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As people increasingly embrace exercise and physical activity as part of a healthy lifestyle, the need for therapies that address overuse and injury is on the rise. Simultaneously, the field of rehabilitative physical therapy is expanding to embrace new technologies and innovative therapies that are often overlooked or ignored by traditional medicine.
One treatment that is growing in popularity to address muscle pain and dysfunction is ultrasound guided dry needling. The treatment targets active myofascial trigger points, sensitive knots of muscle tissue that are essentially mini muscle spasms. Trigger points tend to arise around injured tissue, and are thought to play a significant role in many types of pain syndromes, including neck and back pain, TMJ, fibromyalgia, and other musculoskeletal disorders.
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Dr. Lev Kalika is revolutionizing dry needling by using ultrasound guidance to make the procedure ultra-precise and comprehensive. When used in conjunction with other technologies such as ESWT and EMTT, ultrasound guided dry needling renders ultimate results.
Dr.Kalika learned dry needling from its inventor, Dr.Karel Lewit MD, when working with him in Prague’s Motol Hospital.
Tatyana Kapustina has been practicing traditional Chinese medicine for over 15 years. She holds a Master’s degree in Acupuncture from the Pacific College of Oriental Medicine.
Ms. Kapustina learned dry needling procedures from Dr. Jan Dommerholt, founder and CEO of Bethesda Physiocare, who was the first physical therapist in the United States to teach trigger point dry needling and injection techniques to health care providers.
Dr. Kalika further joined forces with Dr. Rostyslav Bubnov, a double board certified specialist in regional anaesthesia and pain management. Dr. Bubnov is a world-renowned pioneer in his approach to ultrasound guided dry needling.
Kalika and Kapustina both studied under Dr. Bubnov to bring his methodology to NYC.
Conventional or “blind” dry needling lacks specificity, and usually requires multiple sessions. With ultrasound guidance, the procedure precisely targets trigger points, eliminating any guesswork.
Dr.Kalika believes that, when performed under ultrasound guidance, dry needling is in itself a diagnostic tool, as it rarely requires more than three needle insertions to learn whether the procedure will be effective or not.
Dr. Kalika has conducted multiple research studies on ultrasound guided dry needling, and has contributed his expertise to multiple publications, He is recognized as an international expert in integrative rehabilitation, sports medicine, myofascial pain and ultrasound guided dry needling.
Ultrasound guided dry needling is performed by two clinicians working together. A manual exam is first conducted to map out the area where suspected trigger points are likely to hide.
Common locations of trigger points are regions with:Shear wave sonoelastography is then used to image changes in tissue elasticity in those regions. Once the zone is narrowed down, grey-scale high resolution ultrasonography is used to locate hidden trigger points. Once located, a needle is inserted into the trigger point by the second practitioner, under ultrasound guidance.
After the needles are withdrawn, we use sonoelastography to check the location for changes in tissue elasticity. We may augment dry needling with other technologies to stimulate a regenerative effect, or use manual fascial release to enhance healing.
The patient may experience some soreness for the next 24 hours, and we recommend that they refrain from sports or excessive walking. Once the soreness wears off, the patient often feels improvement of their original complaint.
If trigger points are chronic, they are likely to reappear in a different location and will need to be dry needled again. Since it is impossible to perform dry needling on both the front and back sides of the body in a single session, multiple sessions may be necessary. However, on average we do not need to perform more than three treatments, and two is often enough. In extreme chronic cases, 3-5 treatments may be necessary.
Patients often wonder if ultrasound guided dry needling replaces physical therapy, and if it should precede or follow physical therapy.
In some cases, ultrasound guided dry needling is all you need to resolve your issue. In other cases, you may need it prior to physical therapy, to make it possible for the physical therapist to release your muscles. Deep and/or chronic trigger points may be impossible to release manually. In certain cases it is better to perform dry needling after regenerative treatment or physical therapy.
Our decisions on when to perform dry needling are based on the individual patient’s diagnosis and imaging results. We recommend a comprehensive consultation prior to the procedure, since every case is unique. Dr. Kalika will perform a meticulous examination and propose the optimal protocol for your treatment.
During trigger point dry needling, a thin needle is injected into an active trigger point to elicit a relaxation response. The procedure is called “dry” because there is no medication injected by the needle. Since trigger points are like minuscule muscle cramps that tend to appear where connective tissue meets nerves and muscle, the needle has the effect of releasing the cramp, eliminating pain and taking pressure off of surrounding muscle, connective and nervous tissue.
When done blindly, dry needling can be a hit-or-miss proposition, falling short of penetrating the trigger point itself. At NYDNR, our dry needling technique is guided by high resolution ultrasound, enabling us to accurately place the needle into the targeted muscle knot without unnecessary multiple attempts.
Both dry needling and acupuncture penetrate the skin with thin needles to provide pain relief. However, that is where the similarities end. Acupuncture is an ancient technique designed to balance and restore healing energy, or chi, to treat a variety of medical conditions. Although the underlying mechanisms of the treatment are not fully understood, acupuncture is recognized as a pain relief treatment by the Western medical community and is highly regulated.
Dry needling is a fairly recent therapy developed by Dr. Karel Lewit of Prague’s famous School of Rehabilitation, along with colleagues Janet Travell and David Simons. The treatment specifically targets myofascial pain brought on by a number of issues, including:
Unlike acupuncture, dry needling is based on knowledge of anatomy and physiology. When the needle penetrates a trigger point, it invokes a localized twitch response in the muscle tissue that ultimately releases the knot and restores normal function.
Trigger point injections deliver pain medication into a trigger point, but the procedure has several drawbacks, and extremely low efficacy.
The first drawback is the pain medication itself. The science tells that no medication can eliminate or reduce trigger points. The mechanism of pain injections is similar to that of dry needling. It comes from the needle piercing the trigger point, not from the medication.
The second drawback is that trigger point injections are performed blind, meaning they can only be used to target superficial trigger points that can be palpated from the skin’s surface. However, most active trigger points are located deep in the tissues, close to joints or inside the muscle belly next to nerves or arteries.
Deep trigger points cannot be injected blind, based on palpation alone. We use ultrasound guidance to visualize trigger points, for accurate targeting that eliminates them for good.
Ultrasound guided procedures at NYDNR use the most advanced ultrasonography equipment, enhanced with sonoelastography, rarely available in private clinics.
High resolution ultrasonography is the method of choice for UGDN procedures, able to detect deep trigger points that cannot be manually palpated.
UGDN is highly effective, requiring only 1-3 applications, versus blind dry needling that requires multiple repetitions.
Blind dry needling cannot access deep trigger points, and lacks precision and specificity.
We are able to combine UGDN with focused and radial shockwaves, for optimal results.
UGDN can eliminate the symptomatic phase of physical therapy, moving the patient directly from symptoms to correction, and reducing care by 4-8 weeks.
UGDN is an evidence based treatment approach with a high degree of efficacy.
Dr.Kalika is an internationally recognized expert in UGDN, with multiple scientific publications to his credit.
Dr. Lev Kalika, clinical director of Physical Therapy Clinic in Midtown Manhattan, learned ultrasound guided dry needling directly from Dr. Karel Lewit (the founder of the method) himself. NYDNR was the first rehabilitation clinic in the US to practice dry needling therapy.
Dry needling is often used in conjunction with other treatment methods, including extracorporeal shock wave therapy, manual therapies and physical therapy.
Myofascial pain specialist in Manhattan Dr. Lev Kalika has been working to revolutionize physical medicine, rehabilitation, sports medicine and athletic performance since 1998. Having conducted multiple research studies in ultrasound guided dry needling, and contributing his expertise to multiple publications, Dr. Kalika is considered an international expert in integrative rehabilitation, sports medicine, injury prevention, athletic performance, and ultrasound guided dry needling. NYDNRehab is considered the most technologically advanced private clinic in the US. The clinic features a range of technologies available only in the world’s top research labs, making them available for patient care, not just research.
HyunJu
YOO, PT, MPT, DPT, CPI (Licensed Physical Therapist)
Dr. Christina Pekar
DC
Dr. Michelle Agyakwah
DC
Mariam Kodsy
Physical Therapist
Ultrasound guided dry needling is an extremely effective evidence-based approach for treating myofascial pain caused by trigger points that rarely requires more then three treatments! Dry needling is perfectly safe and effective when performed under ultrasound guidance. During ultrasound guided dry needling (UGDN), painful trigger points are detected in deep layers of soft tissue using non-invasive high resolution ultrasonography. Once located, the clinician inserts a thin needle into the tissue, guiding it to the exact location of the trigger point. Once the needle penetrates the trigger point, it elicits a twitch response in the tight knotted tissue, causing it to relax and relieving pain. Dry needling is nearly painless, and the needles are “dry,” meaning they do not deliver medication to the site of the trigger point. While trigger point therapy can be performed without ultrasound guidance, it is a hit-or-miss procedure when trigger points are located in deep tissues and cannot be palpated through the skin. With ultrasound guidance, the dry needling procedure is quick and effective, since ultrasound imaging allows the clinician to precisely target each trigger point. Dry needling is legal in NYC.
Dr. Kalika is currently a certified member of:
American Institute of Ultrasound Medicine
Active member of ISMST
International Society of Extra Corporeal Shockwave Therapy
Active member of GCMAS
Gait and Clinical Movement Analysis Society
Active member of NASS
North American Spine Society
Active member of IADMS
International Association of Dance Medicine and Science
Active member of Virtual Rehabilitation Society
Active member of ASRA
American Society of Regional Anesthesia and Pain Medicine
Below is a prime example of how ultrasound can take the guesswork out of diagnosis.
A bad physical therapy experience is one of the primary causes of unnecessary surgery
In this instance, an athlete was originally diagnosed with minor quadriceps muscle strain and was treated for four weeks, with unsatisfactory results. When he came to our clinic, the muscle was not healing, and the patients’ muscle tissue had already begun to atrophy.
Upon examination using MSUS, we discovered that he had a full muscle thickness tear that had been overlooked by his previous provider. To mitigate damage and promote healing, surgery should have been performed immediately after the injury occurred. Because of misdiagnosis and inappropriate treatment, the patient now has permanent damage that cannot be corrected.
The most important advantage of Ultrasound over MRI imaging is its ability to zero in on the symptomatic region and obtain imaging, with active participation and feedback from the patient. Using dynamic MSUS, we can see what happens when patients contract their muscles, something that cannot be done with MRI. From a diagnostic perspective, this interaction is invaluable.
Dynamic ultrasonography examination demonstrating
the full thickness tear and already occurring muscle atrophy
due to misdiagnosis and not referring the patient
to proper diagnostic workup
Demonstration of how very small muscle defect is made and revealed
to be a complete tear with muscle contraction
under diagnostic sonography (not possible with MRI)
Complete tear of rectus femoris
with large hematoma (blood)
Separation of muscle ends due to tear elicited
on dynamic sonography examination
