This year Leigh McCutcheon was invited to present as a key note speaker for the APA Acupuncture and Dry Needing Conference along with Jay Shah from Washington and Jorgen Forsberg from Australia. Leigh presented a pre conference workshop on Whiplash which covered a literature review outlining the multimodal treatment approach for Whiplash Associated Disorder and included the role of acupuncture and dry needling. Objective assessments for musculoskeletal, sensorimotor control, cervico-occular control and postural stability and a practical overview of treatment techniques in relation to needling therapies were considered as well as Third Party/ Workcover and legal considerations.
Within the Acupuncture and Dry Needling program of the APA conference Leigh also presented a literature review of acupuncture and dry needling treatment as a treatment modality for shoulder conditions. A practical demonstration addressed some the complexities associated with needling in the shoulder region. Safety and precautions relevant to needling in the shoulder and the associated thoracic region were addressed and current medical misadventure literature was reviewed.
Toward the close of the program Leigh McCutcheon, Jane Rooney, Jorgan Forsberg and Philip Gabel presented as an expert panel. Leigh’s presentation ‘Minimising risk whilst maximising potential’ covered ‘take home messages’ from the decade she spent on the APA Risk Management Committee. Leigh is presently part of the committee reviewing the Australian Society of Acupuncture Physiotherapist’s Safety Guidelines which will be available in 2018.
Acupuncture and Dry Needling by Australian Physiotherapists, 2016
The use of Acupuncture and Dry Needling by physiotherapists has progressively grown over the past decade or two coinciding with an increasing swell in the evidence base to support using the various needling therapies utilised by Australian Physiotherapists.
Physiotherapists can be trained to use Dry Needling, Western Acupuncture and/or Traditional Acupuncture. Dry Needling involves needling to altered or dysfunctional tissues in order to improve or restore function. This may include needling of myofascial trigger points and periosteum. Western acupuncture utilises needling meridian and trigger points but applies it to ‘western’ reasoning with particular consideration to relevant neurophysiology and anatomy. In Western acupuncture points are stimulated to create local, spinal segmental or supraspinal pain modulated effects. Even though traditional acupuncture points are used with this style of needling Western Acupuncture is not viewed as Traditional Chinese Medicine (TCM) as no paradigms or traditional assessment methods are adopted from TCM. Traditional Acupuncture utilises meridian or other traditional points based on a Traditional Chinese Medicine approach which includes diagnosis and clinical reasoning using various Chinese medicine assessment methods and treatment paradigms.
As contemporary physiotherapists possess entry level degrees, spanning an average of four or five years, which have already included training in anatomy, neurology, pathophysiology and disease diagnosis, needling therapies are viewed as extended training. The minimum standard to commence needling by a registered physiotherapist in Australia is 16 hours of training, including competency based learning assessments and practical examinations. Traditional acupuncture at an introductory level takes considerably longer and is usually taught over a prolonged period of several months and will also include competency based assessments. All physiotherapists must meet these minimum standards to be covered by their professional income insurance.
Evidence based medicine is paramount when considering patient care. In the area of migraine and tension type headaches (TTHA) acupuncture has been shown to reduce the frequency and intensity of migraine and TTHA attacks. Acupuncture and dry needling reports positive reductions in pain and improved functional outcomes in the treatment of chronic neck pain, radicular arm pain, acute and chronic lower back pain and in particular for sub-acute and chronic Whiplash Associated Disorder (WAD). Pelvic girdle pain has been specifically researched in Europe and the latest European Guidelines recommend the use of acupuncture along with pelvic support belts and stabilising exercises.
In the shoulder region acupuncture and dry needling is supported for treatment of rotator cuff dysfunction and impingement and supraspinatus tendinopathy. Systematic review supports the use of acupuncture in all stages of frozen shoulder (adhesive capsulitis) to reduce pain and in the second and third stages needling therapies are supported to be used with multimodal treatment which include specific exercises and mobilisations. Good evidence also exists in the area of tennis elbow (lateral epicondylalgia), OA knee pain and more recently evidence has emerged for the conditions of plantarfasciitis and chronic ankle instability. In the last five years high-quality research has been published regarding jaw pain (Temporo Mandibular Disorder) with positive effects of decreased pain, and improved mouth opening and function being detected. Tendinopathy and fibromyalgia are distinct conditions that now have systematic support in dry needling and acupuncture respectively.
In the area of women’s health, acupuncture has been shown to be effective for reducing pain in dysmenorrhea, polycystic ovarian disease and endometriosis. For pain reduction in cancer, acupuncture has been shown to be effective if combined with drug therapy, whilst surprisingly TENs machine use has inconsistent results. Neurology is another area which has had a marked increase in acupuncture RCTS in the last five or so years. Conditions such as stroke (in particular shoulder pain post stroke), Multiple Sclerosis, Motor Neurone Disease, Bell’s Palsy and Parkinson’s disease all have emerging scientific evidence with a mixed level of support.
In the area of sports physiotherapy acupuncture and dry needling is now commonly utilised. Along with treating injuries, it may also be used in conjunction with sports screening to enhance functional ability and research has shown that dry needling of trigger points increases synergistic muscle activity.
Physiotherapists should be aware that along with the Australian Health Guidelines, the Acupuncture Society of Australian Physiotherapists have specifically developed guidelines for physiotherapists using needling therapies and these can be accessed at http://www.combinedhealth.com.au/safety_guidelines. Additionally the Australian Physiotherapy Association has an active Acupuncture and Dry Needling Group and biannual Conferences are held at various locations around Australia.
The ADNG conference will be held along with the Sports Physiotherapy Conference and the Musculoskeletal Physiotherapy Conference in October 2015 on the Gold Coast.
Leigh McCutcheon will be presenting to the Acupuncture and Dry Needling Group the latest evidence base for needling therapies. Presently approximately 40% of practicing physiotherapists hold additional training in acupuncture and/or dry needling. Evidence in the form of RCTs and case series is substantial in regards to acupuncture with over 20,000 published articles evidenced on Medline, however research in the area of dry needling is lacking and to date less than 200 articles exist on Medline. Subsequently systematic reviews and meta-analyses are more likely to be associated with research relating to traditional or western acupuncture rather than dry needling. Presently the use of acupuncture and dry needling for migraine, tension type headache, chronic LBP, TMD (temporomandibular disorder), adhesive capsulitis, fibromyalgia, depression and dysmenorrhoea have moderate support at systematic review and meta-analysis levels. There is however mixed evidence in the areas of Whiplash Associated Disorder, knee OA, lateral epicondylgia, peripheral joint OA and rotator cuff disorders. The research that exists will be presented and the role of acupuncture and dry needling in a multimodal treatment approach will be expanded upon. The presentation will have implications for physiotherapists working in Musculoskeletal Physiotherapy, Sports, Neurology, Women’s Health and Pain Rehabilitation.
Leigh will also present to the Pain Group research that underpins the neurophysiology of acupuncture and dry needling in relation to the neuropathic patient. Clinical reasoning for the use of acupuncture and dry needling relies on both animal and human research and in more recent years includes functional MRI (fMRI) research to consider the neurophysiological effects which occur at local, segmental and extra-segmental levels. In particular when considering acupuncture as a treatment modality for the neuropathic pain population research highlights reduced glutamate release and NMDA channel down regulation, long term depression of the dorsal horn, and forebrain and limbic system deactivation. Additionally acupuncture has been shown to have a synergistic relationship with tricyclic antidepressants (TCAs) which may be beneficial when treating neuropathic pain and depression. In contrast and worthy of note is the fMRI research which shows that aggressive styles of dry needling (pecking release styles) should be avoided in neuropathic patients due to activation of forebrain centres and the limbic system. Other recent fMRI research will also be considered along with the latest RCTs in relation to conditions that occur within the chronic pain population.
Other key note speakers will include Jenny Longbottom, from the UK, Peter Selvaratnam and Philip Gabel. The Acupuncture and Dry Needling Group’s program sits in and around the 4 day APA conference.
At the end of 2011, the APA was approached by the Jerudong Park Medical Centre in Brunei to run the Musculoskeletal Segmental and Dry Needling for Physiotherapists course.
Authors: McCutcheon, Leigh; Yelland, Michael
Physical Therapy Reviews, Volume 16, Number 2, April 2011, pp. 126-132(7)
Background: Pneumothorax is a very rare but serious complication associated with acupuncture and dry needling around the
thoracic region. Physiotherapists and other health practitioners should be aware of the risks associated with needling in this
region and should take care to minimize the possibility of an iatrogenic pneumothorax.
Findings: An awareness of the signs and symptoms of a pneumothorax is necessary for practitioners using acupuncture and dry
needling in the thoracic region. Understanding the normal anatomy and its variants can minimize risk associated with needling
practices in this region. Various technique modifications are suggested so that the pleura or lungs are avoided while using
acupuncture or dry needling in the thoracic region.
Discussion/Conclusion: Acupuncture and dry needling in this region administered by well-trained physiotherapists and other
health practitioners is very safe; however, to maximize safety therapists should consider the relevant anatomy and not practise
using advanced acupuncture and dry needling techniques without adequate competency-based training.
Publication date: 2011-04-01
The Australian Physiotherapy Association’s 2009 Acupuncture and Dry Needling Group Conference was held at Darling Harbour in Sydney in October. The conference consisted of the latest in scientific research and clinical practice and covered all of the various needling disciplines, including Dry Needling, Western Segmental Acupuncture and Traditional Acupuncture. Presenters came from all around the globe including the US, England and New Zealand with the two main keynote presenters, Assoc Prof Helene Langevin and Dr Jay Shah both from North America.
Associate Professor Helene Langevin presented on the dynamic cellular response to manipulation of the connective tissue architecture via acupuncture needle stimulation. Whilst Dr Jay Shah presented his ground-breaking research on the muscular chemical milieu of trigger points and the response to dry needling. Other keynote speakers included, Mr Christopher Zaslawski who presented research on the impact of site specificity and needle stimulation on pain pressure thresholds following manual acupuncture and Dr Mark Strudwick who presented up to date research on the effect of acupuncture on the autonomic and central nervous system, including functional MRI analysis. The 2-day conference also consisted of presentations by leading Australian lecturers, including Leigh McCutcheon, Dr Peter Selvaratnam and Paula Raymond-Yacoub.
Leigh McCutcheon’s presentations included an opening address which reviewed the latest research in acupuncture and dry needling, the use of acupuncture and dry needling for treating triathletes and western acupuncture and dry needling in spinal regions.
See below for Leigh’s abstracts:
Acupuncture is generally a very safe modality, especially when it is used by skilled, well trained professionals. This has been evidenced in several very large studies from England, Germany, Switzerland and Czechoslovakia involving prospective assessments of 64,000 consultations in the SAFA studies to around 4 million consultations in the GERAC studies. Even though it is rare, pneumothorax is the most common serious adverse event which can occur with the practice of acupuncture. The attached power point handout is a lecture that was presented in August and October of 2008 for the Australian Physiotherapy Association.
In 2006 various physiotherapists who lecture in the areas of Acupuncture or Dry Needling formed a committee to create a guideline for Australian physiotherapists. The attached guideline has been produced under the banner of the Australian Society of Acupuncture Physiotherapists (ASAP). It is designed to be used as a safe practice guide for physiotherapists practicing acupuncture or dry needling in Australia. Acupuncture practice by physiotherapists in Australia may include Traditional Acupuncture, Western Acupuncture or Dry Needling.
The guideline was constructed via consultation with various Australian and International acupuncture guidelines, including the minimum standards set by the International Acupuncture Association of Physical Therapists (IAAPT). The federal governments Infection Control Guidelines (2004) was also considered along with the National Health and Medical Research Council’s Australian Immunisation Handbook (2003) and the Standards of Practice for Acupuncture: Health (Infectious Diseases) Regulations (1990). Relevant journal based literature was also considered. The guidelines will be reviewed and revised by the ASAP as required.
It should be noted that individual states and territories around Australia will have varying guidelines on skin penetration and infection control and physiotherapists are urged to view the relevant information from their local, state and federal governing bodies. Physiotherapists are also advised to refer to any relevant legislation set by individual state physiotherapy registration boards.
The following case report was presented during the APA Conference week held in Cairn’s in October, 2007 as part of the Musculoskeletal Physiotherapy Australia program.
CASE REPORT: Physiotherapy management incorporating direct acupuncture needling to a large intrasubstance supraspinatus tear.
McCutcheon LM1, 2
1Elanora and Robina Physiotherapy Clinics
2Combined Health Acupuncture and Dry Needling Education
A 64 year old woman presented with a two month old traumatic intrasubstance supraspinatus tear measuring 1.8 x 1.2cm. Four treatments consisting of taping, rotator cuff and scapular stabilising exercises, ultrasound and laser were implemented over a five week period with minimal effect on range and no effect on supraspinatus power or pain reduction. The therapy regime was supplemented with acupuncture consisting of threading the supraspinatus tendon from both an anterior (LI 15) and posterior (LI 16) approach with 40mm and 50mm needles respectively.
The aim of acupuncture tendon threading is to produce a local healing response due to the various chemicals and neuropeptides that are activated when a needle is inserted into damaged tissue. Disability of the Arm, Shoulder and Hand (DASH) questionnaire performed prior to the commencement of acupuncture depicted a 71.7 score. Eight acupuncture treatments were performed over a three month period with a reduction to 27.5 on the DASH scale. An additional three treatments were performed over a two month period with a further reduction on the DASH scale to 5. Another diagnostic ultrasound was performed following treatment depicting a small 3mm region of heterogeneity in the supraspinatus tendon which is a common phenomenon in asymptotic individuals within this age group. This study raises the possibility of an alternative to surgery in the case of a torn supraspinatus tendon. Results of this single case report support the need for randomised controlled trials to further investigate the effect of deep acupuncture needling on rotator cuff tears.
Click Here to view the presentation overview.
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