Interview with Dr. Rod Schlegel

The issue of whether the performance of dry needling (sometimes referred to as trigger point dry needling or intramuscular manual therapy) is within the professional and legal scope of physical therapist practice continues to be a question posed to state regulatory boards and agencies. The American Physical Therapy Association (APTA) created this document to provide background information for state chapters, regulatory entities, and providers who are dealing with this issue.

APTA is the national professional association representing more than 77,000 physical therapists, physical therapist assistants, and students nationwide.

Dry Needling by Physical Therapists

Dry Needling is an invasive technique used by physical therapists (where allowed by state law) to treat myofascial pain that uses a dry needle, without medication or injection, which is inserted into areas of the muscle known as trigger points. A trigger point describes a taut band of skeletal muscle located within a larger muscle group. Trigger points can be tender to the touch and can refer pain to distant parts of the body. Physical therapists utilize dry needling with the goal of releasing/inactivating the trigger points and relieving pain. Preliminary research supports that dry needling improves pain control, reduces muscle tension, normalizes biochemical and electrical dysfunction of motor endplates, and facilitates an accelerated return to active rehabilitation.

Numerous terms have been used in conjunction with dry needling. Some of the more common terms include trigger point manual therapy, trigger point dry needling, and intramuscular manual therapy. While the term “intramuscular manual therapy” may be considered by some to be a more accurate description of dry needling when performed by physical therapists as the technique is closely associated with manual therapy, APTA recognizes that dry needling is the more widely accepted and utilized term. The term ‘intramuscular manual therapy’ should not be misinterpreted as an endorsement by APTA to bill dry needling utilizing the CPT code 97140 (manual therapy). Physical therapists should check with the insurance payor to see if it has issued any policies regarding billing of dry needling

Physical Therapy Professional Organizations Positions on Dry Needling

To achieve a better understanding of the use of dry needling in the physical therapist profession nationally and internationally, APTA reached out to the following US organizations:
• Academy of Orthopaedic Manual Physical Therapists (AAOMPT)
• The Federation of State Boards of Physical Therapy (FSBPT)

In addition, APTA reached out to a number of international physical therapy organizations:
• Australian Physiotherapy Association (APA)
• Canadian Physical Therapy Association (CPA)
• United Kingdom Chartered Society of Physiotherapy

Two questions were asked by APTA of the organizations:
1) Have you adopted a formal or established an information statement on the use of dry needling? and,
2) Do you have a formal or informal process for including dry needling, or other “new” tests, measures, or interventions into your scope of practice for physical therapists/physiotherapists?

As to the first question, all groups either said “yes,” or indicated that they intentionally do not specify procedures in their scope but rather define the scope broadly. In each of those cases that did not specify but defined their scope broadly and, with the exception of the UK, they had subgroups or other documents that strongly implied or made it explicit that dry needling is performed and supported by the profession. The scope of practice in the UK would not exclude it.

The responses to the second question were more mixed; however, the majority continued to indicate that they had a process to define scope but not one that would specify procedures or interventions within the scope.

Interview with Dr. Neil Spielholz

This curriculum guideline on Physical Agents/Electrotherapy represents curricular content recommendations based upon feedback from physical therapy educators via a survey conducted by the Section on Clinical Electrophysiology and recommendations from the Electrotherapy/physical Agents
Practice Committee of the Section. New topics will be added when evidenced-based, clinical research provides documented support from controlled or randomized trials published in peer-reviewed journals.

Individual practice setting, Practice Acts, Rules and Regulations regarding physical therapy practice may determine practice limitations and role delineation.

Terminal Behavioral Objectives

After didactic and clinical education, given the results of a client’s evaluation and history, the graduate physical therapist will:
Given the results of a patient/client’s evaluation and history, and the plan of care established by a PT, the PTA student will be expected to:

IDENTIFY, DESCRIBE AND EXPLAIN indications for interventions utilizing physical agents and electrotherapeutic modalities.

IDENTIFY contraindications & precautions to the application of therapeutic modalities.
SELECT the appropriate modality (PTA Students, within the established plan of care)
APPLY the modality in a safe & effective manner.
EXPLAIN normal and abnormal physiologic responses and psychologic reactions to treatment

MODIFY modality application as indicated by the patient/client’s response. (PT A students, through consultation with the PT)
ASSESS treatment outcome in response to the application of a physical agent or electrotherapeutic modality.
INTERPRET patient/client’s response to treatment and make clinical decisions regarding treatment plan. (PTA students, through consultation with the PT)
DOCUMENT specific treatment parameters, application techniques, and treatment outcome.

Physical Agents & Electrotherapeutic Modalities Content Outline

I. Prerequisite and/or Concurrent Information
Basic Clinical tests and measurements
Muscle Strength and Endurance
Sensory Perception Testing
cutaneous pain, temperature, touch, pressure
cognitive awareness
Reflex Testing
Basic gait analysis
Neuroanatomy and Basic Neurophysiology
Cardiovascular System
Peripheral Circulatory System
Heart Rate, Blood Pressure (Vital signs)
Musculoskeletal System
Active & Passive Motion
Basic Postural Assessment
Human Systems and Cellular Physiology
Human Anatomy: neural, muscular, skeletal
Clinical Histology and Pathology including but not limited to:
Inflammation, wounds (burns, ulcers, tissue trauma) & tissue healing
(skin, nerve, tendon, muscle, joint structures)
Pain and Pain Control
Circulatory Disorders
Fundamentals of physics, biology, chemistry
Clinical Pharmacology:
Basic concepts related to potential interactions of drugs with
clinically administered physical agents as appropriate. (e.g. sensitivity to UV, wound care,
inflammatory conditions, clotting factors)
Clinical Neurology, Myology

II. Physical Therapy Clinical Knowledge and Skills
Conductive Heating Agents:
Hot Packs
Deep Heating Agents:
Thermal Diathermy, Short-wave diathermy
Cold packs, Ice packs, Cold Compresses
Ice Massage
Contrast Immersion baths
Cold Compression Devices
“vapocoolant sprays”
Low Power laser

Physical Therapy Clinical Knowledge and Skills continued
Mechanical Traction
Intermittent Pneumatic Compression Devices
Electrotherapy: contemporary electrical stimulation programs and required characteristics
of stimulators utilized for:
Pain control
Neuromuscular Electrical Stimulation for:
Muscle Strengthening
Restricted Joint Motion
Hypertonic/Hypotonic Muscle (e.g. spasticity)
Activation of Muscle for Joint Positioning,
Postural Control or Enhancement of
Functional Movement or Motor Control
Tissue Healing and Tissue Repair
Enhancement of Wound Heating & Circulation
Osteogenesis, Edema Control
Medication Delivery: Iontophoresis of Analgesics &
Anti-inflammatory Agents, etc.
Electrical Stimulation of Denervated Muscle
Other Topics for Inclusion:
Topical Hyperbaric Oxygen Therapy
Pulsed Ultrasound (Non-thermal US)
Pulsed Radio Frequency Radiation (non-thermal)
Biofeedback: electromyographic & temperature

III. Common Features of Physical Agents & Therapeutic Modalities Topics
Physics of Heat, Light, Electricity, Mechanical Principles
Fundamental Concepts &Terminology
Electrotherapy: Describe, Differentiate and Recognize
Types of Electrical Current, Common Amplitude and Time
Dependent Characteristics of Electrical Stimuli
Physiologic Effects of Heat, Electromagnetic Radiation, Electricity,
Mechanical Forces {Normal, Desired effects vs. abnormal or adverse effects)
Calibration and Maintenance
Safety Considerations
Principles of Operation
Indications for Clinical Application
Clinical Application Principles and Procedures
Clinical Problem Solving Skills (case study examples)
Supervised laboratory Experiences (Academic and Clinical)
Contraindications/ precautions and potential adverse reactions to the application of each physical

Integumentary/Wound Management Curriculum Recommendations Updated

The Section is happy to announce completion of the 2014 updates to the APTA’s Section on Clinical Electrophysiology and Wound Management Guide for Integumentary/Wound Management Content in Professional Physical Therapist Education. Originally approved by APTA in late 2007, the 2014 revisions were completed and accepted by APTA on July 17th.

This document was primarily designed to assist entry-level physical therapist education programs in developing integumentary curriculum. Section representatives have delivered two well-attended one-day Combined Sections Meeting (CSM) preconference sessions for educators over the past five years based on these recommendations.

It is our hope that by keeping this document up-to-date, it will serve as the “go-to” reference for educators when planning curriculum, clinical instructors in planning integumentary experiences for students during clinical rotations/internships, and for informing students regarding entry-level expectations in integumentary care. As this document has been utilized and referenced in the Section’s ABPTS petition to establish a wound management specialty, it also appears these recommendations are also being used to inform other stakeholders regarding entry-level integumentary content.

The next review cycle is slated to begin sometime in 2020. At that time a call for volunteers will go out to the membership for new/additional Task Force volunteers. A big “thank you” goes to the current review cycle Task Force: Harriett Loehne, Luther Kloth, Karen Albaugh, and Karen Gibbs. Additional appreciation goes to Lisa Culver, APTA Clinical Practice & Research, and Jody Frost, APTA Lead Academic Affairs Specialist, for their assistance in the review and approval process.

Registration is Open for November 13 Ultrasound Webinar

Registration is open for a one-hour webinar that will present evidence to support the use of ultrasound to enhance the inflammatory, proliferative and remodeling phases of tissue repair, to reduce soft tissue stiffness and contracture, and ultimately to improve function.

Title: Ultrasound – Applying the Evidence to Achieve Effective Outcomes in Musculoskeletal Conditions 
  November 13
Time: 2:00pm EST

Detailed Course Description: The literature points to differences among researchers about what ultrasound parameters to use to treat common musculoskeletal conditions. Meta-analyses generally find weak evidence in support of therapeutic ultrasound but the studies do not account for a possible dose-response pattern associated with benefit; trials are included based on methodology scores rather than appropriateness of treatment.

My approach was to critically appraise positive and negative ultrasound studies to identify possible dose-response patterns that could lead to development of clinical guidelines for treating musculoskeletal conditions. In the process, I found that incomplete reporting of ultrasound parameters was a challenge; journal reviewers should be more demanding of authors in this regard. In addition, I examined relevant basic science literature.

Research deals with two main indications for therapeutic ultrasound: using pulsed ultrasound to enhance tissue repair after injury and using continuous ultrasound to decrease chronic tissue stiffness. Laboratory studies are helpful for establishing optimal ultrasound settings for tissue heating alongside clarifying the limitations in terms of tissue depth and area that can be heated. Clinical studies confirm that ultrasound is ineffective for treating stiffness involving large tissue volumes.  My recommendations include the need to treat healing tissue for longer duration and more frequently than have been used traditionally.

Course Objectives: 

  • Critically appraise the literature on ultrasound
  • Demonstrate the importance of being a discerning consumer of ultrasound literature
  • Demonstrate that using ultrasound to heat tissues need not be a matter of guess work
  • Apply the evidence to develop effective treatment protocols
  • Clarify the limitations of ultrasound as a therapeutic agent

About The Presenter:  Dr. Nussbaum is an Associate Professor in the Department of Physical Therapy at the University of Toronto, Ontario, Canada, where she instructs the curriculum in Electrophysical Agents. She is cross-appointed to Western University, London, Ontario, within the MClSc degree in the wound healing field, and to Toronto Rehab as an adjunct scientist. She has practiced as a physical therapist in a major teaching hospital in the city of Toronto for more than 20 years. Her research mainly involves the use of ultrasound, laser light and ultraviolet radiation in tissue repair. Her work is published in numerous peer-reviewed journals and book chapters. She has held research grants from the Canadian Institutes of Health Research, The Physiotherapy Foundation of Canada, the University of Toronto, Medical Education Research Fund, The Ontario Neurotrauma Foundation and the Bickell Foundation of Canada. She is the receipient of numerous awards including the prestigious Silver Quill Award for the best quantitative research in Physiotherapy Canada, 2007, the University of Toronto Colin Wolff Award for Excellence in Continuing Medical Education and the Canadian Physiotherapy Association award for excellence in research. She is a frequent speaker at national and international conferences and regularly instructs courses involving Electrophysical Agents.