Dry needling

Dry needling is the use of solid filiform needles (which are also used in acupuncture but are not correctly referred to exclusively as "acupuncture needles") for therapy of muscle pain, sometimes also known as intramuscular stimulation. Dry needling 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.

Technique

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 contraction knots, which are related to the production and maintenance of the pain cycle. Deep dry needling for treating trigger points was first introduced by Czech physician 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. Proper dry needling of a myofascial trigger point will elicit 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. Inserting the needle can itself cause considerable pain, although when done by well-trained practitioners that is not a common occurance. No study to date has reported the reliability of trigger point diagnosis and physical diagnosis cannot be recommended as a reliable test for the diagnosis of trigger points. Chan Gunn introduced a type of dry needling called intramuscular stimulation in the 1980s that moved away from using trigger points. Baldry developed a version called superficial dry needling in 2005, in which the needle is inserted about 5-10mm into the tissue above the trigger point.

Efficacy

A systematic review concluded that dry needling for the treatment of myofascial pain syndrome in the lower back appeared to be a useful addition to standard therapies, but that clear recommendations could not be made because the published studies are small and of low quality. A 2007 meta-analysis examining dry needling of myofascial trigger points concluded that the effect of needling was not significantly different to that of placebo controls, though the trend in the results could be compatible with a treatment effect. One study (Lorenzo et al. 2004) did show a short-term reduction in shoulder pain in stroke patients who received needling with standard rehabilitation compared to those who received standard care alone, but the study was open-label and measurement timings differed, limiting the use of the study. Again the small sample size and poor quality of studies was highlighted.

Practice

Dry needling is practiced by physical therapists in many countries, including South Africa, the Netherlands, Spain, Switzerland, Canada, Chile, Ireland, the United Kingdom and New Zealand. In the United States, physical therapists in several states including Virginia, Maryland, Ohio, Colorado, Georgia, New Mexico, and Kentucky perform the technique, and several other states, including Louisiana and North Carolina, have recently updated board positions allowing the practice. Physical therapists are prohibited from penetrating the skin or specifically from practicing dry needling in Hawaii, Tennessee, New York, and Florida, though many states have no regulations on dry needling.. Additionally, chiropractors are legally allowed to practice dry needling in many states including Alabama, Colorado, Connecticut, Delaware, Florida, Illinois, Maryland, New Hampshire, New Mexico, North Carolina, Rhode Island, South Carolina, Texas, Utah, Virginia, and West Virginia.

Controversy

Some acupuncturists have argued that dry needling appears to be an acupuncture technique requiring minimal training that has been re-branded under a new name ("dry needling"), but many physical therapists and chiropractors have asserted that they are not practising acupuncture when dry needling.. They assert that much of the basic physiological and biomechanical knowledge that dry needling utilizes is taught as part of their core physical therapy and chiropractic education and that the specific dry needling skills are supplemental to that knowledge and not exclusive to acupuncture. In July 2011, a single commissioner of the Court of Appeals of the State of Oregon issued an Order Staying Administrative Rule Pending Judicial Review (in response to Oregon accupuncturists objecting to a 2011 ruling by the Oregon Board of Chiropractic Examiners to allow dry needling in the chiropractic scope of practice with 24 hours of training). The order asserts that "dry needling" is "substantially the same" as acupuncture. According to the document, the Board of Chiropractic Examiners "has not explained how 24 hours of training, with no clinical component, provides sufficient training to chiropractors to adequately protect patients." Another major component of said ruling is that the Oregon Board of Chiropractic Examiners may have exceeded its authority in the manner in which is made its Adminstrative Ruling. The Oregon Board of Chiropractic Examiners is challenging said ruling, including the claim that there is no clinical component (the first course approved by the Oregon Board of Chiropractic Examiners, Dr David Fishkin's Dry Needling Institute LLC 24 class, is comprised of over 18 hours of clinical [hands-on] training.) Many other states do not agree with the single Oregon commissioner's ruling and said commissioner's ruling has no legal standing in those states.

See also

• Trigger point
• Acupuncture
• Myofascial release