Trigger Point Dry Needling (TDN) is an effective therapy to treat muscular tension and spasm which commonly accompanies conditions such as arthritis, nerve irritation, muscular strain, ligament strains and herniated discs.

What is Trigger Point Dry Needling (TDN)?

TDN is the use of solid filament needles inserted through the skin and into the muscle to release painful myofascial trigger points. Dry needling results in the deepest tissue release allowing for improvements in movement and pain. It is called “Dry” Needling because there is no solution injected as with a hypodermic needle during a flu shot. With Dry Needling, the needle itself and the effects it produces within the tissue is the treatment.

When an injury occurs from repetitive use or acute trauma, inflammation will be produced from the damaged tissues. The damaged tissues will also go into a protective tension state or contracture to guard against further damage from utilizing the injured tissue. This contracture and inflammation inhibit microcirculation which limits both the oxygen rich blood reaching the injury and the waste products leaving the injury. The injury site becomes hypoxic (decreased in oxygen) which stimulates the body to produce fibroblasts, a cell that produces fibrosis or scar tissue. This fibrosis and scarring builds up around the muscles and tissues limiting the tissues ability to fully function (lengthen/shorten) and can also cause compression and irritation of nerves (such as carpal tunnel syndrome) – all of which inevitably lead to biomechanical disturbances in gait and function.

TDN uses a small, solid filament needle which is inserted in a contracted painful knotted muscle to create a local twitch reflex which is both diagnostic and therapeutic as it is the first step in breaking the pain cycle as research shows will decrease muscle contraction, reduce chemical irritation, improve flexibility and decrease pain. When a needle is inserted into muscle it will also produce a controlled lesion and will cut between three to fifteen thousand individual muscle fibers. The body considers the needle as a foreign invader and will activate the immune system as a response. The cut muscle fibers also produce an inflammatory reaction that your body will respond to not just locally but all over the body to reduce inflammation systemically.

Mechanical Effects

Dry Needling may mechanically disrupt a dysfunctional motor end plate
Needling results in a Local Twitch Response (LTR)
The LTR results in an alteration to muscle fiber length as well as having an inhibitory effect on antagonistic muscles

Neurophysiological Effects

Baldry (2001) suggests that dry needling techniques stimulate A-nerve fibers (group III) for as long as 72 hours post needling
Prolonged stimulation of the sensory afferent A-fibers may activate the enkephalinergic inhibitory dorsal horn interneurons, which implies that dry needling causes opioid mediated pain suppression
Another possible mechanism of dry needling is the activation of descending inhibitory systems which would block noxious stimulus into the dorsal horn
The LTR may also utilize the excessive ACh in the tissue which previously was triggering increased firing of localized fibers

Chemical Effects

Studies by Shah and colleagues (2001) demonstrated increased levels of various chemicals at sensitized motor end plates such as: Bradykinin, Substance P and CGRP (regulator of Calcium and Phosphate balance). These chemicals were reduced immediately post a LTR.
CGRP enhances the release of ACh from nerve terminals, which results in increased ACh receptors at the neuromuscular junction
Needle penetration will cause micro-trauma and micro bleeding (localized inflammation) and hence the introduction of PDGF into the area to help promote healing

Is Trigger Point Dry Needling Acupuncture?

No, Trigger Point Dry Needling is based on Western medical research and principles, whereas acupuncture is based on Traditional Chinese Medicine. The main similarity is that the same sterile, disposable solid filament needles are used, but each therapy is a separate and distinct in their methodology, perspectives and practices.

What Types of Conditions Can TDN Assist?

Neck/Back Pain
Shoulder Pain
Tennis/Golfers Elbow
Headaches
Hip and Gluteal Pain
Knee Pain
Achilles Tendonitis/Tendonosis
Plantar Fasciitis
Sciatica
Muscular Strains/Ligament Sprains
Chronic Pain
Athletic Performance

Does TDN Hurt?

You may or may not feel the insertion of the needle. The specific needle manipulation is intended to produce a local twitch response that can elicit a very brief (less than a second) painful response some patients describe as a deep ache or cramping sensation. Again, the therapeutic response occurs with the elicitation of the local twitch response and is a desirable reaction.

What Can I Do To Prepare For My Therapy?

Eat a light meal 1-2 hours prior to your visit and wear loose, comfortable clothing that can be rolled up or down to access your areas of concern with the greatest ease.

What Can I Expect After The Treatment?

We are looking to get improvements even from the first visit such as increased range of motion, ease of movement and decreased signs/symptoms.

Many clients report being sore after the treatment in both the area treated and the area of referred symptoms. Typically this soreness lasts between a few hours and two days and there is occasional bruising. Soreness may be alleviated by applying ice or heat to the area and performing specific stretches for the treated muscle.

VERY IMPORTANT: THIS CALENDAR IS FOR SOUTH AFRICAN CLIENTS PAYING VIA EFT, YOCO OR SNAPSCAN

International Clients please visit:
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Very Important Information about Dry Needling

Dry Needling is a very successful medical treatment which uses very thin needles without any medication (a dry needle) to achieve its aim. Dry Needling is used to treat pain and dysfunction caused by muscle problems, sinus trouble, headaches, and some nerve problems. It is not at all the same as acupuncture. Acupuncture is part of Traditional Chinese Medicine, whereas dry needling is a western medicine technique, which needs to have a medical diagnosis. There is a clear scientific understanding of dry needling, and it carries not spiritual “baggage” as acupuncture may do.

Dry Needling works by changing the way your body senses pain (neurological effects), and by helping the body heal stubborn muscle spasm associated with trigger points (myofascial effects). There are additional electrical and chemical changes associated with dry needling therapy which assist in the healing process. It is important to see the needles as just one part of your overall rehabilitative treatment. Dry needling is not a miracle cure – it forms part of other complimentary therapies. It is vital that you do the exercises and follow the advice your therapist gives you in conjunction with the needling for optimal recovery.

Your therapist has been specifically trained in the various needling techniques. The therapist will choose a length and thickness of needle appropriate for your condition and your body size, and then insert it through the skin at the appropriate place. You will feel a small pinprick. Depending on the type of needle technique chosen by your therapist, you may also feel a muscle ache and a muscle twitch. These are all normal and good sensations, and mean that you will experience good relief from your symptoms.

In general, there is very little risk associated with this technique if performed properly by a trained therapist. You may have a little bruising around the needle site, much the same as you would with any injection. On rare occasions, people may feel very happy, tearful, sweaty or cold. These symptoms all fade quickly. Fainting may occur in a very small minority of people. There are no lasting ill effects of these side effects.

If you are being treated in the shoulder, neck or chest area, there is an additional risk that involves your lung. If the lung itself is punctured, you may develop a condition called a pneumothorax (air in the space around the lung). This is a rare but serious problem, and you should go directly to a hospital casualty department without panicking if it occurs. The symptoms of this event include shortness of breath which gets worse, sudden sharp pain each time you breathe in, a bluish tinge to your lips, and an inability to “catch your breath”. The treatment is very successful for this rare but possible complication.

If you are happy to continue with the therapy as suggested by your therapist, and have asked any questions that you may want to, then please sign the consent form and hand it to your therapist.

Guidelines on Needlestick Injury

Background

Dry needling involves the use if sterile single use needles which penetrate the body wall of humans to achieve therapeutic results. Of necessity, this exposes the therapist to the body fluids of the patient, specifically blood and blood products. The HI virus is transmitted through exposure to blood and some other body fluids. This includes Body fluids’ include semen, vaginal secretions or other fluids contaminated with visible blood such as is encountered when using needle therapy.

(Note that Saliva, tears, sweat, urine and breastmilk are not associated with the risk of HIV transmission in an occupational setting).

Thus the therapist practicing dry needling will be exposed to the increased risk of contracting HIV through contact with infected blood. The average risk of HIV infection from all types of reported percutaneous exposure to HIV infected blood is 0.3%. Although this increased risk is small, it behoves the therapist to take reasonable precautions to minimize this risk both before and after potential exposure. The risk increases with the amount of bleeding and depth to which the needle is inserted (superficial needling carries less risk than deep needling), but this is much less for solid needles such as are used in Dry Needing than it is for hollow needles which are typically used for venepuncture or administration of medication.

This document is written to summarise the official government position on Post-exposure prophylaxis (PEP), and should be read together with the guidelines on needle safety which are also contained in this manual. Remember that if you keep to the safety guidelines on how to needle safely (ie how to keep your self safe), you will probably not need to follow the post exposure guidelines as you will not get pricked.

Heath department recommendations for the management of occupational exposure to blood of body fluids, (adapted for dry needling)

Know your own status now. Be tested after any suspect exposure.
For all exposures, immediately clean the affected area with an antiseptic agent and water and irrigated. Mucus membrane and eye exposures should be rinsed and flushed extensively with water. Get yourself treated first before worrying about the patient’s status
Evaluate the exposure as follows:
1. The following are potential exposures that should be considered for PEP
  - A blood contaminated needle stick injury (ie dry needling, esp. deep needling)
  - An injury with a blood contaminated sharp instrument or similar instruments contaminated with semen, CSF, pleural or other serous fluid (excluding urine and faeces).
  - An exposure to the mucous membranes (eye, mouth) with the above fluids.
  - A blood contamination of compromised or diseased skin (such as a weeping eczema).
  - Prolonged exposure to a large volume of blood on normal skin
2. Determine the HIV status of the exposure source
  1. If there is no record of the HIV status of the source patient, then an attempt should be made to obtain blood from the patient for this purpose. This should according to existing guidelines for HIV testing and include pre and post-test counseling. An approved rapid HIV test could be performed and later confirmed by routine HIV testing procedures. Do not wait for the result of such a test before beginning ARV treatment.
  2. If the patient refuses HIV testing, if there is no record of a recent HIV test result, or if HIV testing is not possible or available, then a doctor caring for the patient should be consulted as to the likelihood of the patient being HIV positive. Clinical signs indicating possible HIV infection include: TB infection, signs of immune deficiency such as oral thrush (candidiasis) and/or oral hairy cell leukoplakia on the tongue, recent herpes zoster or molluscum contagiosum infection, Kaposi sarcoma, recurrent infectious conditions such as diarrhoeal diseases, pneumonia, meningitis, skin sepsis; or unexplained weight loss, seborrhoeic dermatitis or persistent glandular lymphadenopathy. Using these clinical parameters in the absence of an HIV test is far from ideal and many HIV positive persons will be asymptomatic.
    [In situations where there is a high suspicion that the patient may be in the window period, then an HIV PCR or HIV p24 antigen test could be considered.]
Recommendations for PEP
1. PEP is recommended for any high-risk exposure (see table 1). Deep dry needling falls in this category
2. ZVD in combination with Lamivudine is recommended for high risk exposures. Single therapy with ZVD may be effective and is preferable to no PEP but is likely to be less effective than therapy with more than one drug. Single ZVD PEP therapy is not recommended by any recognized international authority.
3. Indinavir can be added for very high risk exposures. Very high risk exposures include:
  1. large volume of blood;
  2. deep injury; and,
  3. if the source patient has been on ZVD for more than 6 months.
4. PEP should be initiated promptly, preferably within 1-2 hours after the exposure. The interval after which there is no benefit from using PEP is not yet defined, however most experts recommend PEP within 24 hours after exposure. Some experts may still consider PEP 7-14 days after the exposure in cases where there is highest risk exposure. To avoid delays in starting PEP, starter packs of recommended drugs should be available in all health care settings.
5. PEP should be continued for 4 weeks. PEP should be discontinued if there are serious toxicities or intolerance and should be continued even in the presence of mild side effects.
6. Exposures such as small blood volumes or other body fluid contact on normal healthy skin are considered very low risk. PEP is not recommended in these cases but can be assessed on a case by case basis. For exposures to urine or faeces, PEP is not recommended unless these are contaminated with blood.
7. If the source patient’s HIV status is not known, initiating PEP should be decided upon on a case by case basis, and based on circumstances including the likelihood of HIV infection in the source patient.
8. PEP is recommended if:
  1. the source patient is HIV positive;
  2. the rapid HIV test is positive; or,
  3. or if there is a high index of suspicion that the source patient is HIV positive.
9. An Elisa HIV test should be done and documented on the exposed health care worker at baseline (i.e. within 24 hours of the injury), at 6 weeks, 12 weeks and at 6 months. In rare instances sero-conversion can take place over a period longer than 6 months.
10. Tests for occupational exposure to Hepatitis B and C, syphilis, malaria etc should also be considered if deemed appropriate. PCR and p24 antigen tests are not routinely recommended as false positive and negative tests are not infrequent and these tests are costly.
11. Supportive counseling should be available to the health care worker. The health care worker should consider using a barrier method for safer sex. Avoidance of pregnancy in female health care workers is also recommended until sero-conversion is excluded. Pregnancy in health care workers should not preclude the use of PEP.
12. If HIV sero-conversion occurs the health care worker should be referred for appropriate counseling and treatment and informed about compensation claims.
13. An appropriate and confidential reporting system should exist within health facilities to document all occupational exposures and details on the source patient, and health care worker for medico-legal purposes and for possible compensation and insurance claims. All HIV related occupational exposures, irrespective of whether PEP is recommended, should be reported to health facilities.
14. Health care facilities should delegate responsible officials to oversee the reporting and recording of occupational HIV exposures.
15. If the HIV test on the source patient is negative, it can be assumed that there is a low risk of exposure to HIV unless there is reasonable information to suggest that the source patient is in the window period. In these cases PEP is not recommended.

Table 1. Type of occupational exposure, risk of exposure, HIV status of the source and recommendations for PEP:

Percutaneous injury	Risk of exposure	Recommendation for PEP
Superficial injury, solid needle (Superficial dry needling)	Some risk	Consider Basic Regimen
Skin puncture, visible blood on the needle, hollow needle,	High risk	Recommend Basic Regimen
Needle used in a vein or artery	Highest risk	Recommend Basic Regimen, Consider Expanded Regimen
Deep intra-muscular injury or injection into the body (Deep dry needling)	Highest risk	Recommend Basic Regimen, Consider Expanded Regimen

Mucousal and skin contacts	Risk of exposure	Recommendation for PEP
Unbroken healthy skin	Low risk	Not recommended
Compromised skin, small volume and brief contact	Low risk	Consider Basic Regimen
Compromised skin, large volume and/or prolonged contact	Increased risk	Recommend Basic Regimen

HIV Status of Source	Risk of exposure	Recommendation for PEP
Negative	Very Low	Not recommended
Positive, Clinical AIDS and/or a low CD4 cell count and /or a high viral load	Low for small volumes or short duration on intact skin	Consider Basic Regimen
HIV Positive, Clinical AIDS and/or a low CD4 cell count and /or a high viral load	High risk for percutaneous injuries	Recommend basic or expanded regimen depending on the severity of injury
Unknown		Consider PEP on a case by case basis

References for Needlestick guidelines

CDC. Case Control study of HIV sero-conversion In healthcare workers after percutaneous exposure to HIV infected blood in France, United Kingdom and United States, January 1988-August 1994.MMWR 1995;44:929-33
Gerberding JL. Management of occupational exposures to blood borne viruses. N Eng J Med 1995;332:444-51
Jochimsen EM. Failures of Zidovudine Post exposure Prophylaxis. Am J Med 1997;102 (5b) 52-55
CDC. Case control study of HIV sero-conversion in healthcare workers after percutaneous exposure to HIV infected blood. France, United Kingdom and United States, January 1988-August 1994.MMWR 1995;44:929-33
Connor EM, Sperling RS, Gelber R, et al. Reduction of maternal-infant transmission of HIV type 1 with Zidovudine treatment. N Eng J Med 1994;331:1173-80.
CDC. Thailand Collaborative Perinatal HIV Prevention Study
Saag MS. Candidate Antiretroviral Agents for Use in Post Exposure Prophylaxis. Am J Med 1997;102( (5b): 25-31
ibid
Centers for Disease Control and Prevention. Update: Provisional recommendations for chemoprophylaxis after occupational exposure to Human Immunodeficiency Virus MMWR. 1996;45:468-472
Jochimsen EM. Failures of Zidovudine Post Exposure Prophylaxis. Am J Med 1997;102 (5b) 52-55
U.S. Department of health and Human Services, Centers for Disease Control and Prevention (CDC). Public health Service Guidelines for the Management of Health-Care Worker Exposure to HIV and Recommendations for Post Exposure Prophylaxis. May 15 1998/Vol47/N0.RR7 page 8-9
Centres for Disease Control and Prevention. Update: Provisional recommendations for chemoprophylaxis after occupational exposure to Human Immunodeficiency Virus MMWR. 1996;45:468-472
Personal Communication with Dr Des Martin, National Institute of Virology
Centers for Disease Control and Prevention. Update: Provisional recommendations for chemoprophylaxis after occupational exposure to Human Immunodeficiency Virus MMWR. 1996;45:468-472
B Schoub. Virus SA . 1997 : Guidelines to the Management of Occupational Exposure to HIV. National Institute of Virology.
Tokars JI, Marcus R, Culver DH, et al. Surveillance of HIV infection and Zidovudine use among health care workers after occupational exposure to HIV infected blood. Ann Intern Med 1993;118:913-9
Centres for Disease Control and Prevention. Update: Provisional recommendations for chemoprophylaxis after occupational exposure to human immunodeficiency virus MMWR. 1996;45:468-472
Adapted from Centres for Disease Control and Prevention. Update: Provisional recommendations for chemoprophylaxis after occupational exposure to Human Immunodeficiency Virus MMWR. 1996;45:468-472, and from B Schoub. Virus SA . 1997 Guidelines to the Management of Occupational Exposure to HIV. National Institute of Virology

National Department of Health HIV/AIDS/STD Directorate: (012) 312-0121.