Dry needling, also known as trigger point dry needling and intramuscular stimulation, is a treatment technique used by various healthcare practitioners, including physical therapists, physicians, and chiropractors, among others. Acupuncturists usually maintain that dry needling is adapted from acupuncture, but others consider dry needling as a variation of trigger point injections. It involves the use of either solid filiform needles or hollow-core hypodermic needles for therapy of muscle pain, including pain related to myofascial pain syndrome. Dry needling is mainly used to treat myofascial trigger points, but it is also used to target connective tissue, neural ailments, and muscular ailments. The American Physical Therapy Association defines dry needling as a technique used to treat dysfunction of skeletal muscle and connective tissue, minimize pain, and improve or regulate structural or functional damage.
There is conflicting evidence regarding the effectiveness of dry needling. Some results suggest that it is an effective treatment for certain kinds of muscle pain, while other studies have shown no benefit compared to a placebo; however, not enough high-quality, long-term, and large-scale studies have been done on the technique to draw clear conclusions about its efficacy. Currently, dry needling is being practiced in the United States, Canada, Europe, Australia, and other parts of the world.
Origin Etymology and terminology The origin of the term dry needling is attributed to Janet G. Travell. In her 1983 book, Myofascial Pain and Dysfunction: Trigger Point Manual, Travell uses the term dry needling to differentiate between two hypodermic needle techniques when performing trigger point therapy. However, Travell did not elaborate on the details of the dry needling techniques: the injection of a local anesthetic and the mechanical use of a hypodermic needle without injecting a solution. The current techniques were based on traditional and Western medical acupuncture.
Initial techniques
Travell preferred a 1.5-in hypodermic needle for trigger point therapy and used this needle for both injection therapy and dry needling. Travell never used an acupuncture needle. Travell had access to acupuncture needles but reasoned that they were far too thin for trigger point therapy. She preferred hypodermic needles because of their strength and tactile feedback: "A 22-gauge, 3.8-cm (1.5-in) needle is usually suitable for most superficial muscles. In hyperalgesic patients, a 25-gauge, 3.8-cm (1.5-in) needle may cause less discomfort, but will not provide the clear feeling of the structures being penetrated by the needle and is more likely to be deflected by the dense contraction knots that are the target... A 27-gauge needle, 3.8-cm (1.5-in) needle is even more flexible; the tip is more likely to be deflected by the contraction knots and it provides less tactile feedback for precision injection".
Development and regulation in the United States The solid filiform needle used in dry needling is regulated by the FDA as a Class II medical device described in the code titled "Sec. 880.5580 Acupuncture needle is a device intended to pierce the skin in the practice of acupuncture". Per the Food and Drug Act of 1906 and the subsequent amendments to said act, the FDA definition applies to how the needles can be marketed and does not mean that acupuncture is the only medical procedure where these needles can be used. Dry needling using such a needle contrasts with the use of a hollow hypodermic needle to inject substances such as saline solution, botox or corticosteroids to the same point.
The founder of Integrative Systemic Dry Needling (ISDN), Yun-Tao Ma, has spearheaded the "dry needling" movement in the United States. Ma states, "Although ISDN originated in traditional Chinese methods, it has developed from the ancient empirical approach to become modern medical art rooted in evidence-based thinking and practice." Ma also states that, "Dry needling technique is a modern Western medical modality that is not related to traditional Chinese acupuncture in any way. Dry needling has its own theoretical concepts, terminology, needling technique, and clinical application."
The American Academy of Orthopedic Manual Physical Therapists states:Dry needling is a neurophysiological evidence-based treatment technique that requires effective manual assessment of the neuromuscular system. Physical therapists are well trained to utilize dry needling with manual physical therapy interventions. Research supports that dry needling improves pain control, reduces muscle tension, normalizes biochemical and electrical dysfunction of motor end plates, and facilitates an accelerated return to active rehabilitation.
Dry needling for the treatment of myofascial (muscular) trigger points is based on theories similar, but not exclusive, to traditional acupuncture; both acupuncture and dry needling target the trigger points, which are a direct and palpable source of patient pain. A high degree of correspondence is reported between myofascial trigger point dry needling and . Acupuncture and dry needling are similar in the underlying phenomenon and neural processes between trigger and acupuncture points. There is a high degree of correspondence between published locations of trigger points and classical acupuncture points for the relief of pain. Dry needling, and its treatment techniques and desired effects, would be most directly comparable to the use of 'a-shi' points in acupuncture. However, dry needling theory only begins to describe the complex sensation referral patterns that have been documented as "channels" or "meridians" in Chinese Medicine. What further distinguishes dry needling from traditional acupuncture is that it does not use the full range of traditional theories of Chinese Medicine, which is used to treat not only pain, but also other non-musculoskeletal issues that often cause pain. The distinction between trigger points and acupuncture points for the relief of pain is blurred.
Technique The technique for dry needling depends on which tissue is being targeted and the overall objective of the treatment. For example, one of the most common treatment objectives for dry needling, myofascial trigger points (TrPs), differs physiologically from treatments for scar tissue, connective tissue problems, and other medical issues.
In the treatment of trigger points for persons with myofascial pain syndrome, dry needling is an invasive procedure in which a filiform needle is inserted into the skin and muscle directly at a myofascial trigger point. A myofascial trigger point consists of multiple, hyperirritable contraction knots related to the production and maintenance of the pain cycle; essentially, myofascial trigger points will generate much local pain upon stimulation or irritation. Deep dry needling for treating trigger points was first introduced by the Czech neurologist Karel Lewit in 1979. Lewit had noticed that the success of injections into trigger points in relieving pain was apparently unconnected to the analgesic used.
Dry needling can be divided into categories in terms of depth of penetration: deep and superficial dry needling. Deep dry needling will inactivate myofascial trigger points by provoking a local twitch response (LTR), which is an involuntary spinal cord reflex in which the muscle fibers in the taut band of muscle contract. The LTR indicates the proper placement of the needle in a trigger point. Dry needling that elicits LTRs improves treatment outcomes, and may work by activating endogenous opioids. The activation of the endogenous opioids is for an analgesic effect using the gate control theory of pain. In addition, deep dry may also decrease pain, increase range of motion, and minimize myofascial trigger point irritability. In regards to the factor of pain reduction, relief occurs at four central levels: local pain, spinal pain through nerves, brain stem pain, and higher brain center pain.
The relief of myofascial trigger points has been more highly researched than the relief of connective tissues, muscle fascia, muscle tension, and scar tissue; however, the American Physical Therapy Association claims that there potentially may be some benefits of dry needling on these ailments according to some available evidence. The APTA also claims that dry needling should not be used as a standalone procedure, but should be used in conjunction with other treatment methods, including manual soft tissue mobilization, neuromuscular re-education, functional retraining, and therapeutic exercises. Once the needle is inserted, one can manually or electrically stimulate the filiform needle depending for the desired effect of treatment.
Efficacy There is currently no standardized form of dry needling. There is a general scarcity of extensive research in the field. Many studies published about dry needling are not randomized, contain small sample sizes, and have high dropout rates. A review recommended the usage of dry needling, compared to sham or placebo, for decreasing pain immediately after treatment and at 4 weeks in patients with upper quarter myofascial pain syndrome. However, the authors caution that "the limited number of studies performed to date, combined with methodological flaws in many of the studies, prompts caution in interpreting the results of the meta-analysis performed". Similarly, a second review of dry needling found insufficient high-quality evidence for the use of direct dry needling for short and long-term pain and disability reduction in patients with musculoskeletal pain syndromes. The same review reported that robust evidence validating the clinical diagnostic criteria for trigger point identification or diagnosis is lacking and that high-quality studies demonstrate that manual examination for the identification and localization of a trigger point is neither valid nor reliable between examiners.
Three more recent reviews reached similar conclusions: little evidence supporting the use of trigger point dry needling to treat upper shoulder pain and dysfunction, evidence not robust enough to draw a clear conclusion about safety and efficacy, and that dry needling for the treatment of myofascial pain syndrome in the lower back appeared to be a useful addition to standard therapies, but stated clear recommendations could not be made because the published studies were small and of low quality. However, a retrospective analysis of 2,910 dry needling interventions as reported by Mabry, et al. identified no reported safety events when dry needling was performed by physical therapists.
Controversy Risks Dry needling is considered invasive. Invasive treatments are associated with infections and cutaneous infections, which can be avoided, however, by using good aseptic (sterile) technique. Nonetheless, the procedure is increasing in popularity despite the unanswered questions regarding its overall effectiveness and safety. Mild adverse events following dry needling are commonly bleeding, bruising, and pain. Severe adverse effects include pneumothorax, injury to the central nervous system and spine, and blood-borne infection transmission. The American Medical Association made a press release in 2016 that said physical therapists and other non-physicians practicing dry needling should – at a minimum – have standards that are similar to the ones for training, certification, and continuing education that exist for acupuncture. AMA board member Russell W. H. Kridel, MD: "Lax regulation and nonexistent standards surround this invasive practice. For patients' safety, practitioners should meet standards required for licensed acupuncturists and physicians."