Therapeutic Dry Needling in the treatment of Temporomandibular Disorders

Inspiration

I must credit my initial interest in this topic to time spent with Mike McMorris as he treated patients at the UNC Orofacial Pain Clinic.  I was struck by the complexity of the patient cases involving the diagnosis of temporomandibular disorder (TMD), along with the considerable pain and disability experienced by so many of these patients.   I came to the conclusion that finding solutions to help these persons was a problem worthy of investigation.  One member of the multi-disciplinary team at the Orofacial pain center was an acupuncturist and several of the patients I met emphasized the positive impact of this treatment on their levels of pain.  During our first course dedicated to evidence based practice, I created an evidence table which includes both studies utilizing therapeutic dry needling (TDN) and acupuncture in patients with TMD.  While I was aware of therapeutic dry needling and had seen it performed before, my primary learning experiences about the role which it can play in the context of physical therapy treatment of musculoskeletal issues occurred during my first clinical rotation with my clinical instructor, Lucas Simoes PT, MS, OCS.  My interest and knowledge regarding therapeutic dry needling and its theoretical underpinnings continued to grow with the help of my second incredible clinical instructor Miranda Bunge PT, DPT, CMTPT, who among many other things, introduced me to the work of Jan Dommerholt.  During the second level course dedicated to evidence based practice, I completed a Critically Appraised Topic (CAT), which involved a systematic search and critical appraisal of the research evidence related to the use of therapeutic dry needling for pain reduction in persons diagnosed with TMD.  My desire to learn more about not only therapeutic dry needling but the larger topic of treatment of TMD by physical therapists lead me to Grace Tang DPT, OCS, CCTT, CMTPT.  Grace has advanced training in both the treatment of patients with TMD and the use of therapeutic dry needling to do so.  Grace treats a high number of patients with the diagnosis of TMD and has been kind enough to allow me to spend time with her at the UNC Orofacial Pain Clinic and at her private practice, Strive Physical Therapy and Fitness.

Project Overview

In addition to learning as much as possible regarding the use of TDN in the treatment of TMD, I wanted to develop resources and improve my own skills to share this knowledge with other physical therapists and students, patients, and potential referral sources.    As part of the Capstone Project, I held a presentation which was attended by physical therapy students, faculty, and physical therapists both in person and remotely.  Verbal feedback and structured feedback in the form of the Presentation Evaluation Form were used to assess my strengths and weaknesses as a presenter and the effectiveness of the presentation in educating the attendees.  I utilized my previous work in the evidence based practice courses and also developed five new products.  Descriptions of these products along with links to access them are provided below:

Products

• Full Power Point Comprehensive, 100 slide power point with extensive detail on TMD, TDN, and the application of TDN in the treatment of TMD.
• Power Point Presentation slides from 4/20/16 to SDPTs, DPT faculty, and practicing clinicians on the use of therapeutic dry needling (TDN) in patients (TMDs).
• Clinical Quick Reference Guide For use of TDN with patients diagnosed with TMD to be used by PT’s in the clinical setting.
• Marketing Handout for Referral Sources One page information sheet appropriate for clinicians who utilize TDN to treat TMD, which can be easily customized to use as educational marketing material appropriate for potential referral sources.
• Patient Education Pamphlet Trifold brochure with information about TDN for treatment of TMD aimed at patients who may be appropriate for this treatment.
• Evidence Table Including Dry Needling and Acupuncture studies to answer the following question:
  • For a patient with Temporomandibular Joint Disorder (TMD) is Therapeutic Dry Needling/Acupuncture Therapy effective in treatment of pain and other symptoms?
• Critically Appraised Topic (CAT) Summary of a systematic search and critical appraisal of research evidence related to the following focused clinical question:
  • For a 30 year old female who is diagnosed with temporomandibular disorder (TMD), do physical therapy treatment interventions which utilize therapeutic dry needling (TDN) result in significantly improved pain outcomes as compared to interventions which do not utilized TDN?

Evaluation

Given the many components of this project, there were many forms of feedback to evaluate the different products.  Presentation evaluation forms were utilized to evaluate my performance as a presenter and the learning of attendees.  I also utilized lecture capture which allows me to experience the presentation from the perspective of someone attending remotely and relive the presentation with the ability to critique my own performance.  Regarding the evidence table, I used the guidance and feedback of Carol Giuliani.  For the critically appraised topic (CAT), I relied upon the guidance and feedback of Prue Plummer and Mary Beth Osborne.  For all other products, I relied upon the feedback and constructive criticism of my committee members Miranda Bunge, Mike McMorris, and Grace Tang, as well as my capstone advisor Mike Gross, and my brother Cameron Ritter, who is a practicing Dentist.

Acknowledgements

There are many persons which I would like to thank for their help making it to this point.  Firstly, my capstone advisor Mike Gross.  Mike I cannot imagine what this project would look like without your considerable help.  Your wisdom and guidance provided with the Capstone Project and challenges along the way were instrumental in its completion.  I know that I tested your patience significantly, but I am truly grateful for the time and effort you dedicated.  Secondly, my committee members Mike McMorris, Miranda Bunge, and Grace Tang.  You are all true role models and through your dedication to hard work, lifelong learning, and willingness to share your knowledge. you provide inspiration for the professional I wish to one day become.  I am grateful for your time and efforts to help me amidst your incredibly demanding schedules.  I would also like to thank Jon Hacke and my advisor Mike Lewek for always being available to talk, listen, and provide much needed perspective on my interests and challenges I face.  Thank you to the entire DPT faculty and my classmates, who have played a role in my development as a student, professional, and person.  Thank you to my family and girlfriend Julia, who have consistently supported/tolerated me throughout this process.  Finally, I would like to thank YOU for visiting this Capstone page.  I strongly encourage you to comment or contact me at Christopher_ritter@med.unc.edu with any questions.