitioner boredom and low reimbursement, modalities typically get delegated to aides who may, or may not, get the same effects as when modalities are judiciously applied.

    Other Acupuncture tools such as cupping and gua sha (rebranded and refined as Graston technique) have been incorporated into Physical Therapy, Chiropractic, and Massage. They are effective and non- invasive.

    Yes, other countries, such as Australia, allow PT’s practice dry needling. However, they also allow massage therapist, chiropractors, podatrists, etc to practice as well. There may well be unintended consequences. If some don’t want their dues going to legal battles with Acupuncturists, know it will be worse when/if the chiropractors follow your lead. Which they likely will do, because in many states where Acupuncture is not well regulated or established Chiropractors can do Acupuncture with several hundred hours training. It could be a free for all that will not benefit the public, nor give significant gains to professional practice.

    Any gains PT’s make in accessing Dry Needling are likely to be short lived. If you get CPT codes for it, whatever reimbursement PTs get from the insurance industry will be whittled away, just like every other modality.

    My concerns after reading the following (which all PTs should read) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4117383/ is the plan, of some, to expand the definition of dry needling to include the expansion of target tissue treated. This will allow the use of distal points which can dramatically expand the scope of dry needling practice to all of what is in the scope of Acupuncture. This paper also asserts that there is good Western based Acupuncture research that PTs should not ignore in order to get better credibility for the use of Dry Needling.

    From an Acupuncturist’s point of view, we/I see this as a group of practitioners co-opting our practice, while maligning the practice of Acupuncture as placebo and without merit, repeating to themselves and the public that Acupuncturists only understand their/our practice in terms of a cultural and energetic perspective.

    This ignores the fact that Acupuncture has demonstrated effects on the neuroendocrine and neuroimmune systems, etc, – and it does take more than a few hours to understand and value what this branch of medicine is– beyond a “sexy new tool, in someone’s tool box.”

    I have direct access, however, I get many referrals from physicians. I frequently refer my patients to Physical Therapy. Some physicians refer patients to me first for pain management, then PT for rehabilitation. The Amazon.com model of offering everything to everybody works better in product delivery, not so well in service delivery.

    .

  125. Jen says:

    I had dry needling done by my physical therapist. Totally pain free. I have fibro and lived with pain more years than I care to think about. It’s nice to have no pain.

  126. Phil Settels says:

    “the acupuncturist is totally defined by one intervention and that TDN is but one tool in an arsenal for PT’s to consider”

    Most acupuncturists have studied Chinese Medicine, rather than simply acupuncture (one of its branches/subsystems), and are thus not “totally defined by one intervention”, despite the unfortunate professional title. Distinguishing what you do from what an acupuncturist does is great. But your point is better made without inaccurately diminishing another healthcare field.

    Licensed Acupuncturists use acupuncture of countless styles (including but definitely not limited to the anatomically-informed systems that are now all the rage in PT), cupping and guasha (also very popular now in PT), Tuina massage, moxibustion, herbal therapy, dietary therapy, lifestyle counselling and advice, etc.

    Acupuncture is but one tool in the acupuncturist’s arsenal.

  127. After being an outpatient orthopaedic PT for 5 years, I decided to get my CMTPT certification and it has revolutionized my practice and given me such a different perspective. It took 5 years of taking weeks or even months to get results from patients with pain, impaired flexibility, limited mobility for me to say, “let’s try something different.” I can literally get patients back to a normal state in days using dry needling compared to traditional PT practices. Why not give it a chance? Yes, it is only 1 tool I use, but such a valuable tool and I don’t understand why it’s being so criticized when it has only helped my patients. I literally treat physicians and have helped people who have had chronic migraines for 20+ years actually live again..they literally light up in the face when their pain is gone. No research can convince me of the results that I see everyday in my patients. I strongly believe that research is damning in order to benefit the pharmaceutical companies that have patients walking around like zombies. Just my piece of mind.

    -Amanda PT, DPT, CMTPT in Virginia.

  128. M D DeMonia says:

    I am a 63 year old female with bulging discs at L3-5 and SI joint narrowing. After suffering with pain for over 12 years, my right piriformis eventually tightened around my sciatic nerve to the point I could barely walk. Since previously going through nerve blocks, SI injections and physical therapy, I had little hope of anything changing. My Dr recommend physical therapy once again. I fortunately went to therapy location that suggested the TDN. After the first treatment, I was skeptical. Then after the second treatment, the pain started going away. Fast forward to 15 months later, I remain pain free by going to maintainance TDN once per month. I am of course, NOW a believer. I’m sure there are some therapist that might not be as good as others, but I am thankful for mine!

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