Clinical Pearl: Real Clinical Talk—When is Enough, Enough?

By Seth Steinhauer PT, DPT, CSCS

One of the awesome perks of teaching for KinetaCore is having the ability to talk shop with many PTs from a wide range of settings and educational backgrounds. On the last course I taught, I had a discussion with course attendees about dosage parameters and tolerance, and I realized this would be great material to share with the dry needling community. So, here you go!

What spurred this discussion was a question that frequently comes up in our dry needling courses and, frankly, all continuing education courses. The question is usually phrased, “When do I discontinue using dry needling (or insert technique used here) with my patient during the treatment process?” Well…it depends.

You all are familiar with this answer from physical therapy school — the one that worked for every question asked in each course. Why isn’t there a solid answer to this question? Just the mere fact that each patient is different no matter the diagnosis is a good reason in and of itself. I thought it would be helpful to discuss a couple of common patient scenarios with the hopes of taming this beast of a question.

Scenario #1 – “The Change”

Let’s start from the beginning: We use dry needling and other modalities to create a change and when that change is made we begin to think, “When is enough, enough?” This was the exact question asked in a small group that I was leading during a Functional Dry Needling® course recently. Guess what my first answer was? “It depends.” I then elaborated (and was maybe a little long winded on the subject), but the reality is that this is a loaded question.

KinetaCore’s Chris Juneau answered this question pretty well in his Clinical Pearl article, Turning on the Lights. The change may need to be reinforced over time because compensatory patterns and existing neurological inefficiencies may be difficult to break with only 1-2 treatments. In addition to this, a great argument could be made for the fact that we often fall victim to our corrective exercise prescription. How often do you have patients who don’t have the motor capability to complete the corrective exercise given?

What about dosage? How much is too much and how much is too little? We may have to continue to clean up these neurological inefficiencies with our treatments until “The Change” sticks and becomes “The Norm.” The right prescription of corrective exercise may reduce the number of needed treatments over time.

What about objectivity? Is there a more objective direction to take? Re-testing what we tested in the first place might be a good place to start. This was beautifully explained in another Clinical Pearl article, The Value of Test/Re-Test, written by KinetaCore lead faculty, Keri Maywhort. She discusses just how simple we need to keep it for ourselves as physical therapists. We test or examine our patients initially, conduct a treatment, and re-test to decipher whether we have made the change both we and the patients desire. Does the change meet expectations? Yes? Well that could be enough, but ultimately assessment over time will give you your answer. You can now rely on correct prescription of exercise which should help maintain “The Change” and make it “The Norm.”

Scenario #2 – “Continuity of Care”

With only six states ruling against the use of dry needling by physical therapists, continuity of care across state lines with regard to the use of dry needling treatment has progressed positively over the last couple of years. But the reality is that even in states where dry needling is a legally provided treatment by physical therapists, there exists very little standard for this modality, being an entry level skill for newly licensed PTs, or even for experienced clinicians to learn the skill. This may create a scenario in which a patient, previously under your care, may need to continue rehabilitation at a clinic where dry needling will not be a treatment option. This is a perfect situation to illustrate the need for weaning a patient from receiving dry needling treatments.

I work in a professional baseball setting in which I remain at a single location and all the athletes requiring short and long term rehab will travel to me to receive their care. When the athletes finish their rehab, they will usually ship out to their respective baseball affiliates (i.e. low A, high A, double AA, etc.) and at these affiliates, dry needling might not be an option. If dry needling was used in their plan of care and an athlete is nearing the end of his rehab, I will progressively alter my dosage and begin to introduce other soft tissue techniques that these athletes will have access to at their respective affiliates.

My approach when discussing this transition with the athlete is a straightforward one. The discussion occurs on Day 1 of treatment and my goal is to establish dry needling early as a means to self-management. Because of this, I like to introduce new treatments (if needed) the moment I see a change with my athletes, explaining that dry needling is a spring board towards returning to independent soft tissue management such as use of a foam roll, lacrosse ball, vibration tools, etc. The other important piece in this scenario is that I always try to give myself enough time during the weaning process to find the right dosage or combination of soft tissue techniques that will continue to successfully manage the different athletes’ conditions.

I understand that my example may not be applicable to many so I thought of another, in the form of a “snow bird.” Snow birds are those people who live down in Florida for maybe 4-6 months out of the year to escape the harshness of the winter. Florida is a state in which dry needling is not yet accepted as a treatment provided by physical therapists. These types of patients may need to wean from FDN to promote independent management of their condition and ease the continuance of care by a provider in Florida, who will not be able to offer dry needling as part of their plan of care.

No matter our patient population or demographic, we try to educate our patients throughout the rehabilitation process and explain to them the reason that discontinuing certain treatments is part of that process. Deferring to the results of our objective testing can be one of our most powerful teaching tools as PTs. When a patient can see the difference between the initial test and what occurs on the re-test, this can eliminate doubt toward their progress and ultimately help in your ability to transition them to a new treatment. Piggybacking on that milestone of a patient noticing and understanding the change can be perfect timing for transition. This is when I like to introduce a new treatment and make the strong point that one of the primary goals of rehab is to empower the patient to be as independent as possible with the management of their injury or condition.

Scenario #3 – “Transition from Rehabilitation to Maintenance”

We all have those patients who achieve high or even advanced levels of functioning and are pretty adept at managing the majority of their aches and pains. Every now and then, those aches and pains extend beyond their control and they come knocking on our doors for that “tune up” treatment that has worked for them in the past.

We know exactly what treatments will help these patients, but we encounter the problem of insurances not reimbursing for these treatments anymore due to the high level of patient functioning. In these cases, a pay for service option exists to allow for patient access and fulfill the needs of both patient and practitioner. The professional approach would not change in this scenario and our trusty old test/re-test skills stay applicable. The best part about this situation is that the returning patient and/or athlete likely has already heard your spiel, so you can save the lectures and get down to work.

This scenario becomes difficult when the patients and/or athletes seeking the treatment do not have an impairment, but they perceive activity limitation. The “tune up” treatment may be used more as a “feel good” treatment that could arguably be more beneficial to the patient mentally versus physically. Be careful here—you may first want to dive into the subjective with these patients to give you more clues for how to proceed. Maybe the patient was seeing another provider that was selling a specific treatment as a “cure all,” or maybe the athlete has had a lot of success with a specific treatment prior to competitions. In either case, the patient and/or athlete may have already associated a positive outcome with the treatment that they are seeking.

The tough question is; do you give them what they want even if it may not be what they need? Sure, why not? I also politely educate the patient or athlete on what they may be feeling, and I may provide a different treatment in addition to what they are seeking to ensure a positive outcome. If the patients and athletes in this scenario feel strongly about a certain treatment, I am not going to take that from them right away. Even if it is the correct one, introducing a new treatment may not even work due to the built-up dependence this person may have on the treatment in question. I have always taken special care in this situation and empowered the patient or athlete by educating them on WHAT it is they are feeling, WHERE this feeling may be coming from, and HOW they may be able to fix it. I like to lead these patients to the answer and refrain from telling them the answer.

Undoubtedly, we can all share thought processes that factor into weaning a patient from dry needling treatment, and honestly any treatment for that matter. My goal in writing this pearl was to provoke some thought and continue the conversation with the dry needling community alongside!

 

Seth Steinhauer is a physical therapist for the Pittsburgh Pirates baseball club with over eight years of experience. Prior to joining the Pirates, he had worked and managed in orthopedic, sports medicine clinics throughout northern Virginia. He has been an assistant instructor for KinetaCore FDN 1 courses since 2016.