In Part 1 [August issue], I discussed the utility of dry needling in addressing multiple aspects of pathophysiology as part of a multimodal approach to patient care. There is a distinction between practicing as a “cook” who follows recipes, vs. a chiropractic “chef” who can develop care plans on a day-to-day basis based on the presentation of the patient on that day.
By dissecting each condition into its inflammatory, neurological and osseous components, a chiropractic “chef” can create a combination of modalities that’s appropriate for the patient at the time of presentation.
In Part 2, let’s review examples of patient presentations at the various stages of healing within the context of actual conditions. Coding and scope considerations will also be discussed.* Here are some examples of this formula in action as part of a multimodal approach to various patient presentations, which include dry needling in a typical chiropractic setting.
The Acute Patient
Teen athlete with acute, low-grade ankle sprain experiencing pain with active inversion. Dry needles are applied locally to promote circulation. Another pair of perineurial needles are applied with high-frequency TENS attachments to promote local pain gaiting. This is followed by manipulations up the kinetic chain, including the knee and hip.
The patient reports that non-weight-bearing active ankle inversion has increased significantly. Ankle alphabet ROM home exercises are prescribed and the patient is discharged.
The Sub-Acute Patient
Cervical sprain patient, after two weeks of palliative care, continues to suffer right cervical rotation painful restrictions and right upper-extremity paresthesias due to SCM and anterior scalene hypertonicity, making manipulation poorly tolerated. Dry needling is introduced via short rounds of pistoning of the SCM and anterior scalene, followed by high-frequency TENS stimulation of the brachial plexus nerves via perineurial points.
Once a more pain-free right cervical rotation is restored, manipulation is better tolerated and the patient can be sent home with cervical rotation facilitative exercises.
The Chronic Patient
A patient presents with a history of lumbar degenerative arthritis with restrictions in all ranges of motions and pain the patient describes as “mild” to “moderate” discomfort. Deep dry needling is applied to the posterior aspect of the facet joints with periosteal pecking technique to promote local perfusion of the joint capsule. The needles are left in situ within the multifidus and spinalis muscles with low-frequency TENS to promote circulation and reduce muscle tone.
With increased pliability of the muscles and lubrication of the joints, manipulation and decompression therapy can be applied with far greater tolerance. The patient is prescribed home lumbar mobilization and core exercises.
Akin to the adjustment, dry needling takes very little time, is very inexpensive to deliver, requires specialized training (can’t be done by just anyone), is accepted by the general health care community (You don’t have to worry if your patients actually Google it) and is the perfect intervention for those patient who are in too much pain to even touch.
Due to dry needling’s diverse utility in affecting physiology, its application for the treatment of a myriad of conditions during all phases of the rehabilitative process make dry needling an invaluable tool for any chiropractic rehab program.
Reimbursement
There are two CPT codes for dry needling: 20560 (Needle Insertion Without Injection; 1 or 2 Muscles) and 20561 (Needling Insertion Without Injection, 3 or More Muscles). Much like the 9894X codes for adjustments, dry needling codes are not time-dependent, but rather differ in level based on the regions treated. This means that one could needle the upper trapezius, perform a modified-diversified adjustment and satisfy two codes: 20560 and 98940.
In a matter of minutes, the patient would have received two treatments that have shown to be effective at relieving pain and improving range of motion, with very little time and cost relative to most alternatives that can claim the same.
Reimbursement in personal injury and worker’s compensation can be realized with surprisingly little resistance. However, this can vary by region and the attitudes of legal representation. Reimbursement from major medical is rare. However, unlike other modalities that have CPT codes which have yet to yield some, if any reimbursement, dry needling is something other health care providers actually perform.
These codes came about thanks to combined efforts of the ACA and APTA. So, the odds of affecting some progress on this front should come with some cautious optimism; if for no other reason than it’s in the interests of other professions who carry significantly more influence than if it were exclusively a chiropractic endeavor.
Scope of Practice
While nearly half of the states include dry needling in their chiropractic scopes, the amount of training required to actually perform it varies widely. In Arizona, 24 hours are required. In Nevada, it’s 50 hours. In Texas, there is no specific number of hours required as long as an approved course is taken.
Some states require an acupuncture certification. Other states, like Georgia and many along the coasts, have explicit language banning dry needling for chiropractors outright. It’s extremely important that anyone thinking of adding dry needling to their practice make absolutely sure it is permitted by their state practice act; have the satisfactory requisites and training to perform the procedure; have notified their malpractice carrier; and are up to date on the additional responsibilities placed by OSHA and the CDC when any facility begins handling bodily fluids and disposing of medical waste/sharps.
Any dry needling training should include universal precautions; bloodborne pathogens (required by law in some states); and how to implement procedures in their office to mitigate the risk to the patients, the staff and the doctor, since many in chiropractic are also the owners of their practice and can be held liable.
Take-Home Points
Dry needling has overwhelming evidence for its efficacy in treating a host of conditions that present in the typical chiropractic office. Its application is extremely simple, requires very little space, and is cost-effective compared to other technology, modalities, and products that have far less utility. It has the acceptance of the general physical medicine community, and the public awareness due to media on professional athletes means your patients have already heard of it.
Right now, the public tends to associate dry needling physical therapy. However, the chiropractic profession is uniquely positioned to offer this treatment in combination with adjustments and other modalities in a way that is uniquely efficient, convenient and effective.
With the recent literature supporting dry needling’s efficacy against trigger-point injections, epidurals and even Botox, its implementation should be considered by any practitioner who treats musculoskeletal conditions. In the arena of pain management, being able to deliver an adjustment, dry needling and rehabilitation within the same setting is a professional advantage that should not be ignored.
*Always check with your local board, malpractice carrier and coding expert prior to implementing any modality.
When I graduated from chiropractic college in 1981 and started practice, I heard it all, and very little was positive. “You are a quack; you do not know what a subluxation is; you couldn’t get into a real health care program, so you chose the one that is slightly above a mail-order degree; you have no proof that chiropractic works; Are you really licensed?”, and so much more.
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