Scott Webb (Host): Many of you football fans out there may have heard about Pittsburgh Steelers' defensive end TJ Watt suffering a collapsed lung during the season after receiving trigger point dry needling.

 My guests today are here to explain what happened to TJ Watt, the benefits of trigger point dry needling, and how safe the procedure is when it's done by certified experts. I'm joined today by Sami Ahmed, Mollye Lipton, and Russ Patti, all of whom are doctors of physical therapy with OACM.

 Welcome to A Bone to Fix from Orthopedic Associates of Central Maryland Division. I'm Scott Webb, and I've got A Bone to Fix with you. So, I want to thank you all for joining me today. We're going to talk about something really interesting. I have a vested interest. I'm a lifelong Steelers fan, And so, we're going to talk about this TJ Watt situation where he went for trigger point dry needling, had a collapsed lung, was unable to play for a period of time. So, Mollye, I'm going to start with you, just a foundational question here. Like, what is trigger point dry needling, and how does it differ from acupuncture?

Mollye Lipton: Trigger point dry needling is a skilled intervention where we use a thin monofilament needle that is used to penetrate the skin and stimulate what we call underlying trigger points, which is going to help manage pain and movement impairments. So, our preferred sign that we want to be looking for when we do dry needling is called a local twitch response. It's not necessary, but that's kind of what we want to elicit. And a local twitch response is, like, if you think about when you have a Charlie horse in your calf and it Wakes you up in the middle of the night, you got that nice cramp in your calf, that's actually what we're looking to elicit. And that's going to help kind of increase blood flow and oxygenation to the tissues and relax that muscle.

Acupuncture is more based and rooted in traditional Chinese medicine and like the energy meridian theory, whereas dry needling is targeting those local twitch responses and targeting the trigger points.

Host: Yeah. And all of this is so new to me, Mollye, because my experiences with physical therapists have been with myself and my kids, and it was all sort of muscle stuff and moving stuff and exercises and stretching and bands and all of that. So to hear that physical therapists are doing this type of work, I really want to understand this.

And, Russ, I'm going to go to you because I want to find out. And we know what happened with TJ Watt, and the downsides apparently of trigger point dry needling perhaps not being done correctly. Talk about the safety measures. Like, what are some of the key safety considerations that practitioners should follow when they're doing dry needling?

Russ Patti: You know, I think, first and foremost, the biggest safety measure is therapist competency and therapist education and knowledge. And that kind of breaks off into several other subcategories. So, what I mean by that is, you know, the knowledge of anatomy and your positional placement, knowing what muscle you're going to be needling, the ability to palpate it, feel it. We can feel the trigger points. That's what we search for when we're performing the technique. So, it's a palpable, taut band in the muscle. I'm sure plenty of us have had that and can recall what it feels like. But we're able to palpate that, feel it, know where we are in the body based off of our educational background and our skill set.

There are safety precautions that we use when implementing this technique. The biggest one is the lung safety precaution. And that is any of the muscles that have been predetermined as a lung precaution,, we have certain grips that we use. We make sure that there is a bony background so that, when needling the muscle, there's nothing between the needle and the lung field, right? So, there's a bone behind the muscle that we know will protect the lung field. So, those are some of the bigger safety precautions that we use.

And another one too, or a few more actually, are knowing the medical history of the patient, what medications are they on, what other comorbidities might they have that might affect dry needling and the results.

And then finally, I think this is one of the more important ones as well is the constant communication. Understanding that this is not a technique that has to go on if the patient is experiencing a certain response. It's okay to stop the technique. So, having that communication and laying the groundwork And the educating the patient on what they should expect to feel, that goes a long way and helps guide us if we should continue with the technique or not.

Host: Right. Yeah, I get a sense from you there of sort of like the best practices and how scientific this really is, medical this really is. And you know, Mollye, I don't want to skip over and assume that just everybody knows everything about this. You know, what happened to TJ Watt, I mentioned a little bit in my intro there. But maybe you can just kind of get into the specifics as much as possible and why or how what happened to him really highlights the risks and concerns related to dry needling.

Mollye Lipton: Yeah. So, what he experienced was a partially collapsed lung or a pneumothorax, while receiving dry needling. And basically, what that means is that when the needle was inserted, it was going into the pleura, and it hit the lungs and there was air that got in there. And so, the surgery that they talk about that he needed to have was basically a placement of a chest tube in order to evacuate air that entered that pleural space.

Host: Yeah. It all sounds really frightening to me. Even a massively strong human like TJ Watt, I'm sure it was frightening for him and his family, and I know we got updates, you know, from his brother and family along the way. And Russ, let's talk about the sort of purpose of this, right? I get a sense that the reason you would do trigger point dry needling is to help people, to help athletes. How exactly though does it benefit them ultimately?

Russ Patti: What we look for and what we palpate for, as I alluded to earlier, are those taut bands in the muscle. And what those taut bands are are fibers of the muscle. So, all of our muscles are made up of hundreds of thousands of fibers. But let's say that a muscle in particular is made up of a hundred fibers, and 30 of them are kind of stuck in this contracted state. And that's what we feel the tightness as. It's the muscle fibers that are not relaxing and letting go. So, that causes a few different impairments for us. And that kind of boils down to three purposes of dry needling.

One of them is to improve range of motion. So, that's to release those muscles, to allow it to move through a full range of motion again. And that allows our body part to move through the full range And for us to fully strengthen. The next is to improve pain levels. So when a muscle contracts, chemicals flow in and out of that muscle. So if we have some of those muscle fibers that are stuck in that contracted state, those chemicals can't get back out. And that changes the environment of the muscle to an acidic environment, which induces pain. It amplifies pain that we may already have. So, it's a great technique to kind of manage that. And then, the third technique, which personally when I use it, I use it a lot in this regard, and that is to improve muscle function.

So, to go back to that comment before about muscle fibers, if we have a hundred fibers in a muscle and 30 of them are kind of stuck in that contracted state, then that's a 30% deficiency. So if we can release those fibers, and let's just say we get rid of 20 of those fibers stuck in that state, well, now the muscle's working at a 10% deficiency as opposed to a 30% deficiency.

So, those are the three primary reasons we use it: to improve range of motion, improve pain, and improve function. And they actually all kind of coincide with each other. They could all kind of be rationalized as the same purpose, but, you know, divvying it up amongst those three.

Host: Yeah. And you did a great job explaining all of this in audio form, and so I can sort of picture this and see the advantages, you know, getting athletes back on the field faster rather than waiting for their muscles to heal on their own, right? It makes me wonder, Mollye, though, like about the training requirements. Like, what kind of education and training do practitioners need to be able to do this safely?

Mollye Lipton: Yeah. Before we get into that, I want to go back to the pneumothorax thing one more time. Just to say that, you know, in terms of medical procedures that are out there and adverse reactions and adverse effects that you can have. A pneumothorax in a relatively healthy individual is, you know, while it sounds really scary, it's actually not like super scary, I think because, you know, the treatment is, like I said, just kind of placing that chest tube and evacuating the air. And while that, like I said, sounds scary to a lot of people with all the medical procedures that are out there and the adverse reactions and effects that can come from other medical procedures like surgery and, you know, injections and other things like that, like that's relatively non-life threatening when it comes to these other procedures that you could get.

So, you know, going through this and having the potential of getting really good results, we don't want to scare people off and say that, you know, you shouldn't get dry needling because there's this potential for a pneumothorax, which obviously that's there and obviously that's scary. But like, you know, you could go and have surgery and have something much worse happen as well. So, you know, just putting that out there.

 In the state of Maryland, at least, we need 40 hours of didactic education, and then 40 hours of practical hands-on training. After we've done those 80 hours, we need to take a competency assessment and pass that. And then, you know, from there we go through the different, stages of applying to the Maryland board for them to review all of that.

Sami Ahmed: I tell patients this all the time and I tell my athletes this all the time, you know, it is my point of view, and I know we're biased because we're all PTs on this call, is that, you know, in relatively speaking terms, if you think about the amount of hours that are spent learning and handling the anatomy and physiology, there really isn't another medical professional other than potentially an orthopedic surgeon that spends as much time palpating tissue and muscle as physical therapists do.

And so in order for someone to be able to dry needle in the state of Maryland, not only do they have to do that, those hours of requirements of training that Molly just mentioned, but they have to be a physical therapist that has an active license working within the state for a minimum of two years before they can even start applying to get all of that.

So, that's after four years of undergrad and three to four years of a doctorate level of educational anatomy physiology before getting to the training, the beginning of the training stages of this. So, it is a lot of work that it takes for someone to be certified in the state of Maryland to perform dry needling, especially for the guys that are here at OACM. I mean, they're the top-notch candidates.

Host: Right. My daughter, Russ knows this because we've spoken before about this, my daughter wants to be a PT, and I'm just like, "Are you sure you want to go to school for seven years, to be a DPT?" So, you're talking like the maybe seven years for that and two years before you can even begin to work on dry needling. So as you say, Sami, obviously, a lot of experience is required to even get to the point where you're doing this on patients or clients, right?

Sami Ahmed: Absolutely. And it's one of those things where it's built that way on purpose, right? Not every body, not every state, and not every organization, there are some chiropractors that dry needle and there are some athletic trainers, and there are some other groups that perform dry needling and their requirements are different. And personally, I don't want to speak to what those are because I don't know them fully. But Maryland's a pretty strict state. They only want the cream of the crop to be doing it. And I can say, thankfully, that has helped reduce the risk of things like pneumothorax to any of our patients.

Host: That's perfect.

Mollye Lipton: And I feel like, as a PT, our hands are like our eyes, you know?

Host: Totally. Yeah. Yeah. I love it. And it makes me wonder, Russ, like, are there some misconceptions? Can we bust some myths today, if you will, about dry needling?

Russ Patti: Yeah. I think the biggest one is kind of what Molly talked about earlier. You know, the difference between acupuncture and dry needling. Patients come through the door, they see and hear the word needle, and it's kind of like, "All right, yeah. I mean, I got dry needling a couple years ago," or "I got acupuncture a few years ago," and that's what it should feel like. So, I think, you know, the biggest misconception with that is that there is a difference and there's a difference of what you're going to feel during the intervention and also after the intervention.

To kind of piggyback off of that is that, "Hey, you know, you're poking me with a needle here. This is going to be painful, right?" Well, not necessarily. To kind of tag onto what Sami and Molly were saying, our hands are our eyes. We spend hours and hours every week and year kind of feeling the musculature, then to supplement that with the training and the background. You know, personally, when I'm doing this with my patients and when I'm educating them about what they should feel, you hardly feel the needle tap into the skin. You feel the pressure more of my grip during the palpation than you do the needle tapping into the skin. As I descend the needle towards that trigger point, which again is in a safe grip, you start to feel dull, achy sensation come on. And then when I hit the trigger point, you feel the muscle twitch, much to Mollye's point earlier, kind of feels like a cramp in the middle of the night in your calf. Now, we all know that that's not a pleasant feeling. It's somewhere between that and kind of a heavy pressure, almost like a vice grip is kind of cinching down on that area and it just feels like a heavy pressure. So, it's somewhere in between. But, you know, to call it pain, I wouldn't necessarily put it in that category. It's kind of this odd sensation that you really don't know what it feels like until you go through it.

Mollye Lipton: what I always tell my patients, that you're never going to know what it feels like until you've had it done. It's just a weird sensation.

Russ Patti: You got to live it.

Mollye Lipton: You got to live it. And we've all lived it.

Sami Ahmed: Poked and prodded.

Mollye Lipton: With all our training, we practice on each other. So, we've all had it done.

Host: Yeah, that's what I was assuming. I was assuming maybe not just, You know, every day just to pass time around the office. But I'm assuming you, you've all been through this, right?

Sami Ahmed: Absolutely.

Mollye Lipton: My shoulder's hurting, I call up Russ "Hey, can you come stick some needles in me?"

Host: I love it.

Sami Ahmed: the number of times I've called someone to say, like, "Hey, can you get that one spot in my spine? Like, "If you just get it, I can go back to the gym. I can do my normal things, please."

Host: I was going to say, the expression is that a membership has its privileges, right? You're right there and there are experts in the room like, "Hey, I got a thing over here. Can you help me with this?"

Russ Patti: That's right. I think two more misconceptions alongside with that, you know, it's called trigger point dry needling for a reason. Sometimes patients, they're coming to us after they've seen the orthopedic doctor. So, they're expecting, "Hey, you know, I got a cortisone injection with the doctor before. Is this going to be another injection?" The reason it's called dry needling is that there's no medicine involved within it. It's all purely, as Molly said, that solid needle that is administered into the skin. There's no medicine involved with it. There's no air that's getting into it. It's just purely that needle contacting the muscle.

And then, finally, you know, the last misconception that I typically hear, and Sami and Mollye, you know, chime in if you've heard differently, but, you know, sometimes patients say, "Well, how do You know where you're going? How do you know what you're doing?" You know, "Are you going to nick other structures while you're needling?" And to continue on the same train, it's why we're trained in this, that's why the state of Maryland is so strict about it. That's why we have to go through so much training. We know what we're palpating. We know what's behind the muscles. There are certain muscles in the body that we don't needle because either, A, it's too deep, there's certain vasculature around it. The risk is not worth the reward in that. So, you know, those are part of the precautions as well. But a misconception is, you know, what is this? You're closing your eyes and throwing a dart and hope that it sticks. Not necessarily, not in the least bit. We're well aware of what we're feeling and what we're needling.

Host: Yeah.

Sami Ahmed: Russ, I'd say there's a ton of bodies that, you know, taking something like this, like talking about a pneumothorax that, again, I'm not sure what exactly what procedure was done, what muscle was being targeted. I don't think the team has put out any of that information. And they may never put that information out respectfully.

But, you know, talking about muscles around the lung, like if I'm trying to needle a musculature that is a lung precaution around the spine where the lung may be something I'm worried about, I mean, Russ, you tell me, like, there are certain body types that I don't feel comfortable doing it because I can't identify and palpate that structure, right? If I can't know exactly where I am, I will find another treatment technique rather than dry needling to address that dysfunction that's there, whereas other ones should be fine.

Russ Patti: Yeah, a hundred percent. A hundred percent. And, you know, we keep talking about our education. That's part of it too is knowing the right person.

Scott Webb: Well, this has been really educational today. As I said, as a lifelong Steelers fan and rooting for TJ Watt and anybody else having dry needling. Good stuff today. Mollye, I just want to finish up and have you speak specifically about the state of Maryland when it comes to regulatory standards from the time where you go, "You know, I think I want to do dry needling" to actually being able to do it. Take us through that process.

Mollye Lipton: Sure. So as Sami said, you do need to have been practicing as a physical therapist for two years before you can even start taking the courses. And then, once you have taken the courses, passed the competency assessment, in the state of Maryland, you need to have completed all three of those courses. You need to have passed the competency assessment. Then, you have to apply to the Maryland Board of Physical Therapy Examiners and be registered for dry needling in the state of Maryland in order to legally perform it. I don't know specifically in all of the states, but I know that in some other states, when you take the first , you can then practice on your patients the muscles that you have learned in that first course. As Sami mentioned earlier, Maryland's a little bit more tight on those rules. So, we have to take all three and pass that exam before we can even start treating our patients with it.

Scott Webb: Yeah, and I'm just thinking to myself, I'm like, "All right, well, that means in the state of Maryland, and certainly at OACM, that patients are in good hands. And you mentioned earlier-- I'm tying all these things together-- Mollye, you mentioned earlier that your hands are your eyes.

Mollye Lipton: That's right.

Scott Webb: I feel like I've connected all the dots and I've learned so much today. I'm sure listeners agree. So, thank you all for being here.

Russ Patti: Thank you.

Mollye Lipton: Thank you for having us.

Sami Ahmed: Thank you for having us.

Host: And if you're thinking about the benefits of dry needling or other issues that physical therapy could help with, call us at (443) 478-4449 to book an appointment and talk to an expert.

 Find out more about us online at mdbonedocs.com. And please remember to share and subscribe to this podcast. And that's all for today. I'm Scott Webb, and that was A Bone That's Fixed.