Dry needling

Dry needling is the use of solid filiform needles for therapy of muscle pain, sometimes also known as intramuscular stimulation.^[1] The needles are similar to acupuncture needles. 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.^[2] Acupuncture and dry needling techniques are similar, but their rationale and use in treatment are different.^[3]

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.^[4] Lewit had noticed that the success of injections into trigger points in relieving pain was apparently unconnected to the analgesic used.^[2] 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,^[5] and may work by activating endogenous opioids.^[4] Inserting the needle can itself cause considerable pain,^[4] although when done by well-trained practitioners that is not a common occurrence.^{[citation needed]} 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.^[6][7] Chan Gunn introduced a type of dry needling called intramuscular stimulation in the 1980s that moved away from using trigger points.^[1][8] 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.^[1][9]

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.^[5] 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.^[10]

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,^[11] Georgia, New Mexico, and Kentucky perform the technique, and several other states, including Louisiana, Tennessee 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 California, Hawaii, Nevada, New York, and Florida, though many states have no regulations on dry needling.^[12] 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.^{[citation needed]}

Controversy

Many 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"). Whether dry needling is considered to be acupuncture depends on the definition of acupuncture, and opinions vary on whether trigger points correspond to acupuncture points or meridians.^[1] Many physical therapists and chiropractors have asserted that they are not practising acupuncture when dry needling.^[12] 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 the Court of Appeals of the State of Oregon issued an order asserting that dry needling is "substantially the same" as acupuncture.^[13] In September 2011,the Oregon Board of Chiropractic Examiners And Oregon Attorney General appealled said order on the grounds that they feel the commissioner who issued the order was mistaken in his assertion.^[14]

See also

• Trigger point
• Acupuncture
• Myofascial release

References

1. ^ ^{a b c d} Fernández De las Peñas, César; Arendt-Nielsen, Lars; Gerwin, Robert D. (2009). Tension-Type and Cervicogenic Headache: Pathophysiology, Diagnosis, and Management. Jones & Bartlett Learning. p. 250. ISBN 0763752835. http://books.google.co.uk/books?id=E77N-9iIaMAC&pg=PA250. 
2. ^ ^{a b} K. Lewit (February 1979). "The needle effect in the relief of myofascial pain". Pain 6 (1): 83–90. doi:10.1016/0304-3959(79)90142-8. PMID 424236. 
3. ^ Marcus, Alon; Kuchera, Michael (2001). Foundations for integrative musculoskeletal medicine: an east-west approach. North Atlantic Books. p. 264. ISBN 1556435401. http://books.google.co.uk/books?id=WbThUt45ZXgC&pg=PA264. 
4. ^ ^{a b c} Baldry, Peter; Yunus, Muhammad B.; Inanici, Fatma (2001). Myofascial pain and fibromyalgia syndromes: a clinical guide to diagnosis and management. Elsevier Health Sciences. p. 36. ISBN 0443070032. http://books.google.co.uk/books?id=VpjTcoDLXPQC&pg=PA36. 
5. ^ ^{a b} Furlan AD, van Tulder MW, Cherkin DC, et al. (2005). Furlan, Andrea D. ed. "Acupuncture and dry-needling for low back pain". Cochrane Database of Systematic Reviews (1): CD001351. doi:10.1002/14651858.CD001351.pub2. PMID 15674876. http://mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD001351/frame.html 
6. ^ Lucas, N.; Macaskill P., Irwig L., Moran R., Bogduk N. (2009). "Reliability of physical examination for diagnosis of myofascial trigger points: a systematic review of the literature". The Clinical Journal of Pain (Eastern Pain Association) 25 (1): 80–9. doi:10.1097/AJP.0b013e31817e13b6. ISSN 0749-8047. PMID 19158550. http://journals.lww.com/clinicalpain/Abstract/2009/01000/Reliability_of_Physical_Examination_for_Diagnosis.12.aspx. 
7. ^ Tough, Elizabeth A.; White, Adrian R.; Richards, Suzanne; Campbell, John (2007). "Variability of Criteria Used to Diagnose Myofascial Trigger Point Pain Syndrome-Evidence From a Review of the Literature". The Clinical Journal of Pain (Eastern Pain Association) 23 (3): 278–286. doi:10.1097/AJP.0b013e31802fda7c. PMID 17314589. http://journals.lww.com/clinicalpain/Abstract/2007/03000/Variability_of_Criteria_Used_to_Diagnose.13.aspx. 
8. ^ Kermode-Scott, Barbara (August 13, 2002). "Vancouver MD Develops Acupuncture Therapy". The Medical Post, Volume 38, Issue 29. 
9. ^ Baldry, Peter (2005). Acupuncture, Trigger Points, and Musculoskeletal Pain, Third Edition. Elsevier Churchill Livingston. ISBN 0 443 06644 2. 
10. ^ Tough, Elizabeth A.; Adrian R. White, T. Michael Cummings, Suzanne H. Richards, John L. Campbell (2009). "Acupuncture and dry needling in the management of myofascial trigger point pain: A systematic review and meta-analysis of randomised controlled trials". European Journal of Pain 13 (1): 3–10. doi:10.1016/j.ejpain.2008.02.006. PMID 18395479. http://www.europeanjournalpain.com/article/S1090-3801%2808%2900055-4/fulltext. 
11. ^ Colorado Physical Therapy Licensure, Policy 30-2, Director's Policy on Intramuscular Stimulation, July 20, 2005
12. ^ ^{a b} Dommerholt, Jan (2008). "The "Dry Needling Issue"". Qi-Unity Report. http://www.aaaomonline.info/qiunity/08/07/3a.html. Retrieved 16 June 2010. 
13. ^ James W Nass, Order Staying Administrative Rule Pending Judicial Review, Court of Appeals State of Oregon, No. A148924, July 29, 2011
14. ^ OBCE & Oregon State Attorney General Motion Requesting Reconsideration of Adminstrative Stay, September 22, 2011