Dry Needling Explained

Understanding Its Origins, Current Practice, and Distinctions from Traditional Acupuncture

Dry needling is a therapeutic technique that has garnered significant attention in the fields of physical therapy, acupuncture, and sports medicine over the past decade. Despite its growing popularity, there remains considerable confusion about what dry needling is, where it originated, and how it differs from traditional acupuncture. This blog post aims to provide a comprehensive overview of dry needling, its history, current practices, and the nuances that distinguish it from acupuncture.

Key Points

• Dry needling originated from the study of myofascial trigger points and trigger point injections.

• The technique has evolved to use acupuncture needles, blurring the lines between dry needling and acupuncture.

• Dry needling focuses on releasing myofascial trigger points based on their referral patterns.

• Traditional acupuncture is based on the principles of Traditional Chinese Medicine, using needles to regulate the flow of Qi or energy along meridians.

• Modern scientific research supports many of the ancient metaphors of TCM, aligning them with physiological processes such as neural pathways and circulation.

• There are numerous styles of acupuncture, including electro-acupuncture, Western medical acupuncture, and sports medicine acupuncture, each with unique methodologies and applications.

• True dry needling doesn’t involve needle retention - that crosses over into the world of acupuncture.

• Inserting a needle into the body has the same physiological effects whether you call it acupuncture or dry needling.

• There is a disparity in training requirements between physical therapists and acupuncturists for using needles.

• The practice of dry needling varies by state laws and can be performed by various healthcare providers.

What is Dry Needling?

Dry needling is a therapeutic technique that involves the insertion of thin, sterile needles into specific points on the body to treat myofascial pain and dysfunction. Originating from the study of myofascial trigger points and their referral patterns, dry needling focuses on the mechanical disruption of these points to relieve pain and improve muscle function. Unlike traditional acupuncture, which is based on the principles of traditional Chinese medicine (TCM) and concepts such as Qi and meridians, dry needling is grounded in Western medicine's understanding of anatomy and physiology.

The mechanical needle effect is a key component of dry needling, as the insertion of the needle stimulates nerve endings, enhances blood flow, and initiates localized inflammatory responses that promote healing. This effect occurs regardless of whether the technique is termed dry needling or acupuncture, highlighting the physiological impact of needling on the body. Dry needling often involves more aggressive needle manipulation to provoke a twitch response in the muscle, releasing tension and alleviating pain. This approach differs from the more static needle retention methods commonly used in traditional acupuncture, although there are robust needling techniques within acupuncture that share similarities with dry needling.

Interestingly, both dry needling and acupuncture frequently target similar anatomical points, with many myofascial trigger points corresponding to traditional acupuncture points. This overlap suggests a shared recognition of effective therapeutic points on the body, despite the differing theoretical frameworks. The convergence of these practices underscores the validity and efficacy of needling techniques in treating musculoskeletal pain and dysfunction, providing a bridge between Eastern and Western medical traditions. By understanding the nuances and shared principles of dry needling and acupuncture, practitioners and patients can appreciate the benefits of both approaches in modern healthcare.

Current Practice of Dry Needling

In modern practice, dry needling is used to treat a variety of musculoskeletal conditions. Practitioners insert needles into myofascial trigger points to alleviate pain, improve range of motion, and promote healing. The technique is often integrated into a broader treatment plan that may include traditional acupuncture, physical therapy, exercise, and other modalities.

What is Traditional Acupuncture?

Traditional acupuncture is a therapeutic practice rooted in the ancient medical traditions of China, believed to have originated over 2,000 years ago. As a core component of Traditional Chinese Medicine (TCM), acupuncture involves the insertion of fine, sterile needles into specific points on the body to regulate the flow of Qi (vital energy) along pathways known as meridians. These meridians are thought to connect various organs and systems, ensuring the harmonious flow of energy and the maintenance of health.

In the framework of Chinese medicine, Qi is a metaphor for the body’s physiological processes, and meridians represent the pathways through which these processes occur. Modern scientific research has begun to validate many of the ancient theories of TCM, revealing that the metaphors of Qi and meridians often align with actual physiological mechanisms, such as neural pathways, blood circulation, and tissue connectivity. Studies have shown that acupuncture can stimulate nerve endings, release neurotransmitters, and modulate the body's pain response, supporting the therapeutic claims of TCM through a contemporary scientific lens.

Acupuncture encompasses a wide array of techniques and styles beyond the traditional TCM approach. These include electroacupuncture, which combines needle insertion with electrical stimulation; Western or medical acupuncture, which integrates anatomical knowledge and evidence-based practices; and sports medicine acupuncture, which focuses on treating musculoskeletal injuries and enhancing athletic performance. Despite the diversity in techniques, the common thread among all forms of acupuncture is the use of needles to achieve therapeutic effects.

While traditional Chinese acupuncture is often based on concepts of Qi and meridians, modern variations of the practice utilize anatomical points and scientific principles. This distinction highlights the adaptability and evolving nature of acupuncture, bridging ancient wisdom with contemporary medical understanding.

Before Dry Needling: Trigger Points

The concept of myofascial trigger points (MTrPs) has evolved significantly over the centuries. Early references to muscle pain disorders date back to the 16th century, with detailed descriptions provided by Guillaume de Baillous in France. In 1816, British physician Balfour identified "thickenings" and "nodular tumors" in muscle linked to local and regional pain. Various terms and descriptions emerged over time, reflecting a slow evolution in understanding MTrPs. For example, Froriep in 1843 coined the term “muskelshwiele” (muscle callouses) to describe what he believed were calluses of connective tissue in patients with rheumatic disorders. In 1904, Gowers suggested that inflammation of fibrous tissue (i.e., “fibrositis”) created these hard nodules, though the term was later discredited due to a lack of supporting biopsy data.

Significant contributions came from J.H. Kellgren in the 1930s, who meticulously mapped out pain patterns by injecting hypertonic saline into muscles and noting referred pain zones. His work laid the groundwork for understanding the referred pain patterns associated with myofascial trigger points.

The most substantial advancements in the study of trigger points came from Dr. Janet Travell and Dr. David Simons. In the 1950s, Dr. Travell identified trigger points as a primary source of musculoskeletal pain and developed effective treatment protocols. She documented these findings in numerous publications and, together with Dr. Simons, authored "Myofascial Pain and Dysfunction: The Trigger Point Manual," which remains a foundational text in the field.

Travell and Simons' work provided a comprehensive overview of trigger points, their referred pain patterns, and methods for treatment, including trigger point injections. This text solidified the understanding of trigger points and influenced subsequent generations of clinicians and researchers.

Today, the recognition and treatment of myofascial trigger points continue to evolve, integrating various techniques such as dry needling and acupuncture. The blending of traditional approaches with modern medical insights has led to more effective management strategies for chronic pain and musculoskeletal disorders.

This historical perspective underscores the importance of ongoing research and clinical practice in refining the understanding and treatment of myofascial pain syndromes. The legacy of early pioneers like Travell and Simons continues to shape contemporary approaches to pain management and physical therapy.

History of Dry Needling

Origins and Conceptual Foundations

Dry needling, a therapeutic technique that involves inserting needles into muscle trigger points without injecting any substance, has its roots in the management of myofascial pain. This approach evolved to address the need for effective treatment of musculoskeletal pain. The term "dry needling" was coined to differentiate it from traditional trigger point injections that use anesthetics or other substances.

Early Development of Trigger Point Theory

The foundation of dry needling is based on the study of tender points, later termed trigger points, and their significance in musculoskeletal pain. In the late 1930s, John Kellgren, under the guidance of Sir Thomas Lewis at University College Hospital in London, conducted groundbreaking research on referred pain and the effects of saline injections into muscles. Kellgren's research showed that muscle pain could be referred to distant areas and that injecting tender points with anesthetics could provide prolonged pain relief, beyond the anesthetic’s immediate effect.

Beginnings of Dry Needling

Dry needling began to take form in the early 1940s. In 1941, Brav and Sigmond conducted a crucial study that revealed needling painful muscle points without injecting any substance could provide pain relief nearly as effectively as anesthetic injections. This significant finding did not gain immediate widespread recognition. The term "dry needling" was officially introduced by Paulett in a 1947 Lancet article, highlighting that inserting needles into tender points without injection could alleviate pain effectively.

Integration of Acupuncture in Western Medicine

The 1970s saw a heightened interest in acupuncture, largely due to China opening its doors to international exchange. During this time, there was an increase in clinical trials and studies examining acupuncture's effects on pain management. Researchers such as Ghia et al. (1976) and Melzack (1981) explored the overlap between acupuncture points and myofascial trigger points. These studies indicated that the effectiveness of needling might rely more on the intensity of the stimulus rather than the precise location, aiding the acceptance of dry needling in the medical field.

Distinction from Acupuncture

During the late 1970s and early 1980s, influential figures like Chan Gunn and Karel Lewit were instrumental in distinguishing dry needling from traditional acupuncture. Gunn developed intramuscular stimulation, which combined elements of acupuncture with neurological and trigger point theories. Lewit’s influential 1979 paper on the "needle effect" emphasized that needling tender points without injection could significantly alleviate chronic pain. Both practitioners used acupuncture needles and stressed the importance of eliciting a local twitch response during needling. Releasing myofascial trigger points with acupuncture needles causes fewer side effects compared to hypodermic needles, which tend to result in more bleeding, bruising, and post-treatment pain and soreness. This makes acupuncture needles better suited for dry needling.

Modern Advances in Dry Needling

The early 2000s saw a renewed interest in dry needling, marked by a surge in academic research and clinical application. Comprehensive manuals by authors such as Peter Baldry, Jan Dommerholt and the global spread of dry needling courses have contributed to its widespread use. Today, dry needling is a recognized technique for managing musculoskeletal pain, employed by various healthcare professionals, including acupuncturists, physiotherapists, osteopaths, and chiropractors. Despite ongoing debates about its scope and appropriate application, dry needling has established itself as a distinct and effective modality for pain management.

Evolution of Dry Needling

The term "dry needling" originally referred to the use of hypodermic needles without any fluid. However, over time, practitioners began using fine, filiform needles, similar to those used in acupuncture, to target trigger points. This shift blurred the lines between dry needling and acupuncture, leading to some of the current confusion.

Today, dry needling involves inserting thin, sterile needles into myofascial trigger points to relieve pain and improve function. The practice focuses on the mechanical effects of needle insertion, rather than the traditional Chinese medicine concepts of Qi and meridians. It is important to note that dry needling does not typically involve needle retention or the use of electrical stimulation, practices more commonly associated with acupuncture. However, the lines between these practices have become increasingly blurred, with many dry needling techniques now incorporating elements traditionally associated with acupuncture.

Blurring the Lines with Acupuncture

While dry needling was initially distinct from acupuncture, using different techniques and theoretical foundations, the two practices have converged over time. Both techniques involve inserting needles into specific points on the body to achieve therapeutic effects, and there is significant overlap in the points targeted for treatment. For example, many myofascial trigger points correspond to traditional acupuncture points, and both methods aim to release muscle tension and alleviate pain.

Moreover, the use of acupuncture needles in dry needling has further blurred the lines between the two practices. This convergence raises questions about the appropriate scope of practice for different healthcare providers. For instance, physical therapists typically receive 80 to 100 hours of training in dry needling, which is significantly less than the extensive training required for acupuncturists. This disparity in training has led to debates about the qualifications necessary to perform needling techniques safely and effectively.

The Mechanical Needle Effect

When a filiform or acupuncture needle is inserted into the body, a range of physiological responses is triggered, regardless of whether the technique is called dry needling or acupuncture. This mechanical needle effect involves several mechanisms that affect the body's nervous system, circulation, and inflammation. The insertion of a needle stimulates nerve endings, which send signals to the brain, potentially modulating pain perception and promoting the release of endorphins, the body's natural painkillers. Additionally, needling can enhance blood flow to the area, improving circulation and facilitating the delivery of oxygen and nutrients essential for tissue repair. The act of needling also initiates a localized inflammatory response, which can help in breaking down old scar tissue and promoting healing.

The mechanical disruption caused by the needle can relieve tension in the muscle fibers, leading to a reduction in muscle tightness and pain. This effect is particularly relevant in dry needling, where the technique involves manipulating the needle to provoke a twitch response in the muscle, thereby releasing myofascial trigger points. This manipulation can be more aggressive than traditional acupuncture, which typically involves inserting the needle to a certain depth and allowing it to remain in place. However, traditional acupuncture also includes more robust techniques such as muscle needling, bone needling, and tendon needling, which share similarities with dry needling methods.

Interestingly, both acupuncture and dry needling often target similar anatomical points. This convergence suggests that, despite differing theoretical foundations, both practices recognize and utilize the same therapeutic points on the body. Many traditional acupuncture points correspond to myofascial trigger points, and their indications for treatment align closely. This overlap not only validates the efficacy of both acupuncture and dry needling but also highlights a shared understanding of the body's structure and response to needling. By acknowledging this common ground, we can appreciate the benefits of both practices and their contributions to pain management and musculoskeletal health.

The Debate About Dry Needling vs Acupuncture

There is an ongoing debate within the medical community about whether dry needling can be considered a form of acupuncture. Acupuncturists often claim that dry needling is a type of acupuncture because it uses acupuncture needles and involves inserting these needles into specific points on the body. This argument is based on the fact that both practices use similar tools and techniques to achieve therapeutic effects. If practiced by an acupuncturist, dry needling might indeed be classified as a subset of acupuncture, particularly because it involves techniques familiar to traditional acupuncture, such as targeting trigger points to relieve pain and tension.

However, it is important to note that dry needling originated from pain management and trigger point injections rather than traditional Chinese medicine (TCM). The foundational principles of dry needling are based on Western anatomical and physiological knowledge, focusing on the mechanical disruption of myofascial trigger points. This contrasts with the TCM concepts of Qi and meridians, which form the basis of traditional acupuncture. Therefore, while dry needling shares some similarities with acupuncture, it does not adhere to the holistic and energy-based framework of traditional acupuncture practices. It can be considered a modern evolution of acupuncture like electroacupuncture and medical acupuncture.

On the other hand, many physical therapists and non-acupuncturists argue that dry needling is distinct from acupuncture. They emphasize that dry needling is a manual therapy technique designed to treat musculoskeletal pain through the mechanical stimulation of trigger points. Despite this distinction, it is undeniable that dry needling uses acupuncture needles. Given the overlap in tools and methods, it is challenging to categorically separate dry needling from acupuncture. The use of acupuncture needles, which are regulated and require specific training for safe and effective use, raises questions about the adequacy of training for non-acupuncturists.

It is also worth noting that many of the people who claim dry needling is not acupuncture are not acupuncturists themselves. This can be frustrating for acupuncturists, as those making such claims often lack the in-depth training and licensure in acupuncture, which involves extensive study and practice over several years. It is challenging for individuals outside the acupuncture profession to fully understand and accurately comment on the nuances of the practice.

Training and Scope of Practice

The practice of dry needling varies by state and country, with regulations determining who can perform the technique. In the United States, dry needling can be performed by physical therapists, acupuncturists, chiropractors, medical doctors, dentists, nurse practitioners, athletic trainers, occupational therapists, physician’s assistants, and others depending on state laws. Training requirements also vary, with some states mandating specific certifications or continuing education. There is no formal dry needling certification or regulatory body that exists, but rather it is managed within each profession that is allowed to practice it.

The inclusion of dry needling within the physical therapy scope of practice is intriguing, given its origins in pain management and medical procedures like trigger point injections. The use of acupuncture needles, traditionally within the purview of acupuncturists, by physical therapists has raised questions about scope of practice and the adequacy of training. This situation highlights the need for clear guidelines and standards to ensure patient safety and treatment efficacy.

Dry needling is also in the scope of many medical professionals, especially when billing insurance. New insurance codes specify that dry needling is a medical procedure which may put it in the scope of many medical professionals depending on state by state laws.

Less Training Means Less Safety

The disparity in training requirements is a significant point of contention. Physical therapists typically receive 80 to 100 hours of training in dry needling (usually about half is hands-on), which is substantially less than the comprehensive education that acupuncturists undergo. Acupuncture training is at least 3 years and includes over 1,000 hours of hands on needle training as part of approximately 2,000 to 3,000 hours of acupuncture specific training.

This difference in training can impact the skill and technique with which needles are used. Patients who have experienced both dry needling by physical therapists and needling by acupuncturists often report that treatments by acupuncturists are less painful, likely due to the extensive training and refined needling skills that acupuncturists possess. Thus, while dry needling and acupuncture may share some common elements, the expertise required to perform these techniques effectively and safely varies significantly.

A 2024 study surveyed 203 Australian physiotherapists to understand their use of dry needling and experiences with adverse events. Most respondents worked in private practice and used dry needling to reduce pain and muscle tension. The survey revealed that minor adverse events, such as discomfort during treatment and bruising, were common. Notably, between 8% and 13% of physiotherapists reported experiencing major adverse events, including prolonged symptom aggravation and syncope, highlighting a significant rate of serious complications in Australian physiotherapy practice.

Another 2020 study found that over 35% of dry needling treatments resulting in minor adverse events, while only 1% resulted in major adverse events.

A 2023 study reviewed 535 systematic reviews (SRs) on acupuncture and found that severe needle-related adverse reactions are extremely rare, with serious adverse events occurring in only about 0.001% of cases. In comparison, minor adverse events, had an incidence rate ranging from 6 to 9%.

To date there have not been any studies comparing needling safety between acupuncturists and non-acupuncturists when performing dry needling and to better understand adverse events and safety this would be good to see to determine how much additional training might be warranted for practitioners with less than 100 hours of needle training.

Summary of Dry Needling

What Dry Needling Is:

• A technique for treating myofascial pain by targeting trigger points.

• Uses thin, filiform needles similar to acupuncture needles.

• Focuses on the mechanical disruption of trigger points to relieve pain.

• Can be performed by various healthcare providers, including physical therapists, acupuncturists, medical professionals, and others depending on state regulations.

What Dry Needling Isn't:

• It is not based on traditional Chinese medicine concepts like Qi and meridians.

• It does not typically involve needle retention or electrical stimulation.

• It is not synonymous with acupuncture, although it uses similar tools and techniques.

Dry needling is a valuable therapeutic tool for treating myofascial pain and dysfunction. While it shares some similarities with acupuncture, it is distinct in its principles and application. By understanding the origins and current practices of dry needling, practitioners and patients can better appreciate its role in modern healthcare. It is crucial to recognize the nuances and avoid conflating dry needling with traditional acupuncture, ensuring that the technique is used effectively and appropriately.

Frequently Asked Questions About Dry Needling

Why is it called dry needling?

Dry needling originated from the practice of trigger point injections, where a hypodermic needle was inserted into trigger points without injecting any fluid, hence the term "dry." The technique was initially distinct from acupuncture but began to overlap when practitioners started using acupuncture needles.

Does dry needling use acupuncture needles?

Today, dry needling uses acupuncture needles to target myofascial trigger points based on their referral patterns. While some practitioners incorporate needle retention and electrical stimulation, these practices blur the lines between dry needling and traditional acupuncture.

What’s the difference between dry needling and acupuncture?

Dry needling and traditional acupuncture share similarities, such as the use of thin needles and the insertion of needles into specific points. However, dry needling focuses on myofascial trigger points and musculoskeletal pain, while traditional acupuncture is based on balancing Qi and meridians. Despite these distinctions, the overlap in techniques and points used makes the boundary between the two practices increasingly blurred.

Is dry needling a type of acupuncture?

While dry needling uses similar needles and can overlap with acupuncture points, it is not considered traditional acupuncture. Dry needling originated from trigger point therapy and pain management techniques, whereas acupuncture is based on traditional Chinese medicine principles. However, some acupuncturists may incorporate dry needling techniques into their practice so to them it may be considered another acupuncture style.

How much training is required for dry needling compared to acupuncture?

Physical therapists typically undergo 80 to 100 hours of training in dry needling, focusing on anatomy, trigger points, and needling techniques. In contrast, acupuncturists complete several years of comprehensive training that covers traditional Chinese medicine theories, acupuncture techniques, and extensive clinical practice.

Can dry needling be as effective as acupuncture?

Effectiveness can vary depending on the condition being treated and the practitioner's skill. Dry needling is highly effective for targeting specific musculoskeletal issues and trigger points, while acupuncture offers broader therapeutic benefits based on traditional Chinese medicine principles. Both modalities can provide significant relief for various conditions.

Who is qualified to perform dry needling and acupuncture?

Dry needling can be performed by acupuncturists, physical therapists, chiropractors, and other healthcare providers, depending on state regulations. Acupuncture is typically performed by licensed acupuncturists who have undergone extensive training in traditional Chinese medicine. It is essential to check local regulations and the practitioner's qualifications before receiving treatment.

Do acupuncture and dry needling feel the same?

Both acupuncture and dry needling involve inserting thin needles into the skin, which may cause similar sensations. However, the techniques and intentions behind each practice can result in different experiences. Acupuncture often involves more subtle, gentle needling aimed at balancing energy, while dry needling may produce a more pronounced sensation due to the direct targeting of trigger points. Patients often feel relaxed after a traditional acupuncture session but may feel sore and fatigued after a dry needling treatment.

Where is dry needling illegal?

As of 2024 - New York, California, Oregon, and Hawaii explicitly do not allow physical therapists to perform dry needling as the use of an acupuncture needle in those states is considered to be the licensed practice of acupuncture. In many other states physical therapists and other professions have added dry needling to their scope of practice by using wording that says their practice is not in accordance with Chinese Medicine principles which means that it is not acupuncture. Some states do not have any regulations on dry needling. In many states Medical Doctors (MDs) can be certified in acupuncture or dry needling with around 300 hours of training.

Over to you

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Sources:

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• Travell, J. G., & Simons, D. G. (1999). Myofascial Pain and Dysfunction: The Trigger Point Manual. Lippincott Williams & Wilkins.

• Lewit, K. (1979). The needle effect in the relief of myofascial pain. Pain, 6(1), 83-90.

• Gattie, E., Cleland, J. A., & Snodgrass, S. (2020). A survey of American physical therapists' current practice of dry needling: Practice patterns and adverse events. Musculoskeletal science & practice, 50, 102255. https://doi.org/10.1016/j.msksp.2020.102255

• Jenkins, L. C., Summers, S. J., Nasser, A., & Verhagen, A. (2024). Dry needling perceptions and experiences: A survey of Australian physiotherapists. Musculoskeletal science & practice, 69, 102895. https://doi.org/10.1016/j.msksp.2023.102895

• Xu M, Yang C, Nian T, Tian C, Zhou L, Wu Y, Li Y, Deng X, Li X, Yang K. Adverse effects associated with acupuncture therapies: An evidence mapping from 535 systematic reviews. Chin Med. 2023 Apr 10;18(1):38. doi: 10.1186/s13020-023-00743-7. PMID: 37038228; PMCID: PMC10088157.

• Boyce D, Wempe H, Campbell C, Fuehne S, Zylstra E, Smith G, Wingard C, Jones R. Adverse Events Associated With Therapeutic Dry Needling. Int J Sports Phys Ther. 2020 Feb;15(1):103-113. PMID: 32089962; PMCID: PMC7015026.

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