Dry needling involves inserting solid, filiform acupuncture needles into tissues for therapeutic purposes.
It contrasts with wet needling, which uses hollow hypodermic needles to inject substances.
Example: Inserting an acupuncture needle into the dorsal intraosseous muscle.
History of Dry Needling
Western medicine practitioners have a history of using needle modalities for musculoskeletal pain.
Lewis and Kellgren injected myofascial trigger points to evaluate referred pain areas.
Travel and Ritzler also injected saline into myofascial trigger points to assess pain referral.
Lewis and Kellgren stimulated the periosteum of the vertebra to evaluate pain referral.
Stimulating the atlas referred pain to the vertebral region.
This was initially taught as a way retorbital pain could be referred from the upper cervical region.
Bokdook and April injected cervical facet joints (e.g., C2-C3, C5-C6) to evaluate pain referral by blocking the region and evaluating whether the pain was reduced.
Terminology and Key Contributors:
The term "dry needling" was coined by Dr. Chan Gan and his colleagues in Canada in 1976.
Dr. Gan adapted TCM approaches to Western medicine for treating musculoskeletal pain due to the limited acceptance of traditional Chinese medicine (TCM) in Canada.
Dr. Gan published the Radiculopathy model, a novel concept of nerve root involvement in the presentation and treatment of distal and peripheral symptoms.
In 1979, Dr. Carol Lewis described treating myofascial trigger points using local deep dry needling with acupuncture needles to produce a twitch response.
Example: Needle insertion into the first dorsal interosseous muscle.
In 1983, Travel and Simons published a trigger point manual proposing local hypodermic needle injections, spray and stretch techniques, or soft tissue treatments into myofascial trigger points.
In 1989, Dr. Baldry from England described a combined needling approach using traditional acupuncture points and superficial dry needling into regions of myofascial trigger points.
He recommended superficial needling due to concerns about potential pneumothorax but did needle muscular tendinous junctions and the periosteum superficially and deeply.
Dr. Jay Shah in the US investigated the biochemical environment in active and latent myofascial trigger points and the effect of needling.
He assessed the upper trapezius and calf muscle.
Dalvohalt reviewed and published the evidence of mild fashion trigger points and the neurophysiological effects of trigger point needling.
Selvaratnam and Gabel proposed needling along nerve pathways and hyperalgesic points in dermatomes or myotomes to have a central neural effect when they commenced the APA dry needling course in Victoria in 02/2004.
Example: Needling in the pathway or distribution of the sciatic nerve, avoiding direct nerve contact.
Selvaratnam and Gabel also proposed that needling the cervical or lumbar region would have local and distal effects.
Example: Needling the right L5 paravertebral gutter to affect the L5 segmental innervated area and stimulate the right L5 and/or S1 anterior primary rami, thereby distally affecting the sciatic nerve.
Dry Needling Approaches
Myofascial Trigger Point Model: Local needling of myofascial trigger points (e.g., trapezius).
Needle posteroanteriorly due to the apical region of the lung.
Local Needling: Into tender and tight areas of tissue on palpation as part of a standard physiotherapy examination.
Radiculopathy Model: Recommended by Dr. Chan Gan to needle the cervical region for people with forearm pain (e.g. C6, C7) and distally the forearm region.
This follows the Chinese medicine concept of treating local and distal regions.
Needling Along Nerve Pathways, dermatomes, and myotomes
Example: Needling along the pathway of the sciatic nerve.
Example: For L3 nerve pain in the anterior aspect of the thigh, needle the L3 region and the quadriceps region or the local region in the L3 paravertebral gutter.
Example: For headaches, needle the upper cervical regions around C2 instead of the head to affect the frontal or orofacial region due to the trigeminal cervical nucleus innervation to the upper cervical region.
Western Acupuncture: Combining traditional acupuncture points with dry needling techniques.
Outside the scope of this course.
Fascial Needling and Dr. Fu's subcutaneous needling are more recent approaches.
Trigger Points
A trigger point is a localized area of deep tenderness and increased resistance within the muscle belly or at the musculotendinous junction.
The muscle may consist of multiple contraction knots.
Trigger points can be active or latent.
Active trigger points reproduce the patient's familiar pain upon examination, which can be local or referred.
Latent trigger points are non-painful asymptomatic nodules that may contribute to restricted range of movement and muscle stiffness and have the potential to become active, and they may be painful on palpation.
Central Pain Mechanisms and Myofascial Trigger Points
Active myofascial trigger points have a clinical distinction from acupuncture points.
Digital pressure or needling into trigger points may elicit a twitch response or reproduce the patient's pain locally or distally.
Patients may display a jump sign like a pain flexor withdrawal, which is distinct from a fear response.
Acupuncture points do not typically elicit a twitch response.
Evidence of Myofascial Trigger Points
Previous radiological, histological, and electrophysiological studies have been deficient.
Domohod suggested that myofascial trigger points were due to excessive release of acetylcholine from motor end plates.
Others argue that myofascial trigger points are mediated by the central nervous system.
The two camps are:
Those who say that myoflature trigger points exist and are local.
Those who say it's from the spinal column and from the brain.
Some argue that centrally mediated trigger point treatment can be done with muscle relaxants (e.g. valium).
Treatment peripherally with soft tissue or needling can also affect the spinal cord and thereby the central nervous system and relax the muscles.
Nelsat and coworkers reported that 71% of myofascial trigger points correlated with the 14 primary channels and eight extra channel acupoints.
Dorscher evaluated 255 myofascial trigger points described by Travel and Simons and 386 acupoints by the Shanghai College of TCM.
They found a strong relationship between the myofascial trigger points and acupines.
Birch found that only 18% of channel and extra acupoints correlated with myofascial trigger points when tender ashi acupoints were excluded.
Acupoints do not display the twitch response of an active myofascial trigger point.
Dorscher and his coworkers evaluated the anatomic relationships between classical acupoint locations and those of myofascial trigger points both qualitatively and quantitatively.
They used graphics software to demonstrate the different muscle layers of a virtual digitized human cadaver.
They found that of the two arm 55 common myofascial trigger points, 93% were hypothesized to anatomically correspond to classical acupoints.
Quantitatively, 37% of these myofascial trigger point acupoint pairs were estimated to be within 10 millimeters of each other, 45% within 10 to 20 millimeters, and 13% within 20 to 30 millimeters of each other.
In reality, such a virtual study in cadavers does not correlate with the presence or absence of myocardial trigger points in a region since the location will vary within a person and between people, and The study indicates poor overlap between the trigger points and acupoints.
Potential Causes of Myofascial Trigger Points:
Address musculoskeletal causes, which could be due to:
Direct trauma (e.g., after a motorbike accident).
Muscle imbalance, overactivity, or sustained contraction of muscles (e.g., playing the violin).
Sustained postural stressors (e.g., working as a physiotherapist or office worker).
Bruxism due to habitual clenching and grinding of the teeth.
Evaluate if the referred pain is due to articular neural conditions and not due to muscles.
Non-musculoskeletal causes:
Anxiety, depression, or emotional stressors.
Hormonal changes (e.g., myofascial trigger points in the neck causing headaches or low back pain during the menstrual cycle).
Nutritional deficiencies (e.g., vitamin D or vitamin B).
Food sensitivities (e.g., tyramine or gluten).
Central sensitization causing fibromyalgia or headache with neck pain.
Neoplastic changes (e.g. collapsed C4 vertebral body, which was found after a patient had limited movement due to breast carcinoma).
Clinical Experience
Myofascial trigger point locations can vary from those described by Travel and Simons.
There could be individual anatomical variants.
Individual changes in one's biomechanics.
Example: Strees fracture to a bowler who had an unusual action.
Correlational studies and historical input infer acupoints have specific locations; hence, myofascial trigger points and acupoint locations need to be further evaluated.
Maitland Grading System for Myofascial Trigger Points
Grade A: At the entrance of the muscle near the skin.
Grade B: Where one would feel resistance (e.g., the gluteal muscles).
Grade 1: Superficial, at the entrance of the muscle (skin or subcutaneous tissue) -Indication: acute pain or hyperalgesia.
Grade 2: Mid-depth, at the entrance of the myofascial trigger point, just feeling the resistance - Indication: subacute pain or irritable conditions.
Grade 2-: Just before resistance.
Grade 3: Deep myofascial trigger point, mid-depth through the myofascial trigger point - Indication: ongoing non-irritable conditions.
Grade 4: Deep end-range, indications again ongoing and non-irritable conditions.
Grade 4-: Just before in range.
Summary of Dry Needling
A western medicine paradigm to treat neuro-musculoskeletal conditions.
Common approaches include the myofascial trigger point model, the radiculopathy model, neural pathway approach, the western acupuncture model, and the central neural effect model.
Distinguish from examination the potential source of the myofascial trigger point and identify whether or not the trigger point is arising due to central or peripheral sensitization or a non-musculoskeletal or sinister origin.
Acupuncture vs. Dry Needling
Traditional Chinese Medicine (TCM) is an ancient health management paradigm originating from Taoism and Eastern religious philosophy.
Acupuncture is one of the many treatment approaches utilized in TCM and has been practiced for over two thousand five years.
TCM believes that Qi is a vital life force that binds all things together and generates all transformations in the universe.
Qi flows throughout the body in prescribed invisible energy channels called meridians or the meridian system.
Qi consists of two interdependent fundamental forces yin and yang, and excess obstruction or deficiency of this Qi energy can cause symptoms of illness and disease, according to TCM philosophies and beliefs.
Yin: Negative energy, cold, heavy, descending, moist, and dark.
Yang: Positive energy, nebulous, hot, active, dry, rising, and aggressive.
There are 12 major and eight special meridians that do not conform to human physiology but are unseen supernatural conduits of chi, for with no tangible Western proof of their existence.
Acupuncture points are certain areas on each of these meridian systems, and each point has particular functions and indications and do not display the typical twitch response of a myofascial trigger point.
TCM Pathogens vs. Western Medicine:
TCM: invasion of damp or heat, wind, cold, dryness, a blood deficiency, or a blood excess, and emotional states.
TCM Assessment includes pulse examination of the radial artery.
TCM understands that there are 12 pulses, six on the left radial artery, six pulses on the right radial artery, which represent different organs, and assessment of this yin yang imbalance.
TCM practitioners also palpate the abdomen and look at people's tongue, in addition to gleaning general health information to give them a diagnosis.
TCM treatment is a holistic approach to rebalance the yin yang energy and restore the free flow of Qi
Treatment May include herbal medicines, dietary and general health advice, in addition to acupuncture techniques.
Diagnostic philosophy and criteria are yet to be scientifically validated.
In contrast to acupuncture, Dry Needling has a diagnosis and management based in Western medicine philosophy and standard musculoskeletal and general health assessment.
TCM vs. Dry Needling
Similarities
Both use Solid filiform needles
Differences
TCM: Assesses the whole person History has a spiritual paradigm
Dry needling: Assessment based on Western medicine & musculoskeletal assessment, though Western medicine did actually originate from a spiritual paradigm as well.
TCM: Look at pulses, tongue examination, abdominal palpation, glandular health information, and energy level information.
Western medicine: look at blood pressure, auscultation of lung air entry etc. Asking about physical symptoms and look at functional movement, particularly physiotherapists, and also looking at local region assessment, musculoskeletal trigger points, neurological and neurodynamic examination, as well as a neuromuscular assessment.
TCM: pathogens such as wind, damp, heat, cold, which cause Qi deficiencies or obstructions and therefore result in disease.
Western medicine: pathogens such as bacteria and viruses or, in the musculoskeletal world, joint inflammation, degeneration, nerve and muscle injury.
TCM Practitioners needle into acupuncture points, which are points along meridians. They also needle into archi points, plus or minus moxibustion and sometimes include ear and scalp points.
the aim of the needling is to restore the yin yang balance and thus the free flow of Qi, which corrects the disease.
Dry needling is needling into MTPs, taut bands, hyperalgesic areas within dermatomes, myotomes, or along nerve pathways into skin, ligaments, and musculotendinous junctions.
The aim of dry needling is to reduce pain and improve the soft tissue mobility and thereby improve function.
TCM involves needling along meridian energy lines is believed to result in a correction of the positive and negative energy flow and thus correct disease and is often applied in conjunction with herbal therapies, general health and dietary advice to manage disease.
Dry needling in contrast involves needling is applied into tight bands, MTPs, and areas of pain to improve tissue compliance and function and is usually used in conjunction with other physical treatments.
How Dry Needling Works: Specific Evidence
Reduction in spontaneous electrical activity in myofascial trigger points of rabbits, biochemical menu changes, and brain activity changes.
Animal EMG studies performed in rabbits by Huginning and Bruckner in Melbourne have shown a reduction in spontaneous electrical activity in myofascial trigger points following elicitation of a twitch response with dry needling.
Myofascial trigger points have associated increased electrical activity, which may be reduced by dry needling.
Schar's team showed that eliciting a twitch response when needling the upper trapezius active myofascial trigger point had a biochemical effect on selected inflammatory mediators in the myofascial trigger point.
In active myofascial trigger points of the upper trapezius, there were higher concentrations in the immediate biochemical milieu of the following neuropeptides, which are associated with nociception as compared to normal muscle tissue, such as bradykinin, interleukin one, norepinephrine, serotonin, CGRP, tumor necrosis factor, and substance B.
In latent trigger points, there was a high concentration in the immediate biochemical milieu of CGRP and substance P compared with normal muscle tissue, but this was lower in concentration compared with active myofascial trigger points.
Needling of the upper trapezius drops serotonin levels when Xia elicited a twitch response in the upper trapezius active myofascial trigger point, and there was normalization of the biochemical milieu in the tissue in the immediate vicinity of the myofascial trigger point.
Regarding brain activity changes, functional MRI study was conducted by Needham and his group.
Increased activity in the somatosensory cortex S1 S2, inferior parietal and midinsular region, and the limbic region.
Suppressed right dorsal hippocampal activity.
Needling has an effect on pain modulatory regions in the central nervous system as well as the emotional centers.
How Acupuncture Works.
More evidence for acupuncture than dry needling, but perhaps we can extrapolate some of that information acupuncture, needling to dry needling.
Evidence for opiate peptide release, release of adenosine, brain activity changes, diffuse noxious inhibitory control, fibroblast changes, and there are also theoretical pain models which can be applied for acupuncture.
Opiate Peptide Release
Some studies demonstrate increased regions of release of opiate peptides when analyzed with a PET scan.
Electroacupuncture is noted to selectively increase the release of enkephalin, beta endorphin, and endomorphin at 2 Hz, and dynorphin at 100 Hz.
These opiates are considered to modulate pain.
Adenosine Release
Animal models demonstrate that acupuncture needling causes a release of adenosine, a chemical released with skin trauma.
Adenosine is considered to inhibit nerve signals that trigger pain.
Brain Activity Changes
Fang assessed the effect of acupuncture needling in 15 healthy subjects using functional MRI.
They found increased activation in the somatosensory cortical areas, the frontal regions, the right side of the thalamus, the left side of the cerebellum during needle stimulation.
Lee and coworkers conducted fMRI studies and found that stimulation of manual acupuncture with different durations could induce different effects in the central nervous system on the human brain; hence, longer duration of manual acupuncture might induce more significant brain areas.
Kai and coworkers conducted systematic review of 44 fMRI studies who reported there was significantly greater connectivity of genuine acupuncture effects between the periaqueductal gray, anterior cingulate cortex, left posterior cingulate cortex, the right anterior insula, the limbic paralimbic and precuneus compared with sham acupuncture.
Diffuse Noxious Inhibitory Control, which says primary information is blocked in the application of a new noxious simulation, causing DNIC at the supraspinal level.
Fibroblast Changes
Langevin reported that fibroblast changes can cause neuromodulation.
She observed that superficial needle rotation of subcutaneous tissues resulted in fibroblasts changing from a rounded appearance to a more spindle-like shape.
Proposed this altered shape could lead to cellular and extracellular events including mechanoreceptor and nociceptive stimulation, variation in gene expression, and extracellular matrix, and eventually to be contributing to neuromodulation.
Theoretical Pain Model
Superficial dry needling stimulates the a delta sensory afferents, which project to wildeye cells in lamina one in the dorsal horn and stimulate stalk cells between lamina one and two and is considered to release opioid peptide enkephalin.
Melzak and Wall propose that this reaction from dry needling inhibits activity in the substantia gelatinosa cells to which unmyelinated sensory afferents project from the myofascial trigger points, thus blocking noxious input from these nociceptive fibers.
Further plane suppression occurs because the dorsal column pathways project to the periaqueductal gray and activate the descending inhibitory pathways.
Embryological Model - nerve fibers travel and can see those red lines to the muscles and to the deep organs.
Homunculus Theoretical Model
Needling the hand could have a neural effect on the head.
With headaches patients had increased activity in the head region, and with knee pain, patients had increased activity in the knee region, per Professor Lorimer Mosley.
When you are thinking about needling, do not only think about the local region of the muscles but also the brain.
Neurophysiological Findings: Acupuncture and Dry Needling
Acupuncture: Electrical changes due to electrical impedance change in these acupoints.
Dry needling: Reduction in the spontaneous electrical activity in the myofascial trigger point.
Acupuncture and dry needling: Functional MRI studies show changes in brain activity in different parts of the brain.
Acupuncture: PET scan studies indicate release of endorphins and interferons.
Acupuncture: Release of adenosine.
Dry Needling: There are biochemical mileage changes following dry needling and producing a twitch response.
Acupuncture: There are fibroblast changes on needling.
There is the theory and research on rats to postulate regarding diffuse noxious inhibitory control.
Dry Needling Efficacy Evidence
Sackett put forward evidence based medicine in 1976 and subsequently in 1996 evidence informed medicine.
Bruckner and Huginning investigated 59 Australian football league players with long-standing hamstring pain using dry needling of gluteal trigger points and reported reported that both interventions resulted in subjective improvement in activity-related muscle pain with running 500 meters post-intervention, twenty-four hours and seventy-two hours later, and also in hamstring tightness.
Both placebo needling and experimental needling can have a positive effect because you Either place a blunt needle or a retractive needle which also touches the skin, it's going to stimulate mechanoreceptors and thereby the nervous system and have an effect on the spinal cord and the brain.
Researchers conducted a systematic review and meta-analysis in 2018 on dry needling for treating low back pain performed on trigger points and stated that dry needling resulted in significant pain intensity reduction and functional disability, with combination dry needling treatments being more effective than dry needling alone.
Evidence for Headache and Upper Quarter Pain
There is evidence for the use of dry needling and physiotherapy in cervicogenic and tension-type headache management and on the effectiveness of grinding for upper quarter mouth fascia pain.
Evidence for Hips and Knees
Acupuncture showed statistically significant short-term improvements in pain compared with sham-controlled treatment, but again, addressing biomechanics, strength, and conditioning of the lower quarter.
Evidence-Informed Medicine
Addresses using evidence of research, patient experience, and physician's wisdom in treating the patient rather than basing it on one parameter.
There's evidence for both dry kneeling and acupuncture for some specific conditions from Cochrane reviews, systematic reviews, RCTs, and published case series.