TDN competency Flashcards
(20 cards)
How does TDN work? (2)
it is not acupuncture!
1. helps to alter the current state of tissue to restore normal length and tone
2. improve blood flow to tissues that are not fully healed or healed improperly
Is TDN painful?
there is some discomfort, sometimes a local twitch response is elicited. Discomfort can last up to 24 hours. It may feel like a dull ache
introduction of TDN to patient
One option we might consider is dry needling. It often brings immediate relief and can help us measure immediate progress to your goals. In my professional experience, it’s particularly beneficial for patients with your [condition/signs/goals]. Please keep in mind that insurance typically doesn’t cover dry needling, so it would be an out-of-pocket expense. I want to make sure this aligns with your needs and preferences before we proceed: Would you like to move ahead with dry needling during today’s visit?”
spinal levels of lung field
c6-L2
Thoracic Multifidus:
1. Needle range
2. pt position
3. structures of concern
4. therapist position
5. action.
Needle Range: ‘J type’ or ‘L type’, .30 x 40-60mm
* Patient position
– Prone with head supported in neutral and pillow under legs for neutral spine posture.
– Optional pillow under the abdomen depending on the degree of lumbar lordosis.
* Structures of Concern
– Nerve roots with improper needle direction, lungs if treatment is too lateral.
* Therapist position
– The therapist stands on the opposite side of the table to the targeted multifidus with a
wrap technique or may stand ipsilateral to treatment side if using rabbit ear technique.
– The therapist assesses the tissue and palpates for spinal orientation (degree of kyphosis
or possible scoliosis) and bony landmarks (spinous process of targeted level).
– The therapist performs a clean sweep technique with alcohol.
* Action
– Wrap technique: Standing contralateral find spinous process, then use your pointer and
middle fingers to wrap lateral and ventral to create a groove for the needle insertion.
– Rabbit ear technique: place your palpating fingers directly lateral to the sides of the
spinous process, apply ventral force with the palpating finger and the needle insertion is
directly cranial to tip of the finger.
– The therapist prepares and inserts the needle at an angle perpendicular to the spine and
targeting the bony backdrop of the lamina.
– Perform the technique of spinning, if necessary, then remove the needle.
Rhomboids
1. Needle range
2. pt position
3. structures of concern
4. therapist position
5. action.
6. palpation site
Needle Range: ‘J’, .30 x 30-50mm
* Patient position
– Mandatory use of bolster under ventral shoulder.
– Prone with head supported in neutral and pillow under legs for neutral spine posture.
– Optional pillow under the abdomen depending on the degree of lumbar lordosis.
– The patient’s arm is placed in internal rotation and resting on low back if possible.
* Structures of Concern
– Lungs if a ventral needle direction or insufficient winging of the scapula.
* Therapist position
– The therapist stands on the same side of the table to the targeted rhomboid.
– The therapist assesses the tissue and palpates the medial border of the scapula.
– The therapist performs a clean sweep technique with alcohol.
* Action
– The therapist prepares and inserts the needle at an angle parallel to the lung field and
towards the medial border of the scapula.
– An aggressive wrap technique is required to wrap fingers deep to the medial border of
the scapula.
– Ensure sufficient scapular winging is obtained before needle insertion.
– Perform the technique of spinning, if necessary, then remove the needle.
Palpation sites: Spinous process of T1-T5, medial scapular border from spine of scapula
to inferior angle. Use scapular retraction with humeral internal rotation to confirm.
QL
- Needle range
- pt position
- structures of concern
- therapist position
- action.
- palpation site
Needle Range: ‘J’, .30 x 50-75mm
* Patient position
– Side lying with head supported and pillow under lumbar spine for contralateral side
bending.
– Patient legs can be placed off the edge of table to further promote side bending.
* Structures of Concern
– Kidneys if a ventral needle direction, lungs if cranial to L2, nerve roots if using a medial
needle direction.
* Therapist position
– The therapist stands dorsally at the caudal portion of the QL to encourage the caudal
direction of the needle.
– The therapist assesses the tissue and palpates for spinal orientation and bony landmark
including L3 spinous process, iliac crest and 12th rib. Palpate the lateral border of the QL
with the muscle on tension.
– The therapist performs a clean sweep technique with alcohol.
* Action
– The therapist prepares and inserts the needle using the wrap technique (index and
middle finger on the lateral border of the QL) to target the ventral/lateral side of the QL.
Needle angle is laying nearly parallel to the body.
– Treatment direction is towards the ipsilateral PSIS.
– The therapist performs the techniques of spinning or flossing, if necessary, then
removes the needle.
* Clinical thoughts
– Start at L2 and treat caudally to avoid the lung field.
– KEY: put the muscle on tension by maximizing side bending.
– Can be useful in patients with low back pain (discogenic pain).
– Palpate lumbar spinous process level by starting at T12 with rib identification and go
down. Active hip hiking can confirm muscle location and orientation.
Levator scap (prone)
1. Needle range
2. pt position
3. structures of concern
4. therapist position
5. action.
6. palpation site
Needle Range: ‘J’, .30 x 40-50mm
* Patient position
– Mandatory use of bolster under ventral shoulder.
– Prone with head supported in slight flexion and pillow under legs to support neutral
spine posture.
– Patient arm placed in internal rotation and resting on low back.
* Structures of Concern
– Lungs if needle angle does not remain parallel and superficial to lung field.
* Therapist position
– The therapist may stand on either side of the levator being targeted. Preference is given
based on the ability to create the safest grasp with the palpating hand.
– The therapist assesses the tissue and palpates for spinal orientation and the superior
angle of the scapula.
– The therapist performs a clean sweep technique with alcohol.
* Action
– The therapist grasps the levator cranial to the superior angle of the scapular border with
the thumb and second finger. An alternate acceptable palpation is to bracket the
superior medial scapular border with index and middle finger. Both are shown above.
– The needle is inserted at the medial or lateral edge of the levator just cranial to the
superior angle of the scapula.
– Immediately after tapping in, redirect the needle angle parallel to the lung field. The
needle direction is towards the acromion.
– Perform the technique of spinning, if necessary, then remove the needle.
* Clinical thoughts
– It is acceptable to insert the needle on either the medial or lateral border of the levator
if the correct needle direction is utilized.
– Consider the width of the levator scapula: approximately 20mm of needle insertion
parallel to the lung field should be sufficient.
– Can be a helpful technique in headache moderation and neck pain.
– Palpation sites: Spine of scapula, superior angle of scapula, upper cervical transverse
processes. Use ipsilateral scapular hiking confirm muscle location and orientation.
Levator scap (SL)
1. Needle range
2. pt position
3. structures of concern
4. therapist position
5. action.
6. palpation site
Needle Range: ‘J’, .30 x 40-50mm
* Patient position
– Patient side lying with treatment side up.
– Patient arm placed in internal rotation and resting on low back.
* Structures of Concern
– Lungs if needle angle does not remain parallel and superficial to lung field.
* Therapist position
– The therapist may stand on the ventral or dorsal side of the patient. Preference is given
based on the ability to create the safest grasp with the palpating hand.
– The therapist assesses the tissue and palpates for spinal orientation and the superior
angle of the scapula.
– The therapist performs a clean sweep technique with alcohol.
* Action
– The therapist grasps the levator cranial to the superior angle of the scapular border with
the thumb and second finger. An alternate acceptable palpation is to bracket the
superior medial scapular border with index and middle finger.
– The needle is inserted at the lateral edge of the levator just cranial to the superior angle
of the scapula.
– Immediately after tapping in, redirect the needle angle parallel to the lung field. The
needle direction is towards the palpating finger.
– Perform the technique of spinning, if necessary, then remove the needle.
* Clinical thoughts
– It is acceptable to insert the needle on either the medial or lateral border of the levator
if the correct needle direction is utilized.
– This modified position is useful for a patient that has difficulty lying prone.
– Consider the width of the levator scapula: approximately 20mm of needle insertion
parallel to the lung field should be sufficient.
– Can be a helpful technique in headache moderation and neck pain.
– Palpation sites: Spine of scapula, superior angle of scapula, upper cervical transverse
processes. Use ipsilateral scapular hiking confirm muscle location and orientation.
UT (prone)
1. Needle range
2. pt position
3. structures of concern
4. therapist position
5. action.
6. palpation site
- Needle Range: ‘J’, .30 x 40-50mm
- Patient position
– Mandatory use of bolster under ventral shoulder.
– Prone with head supported in slight flexion and pillow under legs to support neutral
spine posture.
– Optional pillow under the abdomen depending on the degree of lumbar lordosis. - Structures of Concern
– Lungs if needle angle is not in a cranial direction and parallel to lung field. - Therapist position
– The therapist stands at the head of the table on the side of the targeted upper trapezius.
– The therapist assesses the tissue and palpates for a ropey band in the musculature, as
well as assessment of spinal orientation and bony landmarks (scapula, cervical and
thoracic segments, first rib).
– The therapist performs a clean sweep technique with alcohol. - Action
– The therapist places the upper trapezius on tension by grasping the muscle belly and
slightly twisting and pulling it away from the lung field. The twist direction is the thumb
traveling towards the spine.
– The therapist prepares and inserts the needle, immediately redirecting the needle angle
to parallel away from the lung field with a superior/cranial treatment direction.
– Perform the technique of spinning, if necessary, then remove the needle.
– NOTE: Never release the grasp of the upper trapezius while the needle is in situ. - Clinical thoughts
– Can be useful in facilitating scapular position.
– Can be a helpful technique in headache moderation.
– Palpation sites: C7/T1 spinous process, 1st rib. Use cervical side bending to confirm
muscle location and orientation.
UT (supine)
1. Needle range
2. pt position
3. structures of concern
4. therapist position
5. action.
6. palpation site
Needle Range: ‘J’, .30 x 30-50mm
* Patient position
– Supine with arm resting by side and head rotated/side bent away from targeted upper
trapezius.
* Structures of Concern
– Lungs if needle angle is not cranial and remain parallel and superficial to lung field.
* Therapist position
– The therapist stands on the same side as the targeted upper trapezius, above the
patient’s head
– The therapist assesses the tissue for ropey band and palpates for spinal orientation and
bony landmarks (first rib).
– The therapist performs a clean sweep technique with alcohol.
* Action
– The therapist palpates the upper trapezius, then grasps and pulls the sensitive muscular
band up by adding a slight twist. Twist direction is the thumb moving towards the spine.
– The therapist prepares and inserts the needle then redirects the angle in a superior
direction away from the lung field.
– Perform the technique of spinning, if necessary, then remove the needle. No pistoning.
* Clinical thoughts
– Can be useful in facilitating scapular position.
– Can be a helpful technique in headache moderation.
– Palpation sites: C7/T1 spinous processes, 1st rib, clavicle. Use cervical side bending to
confirm muscle location and orientation.
– Supine technique may be helpful if the patient’s muscle pain/banding is located more
ventral within muscle.
Infraspinatus
1. Needle range
2. pt position
3. structures of concern
4. therapist position
5. action.
6. palpation site
Needle Range: ‘J’, .30 x 40-50mm
* Patient position
– Prone with head supported in slight flexion and pillow under legs to support neutral
spine posture.
– Targeted upper extremity placed in 90 degrees of abduction off the side of the table.
– May alternately allow the patient to rest arm at the side for comfort. However, ensure
palpation is completed with the arm at a consistent position.
* Structures of Concern
– Lungs if needle angle is directed ventral or medial, or if infraspinous fossa is not properly
palpated during set up.
* Therapist position
– The therapist stands on the same side as the targeted infraspinatus, caudal to the axilla.
– The therapist assesses the tissue and palpates for bony landmarks (spine of the scapula).
– The therapist performs a clean sweep technique with alcohol.
* Action
– The therapist palpates the lateral portion of the infraspinatus just caudal to the spine of
the scapula and pushes the targeted tissue into tension.
– The therapist prepares and inserts the needle at the appropriate angle in a
perpendicular direction to the muscle orientation and directed away from the lung field.
– If the boney backdrop of the scapula is not quickly reached with the anticipated needle
depth, stop, then remove the needle.
– Perform the technique of spinning, if necessary, then remove the needle.
* Clinical thoughts
– Scapula position changes with shoulder abduction. Ensure to use a consistent patient
resting arm position for palpation confirmation before needle insertion.
– Can be useful in facilitating rotator cuff function.
– Can be a helpful technique for shoulder pain.
– Palpation sites: Spine of scapula, inferior angle of scapula, medial/lateral scapular
borders. Use active or resisted shoulder ER to confirm muscle location.
* Notes
Subscapularis (supine)
1. Needle range
2. pt position
3. structures of concern
4. therapist position
5. action.
6. palpation site
Needle Range: ‘J’ or “L’ type .30 x 40-60mm
* Patient position
– Supine with arm in approximately 90 degrees of abduction and external rotation to
expose the scapula. Use slight adjustments to improve access the ventral scapula.
* Structures of Concern
– Lungs if needle angle does not remain lateral and parallel lung field, with sufficient
exposure of the scapula to allow boney backdrop of the subscapular fossa.
* Therapist position
– The therapist stands on the same side as the subscapularis being addressed, inferior to
the axilla.
– The therapist assesses the tissue and palpates for bony landmarks including the lateral
surface of ribs and ventral surface of lateral scapula.
– The therapist performs a clean sweep technique with alcohol.
* Action
– The therapist prepares and inserts the needle at the appropriate angle directed away
from the lung field from medial to lateral. Use the palpating hand to slide down along
the rib angle, creating a ledge that separates the subscapularis from the ribs.
– The needle direction must stay lateral to the ribs and parallel to the lung field, with a
target of boney backdrop on the ventral surface of the scapula.
– Perform the technique of spinning, if necessary, then remove the needle.
* Clinical thoughts
– Proper palpation set-up for safe needling may be uncomfortable for the patient.
– Can be useful in a guarded shoulder, i.e. post-operative sling position.
– Can be a helpful technique in shoulder pain and improving shoulder elevation.
– During set-up therapist may use lateral traction to the humerus to move the scapula
laterally if unable to palpate to subscapular fossa in the initial treatment position.
– Palpation sites: lateral rib cage, lateral border of scapula. Use humeral IR to confirm.
Subscapularis (prone)
1. Needle range
2. pt position
3. structures of concern
4. therapist position
5. action.
6. palpation site
- Needle Range: ‘J’ or “L’ type .30 x 40-60mm
- Patient position
– Prone with arm resting on low back. Same position as serratus anterior.
– Preferred position will include bolster under ventral shoulder for scapular winging. - Structures of Concern
– Lungs if needle angle does not remain parallel and superficial to lung field with sufficient
scapular winging to access the subscapular fossa. Without sufficient winging, utilize the
subscapularis technique in supine. - Therapist position
– The therapist stands on the same side as the subscapularis being addressed.
– The therapist assesses the tissue and palpates for bony landmarks (inferior angle and
medial border of scapula, ribs).
– The therapist performs a clean sweep technique with alcohol. - Action
– The therapist prepares and inserts the needle at the appropriate angle in a parallel
direction to the muscle orientation and directed away from the lung field, targeting the
ventral aspect of the scapula.
– Palpating hand finger(s) are lifting the inferior angle of the scapula away from the ribs
and remains in place for the entirety of the needling intervention.
– Perform the technique of spinning, if necessary, then remove the needle. - Clinical thoughts
– Allows access to needle subscapularis for a patient that cannot properly position for the
supine technique.
– Can be useful in a guarded shoulder, i.e. post-operative sling position.
– Can be a helpful technique in shoulder pain and improving shoulder elevation.
– Use humeral IR while palpating ventral to the scapular medial border to confirm.
Serratus Anter
1. Needle range
2. pt position
3. structures of concern
4. therapist position
5. action.
6. palpation site
- Needle Range: ‘J’ or ‘L’, .30 x 50-60mm
- Patient position
– Prone with head supported in slight flexion and pillow under legs to support neutral
spine posture.
– Patient arm placed in internal rotation and resting on low back.
– Preferred position will include bolster under ventral shoulder for scapular winging. - Structures of Concern
– Lungs if needle angle does not remain parallel and superficial to lung field with sufficient
scapular winging to allow needle direction to the ventral scapula.
– - Therapist position
– The therapist stands on the same side as the serratus being addressed.
– The therapist assesses the tissue and palpates for spinal orientation and bony landmarks
(inferior angle and medial border of scapula, ribs).
– The therapist performs a clean sweep technique with alcohol. - Action
– The therapist prepares and inserts the needle at the appropriate angle in a parallel
direction to the muscle orientation and directed away from the lung field, targeting the
ventral aspect of the scapula.
– Palpating hand finger(s) are lifting the inferior angle of the scapula away from the ribs
and remains in place for the entirety of the needling intervention.
– Ensure sufficient scapular winging is obtained before needle insertion.
– Perform the technique of spinning, if necessary, then remove the needle. - Clinical thoughts
– Can be useful in a guarded and painful shoulder.
– Can be a helpful technique in shoulder pain and regaining shoulder elevation.
– Palpation sites: dorsal rib cage, inferior angle and medial border of scapula.
– Confirm by palpating ventral to the caudal medial border and feeling serratus activation
pulling scapular protraction while the patient performs active scaption.
Pec Major
1. Needle range
2. pt position
3. structures of concern
4. therapist position
5. action.
6. palpation site
Needle Range: ‘J’, .30 x 40-60mm
* Patient position
– Supine with arm in approximately 90 degrees of abduction and resting off the edge of
the table. Adjust position slightly as needed for palpation and patient comfort.
– Female: Have patient pull away any breast tissue with opposite UE.
* Structures of Concern
– Lungs if needle angle is not in a lateral direction while pulling the muscle tissue away
from ribs and confirm if the patient has breast implants for further precautions.
* Therapist position
– The therapist stands on the same side as the targeted pectoralis major, inferior to the
axilla.
– The therapist assesses the tissue and palpates for bony landmarks (anterior surface of
ribs).
– The therapist performs a clean sweep technique with alcohol.
* Action
– The therapist palpates the muscle by placing fingers underneath and thumb on top of
the pectoralis major. Pulls it away from the rib cage, maintaining tension, by adding a
twist and load to the muscle, which is held throughout the technique.
– The therapist prepares and inserts the needle at the appropriate angle in a
perpendicular direction to the muscle orientation. Needle direction is roughly 45
degrees medial to lateral, parallel to and away from the lung field. The needle should be
aimed at your palpating fingers.
– Perform the technique of spinning, if necessary, then remove the needle.
* Clinical thoughts
– Proper palpation of grasp, twist, and load for safety with needling may be
uncomfortable for the patient.
– Can be a helpful technique in shoulder pain and regaining shoulder elevation.
– Structures to avoid: anterior to posterior needle placement can hit lung tissue.
– Palpation sites: lateral rib cage, coracoid process. Use humeral adduction or IR to
confirm muscle location and orientation
Lat
1. Needle range
2. pt position
3. structures of concern
4. therapist position
5. action.
6. palpation site
- Needle Range: ‘J’, .30 x 40-50mm
- Patient position
– Prone with head supported and pillow under legs to support neutral spine posture, arm
resting comfortably off the side.
– Optional pillow under the abdomen depending on the degree of lumbar lordosis. - Structures of Concern
– Lungs if needle angle does not remain parallel and lateral to lung field. - Therapist position
– The therapist stands on the same side as the latissimus dorsi being addressed, inferior to
the axilla.
– The therapist assesses the tissue and palpates for bony landmarks (ribs).
– The therapist performs a clean sweep technique with alcohol. - Action
– The therapist palpates the muscle to find the treatment location, grasps the muscle to
pull it away from the ribs, then a slight twist to bring the targeted muscle tissue closer to
the needle insertion point. Maintain this grasp and tissue tension throughout the
entirety of the needling intervention.
– The therapist prepares and inserts the needle at the appropriate angle from medial to
lateral, directed away from the lung field.
– Perform the technique of spinning, if necessary, then remove the needle. - Clinical thoughts
– Can be useful in a guarded and painful shoulder.
– Can be a helpful technique in shoulder pain and improving shoulder elevation.
– Palpation sites: Lateral rib cage, inferior angle, and lateral border of scapula. Use
humeral adduction into the table to confirm muscle location and orientation.
Supraspinatus
1. Needle range
2. pt position
3. structures of concern
4. therapist position
5. action.
6. palpation site
- Needle Range: ‘J’, .30 x 40-50mm
- Patient position
– Prone with head supported in slight flexion and pillow under legs to support neutral
spine posture, neutral arm position at the side with the entire arm resting on the table.
– Optional pillow under the abdomen depending on the degree of lumbar lordosis. - Structures of Concern
– Lungs if needle is not directed into the lateral supraspinous fossa utilizing aggressive roll
of palpating fingers. - Therapist position
– The therapist stands on the same side as the supraspinatus being addressed, inferior to
the axilla.
– The therapist assesses the tissue and palpates the spine of scapula.
– The therapist performs a clean sweep technique with alcohol. - Action
– The therapist palpates the lateral 1/3 of the spine of the scapula and creates a tunnel for
needle insertion onto the boney landmark of the lateral spine of the scapula.
– The therapist prepares and inserts the needle at the appropriate angle to the boney
backdrop of the spine of the scapula. After confirming needle contact with the spine of
the scapula, aggressively roll the palpating fingers down into the supraspinous fossa.
– The needle may be slightly pulled out, if needed, to allow the proper needle direction
change before further insertion.
– The needle insertion to the boney backdrop of the supraspinous fossa will be in a caudal
direction to the lateral supraspinous fossa.
– Perform the technique of spinning, if necessary, then remove the needle. - Clinical thoughts
– Can be useful in a guarded and painful shoulder.
– Can be a helpful technique in shoulder pain and regaining shoulder elevation.
– Ensure the bony backdrop of the spine of the scapula! If you do not hit the spine of the
scapula at the expected depth, and the supraspinous fossa at the expected treatment
depth, stop the intervention and remove the needle.
– Palpation sites: Spine of scapula, superior angle of scapula, acromion, supraspinous
fossa. Use abduction of humerus through first 15-20 degrees to confirm.
Teres Minor (Prone)
1. Needle range
2. pt position
3. structures of concern
4. therapist position
5. action.
6. palpation site
- Needle Range: ‘J’, .30 x 40-50mm
- Patient position
– Prone with head supported in slight flexion and pillow under legs for neutral spine
posture.
– Optional pillow under the abdomen depending on the degree of lumbar lordosis.
– Targeted UE placed at 90 degrees abduction off the side of the table. - Structures of Concern
– Lungs if needle angle does not remain parallel and lateral to the lung field with grasping
hand pulling muscle tissue away from lung field. - Therapist position
– The therapist stands on the same side as the teres minor being addressed, inferior to
the axilla.
– The therapist assesses the tissue and palpates for bony landmarks (posterior surface of
ribs and lateral border of scapula).
– The therapist performs a clean sweep technique with alcohol. - Action
– The therapist identifies the muscle with resisted humeral ER, then palpates the muscle
by grasping above and below the scapula. The tissue is rotated to bring the muscle
closer to the needle insertion and that tension is maintained throughout the
intervention.
– The therapist prepares and inserts the needle, then redirects to the appropriate angle
from medial to lateral before further inserting the needle, ensuring it remains directed
away from the lung field.
– Perform the technique of spinning, if necessary, then remove the needle. - Clinical thoughts
– Can be useful in a guarded and painful shoulder.
– Can be a helpful technique in shoulder pain and improving shoulder elevation.
– Palpation sites: Lateral rib cage, lateral border and inferior angle of scapula,
infraspinatus muscle. Use resisted humeral ER to confirm.
