Having just finished the final course to become certified in Fascial Manipulation©, I figured I’d post a web page about it on my site Optimum Function: Portland Chiropractic and Nutrition.
I am VERY excited about this technique, please click on the following to go directly to the page I have devoted to Fascial Manipulation : Portland Fascial ManipulationYours in Health,Tim Irving DC, MS, LMTOptimum Function: 819 SE Morrison St. ste. 215, Portland, OR, 97215Optimum Function = Optimum Health
Well, the Oregon Dry Needling debate shuffles forward……
Of course, as a Portland Chiropractor who wants to use dry needling in my practice for the treatment of myofasacial trigger points, I am biased. I recently read an excellent blog by an Oregon acupuncturist (click for link) on the community acupuncture network. In this blog, the author states why she does not consider the dry needling issue here in Oregon to be one that the acupuncture community should be concerned with. In this blog post, the author dispels many of the myths about dry needling and refutes the arguments against physical therapists and chiropractors performing this technique. The only point I disagree with her on (and it’s a minor point) is her conviction that Dry needling IS acupuncture. To this, and to acupuncturists reading this post, I ask this:
How many hours have you spent learning trigger point theory? Can you explain the etiology behind trigger points? Can you state what the research has shown regarding the use of solid-filament, small-gauge needles and the eradication of trigger points? Have you been taught (in acupuncture school) how trigger points form, what biomechanical effects they have, how to rehab them and teach your patients what to do so they don’t come back? Have you been taught the fine details of locating them?
Trigger point therapy is not adequately taught in acupuncture school. Acupuncturists have mastered the use of solid-filament, small-gauge needles but have not mastered trigger point theory, assessment and treatment. Don’t get me wrong, I know a few acupuncturists who have gone through post-graduate training and are excellent clinicians regarding trigger points but Dry Needling is not acupuncture. Can acupuncturists perform Dry Needling…. yes, of course, they have already mastered the needling aspect of it, most would just need to pursue training on trigger point theory, assessment, rehab and treatment.
In contrast, a video on Vimeo from The Oregon College of Oriental Medicine posted this video (Click Here). In it, they really show their ignorance as to what we, as chiropractors in Oregon are trained to do. The panel consists of various teachers and acupuncturists in Oregon. They even have the nerve to claim that they are the Dry Needling experts in Oregon and they should teach PTs and chiropractors how to perform it….. really?
I wish I was at that meeting, I would have asked this question:
“Please, explain to me, the etiological, biochemical and neurochemical aspects of myofascial trigger points and how Dry Needling takes care of them. Compare and contrast this with other trigger point treatments and explain to me (us) how core acupuncture programs make their graduates experts in this treatment modality.”
I have emailed various individuals in the OCOM and NCNM acupuncture programs about where in the core curriculum is trigger point Dry Needling taught and have received one response that it is the same thing as “ashi points”. Nowhere do they learn the finer details of trigger point theory……. why would they consider themselves experts on this topic then? How insulting….
And so it goes, misinformed individuals guiding and teaching their profession to believe half-truths….
For those of you (no matter what your profession) who want to learn more about modern trigger point theory and therapy, Jan Dommerholt has co-authored an excellent book on the topic: Myofascial Trigger Points: Pathophysiology and Evidence-Informed Diagnosis and Management
In addition, the Simons and Travell 2 volume set has been dubbed “the trigger point bible”: Travell & Simons’ Myofascial Pain and Dysfunction: The Trigger Point Manual
Lastly, there is a ton of great research, mostly coming from the PT profession on trigger points and Dry Needling, all you need to do is search for it on PubMed.
That’s all for today; I am reading a pre-published version of an article that Jan Dommerholt has written with a colleague on how trigger point Dry Needling affects the peripheral and central nervous systems to do more than disrupt the excess achetylcholine secretion and decreased acetylcholine esterase production often seen as one of the causes of trigger points….. stay tuned for my report on this article.Yours in Health,Tim Irving DC, MS, LMTOptimum Function: 819 SE Morrison St. ste. 215, Portland, OR, 97215Optimum Function = Optimum Health
OK, since my last blog post, I have received several email regarding the chiropractic dry needling issue that is currently being discussed in Oregon.
In a nutshell: The insertion of a filament-gauged, solid needle into fascia and myofascial trigger points can produce many physical effects. Most are similar to what a skilled manual medicine practitioner can do (massage therapists, physical therapists, chiropractors etc.). It has been determined that chiropractors can utilize these types of needles as instruments to treat trigger points and myofascial lesions that we currently diagnose and treat. This apparently has some acupuncturists scared that their profession is in danger.
First, it’s not, look at one of the other 16 states where chiropractors are allowed to perform dry needling; if licensed, acupuncturists have continued to grow in number in these states.
Some of the other concerns that have been emailed to me:
Pneumothorax, AKA collapsed lung, this happens as a result of a needle piercing the chest wall and can occur pretty much anywhere in the thorax if the needle is not carefully placed. The only time I have heard of this happening has been in acupuncturists’ offices. In the 16 states where chiropractors are allowed to perform dry needling, I am sure at least a couple of them have produced pneumothorax but I doubt the number is higher (percentage-wise) than with the acupuncture population.
“Chiropractors are minimally trained…” OK, this is just downright offensive! We have over 4000 hours of training; our programs are clinical doctorates…. we are NOT minimally trained. We take classes in diagnosis (western diagnosis; meaning, we have within our scope, the ability to render a diagnosis of myofascial trigger points), physical examinations including, heart and lung, classes on phlebotomy and in Oregon, minor surgery.
“If chiropractors want to do acupuncture, they should become acupuncturists…”
I actually agree with this but is dry needling acupuncture? I am not an acupuncturist so I am not an expert as to what ans what is not acupuncture but I thought using a needle to treat myofascial trigger points and other myofascial lesions is not acupuncture per say…..according to some acupuncturists, I am wrong.
Here’s an analogy, is adjusting a vertebral motion segment the entirety of chiropractic? I hope not, I can’t see why laboratory diagnosis and phlebotomy classes prepared me to do that (tongue-in-cheek ). I know there are a few chiropractors out there who would vehemently disagree with me, that’s fine. I don’t think adjusting is all we do as chiropractors and as such, I have no problem with physical therapists mobilizing joint or even doing high velocity adjusting is they have been trained.
If I am wrong about dry needling not being the entirety of what acupuncturists do, then I am mistaken,; although I don’t think so. Why would the acupuncture community want to sully their art, their craft by distilling it down to be defined as the placement of a needle into a trigger point? Why would anyone spend all the time and money becoming an acupuncturist if that’s all is was?
Can acupuncturists do dry needling? Again, I am not the expert here but I think so….. here’s a question though? Can they diagnose myofascial trigger points (ICD-9 codes: 728.89, 729.1 etc)? If so, what is the standard of care for acupuncturists and trigger points? Can they diagnose joint adhesions and fibrosis to be treated with the insertion of a needle to promote fibroblast activity? If so, what ICD codes would they use?
My point is this, acupuncturists can perform dry needling just as naturopaths and physical therapists can perform high velocity adjusting, dry needling is to acupuncture what high velocity adjusting is to chiropractic….. a tool.
Another argument: “24 hours of training is not enough to perform dry needling…”. See the above retort, we have over 4000 hours of training on the human body; the extra 24 is to tie some of that information into the context of dry needling. Most of it is about safe needle selection and placement and adequate hands on time. This is plenty of time to teach doctors, who have an excellent working knowledge of the body, including precise placement of nerves, vessels, bones, muscles and depth of chest-wall cavity. In addition, we know when to use one of the other tools in our toolbox if an area is dangerous or prone to pneumothorax…. it’s really kind of simple. Answer this question, how long did it take until you (acupuncturists) were able to insert a needle into someone’s musculoskeletal system? Not long, huh? Most of the time you spent was on point location and other aspects of oriental medicine….. right?
In conclusion, let’s be fair and honest with what this is all about….. MONEY; and actually it’s only the perceived effects that chiropractors performing dry needling will have on the money in Oregonian acupuncturists’ pockets. I think we will all find out, it’s not going to have much of an effect, the rate of pneumothoraxs will not increase, patients will have access to another helpful, effective tool to treat myofascial lesions….. period.
What Oregon has the unique opportunity to do is makes sure the health care world knows that chiropractors cannot perform acupuncture without going through an approved acupuncture program but they CAN perform dry needling with some training on how to utilize needles in an effective and safe way. By doing this, the barrier to care perceived by the public regarding needling of any kind will be diminished and the acupuncture community in Oregon will actually benefit from this; the problem is, a few of them are just to short-sighted to see thisYours in Health,Tim Irving DC, MS, LMTOptimum Function: 819 SE Morrison St. ste. 215, Portland, OR, 97215Optimum Function = Optimum Health
OK, many of you know that I have been involved in the efforts to allow chiropractors to perform dry needling (especially if you are a patient). This spring, the Oregon Board of Chiropractic Examiners (OBCE) ruled in our favor, allowing chiropractors to use this technique in the treatment of myofascial trigger points. What is dry needling? I’ll get to that in a bit….
Chiropractors in Oregon and the rest of the world, have been treating myofascial trigger points and myofascial pain since we became a profession. The big issue here is that many of us want as many tools to treat these issues as possible; this is where using small gauge, solid filament needles comes into play. Currently, there are a number of states that allow chiropractors to use this tool in the treatment of their patients with myofascial problems; I have chiropractic colleagues in Colorado who use dry needling to treat their patients and have communicated with chiropractors in other states that allow dry needling about how effective it is in treating myofascial trigger and tender points. I was first introduced to dry needling while I was working as a massage therapist in an osteopath’s office in Colorado. I observed hundreds of patients receive this treatment and the osteopath I worked with was great with regards to teaching me what and why he was performing it.
Dry needling involves placing a very thin, single use, disposable, sterile, solid filament needle (not hollow) with clean needle technique into a myofascial trigger point and/or tender point. The number of needles used during any individual visit and the number of visits you are given this treatment depends on many factors that differ from patient to patient. These points are detected an number of different ways. As chiropractors, we have been assessing myofascial dysfunction and treating it with various techniques, like:
- Chiropractic adjusting
- Manual trigger point therapy
- Pin and stretch techniques
- Physiotherapy modalities like electric stim and cold laser
- Active rehab and myofascial release
- Instrument-assisted soft tissue therapies
We fully understand why and how myofascial problems arise; aberrant biomechanical processes, joint dysfunction, injury and repetitive stress are all avenues to developing myofascial pathologies and chiropractors are aptly trained and qualified to both detect, diagnose and treat these pathologies. Using dry needling is yet another tool with which we treat these issues; in my experience observing, performing and having dry needling performed on me, I can say that it is often more efficient, just as effective and less painful than the other therapies listed. This is why I have been fighting for the inclusion of this technique into my scope of practice since I was still a chiropractic student.
What’s the problem? Well, the acupuncture community in Oregon have been duped into thinking that this ruling means chiropractors will be stealing patients from them and it would hurt the profession. This is just not the case, in most of the states where chiropractors are allowed to perform dry needling, acupuncture, as a profession, is doing just fine and has been growing at rates that are as good, if not better than in those states where chiropractors can’t perform dry needling. Having a chiropractic clinic in SE Portland and a teaching shift at the NCNM clinic in SW Portland, I refer patients for acupuncture all the time when it is appropriate; I have even referred my patients for acupuncture for myofascial issues. When I give these types of referrals, I have often been very disappointed in that the acupuncturist sometimes ignores needling the injured tissue and treats the patient more constitutionally, needling distant acupuncture points. This is the beauty of acupuncture, it is a healing modality at the foundation of Oriental medicine that works wonders with patients on many levels. Dry needling is an incredibly superficial technique compared to the broad scope of acupuncture and is only used to treat myofascial pathologies.
Last week, the OBCE approved me to utilize dry needling in my practice and I did, on many patient suffering from myofascial pathologies, the results were profound and now this week, because the Oregon Association of Acupuncture and Oriental Medicine filed an injunction, I cannot continue to use this technique to benefit my patients. Will I send these patients to an acupuncturist? No, there’s no need, I have other treatments that will work just as well as dry needling but may take longer and cause a bit more discomfort. Would these patient have gone to see an acupuncturist for their problem to begin with? No, they came to see me because it is more appropriate for them to do so, for this specific issue.
It’s really quite silly, as a chiropractor, I often perform high velocity, low amplitude thrusts to joints that need to have movement restored. The reason chiropractors do this is to help restore balance in the body so our innate healing properties can flourish. Does this mean chiropractors “own” this technique? No, there are other providers that use the same high velocity, low amplitude thrusts to joints; usually, these other providers are using this tool for slightly different reasons and what they are doing is not inherently chiropractic. Acupuncturists use solid filament needles to perform their craft; as a chiropractor, I would use the same needles to treat myofascial trigger and tender points; does this mean I would be performing acupuncture? Absolutely not, in fact, to imply this is a slap in the face to acupuncturists and Oriental medical practitioners just as saying a physical therapist who performs joint mobilizations is performing chiropractic. Both are using similar s tools for VERY different reasons!
What Oregon has is an opportunity to create dry needling verbiage in the Oregon rules and regulations that actually protects the scope and right of acupuncturists. there are states (I am not going to name them), who allow chiropractors to perform “chiropractic acupuncture” and “biomedical acupuncture”; these are unprofessional, inappropriate terms that disrespect the ancient art that is acupuncture. Oregon can be the first state to clearly define dry needling as completely separate from acupuncture just as joint mobilizations and manipulations performed by non-chiropractic providers are completely separate from the art of chiropractic.
I needed to replace the memory in a laptop computer today and getting to it with traditional tools seemed impossible without damaging the computer. I was able to use a couple of bicycle-specific tools to do the job effectively, efficiently, and without undue damage to the computer. Was I performing bicycle mechanics to my computer? No, that’s obvious, I was just using another tool for the job, a tool that performed better than the more traditional tools in my toolbox.
The acupuncture association in Oregon is now going to spend $30,000 to fight this and, in the end, chiropractors will likely be able to perform dry needling in Oregon; what a waste of money! In addition, I am also concerned that this move may create a false sense of extreme competition between chiropractor and acupuncturists and erode any collaborative efforts our two professions may put forth to bring more complementary medical treatments to Oregonians.
OK, rant over, I needed to get that off my chest. I hope this is over soon so I can use whatever tool necessary toYours in Health,Tim Irving DC, MS, LMTOptimum Function: 819 SE Morrison St. ste. 215, Portland, OR, 97215Optimum Function = Optimum Health
A Study published in October entitled: Cost of Care for Common Back Pain Conditions Initiated With Chiropractic Doctor vs Medical Doctor/Doctor of Osteopathy as First Physician: Experience of One Tennessee-Based General Health Insurer suggests that initiating care through a chiropractic doctor for back pain was more cost effective than initiating care through a medical doctor. In fact, this study found that care initiated through a chiropractic was 40% less than that initiated through a medical doctor.
Chiropractor can and do often act as portal of entry and/or primary care physicians; this is very similar to many general practice medical doctors. As a chiropractor who practices like this, I often see patients that receive care from me and other providers on my recommendation. In addition, I can act as a “hub” for the patients’ care, to help organize care and keep all the providers on the same page. In Oregon, chiropractors are primary care physicians; this means we diagnose and treat a variety of health conditions, naturally, and predominantly with manual medicine. In addition, there are those of us like me who also use nutrition (in the form of actual food) and functional medicine to help patients reach all of their health and wellness goals.
So, the next time you have back pain, consider seeing a chiropractor first. Most chiropractors will do a thorough examination, let you know what’s wrong, and if they can’t help, they can get to to the correct provider. With health care costs sky-rocketing; you can help to decrease spending by up to 40% by doing this; at least regarding back pain treatments.Yours in Health,Tim Irving DC, MS, LMTOptimum Function: 819 SE Morrison St. ste. 215, Portland, OR, 97215Optimum Function = Optimum Health
This is just too good to be true! Finally, the government “for the people, by the people” has taken a step towards doing something that our health as a nation will benefit from….. Wow!
Here’s the link:
What do you think?Yours in Health,Tim Irving DC, MS, LMTOptimum Function: 819 SE Morrison St. ste. 215, Portland, OR, 97215Optimum Function = Optimum Health
Here’s an interesting article about “Orthorexia”. While I do agree that we need to have a healthy relationship with HEALTHY, NUTRITIOUS foods, I fear this could lead to people getting slapped with a label just because they don’t want to put trans-fats and high fructose corn syrup in their body (which science is telling us we shouldn’t be doing anyway). What do you think?
Here’s the link: Orthorexia: Can Healthy Eating Be a Disorder?Yours in Health,Tim Irving DC, MS, LMTOptimum Function: 819 SE Morrison St. ste. 215, Portland, OR, 97215Optimum Function = Optimum Health
Frozen Shoulder and Diabetes….. Is There A Connection?
Frozen Shoulder, AKA “adhesive capsulitis” is a common shoulder condition that I treat in my SE Portland chiropractic and nutrition clinic, Optimum Function (http://optfunction.com). What suprises patients is when I ask about their blood sugar or hemoglobin A1c; often, no one has considered diabetes, pre-diabetes or another physiologic cause of their shoulder issue.
Frozen Shoulder is a syndrome (meaning, a set of symptoms) that is not well-defined but usually consists of painful restriction of shoulder movements that results in overall decreased shoulder mobility. It is often deemed “idiopathic”; this means that there is usually no identifiable cause for the problem.
To consider all frozen shoulders idiopathic would be overlooking a variety of physiological states that can lead to this condition.
Possible Non-Mechanical Causes of Frozen Shoulder
The physiological conditions most commonly associated with frozen shoulder are diabetes, hypothyroidism/hyperthyroidism, and hypertriglyceridemia.
Here are some facts when considering the link between diabetes and frozen shoulder:
- The incidence of frozen shoulder is 2-4 times higher in people with diabetes than in the general population.
- The total prevalence of diabetes (frank diabetes and pre-diabetes or metabolic syndrome) in patients with frozen shoulder was 71.5%
- Shoulder capsulitis is common in type I and type II diabetic patients. However, it is occurs more commonly as the diabetic patient ages
Patients with diabetes clearly have a higher incidence of frozen shoulder. While the “why” behind these stats is not clear, we can speculate that poor circulation may lead to abnormal collagen repair and speed up degenerative changes. The theory is that platelet derived growth factor is released from blood vessels that have become inefficient due to the diabetic condition. This growth factor will then act as a stimulus to scar tissue development which will help to continue this process leading to a vicious cycle that started because diabetics have problems with the small, peripheral blood vessels.
So, please take this information the next time someone tells you that your shoulder dysfunction can be diagnosed as Frozen Shoulder. Click on the following link to download and shar this article with friends and loved ones: Diabetes and Frozen Shoulder Article
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- Balci N, Balci MK, Tüzüner S, Shoulder adhesive capsulitis and shoulder range of motion in type II diabetes mellitus: association with diabetic complications, J Diabetes Complications, May-Jun;13(3):135-40, 1999
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Processed sugars, including food and drinks that contain them, harm our health more than anyone wants to admit: BP Drops when Sugary Drinks Are ReducedYours in Health,Tim Irving DC, MS, LMTOptimum Function: 819 SE Morrison St. ste. 215, Portland, OR, 97215Optimum Function = Optimum Health