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Dry needling (Myofascial Trigger Point Dry Needling[1][2][3][4]) is the use of either solid filiform needles (also referred to as acupuncture needles) or hollow-core hypodermic needles for therapy of muscle pain, including pain related to myofascial pain syndrome. Dry needling is sometimes also known as intramuscular stimulation (IMS).[1] Acupuncture and dry needling techniques are at times identical, depending on the style of practice of the practitioner. Chinese style hyperalgesia acupuncture relies on careful palpation of what are called “Ah Shi” points, which often correspond to both trigger points and/or motor points in the myofascial tissue. Chinese acupuncture tends to use the lower gauge needles necessary for puncturing contraction knots with a high degree of precision. On the other hand, lighter styles of acupuncture, such as Japanese style, or many American styles, require very shallow insertions of higher gauge needles, as well as a detailed knowledge, not of western anatomy, but of the channel networks and connections. Thus, while some forms of acupuncture are not at all the same as dry needling, the term dry needling can refer quite specifically to what is now called Myofascial Acupuncture or some versions of Sports Acupuncture.

The origin of the term “dry needling” is attributed to Janet G. Travell, M.D. In her book, ‘Myofascial Pain and Dysfunction: Trigger Point Manual’, Dr. Travell uses the term “dry needling” to differentiate between two hypodermic needle techniques when performing trigger point therapy. The two techniques she described are the injection of a local anesthetic and the mechanical use of a hypodermic needle without injecting a solution (Travell, Simons, & Simons, 1999, pp. 154–155). Dr. Travell preferred a 22-gauge, 1.5-in hypodermic needle for trigger point therapy and used this needle for both injection therapy and dry needling. Dr. Travell never used an acupuncture needle. Dr. 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 hyperalgesia patients a 25-gauge, 3.8-cm (1.5-in) needle may cause less discomfort, but will not provide the clear “feel” of the structures being penetrated by 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” (Travell, Simons, & Simons, 1999, p. 156).

The use of a hypodermic needle for dry needling was described by Dr. Chang-Zern Hong in his research paper on “Lidocaine Injection Verses Dry Needling to Myofascial Trigger Point”. In his research, he describes the procedure for trigger point injection and dry needling by using a 27-gauge hypodermic needle 1 ¼-in long (Hong, 1994). Both Travell and Hong used hypodermic needles for dry needling. Dr. Hong, like Dr. Travell, did not use an acupuncture needle for dry needling.

Although dry needling originally utilized only hypodermic needles due to the concern that solid needles had neither the strength or tactile feedback that hypodermic needles provided and that the needle could be deflected by “dense contraction knots”, those concerns have proven unfounded and many healthcare practitioners who perform dry needling have found that the acupuncture needles not only provides better tactile feedback but also penetrate the “dense muscle knots” better and are easier to manage and caused less discomfort to patients. For that reason both the use of hypodermic needles and the use of acupuncture needles are now accepted in dry needling practice. Often times practitioners who use hypodermic needles also provide trigger point injection treatment to patients and therefore find the use of hypodermic needles a better choice. As their use became more common, some dry needling practitioners without acupuncture in their scope of practice, started to refer to these needles by their technical design term as “solid filiform needles” as opposed to the FDA designation “acupuncture needle.”

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” as “a device intended to pierce the skin in the practice of acupuncture.” [5] 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.[6][7][8][9][10] Also the FDA definition does not mean that the FDA or any US Regulatory agency defines Dry Needling as a form of Acupuncture or that the two terms are interchangeable. 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. Such use of a solid needle has been found to be as effective as injection of substances in such cases as relief of pain in muscles and connective tissue. Analgesia produced by needling a pain spot has been called the needle effect.[11]

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 is a direct and palpable source of patient pain. However, dry needling theory is only beginning to describe the complex sensation referral patterns that have been documented as “channels” or “meridians” in Chinese Medicine. Dry needling, and its treatment techniques and desired effects, would be most directly comparable to the use of ‘a-shi’ points in acupuncture.[12] 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 other non muscular-skeletal issues which often are the cause of pain. The distinction between trigger points and acupuncture points for the relief of pain is blurred. As reported by Melzack, et al., there is a high degree of correspondence (71% based on their analysis) between published locations of trigger points and classical acupuncture points for the relief of pain.[13] The debated distinction between dry needling and acupuncture has become a controversy because it relates to an issue of scope of practice of various professions. In fact, Flynn says, his experience with Kitchener led him to expand his use of trigger point dry needling—the dominant form of the intervention, so named because it targets the tight points within muscular tissue that produce and refer pain. “Karen’s case opened up a broader perspective,” he says. “I now use dry needling with patients who’ve had partial nerve injuries after spinal surgery. We’re using it post-CVA [cerebrovascular accident] in folks who have movement disorders.”

Still, for all of Flynn’s enthusiasm for dry needling, he adds that he—and his PT colleagues at Evidence in Motion, another training provider for which he teaches the intervention—are “very cautious about overselling the tool.” He notes that the mechanism behind dry needling—precisely why it works, when it does—is as yet unclear, although a growing body of evidence confirms that it does work, particularly at trigger points. (It also is used by some practitioners to treat such conditions as cervicogenic headaches, carpal tunnel syndrome, lateral epicondylitis, and plantar fasciitis.)

 dry needling

In a way, Flynn’s qualifying remarks hint at a duality when it comes to the practice and perceptions of dry needling. Jan Dommerholt, PT, DPT, DAAPM, a Maryland-based, Dutch-trained therapist who says he taught the first US course in the intervention for PTs in 1997, marvels at the results dry needling sometimes can achieve, yet describes the technique rather more blandly as simply a form of instrument-assisted manual therapy. Practitioners interviewed for this article characterize it, with similarly qualified enthusiasm, as a safe, easy-to-learn, minimally discomforting, and often-effective technique for patients with certain presentations. They’ve witnessed grand results but make no grand claims. They don’t tout dry needling as a panacea. They express dismay, and a degree of surprise, that so much as a whiff of controversy surrounds an intervention they see as nothing more than a single tool in the PT’s toolbox.

“The technique is very simple, and it’s very safe in the hands of PTs,” Dommerholt says. “People who have issues with it are blowing things far out of proportion.”

Yet controversial it is. Yes, it is firmly within PTs’ scope of practice—cited in the APTA Board of Directors policy Guidelines: Physical Therapist Scope of Practice1 as a therapeutic intervention for “alleviating impairment and functional limitation” and listed among valid manual therapy techniques in the Guide to Physical Therapist Practice 3.0.2 And yes, the numbers of PTs who see value in it and are adopting it clearly are growing. (Those numbers likely are in the thousands, based on course numbers and class sizes, but even a rough estimate is anyone’s guess, given that training providers don’t share records and states don’t keep registries.)

In the words of Justin Elliott, director of state government affairs at APTA, “PTs who do dry needling love it, swear by it, and are very passionate about it.”

Definition and Distinction

What is dry needling?

“Dry needling is a skilled intervention that uses a thin filiform needle to penetrate the skin and stimulate underlying myofascial trigger points, muscular, and connective tissues for the management of neuromusculoskeletal pain and movement impairments. [It] is a technique used to treat dysfunctions in skeletal muscle, fascia, and connective tissue, and to diminish persistent peripheral nociceptive input, and reduce or restore impairments in body structure and function, leading to improved activity and participation.”

Source: APTA document Description of Dry Needling in Clinical Practice: An Educational Resource Paper. www.apta.org/StateIssues/DryNeedling/.

How is it different from acupuncture?

“Health care education and practice have developed in such a way that most professions today share some procedures, tools, or interventions with other regulated professions. It is unreasonable to expect a profession to have exclusive domain over an intervention, tool, or modality.”

“The practice of acupuncture by acupuncturists and the performance of dry needling by physical therapists differ in terms of historical, philosophical, indicative, and practical context. The performance of modern dry needling by physical therapists is based on western neuroanatomy and modern scientific study of the musculoskeletal and nervous system. Physical therapists who perform dry needling do not use traditional acupuncture theories or acupuncture terminology.”

Source: APTA document Physical Therapists & the Performance of Dry Needling: An Educational Resource Paper. www.apta.org/StateIssues/DryNeedling/. Acupuncture is a component of the health care system of China that can be traced back at least 2,500 years. The general theory of acupuncture is based on the premise that there are patterns of energy flow (Qi) through the body that are essential for health. Disruptions of this flow are believed to be responsible for disease. Acupuncture may, it has been theorized, correct imbalances of flow at identifiable points close to the skin.

The practice of acupuncture to treat identifiable pathophysiology (disease) conditions in American medicine was rare until the visit of President Richard M. Nixon to China in 1972. Since that time, there has been an explosion of interest in the United States and Europe in the application of the technique of acupuncture to Western medicine.

Acupuncture is a family of procedures involving stimulation of anatomical locations on or in the skin by a variety of techniques. There are a variety of approaches to diagnosis and treatment in American acupuncture that incorporate medical traditions from China, Japan, Korea, and other countries. The most thoroughly studied mechanism of stimulation of acupuncture points employs penetration of the skin by thin, solid, metallic needles, which are manipulated manually or by electrical stimulation.Dry needling is Western medicine’s answer to acupuncture.

Modern study of anatomy has revealed that the 2000-year-old understanding of energy pathways is not scientifically accurate. However, it has been found that many of the same points used in acupuncture actually correspond to nerves and muscle points that do, in fact, benefit from the application of needles to relieve pain, restore function, and promote healing. Dry needling uses modern knowledge of musculoskeletal anatomy and the nervous system to relax over stressed muscles, disrupt pain transmissions in nerves, and promote the body’s own healing response.

At MMIPP, our clinicians have the training and expertise to deliver the pain relief of dry needling to you safely and comfortably.