Here are some common pitfalls that limit your overall effectiveness with Trigger Point Dry Needling (TDN) and suggestions on how to fix them! These are all mistakes I have made so I hope you can learn from them.
1. You needle too much. This was common for me when I started needling (as were all these mistakes come speak of it). Needling is like my wife's chocolate peanut butter cookies. Some are awesome. The whole plate and your gonna be dragging tomorrow. Think about TDN like HEP prescription, what are the 1 to 3 spots that are gonna give me the most bang for my buck. Furhter, cleaning up those spots will likely relieve other TrP as seen by Hsieh et al. Also seen here: http://www.ncbi.nlm.nih.
1. You needle too much. This was common for me when I started needling (as were all these mistakes come speak of it). Needling is like my wife's chocolate peanut butter cookies. Some are awesome. The whole plate and your gonna be dragging tomorrow. Think about TDN like HEP prescription, what are the 1 to 3 spots that are gonna give me the most bang for my buck. Furhter, cleaning up those spots will likely relieve other TrP as seen by Hsieh et al. Also seen here: http://www.ncbi.nlm.nih.
2. You don't needle enough. Sounds contradictory right? Well, if we are only needling 1-3 spots (not a gold standard btw) than we need to make sure we completely clean up the local twitch response, LTR. Whether that means leaving the needle in, adding a fibroblastic twisting, or just spending enough time in the area cleaning up TrP clusters in the muscle begin treated. We know with research well be getting better outcomes with a LTR (http://www.ncbi.nlm.nih.gov/
Another point on not needling enough is that we don't use TDN as a Dx tool. I've had multiple patients with localized anterior knee pain that had TrP in the quad and movement dysfunction in squats, etc but you feel like patho-anatomical (MRI) pathology is related to the pain, so you may choose not to treat (maybe solely because you have to explain that pathology doesn't specially correlate with pain to the patient). Worse case you'll improve muscle activation. Best case we can relief all their pain. That's worth the explanation to me.
3. You treat the muscle, not the pattern. There's a lot examples of this but we need to remember if we train movement patterns than TrP with resulting stiffness, pain, weakness/inhibition, and poor motor control will cascade to other muscles and further compensations and overuse. Just take one example, like poor hip ABD control noticed from Trendlenberg gait or knee valgus. Its easy to TDN the glut med, but the pattern will require the QL and glut max as well. Look at these as well and you'll see better results in gait and pain.
Further, you treat solely on TrP referral and palpation and not on the addition of a movement or direction preference assessment. I saw this yesterday when an ER MD came to get TDN, " I know its my traps (upper), the pain is in the back of my head". OK well did you confirm that with elevation, c/s coupled flex & rotation. Using a movement assessment allowed us to pinpoint the lev scap (which had the better pain referral anyway) instead of the UT. Following 1 very large LTR in the lev scap, movement was restored and pain abolished. We should be using clinical clusters that include movement assessments because we know active TrP lead to muscle stiffness and mobility loss. Maybe something like this and this, mentioned in previous posts can help.
4. You forget to reinforce. I've talked about this a lot previously so I wont spend too much time on this. Although, to me this is the most important aspect to make. Maybe instead of TDN all at once and than adding other manual and exer you can make it more dynamic with TDN, man, more TDN, exer, more TDN. The huge advantage to this is the fact it allows us to constantly RETEST!
4. You forget to reinforce. I've talked about this a lot previously so I wont spend too much time on this. Although, to me this is the most important aspect to make. Maybe instead of TDN all at once and than adding other manual and exer you can make it more dynamic with TDN, man, more TDN, exer, more TDN. The huge advantage to this is the fact it allows us to constantly RETEST!
5. You haven't tried intramuscular electrical stimulation (IES) with TDN. I recently started adding IES in conjunction with TDN and have been really impressed with the results. It seems to limit post needle soreness (gate control?). Maybe you can follow Gunn's model and treat just the multifidi of the corresponding muscle or you could try NMES on the involved muscle(s) to assist with retraining.
Hopefully my learning curve will improve your outcomes and stop you from making similar, less efficient treatment decisions. Thanks for reading.
