So, next on our list, we're going to switch a little bit over to some physical therapy controversies. So, Dr. Alban, she's going to come up and talk to us about some of the different techniques that are emerging in physical therapy. First of all, thank you to AOFAS and also FASIG for inviting me to give this talk. I do a fair amount of research in dry needling, and so we'll talk a little bit about that today. I have nothing to disclose, so let's get to the point. I was like laughing by myself when I was putting these slides together. So a little bit of controversy surrounding dry needling, as you can imagine. This doesn't come without risk. There's still some states that do not allow dry needling. Mostly states where Jeff and Chris live seem to be the problem. New Jersey is in red now, but I think they're in the process of changing, so that is a good thing. APTA does support the utilization of dry needling. So today we're going to talk about what dry needling is. We're going to just briefly describe effectiveness of dry needling, talk a little bit about clinical decision making surrounding dry needling and the utilization, and then we'll talk a little bit about some of the research. Okay, so first of all, what is dry needling? It's the skilled intervention used by physical therapists inserting a filiform needle, so a solid needle, into myofascial trigger points, and we'll talk a little bit more about what trigger points are and their relevance in just a second. Muscular and connective tissues for the management of patients with neuromusculoskeletal conditions. So we know trigger points are found in all skeletal muscle. These can be classified as either active or latent. Active trigger points are spontaneously painful, whereas latent trigger points are painful when they are palpated. These can refer pain and they can also elicit a local twitch response, which we'll talk about the importance of that. There are differences between active and latent trigger points. Active trigger points have some increased levels of these different chemicals of pain found around them, whereas latent trigger points do not. Why is this important? So we know that trigger points can affect muscle activation patterns. So in 2010, they published a study looking at scapular elevation and they found increased infraspinatus or early firing of infraspinatus, and this can lead to overuse injuries. We also know that the presence of trigger points is associated with developing muscle fatigue and overloading of the motor units that are around the trigger points. It can also, there's increased stiffness associated with trigger points, and we know that increased stiffness is associated with increased injury to muscles as well. So let's shift a little bit and talk about the effectiveness of dry needling. Can this help our patients or patient populations? What we know is, again, there are these chemicals of pain that are found in and around trigger points, and we know that dry needling can reduce these different chemicals. We also know that dry needling can improve oxygen and blood flow to muscles, which can help with the firing of different muscles, and we'll come back to that in just a bit. So what we looked at in this first study that we published in 2020, we looked at this concept of muscle stiffness, and what we wanted to know is, are there changes that are associated post dry needling? So we randomized patients to receive either dry needling or sham dry needling. They received two different sessions, and we assessed muscle stiffness pre and post dry needling. We found statistically significant decreases in that muscle stiffness. And again, given that muscle stiffness, there are associations with injury, this can be valuable for our patients that we're seeing. This is also consistent with previous research looking at upper extremity, but I think ours was the first study to look at effects of muscle stiffness in lower extremity. Several systematic reviews and meta-analysis looking at the effectiveness of dry needling. This first study was published by Eric Gatti, I think, when he was doing his PhD. And they included patients with chronic ankle instability. They found that individuals that received dry needling had decreases in pain. They had improvements in self-reported outcomes. They also had improvements in pain pressure threshold, which, as we know, is a proxy for pain sensitivity. In 2021, so just last year, another systematic review came out. Again, they included individuals that had ankle and foot pain. And they found improvements in pain for short-term, medium-term, and long-term. This is one of the first systematic reviews where they found long-term effects for decreases in pain post dry needling. So take-home message, dry needling can provide a window for us to provide therapeutic exercise. It can help decrease pain. This is just one tool for our toolbox. This is certainly not appropriate intervention for all patients. Let's talk a little bit about decision making. So does it matter where we needle in patients? Does it matter if we get a twitch response? What is a twitch response? So for those of you that have used dry needling before, this will be very familiar. This is one of our instructors needling one of our residents in the upper trap, of course. And you'll see a twitch response right here. So that's what a twitch response looks like. If we look at this under ultrasonography, this is at half speed. This is a needle being inserted into vastus lateralis, and you can see the muscle fibers moving. This is a pistoning technique, and you'll see, not on this one, but on the next one, you'll see a nice large muscle contraction, and that's our twitch response right there. So is this important clinically for patients? There's some research that suggests that this is, that we should be targeting this twitch response. So a couple different studies, one Shane published in 2017, and another study published in 2013 where they showed improvements in patient reported outcomes and also decreases in pain for patients that have that twitch response. Does it matter where we put the needle? If we put it directly into the trigger point, is there a larger benefit to that? So this was a study that was published in Spain. They randomized patients to receive dry needling directly into the trigger point or two centimeters away from the trigger point. And they found statistically significant and clinically meaningful changes when they needled directly into the trigger point versus in the same muscle, but away from the trigger point. This was in the upper extremity, and that is less exciting. So we duplicated this in the lower extremity, which is much more exciting. So what we did is we looked at gait, patterns in gait, and we looked at individuals that had sustained injury to the ankle or hind foot, and we assessed gait velocity, step length, peak pressures, both at weight acceptance and then also at terminal stance for those that got needled directly into the trigger point and those that were needled away from the trigger point. One of the muscles that we needled that we were gonna potentially needle was posterior tib. So before we started this study, I wanted to see, is it even safe to put a needle in the deep posterior compartment given the neurovascular structures that are there? So we took 20 individuals, put a needle into the posterior tib. Anyway, I hoped I was putting a needle in the posterior tib. We confirmed needle placement with ultrasonography. So the needle was inserted, and then we used the ultrasound machine to confirm needle placement. And then we also measured how far away we were from posterior tibial artery and also from the tibial nerve. And on average, about one centimeter away from both the nerve and the artery. So fairly close, but we were not in artery or nerve in any of the patients. So if we know anatomy, I think pretty safe to needle in the deep posterior compartment. What we know is there are gait deviations that are common in individuals with ankle and hind foot injuries. These individuals have impaired muscle activation following ankle injury. They have decreases in gait velocity, decreases in step length, and we would expect those two things to go together. But they also have alterations in peak ground reaction forces, especially at that loading response. Individuals with ankle instability tend to load in an inverted position. And as you guys can imagine, that's a bit of a problem. So we took 33 individuals, age 18 to 60 years, that had had a previous ankle or hind foot injury in the past year. They had to have some sort of limitations, either in pain balance or with dynamic tests or using ankle lunge tests for dorsiflexion limitations. And these individuals received three dry needling treatments. And then we had a follow-up two weeks after their final dry needling session. So again, they were randomized to receive dry needling directly into the trigger point or away from the trigger point. Then we needled at least two to three other muscles, depending on what the patient's impairments were. What we found is gait velocity statistically improved after the first dry needling session, and that lasted even two weeks after we stopped dry needling these individuals. So statistically and clinically meaningful changes for these individuals. Step length improved as well, which again, as you guys know, is correlated with our gait velocity, so we would expect that. And also peak pressure improved at weight acceptance, meaning patients felt more comfortable at that loading response, and that was significant after our second dry needling session. And again, that lasted even two weeks after we finished our last dry needling session. What's interesting is Coughlin did a study in 2007, and they found no significant changes in gait velocity for individuals with chronic ankle instability that participated in a four-week long neuromuscular training program. And so dry needling might be a way to get patients there a little bit quicker. What may be happening is, as patients have a reduction in pain, they have an increased ability to load at that weight acceptance phase of gait. Individuals that have improvements in muscle function may feel like they're more stable, so they're able to increase their step length, and in turn, gait velocity. And again, we know that inserting a needle can help decrease some of these chemicals of irritation that are found in and around muscle trigger points, and so this may lead to more coordinated muscle function and improved gait patterns. So twitch response may be important for patients. This may be clinically relevant. It appears that dry needling directly into the trigger point or being accurate with where we're placing the needle may be able to help improve pain and function for patients, but more research is needed in this area. So back to our controversy, there is risk associated with dry needling. Anytime we insert a needle into somebody, there's risk of infection, bruising, soreness for patients. Again, not all states support the utilization of dry needling, although, as you can see, many more states are on board with this than even 10 years ago. There are some PT boards that are still being sued. When I moved to Denver in 2017, we were in the process of being sued by the acupuncturists, and as a response to that, we've actually added dry needling to our entry-level curriculum for our students. All right. Thank you.

controversy

dry needling

physical therapy

neuromusculoskeletal conditions

clinical decision making