Part 2 - Dry Needling & Manual Therapy

This is part 2 of last week's post - How I integrate Dry Needling of Myofascial Trigger Points in a course of Physiotherapy

Be aware of ‘dose’ i.e. level of sensory input applied to the central nervous system. Dry needlers are notorious for providing too high a dose during treatment due to use of very vigorous techniques. I feel there is not enough emphasis on dose control during training.

Control dose by the no. of needles used, depth, duration and level of stimulation applied i.e. gentle rotation< lift thrust

Remember dose is cumulative, be careful with needling and then doing manual therapy and exercise as all provide sensory input. If including needling in treatment, any soft tissue therapy should be very gentle and short of pain, see above, so as not to ‘over-treat’ the patient.

The dose should be carefully titrated upwards until a therapeutic response is achieved and then maintained at that level. May need to increase dose slightly if patient response starts to plateau.

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Part 1 - How I Integrate Dry Needling of Myofascial Trigger Points In A Course of Physiotherapy

While conducting a subjective assessment it is very important to determine severity, irritability and nature of the problem. When considering acupuncture / dry needling the irritability is most important i.e. how easily is the pain provoked, what is pain intensity on VAS for example and how quickly does it settle.

Irritable problems must be treated very carefully with dry needling and manual therapy. Also be on the lookout for inappropriate beliefs/ yellow flags as these should alert you to the need for further caution when applying treatment.

General Rules

With acute, sub acute and especially chronic pain patients, always treat below the pain threshold when using dry needling and manual therapy. It is especially important if there are inappropriate beliefs/ yellow flags as these patients may be more susceptible to central sensitization.

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The Role of Inflammation in Tendinopathy

As a physiotherapy clinician who treats a large number of tendon related problems I have given the 'degenerative tendon model' much thought in relation to what I actually see in clinical practice. 

Despite the conventional wisdom nowadays suggesting the process is wholly a degenerative one, clinical evidence often suggests concomitant inflammation. In particular during the early reactive phase as well as possibly the later stages if one was to consider tendon pathology from the continuum model perspective (Cook & Purdam, 2009)

As such it was very interesting to listen to Jon Rees a rheumatologist at Cambridge University Hospitals NHS Foundation Trust who tells Jill Cook in a BJSM podcast why we should reconsider the role of inflammation when treating chronic tendinopathies. Its a very interesting discussion which should enhance our understanding of tendon pathology and also remind us that physical medicine is a continually evolving process and never to take it as all said and done.

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Myofascial Shoulder Pain & Dysfunction - Clinical Practice Case Report

This case report may be helpful in guiding the clinical decision making and management of a common clinical presentation involving the shoulder. Particular emphasis is placed on the integrated use of Medical Acupuncture.

This case was selected from patients seen in an urban private physiotherapy practice.

Note on use of the visual analogue score (VAS)

A 10cm line was used, blank apart from ‘0 No pain’ at one end and ‘10 Worst imaginable pain’ at the other. Patients made a mark on the line corresponding to their level of pain on average over the preceding week. The line was measured using a ruler to give a score out of 10. A new, blank score sheet was used each time.


Myofascial trigger points (TrP’s) can be defined as a hyperirritable nodule of spot tenderness in a taut band of muscle and have been suggested to be a common cause of musculoskeletal pain and dysfunction.1 TrP’s may be either active or latent. An active TrP is one that produces pain spontaneously (with or without activity), is associated with a taut band, produces a local twitch response (LTR) when stimulated manually or with a needle, and refers pain which is familiar to the patient. A latent TrP does not cause pain spontaneously but is painful when stimulated manually or with a needle. It behaves like an active TrP in every other way but does not produce familiar pain.1

The following case study is an example of how both active and latent TrP’s can interact to produce pain of both a myofascial and mechanical nature.

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Revisited - NICE Guidelines For Persistent Non Specific LBP

So what is relevant to the Physiotherapist when using Acupuncture?

Although published a few years ago now, the NICE guidelines for persistent low back pain represented a significant step forward for acupuncture and its integration into more conventional western medical practice.

What follows is a brief review of the guidelines with the practicing Physiotherapy clinician in mind.

The guidelines describe an evidence based management pathway for those suffering from persistent low back pain. This would be defined as those with symptoms of greater than 6 weeks but less than one year and does not include back pain due to or with radiculopathy, cord compression of cauda equina.

Furthermore infection, malignancy and ankylosing spondylois must be excluded. Any other red flags should be medically assessed before treatment. What we are left with is effectively non specific, mechanical low back pain.

Patients with persistent low back pain may present to a Chartered Physiotherapist directly by self referral and so what follows is an interpretation of the guidelines which takes into account this variant.

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