When an old Achilles tendon injury flared up and prevented me from running, I tried all my previous tricks — ice, rehab exercises, rest. At my wits’ end, I sought advice from a physical therapist, who suggested “trigger point dry needling,” a technique in which thin needles are inserted through the skin and into so-called trigger points in the muscle.
Desperate for relief, I was soon facedown on the exam table with needles going into my calves. The procedure didn’t last long, but it felt like electric-charged spikes jabbing my nerves. My calf muscles reacted by twitching and seizing into a prolonged cramp. The next day, they were so sore I could barely walk. A few weeks later, my Achilles problem had healed enough that I could run again. Did the needling help? I have no idea.
The experts aren’t certain, either. On a scale of zero to 10, with 10 being absolute certainty about its effectiveness and zero being no supporting evidence at all, “I’d say it’s probably in the 6 range,” says Edo Zylstra, a physical therapist and owner of Kinetacore in Brighton, Colo., which trains medical professionals in the technique. “The evidence on it is improving all the time — every month there are new studies.”
One recent study randomly assigned people undergoing total knee replacement to receive either trigger point dry needling or a placebo treatment while under anesthesia (neither patients nor their health-care providers knew who was in each group) and found that people who had been needled reported less pain than the controls during the first month after the surgery. A 2005 review published by the Cochrane Collaboration concluded that dry needling may be useful when added to other therapies for chronic low-back pain.
Although it uses the same needles as acupuncture, trigger point dry needling is an entirely different technique based on neurophysiology, says Jan Dommerholt, a physical therapist at Bethesda Physiocare who teaches seminars on the technique. “We share a tool, but that’s it,” he says. “Trigger point dry needling has nothing to do with Asian medicine or meridians and energy flow.” Where acupuncture needles remain close to the skin’s surface, dry needling pushes the them farther into the muscle and thus requires an intricate understanding of anatomy.
The technique arose from observations of muscle injections made as far back as the 1940s. There seemed to be trigger points where injections provided pain relief, regardless of what was in the needle, Dommerholt says. “That suggested that it’s not what you inject, but the mechanical stimulation of the needle that does the trick.” Since then, the technique has been widely studied, but “we still don’t really know how dry needling works,” he says.
Trigger points are like knots in the muscle; when you inject a needle into them, it sparks a change in chemistry inside the muscle. “The environment in these trigger points is extremely acidic, and because of the acidity, there are lots of chemicals released in the muscle that don’t belong there,” Dommerholt says. “We know that within minutes of needling, these chemicals are gone — that’s been shown in humans and rabbits — but we still don’t know why dry needling does that.”
Dry needling is akin to rebooting your computer when it’s trapped in the spinning ball of doom, says Charlie Merrill, my physical therapist at Merrill Performance in Boulder, Colo. “You’re causing micro-trauma in that part of the muscle,” he says, which triggers increased circulation, an inflammatory response and biochemical changes (like the ones Dommerholt mentioned) that help the muscle heal. “When it comes back online, things are working more normally again,” he says.
Needling is not a fix-all solution, Merrill says. “It’s usually only a piece of the puzzle, and often a very small piece.” He says he almost never gives a patient dry needling alone. Instead, it’s one tool in a larger treatment plan that might also include exercises, range-of-motion drills and stretching.
Dry needling is most often done by physical therapists, but doctors, nurses, chiropractors and acupuncturists who have been trained can also do it. If you try it, look for a practitioner who has had specific training in the technique (typically a weekend class), and be sure that your clinic keeps needles sterile.
While the American Physical Therapy Association does not have an official position on dry needling, it recognizes that the technique “is within the professional scope of practice for physical therapists,” says Erin Wendel, the association’s senior media relations specialist.
When done by a physical therapist, dry needling is considered a regular part of physical therapy so patients (and insurers) aren’t charged added fees for it and practitioners don’t have the lure of extra income tempting them to use the technique inappropriately. However, in Idaho, New York, South Dakota and Tennessee, concerns raised by acupuncture advocates about which health-care professionals should be allowed to use needles have led to prohibitions on physical therapists providing dry needling. If you live in one of those states, you’ll have to seek the treatment from a physician.
When I told Merrill how much pain I’d had the day after the treatment, he wasn’t surprised. “It’s not like massage, where you’re going to feel good today,” he says. “It’s a feel-worse-today-to-feel-better-in-a-week-or-two sort of thing.” Dry needling is most painful in the calves and the glutes, Merrill says. When I received the treatment for hip pain on another occasion, it didn’t hurt a bit. But I’m still wondering whether it helped.
The problem I have assessing an intervention such as this is that I can’t know how my injury would have done without the procedure. If it was going to resolve itself on its own over those same few weeks, perhaps its greatest benefit was that it gave me a distraction — and a new pain to deal with, temporarily, and the feeling that I’d done something proactive — while nature ran its course.
What is Dry Needling?
Dry needling is the use of either solid filiform needles or hollow-core hypodermic needles for therapy of muscle pain, sometimes also known as intramuscular stimulation (IMS). Acupuncture and dry needling techniques are similar.
What is Trigger Point Dry Needling (TDN)?
TDN is an effective therapy to treat muscular tension and spasm which commonly accompanies conditions such as arthritis, nerve irritation, muscular strain, ligament strains and herniated discs. It is called “Dry” Needling because there is no solution injected as with a hypodermic needle during a flu shot. With Dry Needling, the needle itself and the effects it produces within the tissue is the treatment.
When an injury occurs from repetitive use or acute trauma, inflammation will be produced from the damaged tissues. The damaged tissues will also go into a protective tension state or contracture to guard against further damage from utilizing the injured tissue. This contracture and inflammation inhibit microcirculation which limits both the oxygen rich blood reaching the injury and the waste products leaving the injury. The injury site becomes hypoxic (decreased in oxygen) which stimulates the body to produce fibroblasts, a cell that produces fibrosis or scar tissue. This fibrosis and scarring builds up around the muscles and tissues limiting the tissues ability to fully function (lengthen/shorten) and can also cause compression and irritation of nerves (such as carpal tunnel syndrome) – all of which inevitably lead to biomechanical disturbances in gait and function.
TDN uses a small, solid filament needle which is inserted in a contracted painful knotted muscle to create a local twitch reflex which is both diagnostic and therapeutic as it is the first step in breaking the pain cycle as research shows will decrease muscle contraction, reduce chemical irritation, improve flexibility and decrease pain. When a needle is inserted into muscle it will also produce a controlled lesion and will cut between three to fifteen thousand individual muscle fibers. The body considers the needle as a foreign invader and will activate the immune system as a response. The cut muscle fibers also produce an inflammatory reaction that your body will respond to not just locally but all over the body to reduce inflammation systemically.
- Dry Needling may mechanically disrupt a dysfunctional motor end plate
- Needling results in a Local Twitch Response (LTR)
- The LTR results in an alteration to muscle fiber length as well as having an inhibitory effect on antagonistic muscles
- Baldry (2001) suggests that dry needling techniques stimulate A-nerve fibers (group III) for as long as 72 hours post needling
- Prolonged stimulation of the sensory afferent A-fibers may activate the enkephalinergic inhibitory dorsal horn interneurons, which implies that dry needling causes opioid mediated pain suppression
- Another possible mechanism of dry needling is the activation of descending inhibitory systems which would block noxious stimulus into the dorsal horn
- The LTR may also utilize the excessive ACh in the tissue which previously was triggering increased firing of localized fibers
- Studies by Shah and colleagues (2001) demonstrated increased levels of various chemicals at sensitized motor end plates such as: Bradykinin, Substance P and CGRP (regulator of Calcium and Phosphate balance). These chemicals were reduced immediately post a LTR.
- CGRP enhances the release of ACh from nerve terminals, which results in increased ACh receptors at the neuromuscular junction
- Needle penetration will cause micro-trauma and micro bleeding (localized inflammation) and hence the introduction of PDGF into the area to help promote healing
Is Trigger Point Dry Needling Acupuncture?
No, Trigger Point Dry Needling is based on Western medical research and principles, whereas acupuncture is based on Traditional Chinese Medicine. The main similarity is that the same sterile, disposable solid filament needles are used. Although Dr. Mulhall is a Fellow for the International Association of Medical Acupuncture (FIAMA) and also practices acupuncture, he was trained through two separate organizations (The American Dry Needling Institute and KinetaCore) to provide detailed and specific TDN therapy and each therapy is a separate and distinct in their methodology, perspectives and practices.
What Types of Conditions Can TDN Assist?
- Neck/Back Pain
- Shoulder Pain
- Tennis/Golfers Elbow
- Hip and Gluteal Pain
- Knee Pain
- Achilles Tendonitis/Tendonosis
- Plantar Fasciitis
- Muscular Strains/Ligament Sprains
- Chronic Pain
- Athletic Performance
Does TDN hurt?
You may or may not feel the insertion of the needle. The specific needle manipulation is intended to produce a local twitch response that can elicit a very brief (less than a second) painful response some patients describe as a deep ache or cramping sensation. Again, the therapeutic response occurs with the elicitation of the local twitch response and is a desirable reaction.
What can I do to prepare for my therapy?
Eat a light meal 1-2 hours prior to your visit and wear loose, comfortable clothing that can be rolled up or down to access your areas of concern with the greatest ease.
What can I expect after treatment?
We are looking to get improvements even from the first visit such as increased range of motion, ease of movement and decreased signs/symptoms.
Many patients report being sore after the treatment in both the area treated and the area of referred symptoms. Typically this soreness lasts between a few hours and two days and there is occasional bruising. Soreness may be alleviated by applying ice or heat to the area and performing specific stretches for the treated muscle.
Here are 10 facts you should know about the illegal and unsafe practice of acupuncture under the term
1. “Dry needling” is acupuncture.
“Dry needling” was first described over 2,000 years ago in China’s earliest and most comprehensive extant medical treatise, the Yellow Emperor’s Inner Classic (Huangdi neijing), where it discusses in detail using tender or painful points, also known as “trigger points” or “motor points,” to treat pain and dysfunction, particularly of the neuromusculoskeletal system. Simply described, “dry needling” involves inserting an acupuncture needle into a tender or painful point and then appropriately manipulating (rotating and/or pistoning) it for therapeutic purposes.
2. Tender or painful points, also known as “trigger points” or “motor points,” are acupuncture points.
Tender or painful points are located in muscles and connective tissues, and, as their name suggests, are identified through tenderness or pain on palpation. This was, in fact, one of acupuncture’s earliest forms of point selection. China’s preeminent physician, Sun Si-Miao (581–682 C.E.), called these tender or painful points “ashi” points. In Chinese, ashi means Ah yes! (That’s the right spot.). So, when the tender or painful point is pressed, the patient feels an unexpected local and/or referred “wince-pain” and says Ah yes! That’s the right spot. Incidentally, in a 1977 study published in Pain (the official journal of the International Association for the Study of Pain), Melzack, Stillwell and Fox established that “every trigger point [reported in the Western medical literature] has a corresponding acupuncture point.”* A number of studies subsequently published in the Western medical literature have reached this same basic conclusion.
* Source: Melzack R, Stillwell DM, Fox EJ. Trigger points and acupuncture points for pain: correlations and implications. Pain. 1977 Feb;3(1):3–23.
3. “Dry needling” is not “manual therapy;” it is acupuncture.
It is important to emphasize that “dry needling” is an invasive, acupuncture needle intervention (that is, it is acupuncture, a specialized form of minimally invasive surgery), whereas manual therapy is a noninvasive, hands-on intervention (for example, massage, mobilization/manipulation). Manual therapy certainly does not include the practice of surgery in any form.
4. “Dry needling” is not a “technique;” it is acupuncture.
To make clear, the act of inserting an acupuncture needle into the body, under any pretense, or for any purpose whatsoever, is the practice of acupuncture.
5. Physical therapists and other allied health professionals who are not licensed by law to practice acupuncture cannot legally purchase acupuncture needles.
The Food and Drug Administration (FDA) classified acupuncture needles as Class II medical devices subject to strict regulations under the federal Food, Drug, and Cosmetic Act (FDCA) and FDA’s regulations. Individuals purchasing or receiving acupuncture needles who are not licensed by law to practice acupuncture are directly violating both civil and criminal provisions of the FDCA intended to protect public safety. 21 U.S.C. § 331(a)–(c), (g). These include the FDA’s requirements that acupuncture needles can only be sold to “qualified practitioners of acupuncture.” 61 Fed. Reg. 64616 (December 6, 1996). FDA prescription labeling requirements themselves specifically prohibit the sale of acupuncture needles to anyone who is not a qualified practitioner of acupuncture. The required FDA prescription labeling on the package from which acupuncture needles are to be dispensed states: “Caution: Federal law restricts this device to sale by or on the order of qualified practitioners of acupuncture as determined by the States.” 21 CFR § 801.109(b)(1) (emphasis added). Any individual who is not licensed by law to practice acupuncture is directly violating the FDCA and FDA’s civil and criminal prohibitions when they purchase or receive acupuncture needles for use in “dry needling.”
6. Physical therapists and other allied health professionals who are not licensed by law to practice acupuncture are using acupuncture needles to perform “dry needling.”
Physical therapists and other allied health professionals who are not licensed by law to practice acupuncture would have you believe that they are not using acupuncture needles to perform “dry needling,” when they are, in fact, using acupuncture needles, which are clearly labeled as such on the dispensing package.
7. Physical therapists and other allied health professionals who are not licensed by law to practice acupuncture are not qualified to perform “dry needling.”
“Dry needling” is far outside both physical therapists’ and other allied health professionals’ scope of practice and their scope of education and training. In most states, to become a licensed acupuncturist, an applicant must complete a minimum of 1,905 hours of education and supervised clinical training (1,245 hours of education and 660 hours of supervised clinical training). Yet physical therapists and other allied health professionals who are not licensed by law to practice acupuncture are inserting acupuncture needles (up to four inches or more in length) into unsuspecting patients with as little as a weekend workshop in acupuncture.
8. There are real risks associated with the use of acupuncture needles by physical therapists and other allied health professionals who lack the education and supervised clinical training of licensed acupuncturists.
These real risks include, but are not limited to, blood vessel, nerve and organ injury from inappropriate acupuncture needle angle and depth of insertion or from inappropriate acupuncture needle manipulation; and infection and cross infection from non-sterile acupuncture needles, poor hygiene in acupuncture needle handling, and inadequate skin preparation.
9. There have been recently reported cases of injury or harm from the use of acupuncture needles by physical therapists and other allied health professionals who lack the education and supervised clinical training of licensed acupuncturists.
In one such case, Emily Kuykendall, a high school teacher from Maryland, had suffered nerve damage from the use of acupuncture needles by a physical therapist. In another such case, Kim Ribble-Orr, a former Olympic athlete from Canada, had suffered a punctured lung and a pneumothorax (the presence of air in the cavity between the lungs and the chest wall, causing collapse of the lung) from the use of acupuncture needles by a massage therapist.
*If you or someone you know has suffered injury or harm from the use of acupuncture needles by a physical therapist or other allied health professional who lacked the education and supervised clinical training of licensed acupuncturists, we want to hear from you. Our phone number is 775-301-5255.
10. It is illegal for physical therapists or any other providers to submit claims for payment to Medicare for “dry needling” (a non-covered service) as “physical therapy” (a covered service).
Since “dry needling” is acupuncture, it is not a covered service. Use of acupuncture needles is not a covered service, whether an acupuncturist or any other provider renders the service. 42 U.S.C. § 1395y(a)(1). Its billing under Current Procedural Terminology (CPT) codes 97112 (neuromuscular reeducation) or 97140 (manual therapy techniques) is a misrepresentation of the actual service rendered and is considered fraud by Medicare. 31 U.S.C. §§ 3729–3733.
*If you suspect Medicare fraud, call the Medicare Fraud Hotline at 1-800-HHS-TIPS (1-800-447-8477). TTY users should call 1-800-377-4950.
*Information on this page is used with consent from the National Center for Acupuncture Safety and Integrity
I would rather not experience pain to heal. With acupuncture there may be a momentary pain in a “hot point” but it quickly dissipates or the needle is removed. I do not have to use ice or heat afterwards. I do not have to wait six weeks for results. Acupuncture from licensed professionals works naturally with your body to help it heal.