One of the more common questions on our courses is – “when do I use e-stim with dry needling?”.
A fair question, because if you feel dry needling is infantile in terms of clinical research, then use and understanding of intramuscular electrical stim is embryonic.
That being said, there has been a dramatic shift towards the use of electrical stimulation with dry needling and clinicians anecdotally reporting improved patient comfort and suspected global effects on pain and the neuromuscular system. Empirical, yes – but I personally agree that stim has a place in dry needling treatment plans. And some of the research emerging is promising.
Exhibit A – Rainey, C. The use of triggerpoint dry needling and intramuscular electrical stimulation for a subject with chronic low back pain: a case report. International Journal of Sports Physical Therapy. 2013 April, 8(2), p145-161.
Exhibit B – Rock JM, Rainey C. Treatment of nonspecific thoracic spine pain with triggerpoint dry needling and intramuscular electrical stimulation: a case series. International Journal of Sports Physical Therapy. 2014 October; 9(5): 699–711.
Exhibit C – Couto C, et al. Paraspinal Stimulation Combined With Trigger Point Needling and Needle Rotation for the Treatment of Myofascial Pain: A Randomized Sham-controlled Clinical Trial. Clinical Journal of Pain. 2014 March, 30(3), 214-223.
So when should you consider using stim, and why? The answer will always be “it depends” on patient selection, chronicity, tolerance, intent, treatment model and aftercare; but here are a few scenarios you may consider using electrical stimulation with dry needling.
1) Deep muscles or tissue layers
Almost all of the research we have suggests eliciting a natural Localized Twitch Response (LTR) is the best response in terms of biochemical and EMG electrical changes, but we also have research that suggests we can’t even see or feel a twitch response from deeper muscles (like multifidus). This recommendation doesn’t come with the endorsement to abandon all needle manipulation techniques, but consider supplementing your treatment with stim to “cover your bases”
Example – Multifidus, Vastus intermedius, short head of Biceps Femoris, Quadratus Femoris…you get it.
2) Patients with aversion to needles
I hope it’s obvious to say if your patient is completely needle adverse or anxious, they may not be the most appropriate candidate for dry needling; but for more sensitive dry needling clients - stim may be a less noxious treatment compared to pistoning. Not all patients enjoy stim (of any kind), however, so again defer to your clinical decision-making skills.
Example – Patients who have a history of fainting with injections or blood draws, or the patients curling up in the corner while you put on your gloves. Probably not worth it.
3) Proximity to sensitive structures
When approaching sensitive neurovascular structures, pistoning or needle manipulation may increase patient discomfort or risk of insult to these structures - start with a low intensity low frequency stim instead.
Example –Proximal attachment of Piriformis (Sciatic nerve) or Tibialis Posterior (Tibial nerve/artery). Unless you’d like to send a sparkle down the leg intentionally?
4) Confirmation of treatment target
As we venture distally in an extremity, the proximity and overlap of our muscular treatment targets increase. Making precision paramount. Muscle activation, palpation, identifying landmarks and using bony backdrops when warranted are all crucial, but use of stim to confirm a specific contractile response can be very helpful. You'll see isolated gross motor movement in open-chain positions or identify specific tendon activation to verify correct needle location.
Example – Think about confirming Tibialis Anterior versus Extensor Digitorum Longus in the anterior compartment; Flexor Digitorum Longus versus Tibialis Posterior; or specific flexors and extensors of the wrist and digits.
This list isn’t exhaustive by any means, but for clinicians considering use of electrical stimulation with dry needling, I think it’s a good start. Your contraindications and precautions for both dry needling and e-stim remain true, so be sure to review these if you’re unsure.
As always, I love you hear your perspective or feedback. Thanks for reading and sharing!
Paul Killoren PT, DPT (@DPTwithNeedles)