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Welcome to The Dr. JJ Thomas Podcast! Here I'll be talking all things physical therapy, raw and unplugged, giving you the unfiltered insights you've been searching for in your cash-based physical therapy business. If you're caught in the grind of the traditional model, swamped with paperwork, or feeling like you're not reaching your full potential as a physical therapist, this podcast was created just for you.
So I will say that I think the big reason this study showed improvement in patient compliance is that potentially these patients had less post needle soreness and that's a good thing. But I would argue that if we're really doing it right, no matter what technique we're using, if we're proving our value to them and showing them that they're gonna get better under our care, they're gonna come back anyway. Welcome to the doctor JJ Thomas podcast. Hey, everybody. Welcome to the Doctor.
Dr. JJ Thomas:JJ Thomas podcast. I'm JJ Thomas. Today, I have a great episode for you. And I know it's gonna be great because it's in response to so many questions I get all the time about dry needling and approaches to dry needling, whether or not people should use the dry needling with e stim and prioritize that approach versus the pistoning approach, the in and out technique. It's a question that has a lot of pieces to it, right?
Dr. JJ Thomas:So I answer the question to the best of my ability when it comes my way, but I thought this is a perfect episode for people who, who need to know the answer. So before we get into it, I wanna first go back and let's talk a little bit about the history and progression of dry needling here in the states. Because I think it's important to have that frame, sort of frame of reference, to understand the progression, not only of the technique itself, but understanding where it came from and where the science was was then and is now, and how that relates to how we can best deliver, treatments to our patients. So, when I started needling in, like, 2,009, there were really only about 300 PTs in the country in in the United States doing it. And at the time, I was working in Delaware, and so I was like the only practitioner in Delaware about to use dry needling, so I did a double certification.
Dr. JJ Thomas:And through that double certification, meaning I did 2 different dry needling certification tracks, with 2 different companies. I did one with what was then Kineticore and, AdoZelstra, and those guys merged in with Evidence in Motion. Great company. And I also did a simultaneous certification track through Jan Damerholt, and his company Myopane Seminars. Also great company, great education.
Dr. JJ Thomas:But to put some framework behind how I learned to dry needle back at that time, it was much heavier on the in and out technique. The stim, the use of stim was very supplemental. We did it a lot with KinetiCore then, back then, More to make sure that we were accurately on the target tissue that we wanted. Not as much really appreciating or recognizing necessarily the importance that that may have on the neuromusculoskeletal system, on the neural input that that muscle was gonna receive from the e stim at that point. A lot of the research was, was referring to Jay Shah's work that looked at the biochemical milieu of the muscles and how how active trigger points in muscles have a distinct dysfunctional biochemical milieu.
Dr. JJ Thomas:So, altered inflammatory markers, altered pH, lower oxygen, all the things you'd expect in an unhealthy tissue. And what they found is that when we get that twitch response in the muscle, that that milieu changes and starts to normalize towards normal healthy muscle tissue. Great. That's great stuff, right? Yes, it is.
Dr. JJ Thomas:There are also studies that measure the electrical conductivity of areas of muscles that were dysfunctional or are dysfunctional. And they found that those areas of muscle that are, related to At that time, we we were centered a lot around trigger point work, related to areas of motor points and and trigger points, essentially. There was a high spontaneous electrical activity. So trigger points, essentially, there was a high spontaneous electrical activity. So that that steady resting state of, of electrical, resting electrical activity in a muscle, in a dysfunctional muscle, was up to a 1000 times of normal action potentials.
Dr. JJ Thomas:So really high, I always describe it when I'm teaching, I describe it as like that lineman that that's false starting because he's so ramped up ready to go and he just mis fires. Right? That's what happens electrical in this dysfunctional muscle area. So a lot of the studies, electrically showed differences, biochemically showed differences, and structurally, we know we can see these contracted areas of muscle tissue on imaging. Right?
Dr. JJ Thomas:So we know that structurally, electrically, and biochemically, these areas of muscle are dysfunctional, right? Our patients know it because it presents as pain. It presents as a movement deficit. It presents as a compensation pattern in some way, shape, or form. So that's all really relevant important information and what I think is helpful before we have this this discussion is to know that a lot of our foundational knowledge and work around the area of dry needling centered around those works.
Dr. JJ Thomas:Right? And to take that further in the Kineticore approach, right away we were we were utilizing through, Gray Cook's selective functional movement assessment in our teaching strategies. We were using SFMA test, retest philosophies with every single muscle group that we taught on these courses. So 2 to 3 days, oftentimes it was 3 days early on in our teaching. I started teaching in 2012 with Kineticore.
Dr. JJ Thomas:So 2 to 3 days of test, retest, doing a full body movement assessment, then needling one area and then reassessing how that full body, how that treating that one area would relate and possibly create changes in that entire body. Very cool stuff. And it what it did for me as a clinician is it helped me trust the process of understanding that we can do better as physical therapists than chasing pain. We can do better because we can find the root cause if we use a regionally interdependent model and we use and trust our test retest strategies to focus on the root cause of dysfunction or underlying movement deficits versus treating pains and symptoms. Great.
Dr. JJ Thomas:So that's our foundation. Right? As I said, early on when I was first teaching around that 2012, 2015, even 2017, we were doing a lot of in and out technique and it worked great. Was there muscle soreness? Yes.
Dr. JJ Thomas:Is there still muscle soreness? Yes. But what we're gonna talk about is the pros and cons to each approach. Now, around the time I was still teaching with that group, that was then Evidence in Motion probably at that time, maybe right before we switched over to Evidence in Motion, a lot of research started coming out that gave pointed to the benefits of the use of e stim with the needling in the muscles in situ. There was a lot of positive research that came out of that.
Dr. JJ Thomas:Right? What it showed is that, yes, the e stim can preferentially, stimulate and activate those type 2 muscle fibers that we know type 2 muscle fibers after injury, immobilization, they shut down. We have a hard time recruiting them. And as we know from our, strength and conditioning studies, in order to activate type 2 muscle fibers, we either need really heavy load or we need, explosive training. A lot of our injured patients can't do that.
Dr. JJ Thomas:Right? We know that we can hack the system a little bit with things like BFR, but we can also hack the system with something like e stim. So now all of a sudden my colleagues are like, woah, this is pretty cool. How can maybe if we can start using e stim more, we can tap into those type 2 fibers. We can create less tissue trauma with less pistoning, right?
Dr. JJ Thomas:And maybe these patients will have great outcomes. Really, what I wanna disclose is through this process I was really excited about that. Like, I was like, yeah, that's awesome. My patients are gonna feel better. Let's let's go for it.
Dr. JJ Thomas:But what I wanna tell you guys is that the reason I don't strictly do e stim now is that clinically, because I'm such a test retest junkie, what I was seeing is that I wasn't getting the same results. So, we're gonna talk about clinically, actually, the the clinical decision process that I use to decide which approach which approach to use when. But before we move on, let's talk a little bit more about the benefits, the pros, to e stim. So one is, yes, we got those type twos. That's awesome.
Dr. JJ Thomas:So we're gonna get type 2 fibers. Let's go, baby. Right? That thing doesn't wanna write. Type 2 fibers.
Dr. JJ Thomas:Let's go. Right? That's good. That's good, good stuff. The other thing that we said, that we mentioned, but I'm gonna highlight on is that you're gonna have less tissue disruption.
Dr. JJ Thomas:Now what do I mean by that? Less tissue disruption. Right? So in theory, if I'm if I'm evaluating somebody and I'm like, oh, boom. That that anterior fibers are glute medman and that TFL, yeah.
Dr. JJ Thomas:They're they're lifting their knee up. They're all hiked. I can just see it here. There's that movement pattern is messed up. I can I have 2 options?
Dr. JJ Thomas:Right? I can go in and I can in and out needle that, and get that electrical, biochemical, and structural reset that we talked about early on from those early studies, or I can put a needle in or a couple needles in and stem it, get those type 2 fibers kicked on, maybe reset the system neurologically. Right? Because the nervous system speaks electrically. Right?
Dr. JJ Thomas:That language of the nervous system is electrical. And so that's a great option. What I mean by less tissue disruption is if I just decide to place the needles in the in the glute med man and t f l and then apply the stem, there's less needle passing. Right? So there's less, trauma, if you will, even though it's a very fine filament needle.
Dr. JJ Thomas:There's less trauma to the tissue, so therefore, there's less tissue recovery needed. That might be a really big pro. Right? That might be something that I want for my patients. We're gonna go through the clinical scenarios of when I want that for sure versus when I might choose to still piston.
Dr. JJ Thomas:The other thing that comes along with this less tissue disruption thing is that studies are actually coming out that show, and my friend Paul Kallorian with Idry Needle and Ice Physio is really one of the ones that first started pointing this out to me. These studies show that potentially there's better patient compliance when people choose to do e stim versus pistoning. I'm all I'm all for a great study and I can see where this is true in in one end. In the fact that if patients are having less tissue disruption then potentially they're having less post needle soreness and potentially that is gonna make them, less nervous or less inhibited in coming back for that next session. Right?
Dr. JJ Thomas:Their compliance is gonna be better. I will talk about a, I think, a missing part of this study, which is because in my practice, I as I said, I do a lot more pistoning than I would say the majority of physical therapists who are dry needling right now. And my patient compliance is through the roof. People do not miss these appointments. And, I mean, literally.
Dr. JJ Thomas:We have a wait list and there's loads of people on the wait list. And patients joke with they joke with me, but they're not kidding. They're like, they get a notification when someone cancels on my schedule, which doesn't happen often. And when they get this notification, they literally they're like, I'm out to dinner with the president. I stop and I try to get that appointment and it's gone within minutes.
Dr. JJ Thomas:Because our patient compliance is great because patients know that every session we're gonna make a change because of the test retest strategy that we use. So, I will say that I think the big reason this study showed improvement in patient compliance is that potentially these patients had less post needle soreness, and that's a good thing. But I would argue that if we're really doing it right, no matter what technique we're using, if we're proving our value to them and showing them that they're gonna get better under our care, they're gonna come back anyway. So we'll talk about that. And then there's one last, benefit to the e stim that I wanted to highlight and that's really I kind of touched on it earlier.
Dr. JJ Thomas:It comes down to the nervous system. Right? As I said earlier, the the brain, the the the muscles, the body, the language we speak is electrical. Right? So when we use e stim, essentially, we are we have the potential to improve neural pathways, and we also know from studies that somatosensory mapping in the homunculus is often smudged after injury.
Dr. JJ Thomas:And oftentimes, not as not only is it smudged immediately after injury, but it remains smudged even through therapy at times. So now when we put a very distinct, input via a needle into an area and then we speak its language with stim, oh, baby, we're gonna light that homunculus up. We're gonna wake up that somatosensory map and help neural, remapping, which they need in order to function really a 100% again. So I would say that's another that's another great thing for the e stim category. Okay?
Dr. JJ Thomas:I'm gonna go right to the cons in this category now. So these are all pros. Good good stuff. Right? What are the cons?
Dr. JJ Thomas:We're gonna talk about a few cons. 1 is what I mentioned earlier when we were talking about, compliance. 1 is that it's really hard to use a test retest strategy with something like e stim in situ with in situ needles in a time efficient manner. And what I mean by this is if we also refer to a lot of the e stim studies that prove the value of using e stim with needles in situ, what we see is that the longer duration that we can do the stim, the better patient outcomes they have. Right?
Dr. JJ Thomas:So the studies actually propose doing, like, at least 15 minutes if possible. Now my friends that are big proponents of the e stim method, they say, like, look, some stim is better than no stim and the research supports that, and I think that's true to an extent. However, when my patients are literally paying me by the minute, if I put needles in, there's 2 two reasons the needles with stim makes my test retest difficult. One is if I'm gonna put needles in in stim, I'm gonna wanna put a lot of needles in. Because I've already looked at their movement and I've said, I've already marked, okay.
Dr. JJ Thomas:Their, standing multi segmental rotation is limited and their hips aren't moving and it looks like it's anterior part of TFL, glute med min, looks like it's piriformis, some of the lower rotators as well, even down to lateral thigh. Right? So I've pinged all these things. If I'm gonna test, retest that, first of all, if I'm gonna stim that, then I'm gonna wanna put needles in all of those things. Now, if I do that, I'm gonna have to let them sit for at least 5 minutes to get a potential change.
Dr. JJ Thomas:And then when they get up off the table, I don't have great criteria for understanding the most valuable piece of that. Because if they do if they are better, I now don't know which one it is that made them better. And if they aren't better, I don't know if I just didn't do enough in one area or maybe I didn't get the right spot. Because oftentimes when you're leaving the needles in situ, you're not really doing that redirection with the needling that we do when we do in and out technique. And I personally find that when I do the redirection with the needling in the in and out technique, that is where I end up finding those money spots, those spots that are really gonna create change.
Dr. JJ Thomas:So that's really so honestly, this is really the big con for me with the with the stim, because it one, it takes longer to essentially set up the needles, and 2, set up the needles and let it go through its course of stimming before I get to see if I was able to help them or not. And 2, it's hard it's more difficult to do a few needles, Like, in this technique, with the stim, I'm less likely to put 2 needles here, and then stim it, and then get up and retest. It takes so much longer. I guess they both kinda come back to it takes longer. And my patients deserve me to be very deliberate and fast with their treatments because they're paying out of pocket and they deserve it anyway.
Dr. JJ Thomas:So, I wanna give them my most efficient use of my time. Which brings me to of my time, of our time. Which brings me to the pros and cons of pistoning. Okay? So the pros of pistoning, number 1, oh baby, is my test retest is oh so money.
Dr. JJ Thomas:Right? Like oh, I can't spell it, but it is oh so money. Test, retest. So the way we teach test, retest in our dry needling master classes is essentially everything we do here at Primal and through Primal University and through Primal, Physical Therapy is a regionally interdependent model that treats the body as a system. Right?
Dr. JJ Thomas:We, as physical therapists, have to do a better job of chasing pain, of not chasing pain, essentially. We have to do a better job of right from the get go looking for the, the underlying factors that predispose our patients to be injured in the first place. You know, somebody throws their back out, I guarantee, you know, they're putting the car seat in the car, I guarantee they had, movement deficits leading up to that. Somebody's bending down to pick something up and all of a sudden they throw their back out. I guarantee they had movement deficits leading up to that.
Dr. JJ Thomas:And what we know through lots of different resources is that we have the capacity as doctors in physical therapy to analyze movement and take away the pain component and, accurately assess movement and ping potentially, dysfunctional areas that are related to our pain what the patient's actually coming in for. But in order to test that to test and retest our theories, what we have to do is treat the the less obvious regions first. So if somebody comes in for back pain and I do a full body movement screen and I see problems with their neck or shoulder and I can relate that to their low back pain, that's something we go over in the primal university courses. Don't have time in the capacity of this episode to do it, but if you're interested, let me know. But I'm gonna treat that neck and shoulder first.
Dr. JJ Thomas:And I'm gonna use this pistoning technique often because what I can do is I can tease out each component of that. We're gonna actually go through an example later with Jessica where I'm gonna actually just do a live demo and show you how that what that looks like. But essentially, I can go in and do 3 to 5 needles in one area, in and out, Literally retest range of that shoulder on the table. I do it again, retest range of the shoulder on the table. I might find might maybe I'll do the pec then if I think it's related.
Dr. JJ Thomas:Retest the range. All of a sudden, I've cleared up that shoulder that I already know is related to their low back because I tested it in their movement. Then, when I'm done cleaning up the shoulder with a pistoning in and out, in and out, test, retest, then I get them up and they move their back. I haven't touched their back, haven't touched their hips, and all of a sudden they move better. This is so money with our patients.
Dr. JJ Thomas:I cannot even tell you. It its value is through the roof. So I just haven't despite the very convincing research that supports the use of e stim, I have not been able to let the pistoning technique go exactly for this reason. Now, we're gonna go through some patient scenarios where I still prioritize e stim over pistoning. We'll go through that a little bit.
Dr. JJ Thomas:I still have to go through the cons of pistoning. But, but I will say, you know, through multiple times in my career, I tried you know, my friends, when I taught through Kineticore and then Evidence in Motion, and now I teach on the side with other other, colleagues. And every time I hear them talk and and they tout the research, I'm like, man, I gotta try it again. And I do it and I do my movement assessment and I put the needles in and I sit and my clinical outcomes are just not as good when I am trying to find the root cause of something when I do e stim versus my pistoning method. Now that brings me to my con point.
Dr. JJ Thomas:Because the con of pistoning kinda relates to this e stim. The con of pistoning, there's a couple. One is there's been studies show more post needle soreness, which is true to an extent. There's also, obviously, with in the same lines of that, there's more tissue trauma. Right?
Dr. JJ Thomas:So the patients potentially have more recovery associated with an in and out technique versus the e stim technique. I would like to mention that I do believe that those studies also lack something. In that, therapists who are learning today aren't often taking the time to refine the scale of redirecting the needle. And what I mean by that is, when, you know, when you're needling, people will they'll see this motion if they're trying to do in and out technique and they think they're redirecting. They're doing this crazy thing with their wrist, but they're not coming out to subcutaneous tissue.
Dr. JJ Thomas:So, I can explain this when we work with Jess later, but when they're not really redirecting, they are creating a ton more of tissue trauma. They are gonna have a ton more post needle soreness because the therapist isn't doing a great job of redirecting the needle. In addition, they're also potentially less effective with the in and out technique because they're maybe just missing that mark of that trigger point or that, dysfunctional motor unit ever so bit, ever so slightly. And but when you take the time to redirect and you learn that skill and you learn that feeling, it's a feel, just like joint mobes is a feel, needling and pistoning with needling is a feel. And when you take the time and learn with a master or an expert to refine it, you get so much more accurate and effective with it.
Dr. JJ Thomas:Although this is a con, I will say this is something that is trainable. I think it's important to not limit ourselves. I think we're better than just saying that, you know, there's a reason behind people getting really sore and I think what we can do is refine our skills so we have all of these accessible to us as clinicians. Rather than just saying, you know, therapists can't seem to do this without making people super sore. My patients aren't actually that sore after the way I needle them because I've gotten so good so good at refining my dry needling skill and I'm so good with the feel of when the tissue releases.
Dr. JJ Thomas:And I test, retest so frequently that I don't over needle. I'll tell you another time people get really really sore, it's not just because of the pistoning. It's when a therapist treats the wrong area. When one of my, staff comes to me and they say, I treated this guy's upper trap and he was sore for 4 days, you know. It doesn't happen often, they know better now.
Dr. JJ Thomas:But but when it did happen early on, I would say to them, did you treat did you treat a symptom or did you treat a cause? If you treat a muscle that is a symptom and not the primary driver, that boy's gonna be pissed at you. He's gonna be like, listen, dummy. I tried to tell you that something else is bothering me. So that's another time post needle soreness will be up when you piston.
Dr. JJ Thomas:So I didn't write these down for you, but hopefully you wrote them down yourself. So those are the pros and cons. Like I said, I'm a big proponent of pistoning early on, but that's because here at Primal our method is very test retest driven. I mean, it's a 100% test retest driven. And it's also what really shows our value to our patients.
Dr. JJ Thomas:And it just gets them better faster from from the way we treat. However, in reality, we do a blend of we do a blend of both because I a 100% see the value of e stim too. So we're gonna go through some clinical scenarios that, that might help explain the areas where I might prioritize e stim versus pistoning and vice versa. So one of the times I might prioritize e stim is in a patient that comes in, with an acute injury, maybe a lot of times the the spinal muscles do really well with stim. So if I'm almost always, if I'm gonna target a multifidi, in the spine, I am I am gonna attach them to it at some point.
Dr. JJ Thomas:Now, as I said earlier, early on, I may just in and out just to see if I'm in the right just to get my test retest so I know that I'm putting our efforts in the right place. However, stim is a great great place. I'm sorry. The spine is a great great place to do e stim. Especially if they come in with a hot irritable, you know, if they're shifted or they're, potentially just in a real inflamed state, they may not do well with a lot of up and down, up and down anyway.
Dr. JJ Thomas:So in that case, I may choose to do a lot of needles in the spine, for example, and hook it up to e stim and let them sit there. Now I will caution you, so I'm gonna say, inflamed disc nerve root. Okay? I will caution you that some of these people with hot hot discs that are shifted, they don't lie prone well. They don't So you actually have to know how to treat them in either side lying, because most of them can tolerate that better, or seated.
Dr. JJ Thomas:And a lot of different courses will teach you those, so it's a very valuable thing to to have. Because I I will caution you, early on in my career, when I was e stimming these guys and I put them prone and they loved the stim when it was on and I did 20 minutes, and then all of a sudden they go to get up and it was just the position was too much for them for too long in an inflamed state, and it got them. And so now when I do it more in like a side lying, they do much better with that. So that's one scenario. Another scenario I might choose to e stim preferentially is if somebody has a true radiculopathy.
Dr. JJ Thomas:Right? A peripheral we're gonna call it a a nerve root driven peripheral neuropathy. Actually, muscle weakness, I'm gonna stem that puppy because that's the language. Right? I had I can think of one case where, somebody had a surgery and the surgeon accidentally nicked a peripheral nerve.
Dr. JJ Thomas:It was deep peroneal nerve. Right? So I stem that and and so that nerve is gonna heal, right? Peripheral nerves heal. I stem the heck out of that anterior tip and it eventually really helped.
Dr. JJ Thomas:But, you know, for me to sit there and traumatize that tissue, maybe isn't the best choice because the nerve needs to heal. Right? So we're gonna put those needles in, we're gonna stem the heck out of it, we're gonna change the variability of the frequency with those because we have to teach the nerve. Right? If I just put it on one frequency at for teaching a nerve how to fire, it's not it's gonna get bored.
Dr. JJ Thomas:So we put it on 3, we put it on 10, we put it on 20, we put it back down to 5. Change that variability. We wanna teach that nerve. So peripheral, you know, peripheral I'll call it peripheral neuropathy, neuropathy, peripheral nerve injury or radic. Right?
Dr. JJ Thomas:So if I have somebody with a radic, I'm gonna I'm gonna needle I'm gonna stim and needles in situ in any muscle that is part of that nerve root, that myotome. And then I'm gonna stim that puppy. And same thing, research shows longer is better with those people. So and change the frequency. If we want if we want, I mean, honestly, if we want recruitment, we're gonna go higher frequency, 10 and above.
Dr. JJ Thomas:I'll go up to 20 if they can tolerate it. But however, I will also do something like 3 because, in my opinion, the the nerve needs to learn. So we're gonna do all different frequencies to help teach it and remind it and reestablish that somatosensory cortex. A third example of when I would prioritize e stim is if I have a patient who's actually very fearful of needles. This sounds like a funny one.
Dr. JJ Thomas:Right? But it's true. I mean, a patient who has a fear of needles, it's a it's a really important concept. I mean, some of them may be freaked out by leaving the needles in, but most of them, once you get the stim on, they can feel, they they can anticipate it. For most people, fear is driven by the unknown and miss and, not understanding what's happening.
Dr. JJ Thomas:Right? If I put needles in, and for them I would go less is more, for sure, because we have to reestablish comfort and trust in this patient. But if I put a couple of needles in and then I put the stim to it, they know what to expect now. They can feel it and usually, they'll be okay with it. And then they're gonna learn that that's okay, and that input is healthy for them.
Dr. JJ Thomas:So that's a time where I may choose, to prioritize e stim as well. Another time, I'm gonna call this, general health concerns. So one of the other considerations is that we talked about with pistoning, how a con to pistoning can be, increased post needle soreness and how sometimes that will, affect a patient's compliance. Right? In someone in a patient that I have that is just generally doesn't have as good, doesn't have very good blood flow, maybe they're obese, maybe they're a smoker, maybe they're not active at all, their tissue, their whole system is not gonna recover as well as my athlete who knows how to recover every day.
Dr. JJ Thomas:Right? So if I have a patient that I don't think is gonna recover well with the pistoning, I also will probably choose a stim prioritization. And in that case, everything is risk reward. Right? So as I said on the previous, part of the episode, the test retest method is so important to me and that's a much slower process with e stim.
Dr. JJ Thomas:But for someone that generally doesn't have good recovery because either they're smokers or they're just generally not as healthy, then I may choose the the risk isn't worth the reward there. So I would do the e stim, set it for 5 minutes, and then retest it. And and then there's going to be less tissue trauma. It's not as fast and it may not be as dramatic of a change as if I redirect the needle and get those twitches to release the structural, biochemical, and electrical changes like we get with, the twitch responses. But I'm still gonna be able to make a change in these patients and they're gonna feel good because it's giving a strong neural input.
Dr. JJ Thomas:So, hopefully that clears up some really important scenarios for e stim. I'll say one last thing, actually. I really like e stim for edema control. If somebody has, you know, number 1, if they're coming in for recovery, an athlete who, you know, they just athletes do so many things for recovery now. If we have an athlete that just wants help recovering from heavy training, we can slide those needles in, especially in like the distal lower extremities, if they're runners, basketball players, whatever whatever type of aggressive athlete you have, and slide those needles in, cause very little tissue trauma, and then set that to a low frequency pulse.
Dr. JJ Thomas:And those babies are gonna get good neural input, they're gonna get good vascular input. It's very, very beneficial for them. Those are my goodies for e stim. Okay? There's one more scenario I actually wanna mention that I tend to prefer, prefer the stim, and that's in areas where I need to confirm that I'm in the muscle, for instance the abdominals.
Dr. JJ Thomas:So when we're needling the abdominals, actually if I'm doing the obliques I can pull the tissue away and piston in it and it's I don't worry at all because I know I'm pulled away from any organs, essentially. But if I'm going straight in rectus abdominis, I personally always had a I was always nervous about knowing when I was gonna get there when I was a newer needler. I was nervous about, like like, will I feel that fascial end? And all my teaching colleagues were like, JJ, it's a 100% you can feel it. And I'm like, I'm so nervous.
Dr. JJ Thomas:It just made me nervous. So but what we started doing was, and a friend of mine showed me this. I can't take credit for it. But what we started doing was putting the needles in a little bit, and then attaching the stem to it and then advancing the needle. And the minute the stem kicks on, we know we're in that rectus abdominis muscle.
Dr. JJ Thomas:So it's a really great way to confirm that you're exactly in the muscle with the stim in a very safe and effective way. So, I think those are really important and and a good summary to highlight on my my preferred use of e stim. Okay. Now when do I prefer to piston, the in and out technique versus the e stem? To be honest, I said a lot of this already, but I'm gonna reiterate it because I think it's important.
Dr. JJ Thomas:The number one reason I prefer the pistoning is that test retest value. I I mean, I probably I can't say it enough. I know I've already said it a 1000 times, but it is the number one thing that has made my practice a success. And my my colleagues, my other therapists within our practice, it is the number one thing that has made them a success. Because literally within a session, we are constantly proving our value to our patients and constantly getting them to understand really 2 things.
Dr. JJ Thomas:Number 1, how the body is regionally interdependent. And number 2, how we have the capacity to make immediate changes in their body. And that arms them with, what's the word? With confidence. That arms them with confidence in our system.
Dr. JJ Thomas:And from that, patients, when they have a problem, they know they can come to us and we are gonna investigate and get to that root cause. So test, retest. The second part of that that I just said is finding the root cause. I mean, this is so, so, so important. You know, patients that are like, oh, I had plantar fasciitis 2 years ago, and then it just went away.
Dr. JJ Thomas:It didn't go away. It manifested into something else. Right? These patients, and then they come back. So they come to you and they're like, oh, I had it, then it went away, then I had knee problems, then I had hip problems.
Dr. JJ Thomas:Then the planet fasciitis came back. Yes. The body is like circling through all these things because it's like, hey, you haven't found it yet. So, it allows us, the pistoning, the in and out technique allows us to find that root cause and treat it and get ahead of it finally, rather than chasing our tails all the time or chasing our patients' tails. So the 3rd the 3rd time I really prioritize the pistoning is, in our higher level athletes.
Dr. JJ Thomas:Now, I'm gonna say I say higher level athletes. It's really anybody that wants to be better yesterday. I always say, like, peep people are always like, who's your market, JJ? Like, who who do you guys treat here at Primal? We treat 2 types of people.
Dr. JJ Thomas:We treat people that wanted to be better yesterday, which are usually athletes. And by athlete, I don't just mean professional players. I mean, you know, the, the girl whose social, weekly tennis match is is very important. And she's an athlete, and she needs to get to her match on Tuesday because she's going against that rival that she goes against every year. You know what I'm saying?
Dr. JJ Thomas:Like, it's that athlete that really cares about what they're doing. They wanna be better yesterday. And the second type of people we see are the people that failed treatment everywhere else because we're finding that root cause and we're looking beyond what the average physical therapist look is looking at. So these people, I'd say these athletes, they're the ones that I certainly piston with. And that goes back to the general health and recovery of these athletes is phenomenal.
Dr. JJ Thomas:You don't have to worry as much about that, dry post needle soreness Because if you're doing it correctly, and in our dry needle master class, we go over the actually, I think I even have a a YouTube video about it now, about how to redirect the needle. But when you redirect the needle correctly, you're gonna have less post needle soreness. And when you test and retest, like, literally anywhere from 10 to 20 times within a session, you're also not gonna over treat a muscle. They're not gonna be that sore because you're gonna hit them hit the nail on the head with how much dosing to use with them in that pistoning technique. The very last reason we I choose pistoning is that regional interdependence model.
Dr. JJ Thomas:Because as I said earlier, I can't prove to my patients quickly enough with the e stim by treating a regionally interdependent area as I can with the pistoning. So eventually, so back to clinical scenarios, I don't want to neglect the fact that e stim has a very high value to our patients. But early on, I'm going to find the secret sauce to get them better faster if I do the In N Out technique. And, you know, in the other scenarios supplement with the e stim, But after I get their movement cleaned up, I may now reinforce it with the e stim. Like now, I've confirmed x, y, and z are all related to my patient's back pain.
Dr. JJ Thomas:I'm gonna clean that up. Now I'm gonna hammer it with some e stim. And now I'm speaking that language with the nervous system and it's gonna retain better for them. And then you integrate that with exercises and it's so good. So that concludes our talk about dry needling versus e stim versus pistoning.
Dr. JJ Thomas:What we're gonna do in a future episode, part 2 of this, I'm gonna take you through an actual live case with Jessica, one of our therapists, where I go through the test retest model so you can see what I'm talking about. To really show our value to our patients, integrating dry needling using the pistoning in and out technique, and test retesting multiple times to prove to ourselves and to our patients that we're treating the right area. Looking forward to seeing you on the next one, and talk soon.