Dr. Paul Killoren // #ClinicalTuesday // www.ptonice.com
In today's episode of the PT on ICE Daily Show, Dry Needling division leader Paul Killoren discusses the safety, efficacy, and utilization of palpation when incorporating dry needling treatment into your practice.
Take a listen to the podcast episode or check out the full show notes on our blog at www.ptonice.com/blog
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EPISODE TRANSCRIPTION
PAUL KILLOREN
Good morning, crew. We've got YouTube, we've got Instagram. My name is Paul. I'm representing the dry needling division for ICE. My name is Paul and I would like to talk about palpation this morning. Pretty dry topic you might think, but depending on if you're trained in dry needling and how you're trained in dry needling, palpation may have been one of the key aspects to your course, your training, and then fill in the blank from there. I mean, our accuracy, our safety, and even our effectiveness for dry needling relies at least somewhat, high percentage, low percentage, on palpation. So we're talking palpation this morning, not even actual needles in, but this is heavily a dry needling topic on our clinical Tuesday.
IS PALPATION-BASED DRY NEEDLING SAFE?
First of all, to get it out of the way, there is actually quite a bit of research saying, is palpation-based dry needling enough? Enough being, is it safe? Is it consistently effective? And the answer is yes, most of the time. Meaning there's solid data that says if we're palpating rotator cuff muscles, so a 2023 publication last year said, if we're palpating infraspinatus, even teres and supraspinatus, compared to ultrasound, we're reliable. Maybe that's because it's accessible, we have a big spine of the scapula to rely on, but unfortunately we have data, a publication from 2021 that says if we're palpating ribs, especially posterior ribs, so deep to rhomboid and trap and all of that, unfortunately we're not very reliable. So first of all, to say, um, not the topic exclusively for this morning is can we rely exclusively on palpation for dry needling safety? The answer is yes. Most of the time. Um, I mean, one stance we do with ice, even on our advanced courses that we do not do rib blocking techniques, uh, meaning we don't palpate and rely on the rib as a bony backdrop for for like thoracic extensors, rhomboid, all of those muscles. So we can rely on it most of the time. There are certain regions where it's less, research says it's less consistent, less safe. And that's pretty obvious stuff. Can we palpate everywhere else in the body? Spinous processes for the spine, trochanter sacrum for the glutes. Can we palpate muscles for quads and all that? The answer is yes.
HOW IMPORTANT IS PALPATION FOR DRY NEEDLING?
So really the topic of this morning is how important is palpation for dry needling? And I'm gonna break this, the rest of the discussion into two topics. The first one is how important is dry needling as a diagnostic criteria? And the second one is how important is palpation, we have to put it in the palpation bucket, but I'll say how important is tissue control when we're dry needling? So let's tackle topic number one. How important is palpation as a diagnostic criterion for dry needling? And this is where we'll start to see a separation based on when you were trained and how you were trained. Meaning, if you were trained more than five or 10 years ago, or if you took a fairly exclusively trigger point dry needling course, then palpation is key. as a diagnostic aspect, meaning hopefully you're doing other assessment, but when it comes down to firm pressure in tissue, identifying trigger points or top bands or even muscular tissue that reproduces a patient's symptoms or refers into different patterns, very, very high on that diagnostic algorithm, the palpation is. For ice, we are drifting in almost every respect away from the trigger point paradigm. I mean at the highest level we're drifting away from trigger points being necessarily the singular explanation for pain, the direct dry needling target, and even the twitch response as not necessarily being deactivation of shortened sarcomeres, trigger points, all of those things. So the question is immediately asked, so does that mean that we don't palpate? Are we just randomly, generically floating needles into a muscle? The answer is no. We don't palpate trigger points, we palpate motor banding. This follows other philosophies, but motor banding being a slightly larger, slightly more macroscopic tone, I mean it is palpable, but it's not on that microscopic sarcomere level. If you have been needling for any period at all, or if you do any type of any soft tissue work, you know that you can find motor banding in almost everybody's glute medius, vastus lateralis, medial gastroc, tricep, deltoid, infraspinatus. These aren't trigger points, these are motor bands. And there is value to palpating that, and there's value to treating that tautness, that motor banding for dry needling.
IS PALPATION DIAGNOSTIC?
So back to the question at hand is like, how important is palpation as far as a diagnostic criteria? For ice, for us, it's a little less important than perhaps a purely trigger point based therapist, but it's not completely unimportant. It's just a lower, it's lower importance on our assessment, meaning Hopefully we had a full patient interview, a subjective, a full assessment. There was something that led us to treat vastus medialis for Gladys' knee pain or infraspinatus for Gladys' shoulder pain. So we're already approaching the patient, essentially knowing that we're going to treat these muscles. Then, and the narrative that we use on our courses is that, that very last piece of the puzzle, like if there are any puzzlers out there in the group, you know, depending on how challenging your puzzle is. It just took you a few hours, a few days, a few months. You did the edge first, maybe that's your patient interview. Then you fill in different colors, different objects. Maybe that's the rest of our assessment. But then there's that last puzzle piece. Almost always it's lost under the couch or something, but it's that last piece. And you're like, sweet, found it. I'm gonna put this in. That is our palpation. meaning everything else in our assessment, in our treatment model, interviewing the patient, led us to treat this muscle. That last puzzle piece before we put in a needle, so we've decided we're gonna use dry needling, we've decided we're gonna treat infraspinatus, that last puzzle piece is spending five to 10 seconds finding that motor banding, finding tautness, finding any tenderness, finding anything that reproduces symptoms. But the shift that I'm acknowledging is that that final puzzle piece was not the full puzzle. Depending on how you're trained and when you were trained, palpation was what created the whole puzzle. Meaning if you are a little bit more trigger point centric, we really rely on palpating a trigger point or palpating that banding and having it reproduce the patient's symptoms or at the very least be a familiar sensation. Or to say an extreme opposite of, If you're relying exclusively on trigger point identification and you palpate, you dig your fingers into a muscle and don't find tautness, that almost starts to sound like, okay, we're not gonna treat this muscle. So again, the paradigm shift we're talking about is that palpation is always a part of the equation, even for diagnosis, I'll say, or even when deciding where to place our needle for dry needling. But depending on how you were trained, depending on how much emphasis you put on that pain generating reproduction of palpation based tone, it is like what decides if you're gonna needle at all, or it really just decides where you're gonna put the needle in. So that's number one. If we're just talking palpation this morning, the first topic I wanted to tackle was how important it was diagnostically. and the TLDR there was that we're going to treat that muscle anyways, but there is that final puzzle piece, that final five seconds or so where we look for motor banding. That is where we want to put our needle.
GREAT PALPATION IMPROVES PATIENT COMFORT
Topic number two, I guess we're still going to call it palpation, but now it is about the technical aspects of controlling tissue while our needle is in. No matter what technique, no matter how you were taught to tap the needle in, set up a bracket window with compressed tensioning of tissue, or squeezing, or setting up the OK sign. Now we're saying, how important are the more nuanced aspects of tissue control? So again, we're not talking diagnostic criterion anymore. Here is where this tissue control, this tissue feel, this firmness of palpation separates novice needlers and more experienced needlers. Here we are saying that this is one of the primary aspects for making dry needling comfortable. You could probably argue this is part of making dry needling safe, but here is where palpation, quote unquote, becomes hugely important. very specifically the technical aspects of needling. Myself, when I'm on courses, every once in a while I get on the table for our faculty or just to get some free needles or just to volunteer my body. And when I'm on the table, this probably applies to all of you out there who have been needling for a while or work with someone who's needled for a while, you can tell pretty quickly, meaning before a needle is even tapped in, you can tell pretty quickly how confident that clinician is, how experienced they are based on how they palpate. And that is key. This tissue control, how we identify those motor bands that we just discussed for diagnostic or deciding where to put our needle, but really making the insertion comfortable, getting through some dense fascial planes or deeper into tissue, or just quickly, confidently, consistently getting into a muscle. There's kind of a clinical proficiency here as well. That is an expert art. Masters who do dry needling do this very well. So again, we've split the road. We're no longer talking about that being important for diagnosis. Now we're saying this is what separates expert clinicians from newer needlers is the tissue control. If you've ever taken a course for me or a course for me recently, when we leave the weekend, the last few slides, I kind of give you a few things to remember. And one of those things I hope was, Dry needling is a skill that you have to use, use it or lose it, unfortunately. That's tough in some states where you just learned, you just took your weekend course, you just learned how to dry needle, and you can't immediately go back and start needling every single patient in the clinic. But what you can do is start palpating your colleagues, your partners, your patients. You can work on that firmness of tissue pressure, you can work on tissue control, and really I'll say that is a primary aspect for dry needling. Again, not diagnosis necessarily, but making dry needling more comfortable, more effective, and clinically more efficient.
SUMMARY
And that's where I'm gonna drop off today. I mean, the emphasis today, I'm Paul, I'm one of our leads for the dry needling division, so this is kind of a dry needling topic, but really, didn't talk much about needles today. The question I wanted to answer is how important is palpation? And if you're just jumping on, thanks for joining. See a bunch of folks joining on Instagram. First of all, can we be safe with palpation only, meaning compared to ultrasound guided dry needling? The answer is yes, most of the time in most places. If we're palpating ribs posteriorly, maybe not. Number two, How important is palpation for guiding our diagnostic, our diagnosis, as a diagnostic criteria and how important is palpation? And the answer there is a little less if we're not talking trigger points, but it is that final piece of the puzzle. There is that final three to five seconds before we put the needle in that says, aha, motor banding, just palpated it, that's where I'm going. The third aspect of palpation is how important is it for dry needling, comfort, efficiency, all of that. And that's where we say very high. That is really what separates experts from novice or that's what separates a more efficient, proficient, confident clinician when it comes to dry needling. So the challenge this morning is if you have not really been waiting palpation as important for that pre-insertion with your needle. The challenge this morning is to spend two to three extra seconds. Add five more pounds of pressure through your fingertips. See if you can be a little more precise with identifying your motor banding before you put a needle in. And from there, once you've tapped the needle in, maintain that tissue control or that palpation focus for the entire time the needle is in. So this morning we won't talk about are we gonna piston a bunch, are we gonna twist it, are we gonna just leave it, are we gonna do e-stim. For now I'll just say for the entire time you're inserting the needle, you're moving the needle, you're repositioning the needle, focus on the palpation, the tissue control, maybe more than you were before. That is what separates the experts. So with that, I'm going to drop off. I held it to 15 minutes, which is always a victory for me. I apologize for the darkness this morning. I have my ring light on, but otherwise, kiddo is sleeping right next door. So we are dark and quiet here in the Killoran household. It is very early on the Pacific coast. So if you're jumping on, catch the recording, catch the first 10 to 15 minutes. How important do you feel palpation is? Or even to ask it another way, how do you feel your palpation, your tissue control, your confidence in palpating stuff has matured and improved from when you started dry needling to today? I'd love to hear, I'd love to have a poll, maybe I'll throw it up on Instagram, but I'd love to hear some comments on has it gotten better, has it stayed the same, more important, less important, where do you place palpation on your paradigm of importance, your pyramid of significance when it comes to dry needling.
Otherwise I'm dropping off, if you're trying to catch a dry needling course with us for ice, The next few months are key, meaning we've had a really busy February. We have a really busy March and April. Then things kind of slow down. May, we take Mother's Day off. We have Memorial Day off. We have a post-sampler rest. So things start to slow as we get into the summer. All of our faculty have kiddos and family, and we know you all do too. So the summer will be a little lighter for courses. So if you're trying to catch us before the summer, Check out March and April courses. Ellie will be in Bozeman, Montana this weekend. I'll be in Baton Rouge. And then we've got a handful of other ones coming up. Otherwise, we're setting up our fall calendar now. So keep your eye on the calendar if you're looking for something post-summer for dry needling. As always, at PTONICE.com or check us out Instagram at Ice Physio or DPT with Needles. Thanks for listening, folks. Catch you next time.
OUTRO
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