Dry Needling & Headache Management

Concussion Rehabilitation:Dry Needling & Headache Management

Michelle Ninemire, PT, DPT & Jocelyn Shaal, PT, DPT

Nebraska Brain Injury Conference 2020Omaha, Nebraska

CHI Health Immanuel Rehabilitation

Objectives1. Review proposed mechanisms and effects of trigger point dry

needling. 2. Recognize subjective and objective findings indicating appropriate

referral for dry needling. 3. Understand precautions and contraindications related to dry needling

technique. 4. Identify key muscle groups and associated referral patterns possibly

contributing to headaches. 5. Discuss state laws and limitations related to dry needling.

What is Dry Needling?

Invasive, skilled therapeutic intervention completed by physical therapists and other healthcare providers in which a

thin needle is used to penetrate the skin and stimulate muscular, connective, and neural tissue(s) to reduce pain and

address movement impairments.- American Physical Therapy Association

What is a myofascial trigger point?

● A hyperirritable spot in a tight band of muscle that is painful on compression, stretch, or contraction.

● Muscle overload/overuse causes the muscle to misfire and inadequately respond

● Characterized by local twitch response, spontaneous electrical activity, and biochemical changes

● Provokes weakness, imbalances, pain, restricted motion, and/or spasms causing revolving pain cycle

How does Dry Needling work?● Promotes relaxation of the muscle● Restores muscle’s ability to lengthen

and shorten by releasing the trigger point

● Alters chemical environment to decrease sensitivity and restore normal muscle function

● Increases blood flow and oxygenation to local area of pain for healing

● Attracts nutrients and flushes away acidic chemicals

Dry Needling + Concussion

Concussion review● Type of traumatic brain injury caused by a bump, blow, or jolt

to the head or by a hit to the body that causes the head and brain to move rapidly back and forth○ Sudden movement causes the brain to bounce or twist in the skull○ Causes stretching and damage to brain cells ○ Typically categorized under “mild traumatic brain injury”

Concussion vs. WhiplashA concussion is due to

acceleration or deceleration of the brain, while whiplash

is due to acceleration or deceleration of the neck.

Similarities:● Physical symptoms: headaches,

soreness, aching, dizziness● Cognitive symptoms: confusion

and difficulty concentrating● Behavioral symptoms: fatigue,

irritability, and anxiety

Headache Classifications

Basic Categories of Headaches

Primary Secondary

No underlying origin

Migraine Cluster

Result of other source(ie: inflammation, head/neck injury)

Vascular disorder CervicogenicTension “Brain Freeze”

Cervicogenic Headache

● Meaning “stemming from the neck”● Caused by injury to the neck, shoulders, or scapular regions● Includes a headache accompanied by neck pain

• Typically unilateral • Occasionally involve unilateral upper extremity pain

● Presents with:• Reduced cervical range of motion• Aggravation by movement or sustained neck positions• Palpable trigger points or tenderness in the neck or shoulder regions

• Reproduces or refers pain to familiar locations

Referred Pain + Referral Patterns

What is referred pain?

• “Secondary” pain• Pain that’s perceived at a location other

than the site of the painful origin • Area and size can be variable and can

spread in any/all directions• Descriptors: deep, diffuse, burning, tight,

or difficult to locate• Cause: network of interconnecting

sensory nerves that supply more than one area

Muscle Referral pattern

Upper Trapezius

Muscle Referral pattern

Sternocleidomastoid

Muscle Referral pattern

Splenius capitis + cervicis

Capitis

Cervicis

Muscle Referral pattern

Semispinalis capitis

Muscle Referral pattern

Oblique capitis inferior

Muscle Referral pattern

Cervical mutlifidi

Dry Needling Demonstration

What should I expect after completing Dry Needling?● Post-treatment soreness

○ Common 1-2 days following dry needling technique○ Utilize strategies to reduce severity of soreness by:

■ Using heat or ice on the affected area■ Gently massaging the area■ Stretching the muscle or muscle group as directed by your physical

therapist■ Staying hydrated■ Staying active and utilize body part for regular, daily activities■ Take prescription or over-the-counter medications as recommended by

your physician

● Possible Bruising

When should I avoid Dry Needling?• Needle phobia• Communication or language barriers

Information to discuss with your Physical Therapist:• Abnormal bleeding tendency • Compromised immune system • Vascular disease/Lymphedema• Pregnancy

• Age• Allergies• Medications• Diabetes

How do I know if I’m a candidate for Dry Needling?● Have you had an injury that causes pain?● Has this injury caused a restriction in range of motion or

flexibility?● Is your injured body part tender to the touch?● Can you feel a “knot” in any of the painful areas of your body?● Are you open to other forms of therapy including exercise,

manual treatments, and modalities?

If you answered yes to some or most of these questions, you may be an appropriate candidate for Dry Needling.

Frequently Asked Questions

Is Dry Needling the same as Acupuncture?

Dry Needling Traditional Acupuncture

Origin (Place & Time) Czechoslovakia ~1980 China ~3000 years ago

Basis Western medicine Eastern medicine

Needle insertion Soft tissues Meridian lines

Type of technique Pistoning, static, electrical stimulation

Typically left for a duration

Used for treatments of:

• Neuromuscular conditions• Relieving pain• Improving range of motion

Wide variety of conditions:• Internal ailments• Depression• Nausea• Migraine• Vomiting

Is Dry Needling an Injection?Dry Needling Wet Needling (Trigger Point Injection)

Meaning Without medication Local injection

Type of needle Thin, monofilament Hollow-bore

Cost $45-$85 (MD Save) $358-$591 (MD Save)

Other Information

-- Local anesthetic can reduce post-injection painOccasional use of ultrasound guidance

Is Dry Needling safe?● Yes. Physical therapists are experts in human anatomy and

kinesiology● Technique is learned following completion of accredited

physical therapy educational program and after obtaining licensure in practicing state

Is there anything I should avoid after Dry Needling?

● No. Patients are recommended to continue their typical daily routine following completion of dry needling, including but not limited to:○ Grocery shopping or running errands ○ Child care○ Exercise routine or recreational activities ○ Community interests: volunteer activities, clubs, social groups○ Other hobbies and interests

Are the needles reused or recycled?

● No. Each needle is discarded after use, consistent with medically approved standards and practices.

Billing + State Regulations

State Laws + Regulations

State of Nebraska:• Within scope of PT

practice• Must complete in-

service training prior to implementing the technique into practice

Citations

Citations

1. Dommerholt, J., Fernandez-de-las-Penas, C. 2013. Trigger Point Dry Needling: an evidence and clinical-based approach. Elsevier Health Sciences.

2. Matharu M. Cluster headache. BMJ clinical evidence. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907610/. Published February 9, 2010.

3. International Headache Society. The international Classification of Headache Disorders 3rd edition. https://ichd-3.org/. Published 2019.

4. Chowdhury D. Tension type headache. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3444224/. Published August 15, 2012.

5. Kaljić, E., Trtak, N., Avdić, D., Bojičić, S., Katana, B., & Pecar, M. (2018). The role of a dry needling technique in pain reduction. Journal of Health Sciences, 8(3), 128-139.

6. Dommerholt J. (2011). Dry needling - peripheral and central considerations. The Journal of manual & manipulative therapy, 19(4), 223–227.

7. Dunning, J., Butts, R., Mourad, F., Young, I., Flannagan, S., & Perreault, T. (2014). Dry needling: a literature review with implications for clinical practice guidelines. Physical therapy reviews : PTR, 19(4), 252–265.

8. Gildir, S., Tüzün, E. H., Eroğlu, G., & Eker, L. (2019). A randomized trial of trigger point dry needling versus sham needling for chronic tension-type headache. Medicine, 98(8), e14520.

9. Abbaszadeh-Amirdehi, M., Ansari, N. N., Naghdi, S., Olyaei, G., & Nourbakhsh, M. R. (2013). The neurophysiological effects of dry needling in patients with upper trapezius myofascial trigger points: study protocol of a controlled clinical trial. BMJ open, 3(5), e002825.

10. Page P. (2011). Cervicogenic headaches: an evidence-led approach to clinical management. International journal of sports physical therapy, 6(3), 254–266.

11. Myran, Rigmor & Hagen, Knut & Svebak, Sven & Nygaard, Oystein & Zwart, John-Anker. (2011). Headache and musculoskeletal complaints among subjects with self reported whiplash injury. The HUNT-2 study. BMC musculoskeletal disorders. 12. 129. 10.1186/1471-2474-12-129.

Michelle Ninemire, PT, DPTMichelle.Ninemire@alegent.org

If you have any questions, feel free to contact us via e-mail.

Jocelyn Shaal, PT, DPTJocelyn.Shaal@alegent.org

Thank you!