Episode 18 - What's the Point? Acupuncture vs. Dry Needling
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Episode Summary
Aside from clinical treatments for back pain and pain in general, acupuncture and dry needling are increasingly becoming part of treatment plans prescribed by physicians. However, there are misconceptions about these two interventions, with people often interchanging one for the other.
In this episode of Back Talk Doc, Dr. Sanjiv Lakhia goes into a discussion on dry needling and acupuncture and the significant differences between these two treatment options. It’s not so much as which is more effective than the other, but rather which intervention is the best course of action for your specific issue.
Generally speaking, acupuncture involves the insertion of needles in certain areas of the body to trigger positive physiologic responses. In dry needling though, your physician or physical therapist has to look at nerve and muscle patterns to identify and stimulate trigger points. While acupuncture is more of a system of care that can normalize other issues in the body as well.
He dives deep into the various scientific research studies that show the efficiency and benefits of these two interventions. These include increased blood flow to the pain area, releasing endorphins, a natural pain-relieving hormone, decreasing muscle banding, and triggering other sympathetic responses.
Dr. Sanjiv emphasizes that both dry needling and acupuncture are great additions to a comprehensive treatment plan. It’s important to consult with your physician to see whether these interventions can help alleviate and manage your back pain.
Key Moments in the Episode
History of acupuncture 02:51
Origins of dry needling 04:24
Scientific research on dry needling and acupuncture 07:23
Physiologic research studies on acupuncture 11:10
Physiologic research studies on dry needling 12:42
Trigger points 15:02
Benefits of dry needling 16:27
Differences in acupuncture and dry needling 18:15
Contraindications 20:36
Resources on dry needling and acupuncture 22:45
Links Mentioned in the Episode
Glute power with Ryan Klomparens, PT
All About the Thoracic Outlet Syndrome
Myofascial Pain and Dysfunction, The Trigger Point Manual
The Gunn Approach to the Treatment of Chronic Pain: Intramuscular Stimulation for Myofascial Pain of Radiculopathic Origin
Acupuncture Energetics: A Clinical Approach for Physicians by Dr. Joseph Helms
Getting to Know You: A Physician Explains How Acupuncture Helps You Be the Best YOU by Dr. Joseph Helms
Back Talk Doc is brought to you by Carolina Neurosurgery & Spine Associates, with offices in North and South Carolina. To learn more about Dr. Lakhia and treatment options for back and spine issues, go to backtalkdoc.com. To schedule an appointment with Carolina Neurosurgery & Spine Associates, you can call us at 1-800-344-6716 or visit our website at carolinaneurosurgery.com.
Aside from clinical treatments for back pain and pain in general, acupuncture and dry needling are increasingly becoming part of treatment plans prescribed by physicians. However, there are misconceptions about these two interventions, with people often interchanging one for the other.
In this episode of Back Talk Doc, Dr. Sanjiv Lakhia goes into a discussion on dry needling and acupuncture and the significant differences between these two treatment options. It’s not so much as which is more effective than the other, but rather which intervention is the best course of action for your specific issue.
Generally speaking, acupuncture involves the insertion of needles in certain areas of the body to trigger positive physiologic responses. In dry needling though, your physician or physical therapist has to look at nerve and muscle patterns to identify and stimulate trigger points. While acupuncture is more of a system of care that can normalize other issues in the body as well.
He dives deep into the various scientific research studies that show the efficiency and benefits of these two interventions. These include increased blood flow to the pain area, releasing endorphins, a natural pain-relieving hormone, decreasing muscle banding, and triggering other sympathetic responses.
Dr. Sanjiv emphasizes that both dry needling and acupuncture are great additions to a comprehensive treatment plan. It’s important to consult with your physician to see whether these interventions can help alleviate and manage your back pain.
Key Moments in the Episode
History of acupuncture 02:51
Origins of dry needling 04:24
Scientific research on dry needling and acupuncture 07:23
Physiologic research studies on acupuncture 11:10
Physiologic research studies on dry needling 12:42
Trigger points 15:02
Benefits of dry needling 16:27
Differences in acupuncture and dry needling 18:15
Contraindications 20:36
Resources on dry needling and acupuncture 22:45
Links Mentioned in the Episode
Glute power with Ryan Klomparens, PT
All About the Thoracic Outlet Syndrome
Myofascial Pain and Dysfunction, The Trigger Point Manual
The Gunn Approach to the Treatment of Chronic Pain: Intramuscular Stimulation for Myofascial Pain of Radiculopathic Origin
Acupuncture Energetics: A Clinical Approach for Physicians by Dr. Joseph Helms
Getting to Know You: A Physician Explains How Acupuncture Helps You Be the Best YOU by Dr. Joseph Helms
Back Talk Doc is brought to you by Carolina Neurosurgery & Spine Associates, with offices in North and South Carolina. To learn more about Dr. Lakhia and treatment options for back and spine issues, go to backtalkdoc.com. To schedule an appointment with Carolina Neurosurgery & Spine Associates, you can call us at 1-800-344-6716 or visit our website at carolinaneurosurgery.com.
Intro: 00:01
Welcome, you're listening to Back Talk Doc, where you'll find answers to some of the most common questions about back pain and spine health brought to you by Carolina Neurosurgery & Spine Associates. Where providing personalized, highly skilled and compassionate spine care has been our specialty for over 75 years. And now it's time to understand the cause of back pain and learn about options to get you back on track. Here's your Back Talk Doc, Dr. Sanjiv Lakhia.
Dr. Sanjiv Lakhia: 00:32
One of the more common questions I receive from patients dealing with pain of any type, revolves around the concept of dry needling. Dry needling has become quite popular in the physical therapy arena, and the manual medicine arena in general. And in particular, it's often used to help in the recovery of a back injury. A question that kind of piggybacks on that, that I'll often get, is dry needling the same thing as acupuncture? And I think today I want to break down dry needling and acupuncture on this episode. Once again, thanks for tuning in. I hope if you've followed along on previous episodes, that you're learning a lot about back pain and how to take care of your spine and health in general. And today is a topic that I think you'll find very interesting. I really want to help individuals understand what is the difference between dry needling and acupuncture.
Dr. Sanjiv Lakhia: 01:33
If you look at my background, I was trained through the Helms Medical Institute in 2005, '06ish through the physicians program. It's a 300 credit hour program to help train physicians in medical acupuncture. And it has really been a kind of feather in my cap. I've used it throughout my career. I did my training through the pain management pathway and my teacher, Dr. Joseph House is just phenomenal. He's really a pioneer in the field of bringing acupuncture to the United States. And I get to work with many very knowledgeable physical therapists. If you've heard any of my episodes, you know I've interviewed Ryan Komplarens. I've interviewed just recently Jay Murugavel. And the gang at Carolina Neurosurgery and Spine Associates is very skilled in the art of dry needling to help individuals recover from back injury. So I've got to pick their brain a little bit and dive into the literature on dry needling.
Dr. Sanjiv Lakhia: 02:32
And I want to do a bit of a compare/contrast timeline, and you might find there's a lot more similarities than differences, but hopefully you can take some distinction away from this episode, as you're trying to decide what's the best intervention for your specific issue. So let's kind of dive into it. Acupuncture has been around for centuries. Originated, if you look at the literature, in China and perhaps some evidence that it originated in India as well. We're talking about 206BC to 220AD, through different dynasties in China, where they discovered the insertion of very fine needles into different points can trigger positive physiologic response or change in health. And this was really categorized through just manual learning and interventions. It really progressed into the 1700s, where it became a little more prominent in Europe and particularly in France in the late 1700s and 1800s.
Dr. Sanjiv Lakhia: 03:36
And the first evidence of this in the medical literature really appeared in the Lancet in 1826 and the British Medical Journal in 1858. Subsequent references really permeated the literature through the 1800s and the 1900s. It didn't really come to the United States until the 1970s. The philosophy and the utilization of it really adopted from our European colleagues. If you kind of contrast that to the timeline on dry needling, and I want to give credit to Michael Krok, is a physical therapist. Just in my research online, I came across a wonderful presentation that he gave in 2014 at a scientific symposium. I'm able to kind of steal some of the information that he presented. The first reports of dry needling really originated in the early 1900s, where there are reports in the medical literature of what's described as fibrositis or palpable tenderness and hardness of muscles.
Dr. Sanjiv Lakhia: 04:37
And then other phrases were coined, such as myofascitis, myalgia. These are terms that were used to describe points in the muscular system that when pushed upon created pain. The first trigger point manual, and I'll define trigger point here in a moment, the first manual really originated in 1928 and 1931. Once again, in Germany and Europe. And then as we moved into the early 1900s, the idea of myofascial pain and trigger points originated in JAMA, the Journal of American Medical Association. So it's really interesting, really paralleling some of the research that began to explode on acupuncture. There were cases where tender points were injected with what's called hypertonic saline, which is a concentrated form of saline and it treated pain in other parts of the body, hence the term trigger point, which was really coined by Dr. Janet Chevelle and Dr. Simons in the early 1980s.
Dr. Sanjiv Lakhia: 05:41
And they really authored the hallmark textbooks, Myofascial Pain and Dysfunction, The Trigger Point Manual. These are a couple of very nice, well put together books, a hard cover two volume set. I have a copy of my own that really outlines anatomically all the major trigger points in the body and the referral pain patterns. So a trigger point per se is really a point where if you push in the muscle, not only does it cause irritation where you're pushing, but it can cause pain in other parts of the body. So for example, very common ones that I'll see clinically would be occipital trigger points. So once in the back of the head that when you push on them can cause some achiness in your eye. Also, there's a very common trigger point in the top of the shoulder that when pushed upon it will cause achiness down your arm. And then similarly, in the gluteal muscles, you can find points that when pushed upon will elicit pain going down the leg, very similar to a sciatic type discomfort.
Dr. Sanjiv Lakhia: 06:43
So the American Physical Therapy Association Dry Needling Task Force in May, 2012, defined dry needling as a skill intervention performed by physical therapists that uses a thin filiform needle to penetrate the skin and stimulate underlying myofascial trigger points, the muscular and connective tissues for the management of near muscular pain and movement impairments. I think that's a pretty good definition. You know, the similarity is that acupuncture needles, which are very thin, high gauge needles are the same needles that are used by the physical therapist to perform their dry needling.
Dr. Sanjiv Lakhia: 07:23
Now, let's talk a little bit about some of the research here on dry needling and acupuncture. So if you look at the research on acupuncture, and again acupuncture, we're using these needles, but we're putting them to different spots all along the body. This may or may not include the area of pain. So that's one distinct difference, is that dry needling almost always involves the insertion of these tiny needles into the location of pain. Versus acupuncture, where if you come to see me for back pain, you might find that I'm putting needles in your ankle. Now a good knowledgeable physical therapist will also expand that, and they might treat the local area of pain and then search for tender points and trigger points in areas away from the source of pain. So it's not completely different, but philosophically there is a difference in that regard.
Dr. Sanjiv Lakhia: 08:18
When we look at the research on acupuncture, after the New York Times piece in the 1970s, where they documented a case of acupuncture analgesia, and this is where a reporter received acupuncture for pain relief, or documented acupuncture for pain relief in a patient undergoing an appendectomy. Really the research after that kind of exploded. The physiology behind acupuncture shows that in studies that were done in the 1930s through the 1950s using a galvanometer, and this is a device that measures electrical resistance in the skin, that when you place this over the acupuncture points, there were differences. The electrical flow between points on the same acupuncture channel is increased compared to points at different channels. Acupuncture could be explained easier using visual aides, but for the purpose of the podcast, I think you have to understand that the philosophy behind acupuncture describes energy channels that go through the body, and these channels, we believe, lie between the fascial planes, between the planes of the muscles, the soft tissues and the ligaments. And there are actual research studies where you inject the acupuncture points with a radio isotope, and then you can utilize a camera, see the dye pattern travel along the documented acupuncture channel.
Dr. Sanjiv Lakhia: 09:45
So it's some very, very interesting research that has been done. That study came out in 1987. Again, it's a technician radio isotope that was injected into the acupuncture points, and they were able to see using specialized imaging flow patterns, mimicking the acupuncture channels. Needle electrodes placed in the same channel acupuncture points at different body locations also register different electrical flow. And that was documented by [inaudible 00:10:14] in 1974. So again, it's evidence on the research basis that these acupuncture energy channels do exist. Physiologically, and in particular, looking at the pain response, we know that when you perform acupuncture on rats, you can document increased levels of natural painkillers within their nervous system. And clearly, there's no evidence of a placebo effect in rats. Additionally studies were done in the 1970s that when you give a drug called Naloxone after acupuncture, that it can block the effect of the pain relief. Naloxone does kind of reverse the effects of natural painkillers and opioids such as hydrocodone and oxycodone. And when you give it after acupuncture, it can reverse the effects. So just more evidence that there is a definite benefit to acupuncture.
Dr. Sanjiv Lakhia: 11:10
Acupuncture's main claim to fame is the ability to stimulate the release of endorphins within your nervous system. Endorphins, you can think about it as your natural pain relieving pharmacy. Just like if you went to a Walgreens or a CVS to pick up your prescription pain medicine, we have our own internal pharmacies within the nervous system. So for example, if you were to slam your finger in a door, immediately it would hurt. It would begin to swell, but then instantaneously your body would be releasing these painkillers, these endorphins, flooding the bloodstream with these endorphins to help control the pain. And with acupuncture, I tell patients it's a way for me to access your internal pharmacy. We also can utilize electrical stimulation with acupuncture, where we can use different frequencies of stimulation. High frequency stimulation can release endorphins, such as serotonin and dynorphins and norepinephrine, and low frequency which I often use in the office when I'm treating back pain, stimulates endorphin release as well.
Dr. Sanjiv Lakhia: 12:20
If you look at more of the physiologic research studies, there's a lot of clinical studies in the literature where acupuncture was applied to specific cases. So for example, there's some evidence that it can be useful for surgical anesthesia as well as for dental procedures. So the research has definitely exploded on acupuncture in the last 15 to 20 years. If we circle back to dry needling, there's a similar developing research pattern that's evolved in the literature. From a physiologic basis, there's a few different mechanisms that you want to consider when you're looking at dry needling. Again, in acupuncture we're activating energy channels and meridians. During dry needling, we're utilizing a knowledge of neuroanatomy, meaning where the nerve patterns fall, where the muscle patterns are that cause pain. And you really have to start with a very good and thorough physical exam to identify the deficits. If you do that, you can then using your palpation skills, a physical therapist or a physician can palpate what's called active trigger points. And these have different terms applied to them.
Dr. Sanjiv Lakhia: 13:35
They can be called hyper irritable spots. I've heard them called taut muscle bands. They're painful when you put pressure on them, and they can produce a characteristic referred pain and tenderness. And oftentimes they can even cause motor or strength or autonomic dysfunction. So for example, there are some trigger points in the head and neck that if you push on them can cause some dizziness, or can cause lightheadedness, or even temperature changes. So there's a direct correlation in the trigger points with your nervous system. Now, there are also what's called latent trigger points, and these are painful upon palpation, but they don't normally cause a patient pain. You also have satellite trigger points, which develop in a zone near the key trigger points. This is where a good knowledgeable therapist can kind of go hunting for them.
Dr. Sanjiv Lakhia: 14:30
So if you go to see one of our physical therapists for low back pain, oftentimes you'll find that they're palpating areas in your hip, down your leg, on the side of the leg, or even your calf or foot. And these are all connected with your trigger point. So again, as I spoke earlier, Chevelle and Simon's did a lot of the heavy lifting, where they mapped out these trigger points. And you can even Google, if you put in trigger point referral pattern for neck or shoulder, you will see all of these referral pain patterns on the internet now.
Dr. Sanjiv Lakhia: 15:02
So what's going on at these tender spots? Using physiologic research studies, it appears that the what's called the motor end plate is irritable at rest. And this is the electrical energy of the cells within that area of pain. And this has been well-documented using different technologic instruments to measure resistance patterns. Kind of similar to what I spoke to earlier about acupuncture points. Additionally, there's a well put together original research article that came out in 2008 in the archives of Physical Medicine And Rehabilitation, where Dr. Shah and Associates really looked at the chemical changes that can occur in trigger points. And they investigated a very common trigger point in the upper trapezius muscle in your shoulder. And what they found was that with pressure in these areas, different chemical substances were released into the body, such as bradykinin, substance P. And you don't have to remember these, just understand that there's a direct correlation with the circulating immune chemicals, pain chemicals, and immune chemicals with the trigger points that develop in our body, and that by treating them, you can alter those levels. It's really quite fascinating.
Dr. Sanjiv Lakhia: 16:27
When you look at dry needling, you might say, "Well, what's the point of putting a needle in the area that hurts? What's going on?" Well, there's several mechanisms that are activated when dry needling is employed for your pain. Number one, you can increase blood flow to the area. So blood flow and circulation can remove toxins from the area and promote healing. You decrease what's called muscle banding. This is where, a good analogy is your muscle's almost tied up in a knot, so to speak. So if you took a piece of rope and you tied it in a knot and visualize having someone kind of peck at that knot and then it releases, and now the rope is straight, you can elicit biochemical changes, which we just talked about. And even more fascinating is, you can actually alter the nerve pain patterns in your central nervous system. So you can kind of shut down the pain signals from your brain. That's why dry needling is not just a treatment for local pain. You're actually affecting the physiology throughout your body.
Dr. Sanjiv Lakhia: 17:27
Very similar research in 2012, that demonstrated alterations in substance P, in beta endorphin levels. Again, these are pain related chemicals in your body that are altered through dry needling. Substance P also plays a role in nerve pain. And there's research showing that these levels go down after dry needling, but into local tissues. And it can trigger as well what's called a sympathetic response. This is where you have alterations in blood flow and circulation through the needling effect. So that's very, very similar in my opinion, to some of the local effects of acupuncture, but there are a few different ways to kind of think about this. When you look at acupuncture, in my opinion, it's more of a system of care. For example, with acupuncture, not only can you treat the back pain, but you can help to normalize other physiologic abnormalities in the body that may be contributing to it.
Dr. Sanjiv Lakhia: 18:31
So for example, there are acupuncture points that we utilize to help move the energy through different meridians that affect your gastrointestinal system, that can influence your immune system and your overall circulation, in addition to the localized effect or the dry needling. I think dry needling also is part of a system, but that system is different. That system in my mind is the physical therapy model of treatment, which will include a hands-on mechanical evaluation, prescriptive exercises, stretching, sometimes manipulation, other modalities. The dry needling is one tool in the toolbox that a knowledgeable physical therapists can utilize. And that's an important point. You do not want to go to a physical therapy evaluation and only want to do dry needling. I think if you only do it in the context of your injury and not utilize other more comprehensive interventions, you're going to have limited results.
Dr. Sanjiv Lakhia: 19:31
So for example, I've said before on a previous episode, I somewhat strained my back during this COVID mess. And I was fortunate enough to be treated by my friend, Jay, who we interviewed for the thoracic outlet syndrome podcast. And if you haven't listened to that, you definitely should. But Jay was able to utilize, first a lot of different interventions to kind of balance out my pelvis, look at my muscle imbalance, use facilitation techniques. He gave me some exercises and then he added on a little bit of localized dry needling with electrical stimulation to the area of pain. And the combination was just fantastic, totally pain free, when I thought I was in somewhat trouble with the injury. So that is a really good way to approach, if you're a patient out there and you're wondering will dry needling work, I get that quite a bit.Does dry needling work? It's really the wrong question. The real question is what is going to be the program that evaluates my issues, and is dry needling an appropriate tool that can be used as part of that treatment plan?
Dr. Sanjiv Lakhia: 20:36
Now, contraindications I get asked a lot about, are there situations where dry needling or acupuncture may not be appropriate? Certainly if you have blood disorders, bleeding disorders, Coumadin, you're on anticoagulants, you have to be somewhat cautious, but even in that setting, I don't think it's a clear contra-indication. Typically dry needling and acupuncture, the needle insertion is not very deep. You're going into the muscle layer. You're not going near major blood vessels or arteries. If you have a good knowledge of anatomy and you know what you're doing. But having said that, I think you should have a degree of caution with any intervention. And again, this is for informational purposes only. If you're considering it, you certainly need to speak with your physician before engaging in either activity. The electrical stimulation piece can be an issue for some, if you have stimulators implanted, you have to check again with your physician. If you have a spinal cord stimulator, if you have a pacemaker certainly, you exercise caution in that regard.
Dr. Sanjiv Lakhia: 21:35
Outside of that though, I think both interventions are fairly accessible to most of the population with pain and injury. Acupuncture is normally covered through insurance, but at times it can be cash only. And there are times where we struggled finding insurance coverage for it. Dry needling is often ruled into the physical therapy, evaluation and treatment plan. There are other theoretical constructs of acupuncture and dry needling I don't want to dive too much into. There's a whole concept around acupuncture and movement of the chi or the life force or the energy. And there actually is some research behind that. And we might get into it in another episode, but understand that there is a philosophy, there's almost a cultural heritage behind acupuncture that I don't think you can separate as simply saying it's insertion of needles for pain control, versus dry needling, which is largely just in modality intervention, in my opinion, which can be very, very effective, but there isn't a historical context to it where you bring in elements of culture that led to its roots.
Dr. Sanjiv Lakhia: 22:45
If you want to learn more about dry needling, there are a couple of textbooks out there on the market. Now this may be more for medical personnel that are listening. One is the classic Trevella and Simons Trigger Point Manual. That's a two-volume text. I highly recommend it if you're doing any form of body work, even if you're in massage therapy and you can find it to be helpful. There's also Dr. Chan Gun's Treatment Of Chronic Pain manual, where he uses dry needling more in a radicular manner, meaning how to normalize pain and dysfunction that kind of refers down your arm or leg. And then in terms of acupuncture, there are several different resources out there. Joe Helms has written the authoritative textbook on acupuncture, and that's called Acupuncture Energetics. And that's more for medical personnel.
Dr. Sanjiv Lakhia: 23:43
But a really good read that I recommend you look up on Amazon is called Getting To Know You. And this is a book that Dr. Helms wrote for the lay public, and he really breaks down how acupuncture can categorize people into different constitutional types. And this is somewhat akin to some of the ways that, in traditional Chinese medicine and Ayurvedic medicine, where you can get grouped into a constitution or body type that goes along with personality type. And then it goes along with certain predispositions to health disease and health optimization. So it's really good. You can go through that book and kind of find out what's your type. And we use that in acupuncture as well to help design our treatments. That's just a really fascinating read. I suggest you pick that up if you have time and if you're interested in acupuncture at all, you'll find it to be a quick read and very informative.
Dr. Sanjiv Lakhia: 24:38
So there you have it, that's kind of the compare and contrast of dry needling and acupuncture. I think they're both very valid and useful nonsurgical intervention options for the treatment of acute or chronic back pain. They are both very, very low risk. They're relatively affordable in comparison to other medical interventions. And I think it's something that you ought to check out if you're struggling with back pain or any other type of injury. So I hope you enjoyed the episode today. Again, check out Dr. Helm's book, Getting To Know You, if you want to know more about acupuncture. If you're wondering if you're a candidate for acupuncture or dry needling, feel free to contact our office, get in with one of our physical therapist. And I think you'll find the efforts to be worthwhile.
Outro: 25:25
Thank you for listening to this episode of Back Talk Doc, brought to you by Carolina Neurosurgery and Spine Associates, with offices in North and South Carolina. If you'd like to learn more about Dr. Lakhia and treatment options for back issues, go to backtalkdoc.com. We look forward to having you join us for more insights about back pain and spine health on the next episode of Back Talk Doc. Additional information is also available at carolinaneurosurgery.com.
Welcome, you're listening to Back Talk Doc, where you'll find answers to some of the most common questions about back pain and spine health brought to you by Carolina Neurosurgery & Spine Associates. Where providing personalized, highly skilled and compassionate spine care has been our specialty for over 75 years. And now it's time to understand the cause of back pain and learn about options to get you back on track. Here's your Back Talk Doc, Dr. Sanjiv Lakhia.
Dr. Sanjiv Lakhia: 00:32
One of the more common questions I receive from patients dealing with pain of any type, revolves around the concept of dry needling. Dry needling has become quite popular in the physical therapy arena, and the manual medicine arena in general. And in particular, it's often used to help in the recovery of a back injury. A question that kind of piggybacks on that, that I'll often get, is dry needling the same thing as acupuncture? And I think today I want to break down dry needling and acupuncture on this episode. Once again, thanks for tuning in. I hope if you've followed along on previous episodes, that you're learning a lot about back pain and how to take care of your spine and health in general. And today is a topic that I think you'll find very interesting. I really want to help individuals understand what is the difference between dry needling and acupuncture.
Dr. Sanjiv Lakhia: 01:33
If you look at my background, I was trained through the Helms Medical Institute in 2005, '06ish through the physicians program. It's a 300 credit hour program to help train physicians in medical acupuncture. And it has really been a kind of feather in my cap. I've used it throughout my career. I did my training through the pain management pathway and my teacher, Dr. Joseph House is just phenomenal. He's really a pioneer in the field of bringing acupuncture to the United States. And I get to work with many very knowledgeable physical therapists. If you've heard any of my episodes, you know I've interviewed Ryan Komplarens. I've interviewed just recently Jay Murugavel. And the gang at Carolina Neurosurgery and Spine Associates is very skilled in the art of dry needling to help individuals recover from back injury. So I've got to pick their brain a little bit and dive into the literature on dry needling.
Dr. Sanjiv Lakhia: 02:32
And I want to do a bit of a compare/contrast timeline, and you might find there's a lot more similarities than differences, but hopefully you can take some distinction away from this episode, as you're trying to decide what's the best intervention for your specific issue. So let's kind of dive into it. Acupuncture has been around for centuries. Originated, if you look at the literature, in China and perhaps some evidence that it originated in India as well. We're talking about 206BC to 220AD, through different dynasties in China, where they discovered the insertion of very fine needles into different points can trigger positive physiologic response or change in health. And this was really categorized through just manual learning and interventions. It really progressed into the 1700s, where it became a little more prominent in Europe and particularly in France in the late 1700s and 1800s.
Dr. Sanjiv Lakhia: 03:36
And the first evidence of this in the medical literature really appeared in the Lancet in 1826 and the British Medical Journal in 1858. Subsequent references really permeated the literature through the 1800s and the 1900s. It didn't really come to the United States until the 1970s. The philosophy and the utilization of it really adopted from our European colleagues. If you kind of contrast that to the timeline on dry needling, and I want to give credit to Michael Krok, is a physical therapist. Just in my research online, I came across a wonderful presentation that he gave in 2014 at a scientific symposium. I'm able to kind of steal some of the information that he presented. The first reports of dry needling really originated in the early 1900s, where there are reports in the medical literature of what's described as fibrositis or palpable tenderness and hardness of muscles.
Dr. Sanjiv Lakhia: 04:37
And then other phrases were coined, such as myofascitis, myalgia. These are terms that were used to describe points in the muscular system that when pushed upon created pain. The first trigger point manual, and I'll define trigger point here in a moment, the first manual really originated in 1928 and 1931. Once again, in Germany and Europe. And then as we moved into the early 1900s, the idea of myofascial pain and trigger points originated in JAMA, the Journal of American Medical Association. So it's really interesting, really paralleling some of the research that began to explode on acupuncture. There were cases where tender points were injected with what's called hypertonic saline, which is a concentrated form of saline and it treated pain in other parts of the body, hence the term trigger point, which was really coined by Dr. Janet Chevelle and Dr. Simons in the early 1980s.
Dr. Sanjiv Lakhia: 05:41
And they really authored the hallmark textbooks, Myofascial Pain and Dysfunction, The Trigger Point Manual. These are a couple of very nice, well put together books, a hard cover two volume set. I have a copy of my own that really outlines anatomically all the major trigger points in the body and the referral pain patterns. So a trigger point per se is really a point where if you push in the muscle, not only does it cause irritation where you're pushing, but it can cause pain in other parts of the body. So for example, very common ones that I'll see clinically would be occipital trigger points. So once in the back of the head that when you push on them can cause some achiness in your eye. Also, there's a very common trigger point in the top of the shoulder that when pushed upon it will cause achiness down your arm. And then similarly, in the gluteal muscles, you can find points that when pushed upon will elicit pain going down the leg, very similar to a sciatic type discomfort.
Dr. Sanjiv Lakhia: 06:43
So the American Physical Therapy Association Dry Needling Task Force in May, 2012, defined dry needling as a skill intervention performed by physical therapists that uses a thin filiform needle to penetrate the skin and stimulate underlying myofascial trigger points, the muscular and connective tissues for the management of near muscular pain and movement impairments. I think that's a pretty good definition. You know, the similarity is that acupuncture needles, which are very thin, high gauge needles are the same needles that are used by the physical therapist to perform their dry needling.
Dr. Sanjiv Lakhia: 07:23
Now, let's talk a little bit about some of the research here on dry needling and acupuncture. So if you look at the research on acupuncture, and again acupuncture, we're using these needles, but we're putting them to different spots all along the body. This may or may not include the area of pain. So that's one distinct difference, is that dry needling almost always involves the insertion of these tiny needles into the location of pain. Versus acupuncture, where if you come to see me for back pain, you might find that I'm putting needles in your ankle. Now a good knowledgeable physical therapist will also expand that, and they might treat the local area of pain and then search for tender points and trigger points in areas away from the source of pain. So it's not completely different, but philosophically there is a difference in that regard.
Dr. Sanjiv Lakhia: 08:18
When we look at the research on acupuncture, after the New York Times piece in the 1970s, where they documented a case of acupuncture analgesia, and this is where a reporter received acupuncture for pain relief, or documented acupuncture for pain relief in a patient undergoing an appendectomy. Really the research after that kind of exploded. The physiology behind acupuncture shows that in studies that were done in the 1930s through the 1950s using a galvanometer, and this is a device that measures electrical resistance in the skin, that when you place this over the acupuncture points, there were differences. The electrical flow between points on the same acupuncture channel is increased compared to points at different channels. Acupuncture could be explained easier using visual aides, but for the purpose of the podcast, I think you have to understand that the philosophy behind acupuncture describes energy channels that go through the body, and these channels, we believe, lie between the fascial planes, between the planes of the muscles, the soft tissues and the ligaments. And there are actual research studies where you inject the acupuncture points with a radio isotope, and then you can utilize a camera, see the dye pattern travel along the documented acupuncture channel.
Dr. Sanjiv Lakhia: 09:45
So it's some very, very interesting research that has been done. That study came out in 1987. Again, it's a technician radio isotope that was injected into the acupuncture points, and they were able to see using specialized imaging flow patterns, mimicking the acupuncture channels. Needle electrodes placed in the same channel acupuncture points at different body locations also register different electrical flow. And that was documented by [inaudible 00:10:14] in 1974. So again, it's evidence on the research basis that these acupuncture energy channels do exist. Physiologically, and in particular, looking at the pain response, we know that when you perform acupuncture on rats, you can document increased levels of natural painkillers within their nervous system. And clearly, there's no evidence of a placebo effect in rats. Additionally studies were done in the 1970s that when you give a drug called Naloxone after acupuncture, that it can block the effect of the pain relief. Naloxone does kind of reverse the effects of natural painkillers and opioids such as hydrocodone and oxycodone. And when you give it after acupuncture, it can reverse the effects. So just more evidence that there is a definite benefit to acupuncture.
Dr. Sanjiv Lakhia: 11:10
Acupuncture's main claim to fame is the ability to stimulate the release of endorphins within your nervous system. Endorphins, you can think about it as your natural pain relieving pharmacy. Just like if you went to a Walgreens or a CVS to pick up your prescription pain medicine, we have our own internal pharmacies within the nervous system. So for example, if you were to slam your finger in a door, immediately it would hurt. It would begin to swell, but then instantaneously your body would be releasing these painkillers, these endorphins, flooding the bloodstream with these endorphins to help control the pain. And with acupuncture, I tell patients it's a way for me to access your internal pharmacy. We also can utilize electrical stimulation with acupuncture, where we can use different frequencies of stimulation. High frequency stimulation can release endorphins, such as serotonin and dynorphins and norepinephrine, and low frequency which I often use in the office when I'm treating back pain, stimulates endorphin release as well.
Dr. Sanjiv Lakhia: 12:20
If you look at more of the physiologic research studies, there's a lot of clinical studies in the literature where acupuncture was applied to specific cases. So for example, there's some evidence that it can be useful for surgical anesthesia as well as for dental procedures. So the research has definitely exploded on acupuncture in the last 15 to 20 years. If we circle back to dry needling, there's a similar developing research pattern that's evolved in the literature. From a physiologic basis, there's a few different mechanisms that you want to consider when you're looking at dry needling. Again, in acupuncture we're activating energy channels and meridians. During dry needling, we're utilizing a knowledge of neuroanatomy, meaning where the nerve patterns fall, where the muscle patterns are that cause pain. And you really have to start with a very good and thorough physical exam to identify the deficits. If you do that, you can then using your palpation skills, a physical therapist or a physician can palpate what's called active trigger points. And these have different terms applied to them.
Dr. Sanjiv Lakhia: 13:35
They can be called hyper irritable spots. I've heard them called taut muscle bands. They're painful when you put pressure on them, and they can produce a characteristic referred pain and tenderness. And oftentimes they can even cause motor or strength or autonomic dysfunction. So for example, there are some trigger points in the head and neck that if you push on them can cause some dizziness, or can cause lightheadedness, or even temperature changes. So there's a direct correlation in the trigger points with your nervous system. Now, there are also what's called latent trigger points, and these are painful upon palpation, but they don't normally cause a patient pain. You also have satellite trigger points, which develop in a zone near the key trigger points. This is where a good knowledgeable therapist can kind of go hunting for them.
Dr. Sanjiv Lakhia: 14:30
So if you go to see one of our physical therapists for low back pain, oftentimes you'll find that they're palpating areas in your hip, down your leg, on the side of the leg, or even your calf or foot. And these are all connected with your trigger point. So again, as I spoke earlier, Chevelle and Simon's did a lot of the heavy lifting, where they mapped out these trigger points. And you can even Google, if you put in trigger point referral pattern for neck or shoulder, you will see all of these referral pain patterns on the internet now.
Dr. Sanjiv Lakhia: 15:02
So what's going on at these tender spots? Using physiologic research studies, it appears that the what's called the motor end plate is irritable at rest. And this is the electrical energy of the cells within that area of pain. And this has been well-documented using different technologic instruments to measure resistance patterns. Kind of similar to what I spoke to earlier about acupuncture points. Additionally, there's a well put together original research article that came out in 2008 in the archives of Physical Medicine And Rehabilitation, where Dr. Shah and Associates really looked at the chemical changes that can occur in trigger points. And they investigated a very common trigger point in the upper trapezius muscle in your shoulder. And what they found was that with pressure in these areas, different chemical substances were released into the body, such as bradykinin, substance P. And you don't have to remember these, just understand that there's a direct correlation with the circulating immune chemicals, pain chemicals, and immune chemicals with the trigger points that develop in our body, and that by treating them, you can alter those levels. It's really quite fascinating.
Dr. Sanjiv Lakhia: 16:27
When you look at dry needling, you might say, "Well, what's the point of putting a needle in the area that hurts? What's going on?" Well, there's several mechanisms that are activated when dry needling is employed for your pain. Number one, you can increase blood flow to the area. So blood flow and circulation can remove toxins from the area and promote healing. You decrease what's called muscle banding. This is where, a good analogy is your muscle's almost tied up in a knot, so to speak. So if you took a piece of rope and you tied it in a knot and visualize having someone kind of peck at that knot and then it releases, and now the rope is straight, you can elicit biochemical changes, which we just talked about. And even more fascinating is, you can actually alter the nerve pain patterns in your central nervous system. So you can kind of shut down the pain signals from your brain. That's why dry needling is not just a treatment for local pain. You're actually affecting the physiology throughout your body.
Dr. Sanjiv Lakhia: 17:27
Very similar research in 2012, that demonstrated alterations in substance P, in beta endorphin levels. Again, these are pain related chemicals in your body that are altered through dry needling. Substance P also plays a role in nerve pain. And there's research showing that these levels go down after dry needling, but into local tissues. And it can trigger as well what's called a sympathetic response. This is where you have alterations in blood flow and circulation through the needling effect. So that's very, very similar in my opinion, to some of the local effects of acupuncture, but there are a few different ways to kind of think about this. When you look at acupuncture, in my opinion, it's more of a system of care. For example, with acupuncture, not only can you treat the back pain, but you can help to normalize other physiologic abnormalities in the body that may be contributing to it.
Dr. Sanjiv Lakhia: 18:31
So for example, there are acupuncture points that we utilize to help move the energy through different meridians that affect your gastrointestinal system, that can influence your immune system and your overall circulation, in addition to the localized effect or the dry needling. I think dry needling also is part of a system, but that system is different. That system in my mind is the physical therapy model of treatment, which will include a hands-on mechanical evaluation, prescriptive exercises, stretching, sometimes manipulation, other modalities. The dry needling is one tool in the toolbox that a knowledgeable physical therapists can utilize. And that's an important point. You do not want to go to a physical therapy evaluation and only want to do dry needling. I think if you only do it in the context of your injury and not utilize other more comprehensive interventions, you're going to have limited results.
Dr. Sanjiv Lakhia: 19:31
So for example, I've said before on a previous episode, I somewhat strained my back during this COVID mess. And I was fortunate enough to be treated by my friend, Jay, who we interviewed for the thoracic outlet syndrome podcast. And if you haven't listened to that, you definitely should. But Jay was able to utilize, first a lot of different interventions to kind of balance out my pelvis, look at my muscle imbalance, use facilitation techniques. He gave me some exercises and then he added on a little bit of localized dry needling with electrical stimulation to the area of pain. And the combination was just fantastic, totally pain free, when I thought I was in somewhat trouble with the injury. So that is a really good way to approach, if you're a patient out there and you're wondering will dry needling work, I get that quite a bit.Does dry needling work? It's really the wrong question. The real question is what is going to be the program that evaluates my issues, and is dry needling an appropriate tool that can be used as part of that treatment plan?
Dr. Sanjiv Lakhia: 20:36
Now, contraindications I get asked a lot about, are there situations where dry needling or acupuncture may not be appropriate? Certainly if you have blood disorders, bleeding disorders, Coumadin, you're on anticoagulants, you have to be somewhat cautious, but even in that setting, I don't think it's a clear contra-indication. Typically dry needling and acupuncture, the needle insertion is not very deep. You're going into the muscle layer. You're not going near major blood vessels or arteries. If you have a good knowledge of anatomy and you know what you're doing. But having said that, I think you should have a degree of caution with any intervention. And again, this is for informational purposes only. If you're considering it, you certainly need to speak with your physician before engaging in either activity. The electrical stimulation piece can be an issue for some, if you have stimulators implanted, you have to check again with your physician. If you have a spinal cord stimulator, if you have a pacemaker certainly, you exercise caution in that regard.
Dr. Sanjiv Lakhia: 21:35
Outside of that though, I think both interventions are fairly accessible to most of the population with pain and injury. Acupuncture is normally covered through insurance, but at times it can be cash only. And there are times where we struggled finding insurance coverage for it. Dry needling is often ruled into the physical therapy, evaluation and treatment plan. There are other theoretical constructs of acupuncture and dry needling I don't want to dive too much into. There's a whole concept around acupuncture and movement of the chi or the life force or the energy. And there actually is some research behind that. And we might get into it in another episode, but understand that there is a philosophy, there's almost a cultural heritage behind acupuncture that I don't think you can separate as simply saying it's insertion of needles for pain control, versus dry needling, which is largely just in modality intervention, in my opinion, which can be very, very effective, but there isn't a historical context to it where you bring in elements of culture that led to its roots.
Dr. Sanjiv Lakhia: 22:45
If you want to learn more about dry needling, there are a couple of textbooks out there on the market. Now this may be more for medical personnel that are listening. One is the classic Trevella and Simons Trigger Point Manual. That's a two-volume text. I highly recommend it if you're doing any form of body work, even if you're in massage therapy and you can find it to be helpful. There's also Dr. Chan Gun's Treatment Of Chronic Pain manual, where he uses dry needling more in a radicular manner, meaning how to normalize pain and dysfunction that kind of refers down your arm or leg. And then in terms of acupuncture, there are several different resources out there. Joe Helms has written the authoritative textbook on acupuncture, and that's called Acupuncture Energetics. And that's more for medical personnel.
Dr. Sanjiv Lakhia: 23:43
But a really good read that I recommend you look up on Amazon is called Getting To Know You. And this is a book that Dr. Helms wrote for the lay public, and he really breaks down how acupuncture can categorize people into different constitutional types. And this is somewhat akin to some of the ways that, in traditional Chinese medicine and Ayurvedic medicine, where you can get grouped into a constitution or body type that goes along with personality type. And then it goes along with certain predispositions to health disease and health optimization. So it's really good. You can go through that book and kind of find out what's your type. And we use that in acupuncture as well to help design our treatments. That's just a really fascinating read. I suggest you pick that up if you have time and if you're interested in acupuncture at all, you'll find it to be a quick read and very informative.
Dr. Sanjiv Lakhia: 24:38
So there you have it, that's kind of the compare and contrast of dry needling and acupuncture. I think they're both very valid and useful nonsurgical intervention options for the treatment of acute or chronic back pain. They are both very, very low risk. They're relatively affordable in comparison to other medical interventions. And I think it's something that you ought to check out if you're struggling with back pain or any other type of injury. So I hope you enjoyed the episode today. Again, check out Dr. Helm's book, Getting To Know You, if you want to know more about acupuncture. If you're wondering if you're a candidate for acupuncture or dry needling, feel free to contact our office, get in with one of our physical therapist. And I think you'll find the efforts to be worthwhile.
Outro: 25:25
Thank you for listening to this episode of Back Talk Doc, brought to you by Carolina Neurosurgery and Spine Associates, with offices in North and South Carolina. If you'd like to learn more about Dr. Lakhia and treatment options for back issues, go to backtalkdoc.com. We look forward to having you join us for more insights about back pain and spine health on the next episode of Back Talk Doc. Additional information is also available at carolinaneurosurgery.com.