PELATIHAN

TEKNIS
FISIOTERAPI
2014
Dry Needling
Dry Needling: OBJECTIVES

 Understand what dry needling is and is not

 Understand what the current literature says and in relation

to dry needling

 Understand how dry needling is being used in clinics today

 DRY NEEDLING
History, Definitions, and Terminology
 JH Kellgren
•Hypertonic saline
injections
•Referral patterns

Sir William Gowers Karl Lewit, MD, DSc

•BMJ 1;117-121 •“The Needle Effect”
•Fibrositis”
•Palpable tenderness
and hardness of the
muscle C. Chan Gunn

1931 1996
Fred H. Albee, Radiculopathic
MD, ScD Model
• “Myofascitis Janet Travell, MD and
DIFFERENTIAL DIAGNOSIS OF David G. Simons, MD
from an
PAIN LOW IN THE BACK
orthopedic
ALLOCATION OF THE SOURCE OF PAIN Coined “Trigger Point”
standpoint”
BY THE PROCAINE HYDROCHLORIDE
METHOD Myofascial Pain and
Max Lange JAMA. 1938;110(2):106-113 Dysfunction, The Trigger
1st Trigger Point Manual Point Manual. Lippincott
Arthur Steindler Williams & Wilkins.
Die Muskelhärten (Myogelosen): •“Myofascial pain”
Ihre Entstehung und Heilung •“Trigger points” Trigger Point Model
Dry Needling-Definition

Dry Needling
A skilled intervention
performed by a physical
therapist that uses a thin
filiform needle to
penetrate the skin and
stimulate underlying
myofascial trigger points,
muscular and connective
tissues for the
management of
neuromusculoskeletal
pain and movement
impairments. 
(American Physical Therapy Association
Dry Needling Task Force, May, 2012)
Dry Needling Terminology
Why Not Call It TDN?

 Trigger Point Dry Needling implies we

only treat taunt bands in muscles . . .
 What about CTS, tendinopathies,
neuropathies, scar tissue, paresthesia
…
What is DN cont.:

Words to avoid at State & National

Levels:
 Trigger Point Dry Needling (TDN) – Myopain
 Functional Dry Needling - Kinetacore
 Integrative Dry Needling – Am. DN Institute
 Intramuscular Stimulation (IMS) – Gunn
 Intramuscular Dry Needling
 Intramuscular Manual Therapy
 BioMedical Dry Needling – Am. DN Institute
 Is
Dry Needling
within
the
Scope
of
Physical
Therapy
Practice?
 POSITION STATEMENT
It is the position of the AAOMPT that dry
needling is within the scope of physical
therapist practice.
October, 2009
 SUPPORT STATEMENT
Dry needling is a neurophysiological evidence-based
treatment technique that requires effective manual
assessment of the neuromuscular system. Physical
therapists are well trained to utilize dry needling in
conjunction with manual physical therapy
interventions. Research supports that dry needling
improves pain control, reduces muscle tension,
normalizes biochemical and electrical dysfunction of
motor endplates, and facilitates an accelerated
return to active rehabilitation.
October, 2009
Federation of State Boards
Resource Paper 2010
Federation of State Boards
Resource Paper 2010
Federation of State Boards
Resource Paper 2010

CONCLUSIONS:
Dry Needling by Physical Therapists meets requirements
of:
Historical basis
Available education and training
Educational foundation (CAPTE)
Supportive scientific evidence

IMT is not an entry level skill and should require additional training
Will this be true for the future though?
Federation of State Boards
Resource Paper 2010

CONCLUSIONS (cont.)

Procedures do not define a profession, scope does



There will be overlap of treatment techniques between different

scopes
Federation of State Boards
Resource Paper 2010

It is clear that no single profession owns any procedure

or intervention. Overlap among professions is expected
and necessary for access to high quality care.

Federation of State Boards: Intramuscular Manual

Therapy (Dry Needling) Resource Paper,
2010
APTA Resource Paper
January 2012
 Physical Therapist
Education
 Licensure and Regulation
 Current Status of Dry
Needling in Physical
Therapist’s Legal Scope of
Practice in the United
States
 Distinction Between
Profession’s Scopes of
Practice
 Summary Research
Review on Dry Needling
 Is
Dry Needling
Acupuncture?
Dry Needling versus Acupuncture

Similarities Differences

The Tool Evaluation

Application

Overall Goal
Tools don’t define a profession

Calculator Accountant

=
Tool should never define the profession that uses it.
 Traditional Chinese
Acupuncture

Evaluation utilizes
examination of tongue
and pulse

www.kinetacore.com
Traditional Chinese
Acupuncture
Needle insertion points
are founded in knowledge
of meridians
 www.tcmcentral.com

Traditional Chinese
Acupuncture
Uses needle to balance
energy, life-force, or qi in
the body

www.yangacupunctureherbalinstitute.com
 Dry Needling in
Physical Therapy

Needle insertion points

based on assessment
and knowledge of
neuroanatomy
Dry Needling in
Physical Therapy

Evaluation includes subjective

and objective examination of the
neuromuscular system
Why Dry Needling?

Understandi
ng how and
why it works
starts with…
Understanding Neuromuscular
Dysfunction
Trigger Points (Simons, Travell, and Simons, 1999)

Definition
Active Trigger Points
 hyperirritable spots
 taut band of skeletal
muscle/fascia
 painful upon
compression
 produce
characteristic pain,
referred tenderness,
motor dysfunction
and/or autonomic
phenomena
Trigger Points (Simons, Travell, and Simons, 1999)

Definition

 Latent Trigger Points

Painful upon palpation

Sensations not recognizable

 Satellite Trigger Points

Develop in a zone of reference of key trigger points

(synergist, antagonist, neural link or referral zone)
Trigger Points
Travell and Simons
Mapping

Myofascial Pain and Dysfunction: The Trigger Point

Manual Volume , 1 2nd Edition
Image Copyright Lippincott Williams & Wilkins
Trigger Point
Characteristics:
SPONTANEOUS ELECTRICAL ACTIVITY

Dysfunctional motor endplate potential at rest

(From Ge H-Y, et. al., 2009)

Trigger Point
Characteristics:
BIOCHEMICAL CHANGES

(J Appl Physiol 2005; 1977-1984)

(Arch Phys Med Rehabil 2008; 89:16-23)

Physiological effects
 Healing effects
 Effects on trigger points
 Analgesic effects
Healing effects
 Immediately after the needle is
introduced into the skin, there are
evidences of increased capillary
permeability producing rapid local
vasodilatation.
 The insertion of the needle causes a
minute injury to the epithelium.
 Injury potentials are generated and can
persist and provide electrical stimulation
for days until the miniature wound heals 1.
 The injury potentials are known to
accelerate healing by creating
galvanotaxis (polarity directed cell
migration) along with a host of other
biochemical events.
 The needle, once inserted, can be
manipulated by rotation and pistoning.
 It has been found that needle
manipulation produces winding and
gathering of collagen around the needle.
 Within minutes of needle rotation, this
pulling of collagen toward the needle
induces an active cellular response in
connective tissue fibroblasts up to
several centimeters away from the
needle2. This transduction of the
mechanical signal into fibroblasts can
lead to a wide variety of cellular and
extracellular events leading to
neuromodulation and healing3.
 Needle insertion in the skin also releases
cortisol, body’s own steroid1.
 Increased local cortisol levels have
catabolic effect on connective tissue
stimulating tissue remodelling and scar
tissue breakdown.
Effect on trigger point
 Trigger points are small muscular
contractures caused by dysfunctional
motor endplates4.
 Activation of trigger points may be caused
by acute or chronic muscle overload,
activation by other trigger points,
homeostatic imbalances, direct trauma to
the vicinity,  radiculopathy, infections etc.
 Needling is a widely accepted treatment
choice for deactivation of trigger points.
 When the needle is inserted directly to the
trigger point (Deep Dry Needling: DDN), a small
muscle contraction is obtained, which is called
Local Twitch Response (LTR).
 LTRs normalize the chemical environment of
active MTrPs and diminish endplate noise
associated with trigger point instantaneously 5.
 On the other hand in superficial dry needling
(SDN) only the skin overlying the trigger point is
pierced. This releases the trigger point by reflex
inhibition.
Physiologic Effects of Dry
Needling:
DECREASE SEA

SEA quiets following

LTR

(Chen, 2000)
Analgesic effect
 Needling produces stimulation of
superficial A delta fibers in the skin6.
 This effect may persist for hours after
needling due to the injury potential7.
 Stimulation of the sensory afferent A δ
activates enkephalinergic, serotonergic,
and noradrenergic inhibitory systems.
Together they work as opioid mediated
analgesia system (OMAS).
 This analgesic system involves
segmental as well as suprasegmental
pathways8 working through Substantia
Gelatinosa of Rolando (SGR) in the spinal
cord.
 The following description of needling
related pain modulation is based on
Bowsher’s work9.
Pain pathway
 The segmental modulation

 A delta primary afferent receptors project to marginal

cells (M) which carries pinprick sensations in the lateral
spinothalamic tract.
 The A delta primary afferent receptors also project to
enkephalinergic stalked cells (ST) in the spinal cord,
which inhibits the SGR cells and blocks the
transmission of C pain.
 The serotonergic system

 The fast pain carrying fibers of lateral spinothalamic tract

give collaterals to peri aqueductal gray matter (PAG) of mid
brain.
 PAG in turn activates Nucleus Raphe Magnus (NRM) of
medulla which stimulates ST cells and inhibit SGR.
 The prefrontal cortex can influence the PAG activation via
hypothalamus and activate this descending pain
suppression system.
 The noradrenergic system

 The nucleus paragigantocellularis (PGC) of

medulla influences locus coeruleus (LC) of pons
or similar noradrenergic brainstem structures
which controls firing of SGR and modulates pain.
 This too can be influenced by Pre frontal
cortex- hypothalamus axis.
Diffused noxious inhibitory
control

 Direct input of A delta generated

information to Reticularis Dorsalis (R) in
medulla inhibits pain by its influence on
spinal segment.
Summary
Dry Needling in Clinical Practice

 blood flow
 banding locally
or in segmental
muscles
 Improve ability of
muscle to move
through range
Dry Needling in Clinical Practice
 Deactivate painful
“trigger point”
 nociceptive
sensitizing agents
 SEA
 banding/compress
ion of adjacent tissues
 Segmental Inhibition
(DRG and dorsal
horn)
 Affect on central
mediators (PAG and
endogenous opioids)
Dry Needling in Clinical Practice

 Restore length
tension relationship
 nociception
 Improve
somatosensory
mapping
What is dry needling?
 Dry needling is a procedure where filiform
needles are tapped through the skin to the
target tissue to bring about a therapeutic
effect.

 No medicine is delivered, thus it is called

‘dry’, compared to injections, which are
‘wet’.
 Other names/variations are IMS, TrP DN etc.
Needles

 Needles can be as short a s12.5 mm

or as long as 100 mm. the choice of
needle is based on the target tissue
and specific techniques used.
 Disposable filiform acupuncture
needle with guide tube is used.
(filiform= solid)
 Guide tube minimizes pain
Disposable sterile needles
packed
Needles with guide tubes
Needles sans guide tube
How is it performed?
  With careful precision the structure to be
needled is chosen. Then sterilized disposable
needles are pierced through the skin into the
target tissue.
 Choice of needle is dependent upon depth of
target tissue.
 A clean field technique is used. As there is
minimal or no bleeding, sterile field is not
needed.
 The needles are kept inserted for a span of 30
seconds to few minutes and then withdrawn
and disposed properly.
How is it performed?
 A sharps bin is
mandatory for
needle disposal.

Alternate to sharps
bin
Specific techniques
 Travell & Simon’s Technique: When needle
is pierced deep into the muscle/target
tissue. Local Twitch Response is elicited.
 Hong Technique: “pecking”. Fast in/ out 
Menimbukan LTR berkali2
 Gunn’s Techniique: Sepanjang otot 
sebanyak mungkin TrP
 Superficial Dry Needling: Started by Peter
Baldry, where only the skin overlying the
target tissue is pierced.
 Intramuscular electrical stimulation (PENS)
PENS
Response to needling
 Dry needling, much like MWM, when
indicated, produces immediate effect.
 Different people respond to needling
differently and are thus classified as
strong, average and weak responders. A
strong responder will need minimal
needle stimulation to achieve needling
effect; overstimulation can worsen
patient’s pain2.
ATFL
 LOKASI: Anterior & Inferior Maleolus
Lateralis (pada depresi sisi lateral
tendon EHL)
 Ukuran Jarum : 25mm
 Arah Jarum: Perpendicular
 Tusukan: ATFL
 KEGUNAAN: sprain ankle kronis
Stimulasi Saraf Tibial &
Peroneal Ankle
 LOKASI: Di (depresi) depan basis
Metatarsal II & III
 Ukuran Jarum : 13mm
 Arah Jarum: Perpendicular
 Kegunaan : Nyeri pada kaki
Gastrocnemius
 LOKASI: Dengan palpasi flat/ pincer
 Ukuran Jarum : 25 – 50mm
 Arah Jarum: Menjauhi midline
 Tusukan: Pada Trigger point
 Sering terjadi pegal setelah intervensi.
Jangan menusuk dua Gastroc pada hari
yang sama
TIB.ANT, EHL, EDL, Peroneii
 LOKASI: Dengan palpasi flat/ pincer
 Ukuran Jarum : 25mm
 Arah Jarum: oblique 450
 Tusukan: Pada Trigger point Tib.Ant
 Hindari tusukan pada arteri dan vena
tibialis, dan Saraf Deep Peroneal
 HAMSTRINGS (BF, ST, SM)
 LOKASI: Pada aspek posterior dengan lutut
sedikit fleksi. Gunakan pincer grip
 Ukuran Jarum : 50-75mm
 Arah Jarum:
- Medial Hamstring: Menggunakan pincer grip
 Perpendicular
- Lateral Hamstring: dari tengah menyudut ke
lateral
 Tusukan: Pada Trigger point
 Hindari menusuk Arteri Poplitea dan saraf tibial
(med. Ham) dan Saraf Sciatica (lat ham)
RECTUS FEMORIS
 LOKASI: Trigger point terletak di uujung
proximal
 Ukuran Jarum : 40/50mm
 Arah Jarum: Perpendicular/ pecking
Tusukan: Pada Trigger point
 Hindari menusuk Arteri Femoral atau
sartorius
Rectus Femoris
Patellofemoral : VL & VMO
(ujung bawah)
 LOKASI: Selebar 3jari diatas batas superolateral
patela
 Ukuran Jarum : 25mm
 Arah Jarum: Perpendicular

 LOKASI: Selebar 3jari diatas batas superomedial

patela (lutut flexi)
 Ukuran Jarum : 25mm
 Arah Jarum: Perpendicular
 Tusukan: Pada Trigger point
Vastus Medialis, Intermedius &
Lateralis
Patellofemoral : Tibial Nerve
 LOKASI: Pada depresi posteroinferior
batas bawah kondylus medial tibia
 Ukuran Jarum : 25mm
 Arah Jarum: Perpendicular
 Tusukan: Pada tibial nerve
 Kegunaan : Anterior Knee Pain
GLUTEUS MAXIMUS
GLUTEUS MEDIUS
 LOKASI:
- Menggunakan palpasi flat/ pincer
dengan posisi pasien side lying. Ganjal
bantal di lutut
 Ukuran Jarum : 40 – 75mm
 Arah Jarum: Perpendicular/ pecking
 Tusukan: Pada Trigger point Glut.Med
 Kegunaan: Untuk treatment TrP akibat
LBP
Gluteus Medius
TENSOR FASCIA LATAE
PIRIFORMIS
 LOKASI:
- Tidur miring dengan hip fleksi 900. Lokasinya
pada pertemuan 1/3 sisi luar dan 2/3 medial
pada garis yang menghubungkan trokanter
mayor dengan posterior iliac border SIJ
 Ukuran Jarum : 75mm
 Arah Jarum: Perpendicular  pecking
 Tusukan: Pada Trigger point
 Hati – hati: Saraf sciatic melewati bawah
piriformis dan sebagian menembus otot
piriformis
Piriformis
ILIOPSOAS
 LOKASI:
- TrP terletak pada aspek lateral femoral triangle,
medial terhadap SIAS sepanjang insersio otot
- Berdiri kontralateral terhadap otot yang ditusuk
Ukuran Jarum : 40/50mm
 Arah Jarum: Perpendicular
 Tusukan: Pada Trigger point Iliopsoas
 Selalu perhatikan arteri femoralis dan tahan
tangan kita disitu untuk memastikan kita tidak
menusuk arteri
Iliopsoas
ADDUCTOR (AL, AB, AM)
 LOKASI:
- AM dipalpasi dengan flat/ pincer, pada
midbelly di tuberositas iskiadikus
- AL & B ditusuk dengan arah posteromedial
ke arah arteri femoralismenggunakan pincer
grip sehingga jarum diarahkan ke jari
 Ukuran Jarum : 75mm
 Arah Jarum: Perpendicular  pecking
 Tusukan: Pada Trigger point
 Pada AL & B hindari tusukan ke arteri
femoralis
Adductors
AREA SPINE/ VERTEBRAE
Regio upper cervical &
OCCIPITAL NERVE
 LOKASI: Pada depresi setelah inferior dan
medial dari prosesus mastoideus. Antara
origo upper trapezius dan SCM, sebelah distal
EOP pada perlengketan Upper trapezius
 Ukuran Jarum : 13mm
 Arah Jarum: Oblique, menuju mata
kontralateral
 Tusukan: Occipital nerve, regio upper cervical
 Perhatian : Selalu tusuk menuju mata
kontralateral
UPPER TRAPEZIUS
 LOKASI: Di midpoint dari Upp. Trap, dari
posterior ke klavikula tengah
 Ukuran Jarum : 25mm
 Arah Jarum: Angkat otot ke arah
cephalad  pecking. Ke arah cephalad.
Sholder abduksi 900
 Tusukan: Pada Trigger point
Trapezius
LATISIMUS DORSI
 LOKASI: Gunakan pincer grip untuk
mendapatkan otot pada sisi cephalad di
lipat axila posterior
 Ukuran Jarum : 25mm
 Arah Jarum: Perpendicular
 Tusukan: Pada Trigger point Lat. Dorsi
MULTIFIDUS
 LOKASI: 1 jari ke lateral terhadap prosesus
spinosus C2 sampai L5
 Ukuran Jarum : 25mm
 Arah Jarum: Oblique ke arah spine/ sentral
 Tusukan: Pada Multifidus dan rotatores, saraf2
rami posterior primer
 Kegunaan : Kondisi spinal, titik spinal dimana
local needling tidak memungkinkan
 Perhatian : Selalu mengarah ke spine. Jangan
menusuk spasme pinggang akut
Multifidus
ERECTOR SPINAE
 LOKASI: 2 – 3 jari ke lateral terhadap
batas bawah prosesus spinosus dari L1
sampai L5
 Ukuran Jarum : 25mm
 Arah Jarum: Oblique ke arah spine/
sentral
 Tusukan: Lumbar ekstensor
 Kegunaan : Kondisi lumbal
 Perhatian : Selalu mengarah ke spine.
Iliocostalis & Longissimus
STIMULASI AKAR SARAF
SAKRAL
SUPRASPINATUS (POST)
SUPRASPINATUS (ANT)
TERES MAYOR & MINOR
SUBSCAPULARIS
DELTOID
BICEPS BRACHII