The evidence around the use of dry needling

After recently attending the APA Level 1 Dry Needling course, I was interested in exploring the current evidence around its integration in practice, its effect and the general types of populations and conditions it was most commonly used for.

Firstly, what is dry needling? How does it work? What are the contraindications? What does the evidence say?

Dry needling involves skin penetration using a sterile single-use disposable stainless steel needle. Commonly used for myofascial trigger points, the premise of needling aims to alter the neural pathways from the brain and change the electrical activity within the surrounding muscles and help modulate pain/pressure. Whilst it is not the primary intervention used in physiotherapy, it is typically used as an adjunct or accessory to exercise and education.

Absolute Contraindications:

• Needle Phobia 
• Haemophilia Disorders
• Metal Allergy
• Unable to consent
• Over joint replacements
• Acute skin infections
• Pregnancy

Relative Contraindications:

• Controlled epilepsy 
• Patients on medication: blood thinners
• Joint replacements
• Flare-ups of auto-immune disorders

According to the evidence ~10% of patients will experience post-treatment side effects which can include drowsiness, nausea, fainting, local bruising or temporary worsening of symptoms. More serious complications occur very rarely but can include organ puncture, convulsions, complex regional pain or a punctured lung (pneumothorax). 

The effectiveness of dry needling is certainly impacted by the skills of the practitioner and most importantly requires a thorough understanding of the visceral structures/organs/blood vessels/nerves that are surrounded by the muscle/tissue needled. 

Evidence:

I came across a systematic review and meta-analysis by the journal of orthopaedic and sports physical therapy (JOSPT) 2017 which looked at the effectiveness of trigger point dry needling for musculoskeletal conditions by physical therapists. 

A total of 218 studies were screened and only 13 studies ended up meeting the inclusion criteria. Of the 13 studies, 6 targeted neck pain (1 on mechanical neck pain) and 1 on chronic whiplash, 1 on postoperative shoulder pain, 1 on chronic low back pain, 1 on total knee arthroplasty, 2 on myofascial pain and 1 on fibromyalgia. 

11 of these studies examined the effects of dry needling in participants with chronic musculoskeletal conditions, all dry needling was performed by a physical therapist and all follow-up periods ranged from immediate to 12 months.

The results of this systematic review suggest that there is very low-quality to moderate-quality evidence to support the notion that dry needling is more effective than a no-treatment or sham dry needling for the reduction of pain and improving pressure pain threshold (PPT) during the immediate to 12-week follow up period. 

The caveat to this review is that the included studies investigated any type of musculoskeletal pain, participant samples differed, comparison groups varied,  following times for outcomes were different and only studies were published in English.

In summary, there isn’t a whole bunch of research on dry needling, particularly those of high-quality evidence. There is also a lack of evidence supporting the long-term benefits of its use. 

Take home message: Dry Needling can provide a reduction in pain and improvement in pressure pain threshold when compared to sham dry needling or no treatment at all. As physiotherapists, we can use it in conjunction with active-based treatment and education as a way to provide short-term pain relief. We need to screen regularly to ensure that these patients are deemed suitable and safe to use this form of treatment/intervention. 

The Effectiveness of Trigger Point Dry Needling for Musculoskeletal Conditions by Physical Therapists: A Systematic Review and Meta-analysis. Eric Gattie, Joshua A. Cleland, and Suzanne Snodgrass. Journal of Orthopaedic & Sports Physical Therapy 2017 47:3, 133-149