Osama Imam: Point Taken: Dry Needling Treatment Theory & Applications

Episode Transcript
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Speaker 1 (00:00):
Welcome back to another episode of the Brown Performance and
Rehab Podcast powered by Isofit and Firefly Recovery. Isofit is
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Episodes like this are made possible by Firefly, the official
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(00:22):
more on Firefly, be sure to check out Recovery firefly
dot com. This episode is powered by doctor Ray Gorman,
founder of Engage Movement. Learn how to boost your income
without relying on sessions. Get a free training on the
blended practice model by following at Ray Gorman DPT on Instagram. Osama,
Welcome to the podcast. I'm so glad we're finally able

(00:44):
to do this. Man, you are an incredible individual with
so much knowledge, and I appreciate all that you've done
to help me out and teach me in relation to
dry needling over the past couple of years. Man, for
people who aren't familiar with you, or maybe they haven't
seen the work that you're doing that way, would you
mind fill them in a little bit about who you
are and all the great stuff you're doing.

Speaker 2 (01:01):
Thank you, Dan Man, I really appreciate you having me here,
And yeah, there was a lot of back and forth
as we're trying to get this set up, but we
both have busy lives going on. So my name is Osaima.
I'm a physical therapist. I'm just north of Detroit, Michigan,
where I'm born and raised, and I went through undergrad
physical therapy school in the area. And after physical therapy school,
I just felt like I didn't really know how to
properly help somebody. We learned a lot about how to

(01:23):
not hurt people and how to pass our board exam
and all these different systems, but not enough about like
actual orthopedic care. So I knew that I wanted to
do more. So I immediately went into a fellowship through
the American Academy a manipulative Therapy that's an orthopedic fellowship.
Took about eighteen months to complete. That very very clinical,
like we are learning in a classroom and then immediately

(01:45):
can apply it to our patients. There's mentorship involved with that,
and there's data collection for research. So really it does
try to make you a well rounded clinician. We're going through,
like you know, evaluation, all that, so I honestly really
enjoyed my time in Fellowship, and I do think that
made me significantly better clinician because I felt like I
was actually helping people and utilizing these skills that could

(02:08):
make an immediate change, both in the short term but
also in the long term. But one thing that I
really fell in love with was dry needling. A lot
of different ways to utilize needling, which I'm sure we're
going to get into, but when I was going through Fellowship,
we could take the classes unlimited times, so I tried
to attend the classes. If they were ever in my area.
I would draft to Chicago, I dropped to Cincinnati. We

(02:30):
had a few up in Michigan, so I would drive
around and try to take these classes from different instructors,
and I would read a lot of research on it
and then obviously using it on patients as well, so
seeing a lot of the effects of it, and from
my love for needling, and I was able to do
a medical mission trip that same year during my fellowship,
where I was able to go do even more of

(02:53):
it and teach other clinicians in another country how to
utilize it. All of that really rounded my education of needing,
and I eventually got the opportunity, thankfully, to teach for
the American Academy of Manipulative Therapy. So I travel to
other states and teach other clinicians how to dry You know,
I met you in Richmond, Virginia, and coincidentally, I'm in
Richmond this weekend, so it's been nice. I've been doing

(03:17):
this for about two years and a few months now
I've been teaching, and then I also take on mentees
for the Fellowship, and I have my own cash practice
up in Michigan as well.

Speaker 1 (03:29):
And you're a busy guy. You're truly someone who's kind
of embodied that ten thousand hour rule that it takes
to master something that way, and in particular in relation
to the dry needling, this is something that I feel
has been a very hot topic, and the more time passes,
the more interest I've seen in it from clinicians, from patients,
from parents, and so on that way, so much so

(03:50):
that I'd say at least three four times a week
someone is asking me, Hey, what is dry needling? Should
we be doing dry needling for me? Oh? Is it
just like aki puncture? I get so many different questions
about it on the week to week that way, And
I think now more than ever, you know, especially with
some of these AI advancements, patients are getting smarter and smarter,

(04:11):
they're getting answers, they're getting told about dry needling. Other
people are saying, hey, I did it and it worked
really well for me. So naturally people are more curious
in bringing it up more often that way. But for
people who aren't familiar with dry needling, maybe they haven't
taken a course themselves, maybe they've never had needling done
to themselves. What exactly is it and how does it
differ from that traditional acupuncture school of thought?

Speaker 2 (04:33):
If you will, absolutely you're right, But I mean clinicians
are looking more into it. We're still filling up our classes.
Every single time I teach, I got twenty twenty five
people in the class, So we're still filling out these
classes overall, and patients more and more so are looking
for There is actually a study that showed that there
are increased Google searches for dry needling now where patients
are the ones that are seeking this out. I think

(04:53):
a big reason for that is they've tried other things
that haven't worked. They're looking for other avenues that might
get them some pain really, and maybe some of their
friends have tried it, so they start looking more and
more into it. And that's by far the majority of
people that find me online are looking for dry needling.
And they I mean they see it on my website.
I don't have a listed that many times, but they
also see in my reviews because it's making such a

(05:15):
big difference in people's lives that they're including it in
their Google reviews. So dry needling is just the use
of a monofilament needle. It is a needle that's stainless steel.
There is no medication, and we are putting that into
problem areas in a patient's body in order to stimulate
their own natural healing process. They are the same needles
as acupuncture needles, but we are not putting needles in

(05:39):
as to follow a traditional Chinese diagnosis or an Eastern
medicine diagnosis. So for example, like there is needle that
goes into the infraspinatus in the shoulder, that's one of
the rotator cuff muscles, and that point is for the
small intestine. So something in acupuncture they might utilize that
in order to treat a small test and problem while

(06:01):
I would utilize that for a roadchhator cuff issue. And
this is acupuncture itself is not something that I'm very
well trained in because I didn't learn traditional Chinese medicine.
I did learn it from a Western perspective, and we
do utilize acupuncture studies. Just because a study was done
by a different profession, it doesn't mean that I disregard it.

(06:22):
Just like how if there was a manipulation study or
an adjustment study that was done by a chiropractor, I
don't not read that study because it was done by
a chiropractor because I can still do manipulations under my scope.
So I'm going to utilize that research and I can
apply it to my patients as well. Same thing with
an exercise physiologist and utilizing exercises because that's a big
thing that I do as well. And it's the same

(06:43):
case with acupuncture. So if there is a study that
looks at acupuncture for low back pain and they're putting
needles in the low back, then I can utilize that
study and treat my patients according to the same points.
A nice thing about utilizing acupuncture or excuse the actupoints
is that depending on the research you look at, there's
an overlap between trigger points and actupoints between seventy seven

(07:06):
and ninety three percent. It's a really big overlap that
gives us essentially a nice map to start off with.
It doesn't mean that we have to do all these
points for every single condition, but it gives us an
outline where we can pick and choose what we think
that patient would benefit most from. There's also studies that
are acupunct studies that are just utilizing a regular diagnosis,
you know, carpal tunnel syndrome, lateral elbow pain, headaches. Those

(07:31):
are acupuncture studies that are not treating you know, liver
blood stagnation. So I can still utilize those studies. And
there's been studies that have been published in JOSPT that
have used acupuncture and dry needling interchangeably. So those are
some of the reasons why we still might utilize acupuncture
research or acupoints. But what I want to emphasize that

(07:53):
with drain eiling, we are not doing traditionally Eastern medicine.
I'm trying to stimulate the bodies on healing response. We'll
get a little bit more into that, essentially getting more
bluff to the area and getting a natural opioid release,
so your bodys on pain killers over to the area
of pain. Yeah.

Speaker 1 (08:07):
No, that's incredibly well, said Osama. And just to run
it back, I mean, one of the main things I
like about that acupoint system, as you mentioned, is we
now have a common language between providers of the areas
we're trying to target with a needle, if you will, right,
So instead of saying, well, yeah, you know, I just
felt around, search and destroy and just trigger point, you know,

(08:28):
blew up this whole area. That way, it's like, hey, look,
I can be a lot more specific. So if for
some reason, hypothetically, say I'm leaving and someone else is
going to carry over the needle in care of plan
a plan of care for someone, that way, they can
actually look at it, understand hey, this is roughly where
he was at, this is why he was doing it,
and kind of continue in a similar fashion that way.

(08:50):
I also think, just from an overall like clinical effectiveness standpoint,
if you're constantly shooting all over the place instead of
kind of like targeted and one specific area, you're not
going to know what's actually moving the needle forward. Pun
intended versus like just kind of leaving people stuck where
they are. That way, it's ultimately a way to kind
of look at each patient you work with as their

(09:12):
own case study. You can look at the regions that
you targeted very specifically and say, hey, look, you know
i've worked here, this made this effect, Maybe I need
to continue that, Or hey, I targeted these muscular regions.
We didn't see the progress we expected. What am I missing?
Where do I go next? As opposed to well, you know,
I just felt all around and blasted everything. Right, We're

(09:33):
trying to be a little bit more sniper like than
shotgun focused here, if you will that way, And I
think that's one of the common things I've heard from
people that have had needling by other providers that haven't
had good outcomes with it, is they feel like they
go in and needles are just blasted all over the place,
and it's almost a little bit more stressful for them

(09:54):
than it is actually like relieving in therapeutic if you will,
not to say that, you know, the effect of need
is always you know, relaxing and calming for people, but
you know, they feel like their provider just doesn't have
a clear idea where they're going. And they also feel
like almost like beat up, like in a bad way afterwards.

(10:15):
And a lot of them tell me that, you know,
they were moving the needles all around and jerking them
real quick and different things, and they just didn't necessarily
like how that felt. And I use a slightly different approach,
one more in line with what you taught, where it's like, hey,
you know, instead of moving the needles up and down
or blasting them all over the place, it's like we
try and be a little bit more methodical, but we

(10:37):
also leave them in for a longer period of time.
I like to wind the needles a lot. That was
something that you taught that way. You mentioned the opioid
response that way. I mean physiologically, anything I can do
to like naturally, like dose the body with its own
natural painkillers. Like if people leave better leave feeling better
than they did walking in from that effect, Like I'm

(10:57):
going to make that transaction every time and again if
I'm being that kind of effect through an approach, I'm
not gonna change my approach when I'm getting the outcomes
I want with it.

Speaker 2 (11:06):
That way, I agree with you one hundred percent. There's
a reason that we teach it this way is because
it's typically people's first exposure to it, clinicians being so
if they've never done this before, we want to give
them somewhere to at least start off, and then you
can start to deviate from that as you have more
and more experience and actually see some results. Otherwise you're
just guessing. The problem with just looking for trigger points

(11:29):
is a few one that means you can only target
contractile tissue because only muscles have trigger points. You're not
gonna find a triger point of tendon. You're not gonna
find it in or on a bone, or a ligament
or a nerve, so you're essentially disregarding all these other
things that we could be treating with the needle if
you're only looking for the trigger point. Along with that,

(11:50):
there's between a three point three and six point six
centimeter error to find trigger points, so you and I
Dan would probably not find the same exact point on
a patient, and the needles that we're using at most
or point three oro point three to five millimeters in diameter,
so even more unlikely that we're going to get it.
And then what a lot of people are taught with

(12:10):
trigger point dry needling is that they go into a
trigger point, find a twitch, remove it, and go right
back in. And they're essentially jackhammering a muscle fiber, which
is shown to cause too much damage and typically it's
going to make the patient way too sore. I ask patients,
because a lot of people have had dry needling done
by the time they come see me. Now, I'll ask them,
how do they needle you? Did they keep the needles

(12:32):
in for fifteen to twenty minutes? And if they say
no immediately, I know if they're not trained in the
same way that I am. Did they use electricity? Typically
patients say no, did they Did they come back and
spin the needles every few minutes? Almost everybody says no
to that. Those are really really big deals that will
show that I'm probably gonna get them a better outcome
than the other clinician did. And needles just you know,

(12:53):
a disclaimer, it's not everything that we do. It's just
a it's a part of what we do because if
I can get somebody or result just a little bit,
if I can get them to sleep better that night,
have them in less pain, it gives us a window
of opportunity to really load them. So while everybody else
is looking for these long term results, I'm able to
get a short term result and a long term result.
And patients simply are gonna trust me because I'm able

(13:14):
to get them in effect relatively quickly. You were talking
about how patients can leave feeling a little bit beat
up or sore. There is a study that showed that
fifty one percent of patients they get needled don't want
to be needled again. Half of the patients that we
put needles in are not interested in having that done
to them again, which shows a few things. One they
were way too sore, and two they didn't get the

(13:36):
result they were looking for. Because even if they were sore,
if they felt better, they might say it's worth it.
I'm down to try that again. I've had this pain
for years. But if it's twofold, if they got sore
and they didn't get the result, why would they ever
want to experience that again. And I emphasize this to
people in that you have to make sure it's already
an uncomfortable technique. We want to make it as comfortable

(13:57):
as possible for our patients, So that means that you
need to be confident when you're holding and loading a needle,
when you're inserting it into a patient, if you are
doing it in a lazy way or you look a
little bit awkward with a needle, patients immediately are not
going to trust you. So you have to make sure
that you are you're the clinician, you're the professional. They're
seeking out your help because they don't know what to

(14:19):
do about their pain. So that the aspect of coming
in with confidence and inserting a needle confidently. And you'll
see this on social media whe people are doing this
poorly the entire time, where they will like tap a
needle multiple times, and they'll wind it and they'll tend
and try to rip it out of the body. I've
seen this, and these people have thousands of followers, so

(14:41):
naturally everybody thinks that they are the experts. But I've
also seen the people that are that are experts, that
are that have thousands of followers putting needles straight up
in somebody's lung. So just you know, be careful with
with with who is needling you, especially if they're near
the lung field, and make sure that they have proper training.
So one of the guys that we actually had reached

(15:03):
out to he's a chiropractor in Chicago has fifteen thousand followers,
is literally putting a needle in somebody's lung, and we
reached out. When it comes out he actually isn't training needling.
He just had to be a chiropractor in the state
and that gives him enough anatomy knowledge that the state

(15:23):
allows him to needle, which means he's just gonna hurt
somebody eventually, and that person I would imagine that he
put a needle in didn't end up getting a neumothorax
or a collapse lung because the body is incredibly resilient
and it will typically heal itself. But you only got
to make the mistake one time to ruin somebody's life
and also hurt your profession, hurt your own license, because

(15:44):
that's kind of negligence. So all that being said, the
way that we needle is a huge deal to me
making sure that it is as comfortable as possible for
the patient because we already know it's going to be uncomfortable.
It needs to be uncomfortable. If we don't get an
eighty response, we probably didn't do an enough. So we
don't want to make it even more uncomfortable, giving them
like a really sharp poke with the insertion and then

(16:06):
jackhammering a trigger point. There's a lot of better ways
to be needling a patient.

Speaker 1 (16:11):
Yeah, I think that's so well said. To your point,
it's uncomfortable when you have a needle in your body
or several needles in your body. And you mentioned that
we want the achy response, which you know throws people
off sometimes because you know, when I'm doing other manual
techniques they're looking for like that relieving effect, and this
one it's like we almost have to inflame the tissue
a little bit in order to get it to heal. Right,

(16:34):
it's like in one theory anyways, restarting that inflammation process,
if you will. But to your point, if we over
inflame the tissue, if we move the needle too much,
if we jackhammer it too much, now we're doing more
harm than good. And I think I could be wrong
about this, but the first rule and any kind of
medical practice is to do no harm. So that's where

(16:54):
that's where. Again to your point on the training and
just knowing what you're doing and why you're doing it, right,
this is not just an entry level every clinician ever
is going to be able to do this kind of
thing right. Maybe we'll get there eventually, but in my opinion,
we're not there yet. We want to make sure we
have an adequate knowledge of anatomy of using the needle,
because again, you're piercing the skin and putting something into

(17:15):
someone else's body. There are some risks that we diated
with that, and you have to have respect for that.
You have to know what you're doing, why you're doing it,
And I think the more you have all those things
kind of checked off right you begin with the end
in mind, you know what the end goal is, and
then you're reverse engineering the plan to get there and
understanding how dry needling fits into that, the more successful

(17:36):
you're going to be with this intervention. Again, if you're
just shooting blind and going all over the place, this
is not going to be an effective tool for you.
As a clinician. You have to have a robust framework
for taking dry needling and implementing it into the patient
population that you're working with.

Speaker 2 (17:52):
In the same way that you say that not every
clinician is appropriate to be doing this, not every patient
is appropriate to be receiving this. We have to make
sure it's ashers, then we'll get the result that they need,
along with the other manual therapy techniques that we utilize
or the other modalities and different exercise. I mean, like
if somebody has an issue and you give them exercise
that is going to it's not the best thing for them.
It might irritate them. Same thing with with needling, or

(18:14):
I mean if you didn't exercise too early in somebody's rehab,
or you tried, you know, mobilizing a joint that's hyper mobile,
Like the tool has to match the problem with the
patient is having. So it's the same case with needling.
We don't needle every single thing. And when we are needling,
you got to make sure you're doing it appropriately so
we don't piss in. We usually fan or cone. You

(18:37):
gotta wind the needle or else you're just missing out
on a bunch of the mechanisms of needling. You could
also tend or periostal peck, depending on where you are,
why you're doing it. And then electrical stimulation and the
eastern parameters that we typically use are within a very
comfortable range. I know some others might use a very
high high frequency and like develop a tentany, so like
there's actually a muscle contraction for the page where it's

(19:00):
not you know, it's not like a comfortable tapping muscle contraction.
It's like actually like a spasm almost not typically be
comfortable for a patient from what I've experienced and also
from what I've done to patients. So when you do
it a lot, you get to see what actually works,
what doesn't work. And sure you're gonna look at the research,
because that is the first part of evidence space practice,

(19:22):
but evidence BACE practice has three equal pillars, and that
is evidence, the research that you're reading, clinical experience, what
you've actually seen work, and what you're good at doing,
and patient's expectations. So if patient comes in and they
say that they want needles, we're probably gonna need you
day one. Because you're expecting this, You're probably gonna have

(19:42):
a positive outcome from that, versus if they had a
bad experience of needles. I literally don't even bring it
up to them until I build the trust with them,
and then they'll usually bring it up to me after
like two or three weeks. Because I'm not pushing it,
I'm trying other things. I'm already getting them a result
they're feeling better, I might bring it up maybe, or
I'll bring it up in regards to another patient that

(20:04):
had a similar case, But I'm not necessarily like pushing
this on them because again I've seen it work and
the research as it works. But if a patient doesn't
want it, it's probably not even to get them an outcome.
So we're usually kind of like going to bring it
in slowly or wait for them to bring it up
to us. But don't only look at the research and
forget about the other two equal pillars of evidence based

(20:25):
practice because not everything's been tested yet.

Speaker 1 (20:28):
Now, I think that's such a great point as well,
as you know, part of the evidence based practice is,
as you mentioned, the research, but part of it is
just your own experience and own practice that when I
think we often forget about that. And it's one of
those things too that I feel like understanding where your
own experience and where the patient expectation fits into that
evidence based practice makes conversations with other providers easier as well,

(20:52):
because I've had a lot of conversations with orthopedic providers.
I've had conversations with strength coaches, athletic trainers, even other
pts and chiropractors at times that they just don't see
the value in needling and they don't understand it and
they don't get it. But then we try it with
some of their patients and they see drastic changes, ridiculously fast.

(21:13):
And I think now more than ever, there's this growing
pressure on providers to provide results in a very quick fashion,
and if you don't, then ultimately you're a failure because
you can't provide outcomes, which I mean, that's that's a
whole separate conversation. But we have to respond to this
pressure in a way that does provide the you know,
the outcomes that people are after. And I think needling

(21:35):
is probably the most powerful tool, probably up there with
spinal manipulation, depending on the patient and their overall diagnosis
and presentation, that we have in our toolbox that can
make those kind of changes so quickly that way. And
I think once you start to see the value of hey,
look to your point from before, needling is not going
to be the only thing that we do. We're also

(21:56):
going to load them, We're also going to progress them
in other ways. We can open up this window that
we can actually do those things and make serious change
in a matter of twenty to thirty minutes. Like I'm
making that transaction every time, I'm blocking out time in
my schedule to make sure we've got enough time for
the needling, because then when I do get to those
things that are heavy loaded e centrics, isometrics, whatever, it is,

(22:19):
that way that I'm really putting a lot of stock in,
we can actually do those, we get more out of it.
And I haven't done a whole lot of own personal
assessments on pre and post needling, but one of the
things I've been really interested to see is as we
reduce the pain response right from dry needling, is there
any improvement in some of these other things that we

(22:41):
like to obsess objectively, right like hey, does someone put
out more force output or does someone have better muscular
activation on EMG, because hey, it doesn't hurt as much now.
And I mean, we don't necessarily have all the answers
to these questions, but I think it's one of those
things that, at least for me and my own experience,
I see notable changes functionally in a short amount of

(23:04):
time after needling, and I think that there's something more
to it just from the overall session flow and the
impact it can have for yourself and the work that
other providers are doing with a patient quick break, because
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Speaker 2 (24:03):
Yeah, there are a few studies, but there are some
studies that show that it can work for like athletic
recovery so soreness. Essentially, it can help and improving that.
And then there's a study that showed that it can
work in soccer players to improve I believe it was
endurance of their quads. So there there are somethings that
show within the research, but it's still very, very limited.

(24:24):
I have seen it anecdotally in patients where they get
you know, you can facilitate a muscle so they'll get
better muscle activation. I should feel it turning on, they'll
feel it burn, they'll feel it gets sore afterward. I
felt that myself where I've been needled, and then I
played basketball the same day, and my performance is I mean,
I'm not I don't have a I'm not a great basketball player,
but I got a great jump shot and it was

(24:46):
even better on that day. Where there's there's better athletic
performance that all from me being needled on that same day.
I've had patients break prs and half marathons in five k's,
powerlifters have no failed attempts, and and you know, and
new prs and deadlifts and squads recreation lifters break prs
and deadlifts. Now there's a lot of other things that

(25:07):
they are doing right. It's not like the powerlifter just
got that because because I needled her the day before
she went out for a competition and those workers her
back got tweaked the day before, but she felt so
good afterwards that she was not nervous pushing herself to
do that. She put in all the training and then
she's able to push yourself a little bit more. So
you were saying that want to make sure we can

(25:29):
reduce their pain so that way we can do the
things that really really matter in the long term, which
is loading them. If I can get somebody's pain down sooner,
I can load them sooner, hopefully get them stronger sooner,
and I can save them time and save them money
and get them a better outcome because they're in less
pain throughout. So all of that is really a positive

(25:51):
reason to be utilizing needles. And again, you got to
be utilizing in the right way. So just to talk
a little bit about some of the mechanisms of needling,
we know that if you are if you have a
trigger point. There are a lot of different theories for
what causes trigger points itself, and some people deny their existence.
I do believe that trigger points exist. I just don't
think there are only target for a needle, But essentially,

(26:12):
if you have a sustained amount of a setle colding
at a neuromuscular junction, which will happen, you'll have a
sustained amount of acetal colding there from an acidic environment.
So if you're having a sustain amount of a setle
colding athenuromuscular junction, you're essentially going to have a low
tone muscle contraction. And if we put a needle in that,
it's like throwing a grenade into that into that neuromuscular

(26:33):
junction and using up that remaining a seedal colding, which
is one reason why we probably get a twitch. The
twitch is also just a spinal reflex. It's not something
that they are voluntarily doing. And the twitch is not
everything because there is a poor correlation between pain and
disability in the short term. If you were to have
a twitch response, there is poor correlation and pain disability
in the short term and there's no studies in the

(26:53):
long term, So the twitch cannot be everything that we
are looking for, although it is still a target to
be needling trigger points, that is from putting a needle
in that one spot. But then if you do, let's
say fan in your coning where you're just changing angles,
so the needle goes into one spot, you could retract
it and then redirect it and hit some different hot spots,
whether you're going in a three dimensional or two dimensional pattern.

(27:16):
That I'll get you a lot closer to that room
for air, that three point three to six point six
centimeters air for finding trigger points. But also it's going
to create a lot less damage in the one area
that you just went into fifteen times when you pistoned
that patient. Along with that, if I put a needle here,
I can only affect it here. For those of you
that are just listening, I'm just tapping my shirt. But
if I grab that shirt and I spin it, just

(27:38):
like we spin those needles, we can pull everything in
towards the needle. So we're able to get a little
bit of a wider effect with that needle when we
are winding it, and we're able to get closer again
into that room for air. But also if we're at
some like sensitive areas, maybe you don't want to be
right on top of a nerve, want to be close

(28:00):
to it, well, you can start to affect some of
the tissue around that nerve, and you're pulling in the
fashion all of that just by spinning that needle. Then
you can also tint it, which is just spinning and
pulling on it. That's a bit more aggressive, so it
has to be the appropriate patient. And then also this
periostill pecking, which is just tapping on the bone. So
if you were to insert a needle, like where the
common extensor tendon attaches on the lateral elbow, you could

(28:21):
just put a needle there and then tap on it
to get more blood flow to the area because tendons
have poor blood flow. That's a way to improve blood
flow to the area. Same thing that is done at
joints where we could do that, like let's say at
the knee joint, you're getting down at the joint line
and then tapping right along the joint line to help
get more blood to that area. But also it can
promote chondrocites, which is the precursor to cartilage. We know

(28:43):
that you have to wind it to get the dentisen release.
A dentisine is a issodilator. It's gonna help with pain.
It can help downregulate this area in your brain that
is responsible for the emotional response to pain. So those
that have maybe a trauma associated with their pain, they
got God forbidden, like a car accident. Or I had
a patient once that was thrown off of a horse

(29:05):
and she was so scared to go back and just
just pet a horse. Part of it is that she's
just amped up because they had a trauma associated with it,
and we can reduce that. And that only happens from
the dentiscene, and the dynastine only happens if you spin
the needle. And then along with that, a dentistine is
what your body naturally will break down throughout the entire
day to help you go to sleep at night. So
if you guys are into sleep, just look up the

(29:25):
sleep Diplomat or Matthew Walker. Here's a great book called
Why We Sleep, And in that book he talks about
a dentistine and how a dentistine is built up in
your brain over about sixteen hours, which is why ourr
awake windows are about sixteen hours. And then it leads
to something called sleep pressure, which is not literal, it's
a figurative pressure where you like you can't stay awake
any longer, you start dozing off that happens from a

(29:48):
dentisceine and dnsine will help you both with the timing
of sleep and with actually falling asleep, while melatonin does
not do that. Malatone just helps you know when to sleep,
but it doesn't actually make you fall asleep. Being that,
if we can promote a dentisine, I'm doing it for pain, right,
I'm doing it for more blood float to the area.
But if I can help with somebody's sleep, good, I

(30:08):
want to help you with your sleep. And totally the
closer I am to the head and neck region, the
better they sleep. If I'm like needling their foot, doesn't
matter how much I spin the needle, They're probably not
gonna sleep that much better unless their foot pain was
preventing them from sleeping. So those are some of the
main mechanisms of needling, and then really the biggest of
them is the endogenous opioid release. So if we can

(30:28):
get more natural painkillers into that area, we can significantly
reduce their pain and again give us a window of opportunity.
We also will promote serotonin and nor of an ephrin.
If we can promote serotonin, possibly in the future, this
will be utilized for patients that take SSR eyes so
like anxiety, PTSC, depression, they're already utilizing acupuncture, they're already

(30:52):
utilizing you know, traditional Chinese medicine for those things. I
am not as a physical therapist doing driin needdiling, but
possibly in the future it will be something that we
can consider that might be in our scope of practice.
Because patients are only getting smarter, that's why they're looking
these things up. They're looking for a provider that can
do a lot of different things and not having to
see you know, a physio, a cairo an ACUPUNCTURISTM sauch, therapists,

(31:15):
a personal trainer. We kind of can do all of
these things to an extent, maybe for different reasons. But
if somebody is coming in for pain, I think I'm
a good solution to be helping them with their pain
and getting them back to the high level performance.

Speaker 1 (31:30):
I completely agree with that, and it's one of those
things that I think a lot of younger athletes realize
that a lot of the things they're after are not
going to be you know, accomplished without a little bit
of pain along the way. And again going back to
the pressure element, parents want answers and resolutions now more
than ever. Coaches want resolutions now more than ever. And
the amount of athletes I've had come in with back

(31:52):
pain or you know, soft tissue pain, you know, especially
like places like the cab for example, Like I love
to needle the cat because some of those trigger points
as you mentioned, can be major sources of issue and
can act up and you know, they'll try to dig
in with different things and different tools and it just
won't let go. But that's an area that I've you know,

(32:13):
noticed great impacts from needling. You mentioned the foot as well,
Like I can't tell you how many times I'll have
plantar fascia roll into the clinic. And I know you
mentioned that medial calcaneal tub tubercle or tuberosity a while
back and that being a gnarly point, and I mean
it's true, man, they feel it in the moment, but
let me tell you what, it works so well. And

(32:34):
even like shoulder patients that way as well, where they'll
get you know, told they've got instability or like possible
labrom that way, and a lot of their pain actually
clears up when we do needling to different trigger point
areas like you mentioned the infra spinatus very early on,
like cleaning up that infraspinatus and some of these other

(32:54):
places that can actually refer pain to other portions of
the shoulder makes a notable improvement of them. Now we can,
as we mentioned, load stabilize and have an impact there
as well. But in reality, like there's been very few
things that I've seen walk into my clinic that don't
benefit from dry needling. In fact, I can't think of
one off the top of my head. And one of

(33:17):
the things that I've found, at least for me, that's
really opened my eyes is a lot of times if
you're working with athletes, I don't care if your sports
PTSCS or strength coach or whatever. That way, we think
about things only in terms of sport, when in reality
we forget their people that have lives outside of sport.
And like I stinctly remember there was one college lacrosse

(33:40):
girl that came in because she was having headaches and
she couldn't get them to go away, and it was
actually impacting what she was trying to do from sport
that way, but it impacts other things too, write quality
of life, You mentioned sleep, even just school and academics
that way, because kids are under a lot of stress,
they've got to study, they've got to spend a lot
of time in weird positions times. So it's one of

(34:01):
those things that I went right for the dry needling
on that one because it's like, hey, look, this is
something i've seen help other people. They were, again to
your point from before, they wanted it, they expected it,
and we had great outcomes that way. And I think,
as you mentioned, there's a lot of different mechanisms at play,
there's a lot of different ways we can do the needling,
and I try to take the time to actually explain

(34:22):
some of those to the patients that I'm working with,
because you know, like you mentioned, they might not always
have a great experience. Even if I'm doing things in
a very methodical, well thought out way, it still might
not be one hundred percent outcome on day one or
day two that way. So it's having the conversation with
them to know that there's other processes or other ways

(34:43):
I can do it right. Hey, you know, day one,
I was just spinning the needles. Hey, maybe we need
something more aggressive and I'm going to spin intent or hey,
maybe you know my frequency on the stem was a
little too low. Let's try changing it next time and
see if we feel something a little bit different. There's
all these variables factors that go into it. And again,
since patients are only getting smarter, I think it pays

(35:06):
dividends to tell them on the initial console as much
as you feel comfortable about that, because the more they know,
the more comfortable they're going to feel throughout the entire process,
and the more they're going to trust you as a provider.
Right if you're just trying to like, yeah, you know
it's going to help you, let's just get to it,
and you rush into it, I feel like you're ultimately

(35:26):
doing them a disservice by not adequately preparing them for
what you're literally about to be putting into their body.

Speaker 2 (35:33):
That way, I agree with you, especially with the dosage,
like we're probably not going to get it right day one,
just like if you were to take a medication for something,
it's not like the dose is always the right thing
for that patient, and they you likely we're gonna have
to go back to your physician and adjust the dose
to make sure that they can get you the best
result with the few amount of side effects. Same idea.
With needling, I'm probably not going to get the right

(35:53):
amount day one. I typically will do less on purpose
because I either want to make them better or do nothing.
But I don't want to make them too sore, because again,
fifty percent of patients don't want to be needled again,
so I need to make sure it's an appropriate amount,
that they actually are tolerating it well, and that they'll
let me do it again. I'll usually ask for three
sessions of needles, and that will allow me time to

(36:15):
either increase or decrease the dose, depending on that patient,
in order to get them the result they're looking for.
And while they're on the needles, we are going to
be educating them, whether it's about the needles, like what
we're actually doing with the needle, or we're talking about
their lifestyle. And I think that there's a lot you
can learn from a patient when you're just sitting down
and having a conversation. And sometimes I'm just building rapport,

(36:37):
so I'm just talking about life and learning more and
more about them. But one time I had this patient
that had low back pain and she's on needles in
her low back and we're talking about sleep, and I'm
trying to understand our pain because she wasn't improving as
much as I was expecting her too, so I had
a feeling we were missing something. So one thing I'll
often ask my patients is walking me through twenty four hours.

(36:59):
Just tell me what you do throughout a normal day.
And she started off saying, I wake up in the
morning and I get out of bed, and I start,
you know, I do this, this and this. I'm like,
how do you get out of bed? She's like, what
do you mean, Like, how do you actually get out
of your bed? She said, well, it depends if Donut
is sleeping here. I'm like, who's donut? Is her cat
sleeping right next to her? So she goes off, Donut

(37:21):
sleeping here. Then I just kind of crawl out of bed.
So she doesn't want to wake up her cat, so
she's literally like going down towards the foot of the
bed and like melting out of bed and then getting
up to not wake up her cat. I was like,
wake up your damn cat, And all of a sudden,
her pain started to get better. Where if I didn't
have her on needles, if I didn't have the time

(37:41):
to just talk to her, I probably wouldn't have learned that.
I can guarantee you no other healthcare provider learned that.
But when we address that aspect, her symptoms actually got
significantly better. So it probably wasn't even the needles. It
probably was just a activity modification because she was irritating
her back first thing in the morning before she went
and sat in a chair all day for her job.

(38:03):
So the time that they are needles is a very
valuable time to be educating and learning from your patients,
and that way, I do think that we can get
them the overall result that they're looking for because they
are not coming in to you, like that girl Dan
that came in to see you for headaches while playing lacrosse.
She didn't come in to see you to needle her.

(38:24):
She came in to see you to get her headaches better.
She doesn't care what you do to get her headaches better.
She just was thinking, maybe needles are the thing, and
this guy does needling. So sure, we're gonna throw some
needles in that patient and ideally get an outcome from that.
But there's so many other things that we're able to
do as rehab professionals. Whether you're a physio, a Cairo,
an athletic trainer, like all of us have such a

(38:46):
wide range of things that we are able to do
within our profession that sure needling is going to be
part of it. But always remember, as somebody who needles
a lot, it is not everything for your patient, and
if you treat it as such, probably gonna start to
have limited outcomes. I mean, sure you're gonna help a
lot of people, just like if somebody gets off the
couch and walks into a physical therapy clinic and you

(39:07):
get them to do anything, their pain might get better.
That's that sedentary patient that doesn't really matter what you do,
doesn't need to be specific exercise, just have them do
anything and they feel better because you're having a move
in some way. Similarly, with needles, if you throw needles
in everybody, you're probably gonna get some people better, but
I guarantee you there will eventually be a person who
you are gonna get no outcome, and then what do

(39:28):
you do. There's got to be something else in your toolbox,
and that is that's really why I went to my fellowship,
and I'm still learning, like I'm doing ultrasnography now, so
I need a lot under ultrasound. I do a lot
of manipulation. I do a lot of exercise, be afar,
I do a lot of I do a lot of
joint mobilizations. I do some soft tissue. So there's so
many different things we can do within our profession. And

(39:51):
I mean, even like let's say a joint mope, there's
different intensities, there's different types of drum modes for that
for that specific joint. Same thing with exercise. How heavy
are we low them, when are we loading them? What
type of loading are we doing with them? Needles are
no different. The needle is just the tool. You can
utilize that tool how you see fits. So if you're
going in and doing pistoning and you know, jackhammer the

(40:13):
moussefiber and getting out, you're still technically doing dry needling.
But what you do and what I do are definitely
not the same. Think we're just utilizing the same tool.
That makes sense.

Speaker 1 (40:21):
It does make a lot of sense. And I love
the way that you word that and kind of walk
through that process and to echo your point that way. Man,
I mean, I've learned a lot and definitely gained a
lot of insight as to why someone might be coming
to see me through the conversations I have with them.
And it's interesting because I've actually had some people push
back on that, other providers saying, well, you know, you

(40:41):
don't need to have those conversations, or you know, other
pet clinics they see three, four, sometimes five patients in
an hour. They're still you know, getting better whatever that means.
We never actually come to a common definition of what
success looks like. But regardless, I catch and pick up
on a lot of different things just by the conversations

(41:03):
that I have with someone, and a lot of times
I learned that sometimes I'm not the best person for them.
They might need to see someone else. They might need
a nutrition or dietician console, they might need a mental
health console, they might need other things that I just
personally can't provide. As you mentioned, we can do a
lot in our profession, and sometimes one of the most
powerful powerful things we can do is take the time

(41:26):
that we have with someone, get to know them, get
to know their story, and then just help point them
in the right direction. A lot of times we can help. Again,
a lot of the time we can make a huge
impact for people and get them where they want to be.
But there's sometimes where we're just not the person for them,
and it's okay to know that it's okay to tap out.
I think one of the biggest mistakes that I was

(41:48):
kind of under the impression of getting out of school
was that, well, you're a pt you can do everything,
You're autonomous, you can run the world on your own.
And I lean a lot more into other providers now
than I thought I was going to coming out of
school that way. And that's especially true with the dry needling, because,
as you mentioned, it's not always the thing for everyone,
not every patient is right for it. So there's certain

(42:11):
things that I want to rule out before I start
sticking needles in there.

Speaker 2 (42:15):
Right.

Speaker 1 (42:16):
For example, I had someone come in the other week,
another lacrosse athlete. If you can't tell I live in
Maryland by the amount of lacrosse kids we get, and
I'm very concerned of a possible stress fracture or something
bony within the lumbar spine. I don't want to be
the person to stick a ton of needles directly into that.

(42:36):
I want to kind of rule that out before we
stick a ton of needles in that area. So it's
knowing again, what role do you play what effect can
you have. But as you mentioned before, when is the
right time and not the right time for people? And
I think the more you just emphasize treating people as people,
the value that you can provide for them, even if

(42:58):
it's just leaning into your own net work or the
impact you can have from a conversation and lifestyle modification
with them, the better off you're going to be long term.

Speaker 2 (43:06):
Yeah, I think the network is one of the biggest things.
You're right, like, we have to know when to refer appropriately,
and I think that's where patients start to fall into
they have bad outlook on healthcare is where somebody thinks
they can fix everything and they either mess them up
and make them worse or they just didn't get them
a result, They're like, why did I pay all this money?
I think that our network is one of the most
important things. So you know, I might have to send

(43:28):
you to like an orthopedic surgeon. It might even be
another physio, like I send patients to other pets in
the area. I've had polid Forth patients coming to see
them like I am not a power Forth therapist, this
is not what I do. Or I've had people that
have called me and I always get in a phone
call with any patient. If I'm going to take them on,
I have to really be sure that I can hopefully
get them the outlook that they're looking for. And with

(43:49):
this one patient, I thought it was a neurological case.
You got to go see a neuropet like this is
not my thing. But I'm very thankful that I've built
that network of different healthcare providers where I can send
those patients too, and then hopefully as a collective, we
can get them that outcome. And I think it pays
itself forward. I mean, actually, one guy that I sent
to another I sent him back to his primary care.
He had some red five that sent him back to
his physician, and then I didn't charge him for the

(44:12):
EVA because they didn't do anything. I'm not a good
business owner, I'm I'm just trying to be a good person.
So I sent them to his primary care. He kept
trying to pay me. I said no, and then he
sent me his wife and then bought a package for
his wife. So I ended up helping his wife with
her back pain, and then he also went down He
has to do a lot more testing still, but he
went down to the route that he needed to because I

(44:32):
was not the right solution for that patient.

Speaker 1 (44:35):
And again it's one of those things too. To your
point on the business owner piece, it's like, at the
end of the day, if your goal is to just
help people and lift everyone up, right, rising tides raise
all the ships in the water, I don't think you're
ever going to have to worry about things from a
business and financial standpoint, right, Like you know, I know
you mentioned that your cash based where I am in

(44:55):
Maryland currently were insurance based, which it's a battle sometime,
tis right. You face denials, you face low reimbursement rates.
But again it's like, how can I have a positive
impact on others? And obviously with needling, one of the
things that comes up a lot is you know, hey,
unfortunately it's not covered by health insurances yet, so there's

(45:18):
typically an additional cost to it. However, I do hope
for a day where health insurance recognizes the power and
effect that this can have and if anything, actually help
the system and save some money for people, Right, if
we can get them better and you know, six visits
instead of twelve, then hey, I'm willing to make that
transaction every time. And yeah, it might cost a little

(45:41):
bit more percession in the short term, but if it
saves us in long term. Again, we have to be
thinking bigger picture here instead of just what is going
on in present in the moment. We talked about that
in relation to the evaluation component. We talked about that
with the application of the needles themselves, but even just
as a whole and as a system, we always have
to have that bigger picture mindset in addition to the

(46:04):
you know, in the moment mindset.

Speaker 2 (46:06):
I guess I'll say, no, I agree. I agree with you, like, yeah,
it's not covered by insurance right now, but I do
think it will be covered by insturants in the future,
because eventually they're going to realize that we're actually able
to save a lot of money, a lot of healthcare dollars,
get better outcomes for our patients. And I do think
that starts with us doing the right type of needling
for our patients and getting those outcomes so that way

(46:26):
they can go back and tell their their physicians that like,
look at the outcome that I got and it was
from this person doing this, this, this and needling me,
or just educating these other providers that maybe don't believe
in needling, because if you go on social media long enough,
you'll see that there's a lot of hate towards dry
needling and spot manipulation. But one reason for that is

(46:48):
is I truly don't think they know enough about it.
I mean, there's a study that talked about drying needling
for neck pain where they combined there was one group
that had traditional physical therapy and another that had traditional
physical therapy plus dry needling. Now in the study they
say that their conclusion is that dry needling works well
in the short term up to one month, but has

(47:10):
no long term outcomes and it has no effect on disability,
only helped in pain. But if you go back and
read the methods of that study, they used fifteen millimeter needles,
which is not deep enough to get into the deep
enough in the neck they talk about getting into the
cervical MULTIFII. Fifteen milimeters will not get you into the
cervi U multifi They also said they were looking for
trigger points, which good luck palpitating a trigger point in

(47:31):
the cervicum multifidi. They also did vertical pistoning, so they
went back and forth. They used no electricity, they didn't
wind the needle and they didn't keep it in situ,
and still they had good short term outcomes even though
they did all the wrong things. So people will look
at a study like this, and I've seen this post
and on social media where people will say, look, there's

(47:51):
no effect on disability and there's no long term improvements
from needling. That doesn't tell me that there's no long
term improvements. That tells me that even if you suck
at needling, you're probably still gonna get an out come.
You could just have a better outcome comparatively. There's another
study that was done really well in knee replacement patients
where everybody was going to get a knee replacement and
they were all knocked out on anesthesia and they needled

(48:12):
half of them and they didn't you know, the other half,
and then the therapist did their follow ups for their
for their you know, their their PT sessions afterwards. The
surgeon didn't know who got needled, the patient didn't know
who got needled, so it was really well blinded study.
What they found from one needling session was that there
was better pain up to one month later after the
knee replacement, which is great because that means we can

(48:33):
hopefully get more improvements in range of motion. Along with that,
the one month improvement in the Drinningian group was equal
to the six month improvement in the non dry needling group.
So it just shows you the difference as to how
these studies are done and why some people may be
confused by them. So I don't think that people that
are posting on social media that are hating on needles
just don't want people to get needled. I think they

(48:55):
don't believe in them because they haven't gone a proper
education to how how drying deling worked, what it can do,
and for that reason, they start hating on it because
they don't want patients to waste their money. But I
would argue that if you are one, if you overdose
a patient and they don't want it done again, or
if somebody is hating on it on social media and
a patient's following that therapist and you know they don't

(49:17):
want to try it because someone else is hating on it,
you may have done that patient a huge disservice because
that could have been the thing that was going to
get them out of pain. But I know that I
have a lot of friends that are in healthcare, and
some of my orthopedic surgeon friends didn't believe in it
until I just had to like talk talk to them
about it and let them know that there are studies
that support this, and it's more conservative than you know,

(49:41):
cutting somebody open and changing their knee. It is like
we should be doing this way way early on, and
again it has to be done properly. You were talking
about needling the calf earlier. I had a patient that
I saw that was an NFL player that had an
achilles tendonopathy, and the team was only needling his calf.
No one touched his achilles. They also were not loading

(50:01):
him appropriately and they had him stretching. It bad ideas
for an chili tennopathy, but they were putting needles in
his calf. He would get sore and then his pain
would eventually went away to a point where he was
able to play again, and then he got rehurt pretty
much his next game, like the next game in the
season when I saw him, they just put needles in

(50:22):
the achilles. You have to do it a little bit
more conservatively when they like he was still in season
when I saw him, so I couldn't really go aggressively
on it. But if somebody has an achilles tendon problem,
sure you can go into the calf. It's gonna likely
get you some benefit. They'll probably need it. But you
should also be going into the tendon and you should
know how to do that, because if you go into
attendant and you're not probably training it, you could definitely

(50:44):
cause more harm than good. But all that being said,
when somebody saying that John needling doesn't work, I don't
think they truly understand it, and or they've probably met
people that have had bad outcomes because those that have
needled them didn't really know how to utilize that tool,
use a hammer when they should have used whatever, you know,
a drill.

Speaker 1 (51:03):
No. I think you said that really well, and you're
absolutely right. It's one of those things that, again, the
approach that one provider uses compared to the next can
be drastically different, and as a result, the outcomes can
be drastically different.

Speaker 2 (51:16):
Right.

Speaker 1 (51:16):
You can have the same diagnosis, go to three different
people and get three different treatment plans. And you know,
it's one of those things that I think the more
we kind of standardize things with things like a common language,
we talked about that earlier in relation to using the
acupoint system instead of just sticking needles in everywhere. The
more we can have this common language to discuss as providers,

(51:36):
the better off we're all going to be, and the
more kind of unified in the you know, quest of
optimal outcomes for as many people as we can. We're
going to be that way. And I realized we could
talk about the physical therapy space and we can talk
about dry needling in particular all day long because it's
a topic where you are extremely knowledgeable and very passionate
about that way. But I'm sure someone is gonna have questions,

(51:59):
They're going to want to reach out, They're gonna want
to talk more. Maybe they're even gonna want to sign
up for one of the many courses that you're teaching.
That way, Where can people find out more about you?
At online osama?

Speaker 2 (52:08):
So if you were to look me up on Instagram's
probably the easiest way. My uh well, I'm probably the
only USEMAMM who is a physical therapist. So first name
O s A m A. Last name I M A M.
My Instagram handles at doctor Krack and needles. I love that.
By the way, ther period crack end needles. My website
is Dynamic dpt dot com. UH the company that I

(52:32):
that I work with where I teach train needling is
at Spinal Manipulation dot org. We offer a lot of
different courses, not just train needling, but also we are
definitely the leaders in spinal manipulation. We have BFR courses, ultrascenography,
public floor driving needling, vestibular and concussion instruments, soft tissue mobilizations, diagnosis,
so really robust program offers a lot. I highly recommend

(52:54):
you guys looking to UH into spader Manipulation dot org.
And then I also have an online group which maybe
you can post in the show notes. I also have
it on my Instagram that's called the Manual Method. It's
just all online community. A lot of pts, cairos athletic
trainers that are in there, some like NPSPAS, and we
talk about patient cases. I show some different manual therapy techniques,

(53:16):
so some different joint mobilization, some soft tissue techniques. But
also I'm just one person, and I'm limited by my
experience and my education, and there are a lot of
people that have their own experiences in their own education
that also can be a huge benefit. So the community
really allows us to learn from each other and especially
from other people's questions, because sometimes people will ask a
question where I maybe would have never thought of that,

(53:38):
and it just kind of makes us all better because,
like you said, Dan, a rising tide raises all ships.
And I do think that this is the best way
that we can help more and more people. Is instead
of pinning all of the providers against each other, instead
of pinning the pts against the cairos, against the athletic trains,
against the osteopaths, I think that if we just word

(54:01):
to work together, the only patient's going to benefit is
or the only person's going to benefit is the patient,
and that is the awesome goal, is getting the patient better.
So that's why I have that online community.

Speaker 1 (54:10):
That's awesome. Yeah, I love that. We'll link to all
of that in the description below as well. That way
I didn't quite catch it, you can just click there.
And speaking from personal experience, you guys are the best
when it comes to dry needling instruction. I took some
courses that were not taught by you guys at AMT,
and I just feel like you guys did it the
best that way, So highly recommend getting certifications there if

(54:31):
you're looking for them that way. Osama appreciate your time
and everything you're doing. Man, thanks for everything.

Speaker 2 (54:36):
Thank you for having me Dan, I really appreciate. It's
a lot of fun.

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