Dry Needling – An Alternative Intervention for Chronic Pain. Pt. 2

[SafetyNurse1968, ADN, BSN, MSN, PhD]

My Story

I wrote in part 1 that I had chronic pain in my right hip for over 10 years. I had deep, cramping pain in my sciatic nerve that wouldn’t go away. It was always there, a presence that I now realize colored my days and my sometimes-sleepless nights. I thought the pain was my fault because I exercised too hard. I was devoted to playing Ultimate Frisbee and didn’t want to quit. I accepted that this pain was part of my life. I lived with it.

Then I met my husband. As a nurse, you would think I would have realized that a PT could help me, after all, it is the job of a PT to help injured or ill people improve their movement and manage their pain.1 Somehow, I missed the pain part. My husband helped me a great deal by teaching me exercises to reduce my pain. He taught me that I had persistent weakness and difficulty activating muscles in the deep hip. The length of time my symptoms were present (called chronicity) caused hypersensitivity of my nervous system. My brain associated any stimulation in that area with pain. The exercises helped, but the pain wouldn’t go away.

What does dry needling feel like?

After my husband attended his first dry needling course, he recommended dry needling for my pain, but when I saw the 5-inch needle he would use to reach into my gluteus maximus, I balked. I finally relented after an especially bad bout of pain that kept me from sleeping. When he needled me the first time, it was the strangest feeling – I struggle to describe the deep cramping sensation that gripped the inside of my hip. It was as if he was stimulating the exact spot that caused me so much agony, but in a very targeted and precise way. Instead of the diffuse, radiating pain that was so distracting, the sharp, pinpoint pain from the needle was tolerable. It hurt, but in an entirely different way. I could tell it was a good, healing pain, if that makes any sense. Over the months that followed, I even came to look forward to it, as odd as that may sound, probably because afterwards I experienced profound, blessed relief. After needling, the heating pad I applied eased the soreness and usually by the following day the pain was gone. At first, the pain in my hip gradually returned as time passed, but the interval between needling sessions grew from weeks to months. It’s been several years now since I have needed a needle in my glut, and I consider myself healed.

Dry Needling – a drug alternative

According to the American Physical Therapy Association’s web page2, dry needling is a technique used by physical therapists (where allowed by state law) for the treatment of pain and movement impairments. The technique uses a "dry"needle, one without medication or injection, inserted through the skin into areas of the muscle. Dry needling is not acupuncture, a practice based on traditional Chinese medicine and performed by acupuncturists. Dry needling is a part of modern Western medicine principles, and supported by research

A thin filiform needle is used to penetrate the skin and stimulate underlying myofascial trigger points and muscular and connective tissues. The needle allows a physical therapist to target tissues that are not manually palpable. Physical therapists wear gloves and appropriate personal protective equipment (PPE) when dry needling.2

My husband says dry needling can: 1) stimulate local tissue and reduce inflammation, decrease pain sensitivity, improve circulation and promote tissue healing; 2) reduce the intensity of reflex loops, allowing people holding tension due to discomfort to relax and release; 3) cause cortical reorganization and decrease hypersensitivity. Brain scans show areas in the brain that sense pain can reorganize after dry needling sessions.

Physical Therapy and Chronic Pain

When I talked to my husband, he told me that more than half of the people who enter a Physical Therapy office are dealing with chronic pain. He said, “Many have acute injuries, but many have chronic pain that has been treated episodically, even though they’ve been in pain for years. Our healthcare system supports episodic treatment, but isn’t designed to deal with long-term, chronic conditions.” I asked him, “Why would someone see you instead of a physician?”

He lit up at this question and I could tell that this is where his passion lies when he said, “It’s all about assessment. No one has asked these patients the right questions, not the ER, not their family doctor.” He went on to say that ideal pain management comes from a really good pain assessment that contains two key components:

1. Let people tell their story.

Don’t interrupt. Physicians give patients an average of 11 seconds to explain their reasons for visiting before interrupting.3 There is no chronology or narrative component of health intake forms. It’s important to let people tell their story. The clinician needs to understand it the way the patient understands it.

2. Ask relevant questions.

Elements of chronic or persistent pain don’t fit into our biomedical paradigm. Chronic pain often doesn’t respond to best practice or clinical guidelines. Trying to break it down into a rapid evaluation or a quick turnaround is challenging. Practitioners need to ask about patient understanding of pain levels, what activities are bothersome, baseline levels of functionality, metrics for improvement. According to my husband, we need to ask, “What is important to you? What is relevant to you? What would getting better look like?” He went on to describe how a patient might have a story of a relative who has pain, and they become fearful that they will be “like this other person” they know who lost functionality. He described how “the patient might say, my back hurts…but the pain in the center low back has one descriptor, while the side of the back is different and comes on at different times, with different activities, and they might have leg pain that is different and it may be related or it may not be – we need to find out how these are linked or not linked. They may be three completely separate things, or they may be strongly connected.”

Who can’t be helped?

I ended our interview by asking, “Is there anyone you can’t help?” My husband said, “I can’t help people who have no hope. People who don’t believe they can get better are incredibly challenging. That’s why the story is so important.” PTs are now getting trained in Cognitive Behavioral Therapy and motivational interviewing to better address the psychological components of healing and pain relief. (For more information about motivational interviewing – check out my blog HERE Type I Diabetes: Motivational Interviewing for Chronic Illness)

How to find a PT?

To find a PT click HERE and type in your zip code. My husband says, “You want a PT who specializes in active interventions, hands on, exercise activity modifications, not one who focuses on modalities like e-stim, ultrasounds, ice, or traction – they can be adjuncts, but shouldn’t be the meat of treatment.”

What about insurance? Coverage for dry needling differs from state to state, but all other components of PT like manual therapy and active exercise are covered in every state.

You can self-refer

Don’t wait for your physician to bring it up. You may not even need a referral. PTs are independent practitioners, so in every state there is some component of direct access. I know NC is unrestricted. When talking to your provider, you may need to advocate for yourself. Say you are interested, say, “I’d like to talk to a PT and see if I’m appropriate.” Or simply go see a PT and ask them for help navigating insurance and referrals.

REFERENCES

Antifragile Physical

Dry Needling

Physicians give patients 11 seconds to explain reasons for visit before interrupting

[LibraSunCNM, BSN, MSN, CNM]

It's so interesting---I'd never ever heard of dry needling until a few months ago, when one of my pregnant clients got it during a regular acupuncture session and ended up with a pneumothorax! I truly am all for alternative therapies, especially for complex issues like chronic pain, but my client's experience made me leery.

[SafetyNurse1968, ADN, BSN, MSN, PhD]

On 7/1/2019 at 4:51 PM, LibraSunCNM said:

It's so interesting---I'd never ever heard of dry needling until a few months ago, when one of my pregnant clients got it during a regular acupuncture session and ended up with a pneumothorax! I truly am all for alternative therapies, especially for complex issues like chronic pain, but my client's experience made me leery.

I've been meaning to respond to this comment since you posted it! I am so sorry I didn't get to it sooner. I immediately talked to my PT husband about it and he said, "Yes, there are definitely risks to dry needling and pneumothorax is one of them." What I found fascinating is that PTs in the US don't track error! I was truly shocked to learn this. They are independent practitioners and have no oversight as to how they report and aggregate information on adverse events. I'm planning on writing to the American Physical Therapy Association (https://www.apta.org/) to get more information. In the mean time, he and I did a little digging and found some information about adverse events with acupuncture (I was unable to find any stats about dry needling itself):

"One of the largest needling studies ever performed looked at the question of adverse effects (AEs) with acupuncture...229,230 patients self-reported any AEs following [acupuncture] for chronic osteoarthritis pain of the knee, hip, low back, neck, or for headache, allergic rhinitis, asthma, or dysmenorrhea...[there were] approximately 2.2 million sessions. Of these, 8.6% (19,726 patients) reported experiencing at least one adverse effect, and 2.2% (4,963 patients) reported an adverse effect that required further treatment.29 The most common AEs were bleeding or pain, but two patient's experienced a pneumothorax, and one patient had a nerve lesion with side effects that lasted 180 days."

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4970854/ Halle & Halle (2016). PERTINENT DRY NEEDLING CONSIDERATIONS FOR MINIMIZING ADVERSE EFFECTS

[NRSKarenRN, BSN, RN]

Thanks for info on dry needeling. Spoke with my PT colleagues if they are performing in PA state. Currently PA practice act does not permit them to perform anything below skin level, so awaiting more info re safety/adverse reactions/lawsuits before promoting to state PT board.

[CyclicalEvents]

I believe there is an uptodate article on dry needling vs placebo which found both treatment groups and placebo groups who believed they were receiving treatment reported decreased level of pain.

[K+MgSO4, BSN]

I have seen a physio who was very tech focused - USS, ice/heat, traction taping. I got relief from the immediate injury but continued to have low level chronic back pain. I accidentally discovered that my former colleague had opened a practice in the shopping centre beside my house. He is the complete opposite- recommended dry needleing and Pilates. I found the needleing amazing, the initial few sessions I could feel the needle twanging from the release of the fascia and subsequent sessions this reduced. The clinical pilates program including posture modification has left me nearly pain free.

I have also previously had needleing to my foot for PF with great success.

[LibraSunCNM, BSN, MSN, CNM]

19 hours ago, SafetyNurse1968 said:

I've been meaning to respond to this comment since you posted it! I am so sorry I didn't get to it sooner. I immediately talked to my PT husband about it and he said, "Yes, there are definitely risks to dry needling and pneumothorax is one of them." What I found fascinating is that PTs in the US don't track error! I was truly shocked to learn this. They are independent practitioners and have no oversight as to how they report and aggregate information on adverse events. I'm planning on writing to the American Physical Therapy Association (https://www.apta.org/) to get more information. In the mean time, he and I did a little digging and found some information about adverse events with acupuncture (I was unable to find any stats about dry needling itself):

"One of the largest needling studies ever performed looked at the question of adverse effects (AEs) with acupuncture...229,230 patients self-reported any AEs following [acupuncture] for chronic osteoarthritis pain of the knee, hip, low back, neck, or for headache, allergic rhinitis, asthma, or dysmenorrhea...[there were] approximately 2.2 million sessions. Of these, 8.6% (19,726 patients) reported experiencing at least one adverse effect, and 2.2% (4,963 patients) reported an adverse effect that required further treatment.29 The most common AEs were bleeding or pain, but two patient's experienced a pneumothorax, and one patient had a nerve lesion with side effects that lasted 180 days."

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4970854/ Halle & Halle (2016). PERTINENT DRY NEEDLING CONSIDERATIONS FOR MINIMIZING ADVERSE EFFECTS

Yes, I think it's definitely really rare, and in the case of lower back pain the risk is probably much lower (in her case they needled somewhere around her collarbone, I forget why). I was just so surprised that happened! The client was too and it risked her out of our freestanding birth center and into a hospital-based birth with us because of that, which she was bummed about. It's an interesting topic for sure.

[Jessinurse]

I got a pneumothorax from my first ever steroid shot. There is an area on the back with a very thin muscle layer that needles easily reach through. The physician warned me about the area being thin and able to puncture to cause a pneumothorax directly before doing it. Never went back for more steroids. However, I have had electro acupuncture probably 50-100 times with only one small hematoma that didn’t hurt and resolved in a few days. Quick google search says Adverse effects of opioids, nsaids and steroids are equal or higher than acupuncture. I think it’s a good therapy but outcomes depend on the skill of the practitioner.