# Is dry needling painful?

## Dry Needling Pin Point Relief of Muscle Pain

The trigger point is a direct and palpable source of pain, often containing multiple contracted knots in the muscle that may feel like tight bands. These “muscle knots” can cause pain, limit motion and affect performance. If left untreated, they can worsen over time. Trigger point dry needling is a treatment used by physical therapists to eliminate these trigger points. It involves inserting a sterile thin filament/acupuncture needle into the tight or sore muscle. It is called “dry needling” because, unlike a steroid injection, no substance is put into the body. When the needle penetrates the knots in a muscle, it elicits a twitch response, indicating a release or deactivation of the painful trigger point. At the cellular level, the muscle’s physiology changes to better absorb calcium, improve circulation, encourage tissue remodeling and promote healing. This process can be compared to re-booting the hard drive on a computer.

## Dry Needling, Combined With Other Physical Therapy Treatments, Can Help the Following Conditions:

• Acute and chronic tendonitis/tendinosis
• Athletic overuse injuries
• Baseball throwing related tightness/discomfort
• Carpal tunnel syndrome
• Chronic pain conditions
• Ehlers Danlos Syndrome
• Frozen shoulder
• Fibromyalgia
• Groin and hamstring strains
• Hip pain and knee pain
• IT band syndrome
• Muscle spasms
• Neck and lower back pain
• Post-traumatic injuries, motor vehicle accidents, and work related injuries
• Repetitive strain injuries
• Sciatic pain
• Shoulder pain
• Tennis/golfer’s elbow
• TMJ
• Many other musculoskeletal conditions

## How Long Does it Take for Dry Needling to Work?

In many cases, improved mobility is immediate and decreased pain is felt within 24 hours. Typically, it may take a few treatment sessions (once a week for 2-3 weeks) for a lasting positive effect.

## What are the Advantages of Dry Needling?

• Access – The advantage over other techniques is that we can treat parts of the muscle and deeper layers of muscles which our hands and fingers cannot reach, and it works faster than massage at relaxing the muscles.
• No Drugs – There are no drugs used in dry needling, so we can treat many trigger points during each treatment.
• Immediate Relief – Deactivation of the trigger points can bring immediate relief of symptoms, and then we can immediately stretch and train the muscles to work in their new pain free range of motion. Thus, results are achieved with dry needling which cannot be obtained with any other treatment.

## This Sounds Like Acupuncture

Both services do use the same needles, but that’s where the comparisons end. Our basic understanding of acupuncture is that it is more of an Eastern medicine practice in origin emphasizing energy or flow in relation to the body’s meridians. Conversely, dry needling is more of a Western medicine practice where we target specific problem areas within the muscles themselves.

## Does Dry Needling Hurt?

We use very thin filament needles. The initial feeling of the needle entering through the skin is very minimal; much less than a vaccination or having blood drawn. Once the needle reaches the muscle, the twitch sensation feels more like a deep cramp and doesn’t last long (15-30 seconds). Muscle soreness after a treatment session, may last 12-24 hours, commonly called being “needle sore” but the long-term results are worth it!

## Will Dry Needling Help Me?

Individuals who see good results with massage, but are disappointed when the discomfort returns, will find dry needling a better way to get longer-lasting and deeper relief. Dry Needling allows us to treat almost any muscle in the body, and treat the muscle at depths impossible with other types of bodywork. Many trigger points are just too deep in the tissue for massage, even deep tissue work, to treat effectively. Dry needling is a great way to get more out of your physical therapy by allowing us to eliminate the deep knots and restrictions that have, up until now, been unreachable.

## How Many Needles Will I Need?

We like to start slowly during the first session to give you a feel for the technique. The first session will focus on a few muscles that are key to your problems. These key areas can give you excellent relief with less soreness. Subsequent treatments will target more specific areas to fine-tune the effect. Sessions are usually spaced 5-7 days apart and you should expect to feel a marked difference after only 2 or 3 sessions.

## How Will I Feel After Dry Needling?

You will know positive change has occurred right after the session, as you should have decreased pain and increased mobility and because you will be sore in the way that you would feel after a heavy work out. The muscle will feel fatigued, and the soreness can last from a few hours to 1 or 2 days, but should not interfere with your everyday activities. We encourage you to be active during this time to keep the soreness to a minimum. You can continue your normal activities and gym routine. After a day or so, you’ll experience a new and lasting feeling of less pain and tightness. The injury and pain you thought was there to stay will actually start to diminish. If you’ve been having long standing, chronic muscle pain we’d welcome the opportunity to explain this treatment option in more detail and answer any questions you may have.

## Fed up of Being Injured? Will Dry Needling Work for You?

There is nothing a runner hates more than being told not to run.

Unless you find a medical professional you can trust, it is hard to know whether it actually would be best to rest, or whether there is another treatment that is worth a try.

It seems every year there is a new type of treatment that emerges claiming to help injured runners get back sooner, but one that seems to be gaining a lot of momentum in the running world is dry needling.

Today we are going to look at what dry needling is (and how it is different to acupuncture), what research has found about how effective dry needling is for treatment, whether it is worth giving it a try for your running injury, and of course, the question we all want to know; just how bad does it hurt?

Curing a running injury by sticking needles into your skin might sound crazy, but it’s an increasingly popular treatment for many of the common ailments that distance runners suffer from.

The technique is called dry needling.

It’s quite similar to acupuncture in that it involves inserting several needles into your skin near the point of injury.

The proposed mechanism is a little murky, but many runners nevertheless swear by it.

## What is Dry Needling and is it Safe?

Dry needling is an injury treatment performed by physical therapists and chiropractors who have been certified to treat myofascial injuries.

It arose partially out of scientific studies into acupuncture and injections of medication like cortisone, but has developed into its own area of treatment, and continues to grow in popularity.

Your therapist will use individually packaged, sterile needles for one site only, and very little, if any bleeding will occur due to the needles being around 1/4 mm thick.

The practice is very safe, especially as the therapist must undergo intense training to become certified in the practice of dry needling, and will already have vast knowledge of the anatomy of the body to know where to insert the needles.

### How does trigger point dry needling work?

The therapist inserts needles through the skin into areas of muscle pain, known as trigger points, explaining the name trigger point dry needling, although the treatment is also called intramuscular manual therapy.

The name dry needling is used because there is no medication involved, and the solid filament needles are the same as the ones used in acupuncture, rather than the hyperdermic syringes that traditional injections use.

The number of needles inserted will vary depending on the size of the area in pain, and how often you are able to get treatment. Most treatments will involve 5-20 needles, which are removed just a few minutes after insertion.

### What is the difference between acupuncture and dry needling?

This is one of the most common questions about the technique, and one that is still causing some friction between the two worlds.

Dry needling is part of a western medicine treatment technique that is supported by research, and used to target relief in specific areas. Acupuncture is based on traditional Chinese medicine, which treats the body as a whole, by creating balance within the body.

Therapists use dry needling to relieve pain by using the needles to release trigger points of specific muscles.

### How much does dry needling hurt?

Dry needling can be painful, and the location of the injury affect the amount of pain experienced, but it usually manifests in two ways:

As the needle is inserted through the skin into the muscle, there may be a slight contraction or twitch within the muscle, that creates pain.

Although twitches in the muscles can elicit an initial (but brief!) painful response, twitches in the muscles are considered a good sign that the desired trigger point has been hit.

After the treatment itself, there may be some soreness in the area for up to 48 hours afterwards, but this is not considered a cause for concern, and should be expected for most patients.

If the pain is initially worse:

Don’t panic! Give the muscle 48 hours to calm down after treatment, and if it still feels bad, dry needling probably isn’t for you.

## How Effective is Dry Needling?

We’ll have to look to the scientific research to find out.

### Where did dry needling originate?

One way medical researchers test out treatments is to devise sham treatments to function as a control.

In traditional acupuncture, needles must be applied to specific locations on the body to achieve the intended effect.

To test acupuncture, researchers intentionally inserted needles into the “wrong” location to test whether the theory behind acupuncture holds any water.

Likewise, a “dry” injection (using a needle but injecting no medication) is sometimes used as a placebo treatment in studies on medical injections.

According to a review article by T. Michael Cummings and Adrian R. White, researchers first noticed that the needle itself seemed to have some therapeutic effect in the late 1970s.1

In one study published in 2002, for example, true acupuncture (with proper needle placement) was compared with sham acupuncture (wrong needle placement) in a group of patients with muscle pain.

Both treatment groups experiencing muscle pain noticed substantial improvement following treatment, but there was no difference between true and sham acupuncture!2

After this and other similarly surprising discoveries, researchers began to consider dry needling as a treatment in and of itself more closely.

By 2005, enough evidence had accumulated to allow for a review study.

A group of researchers led by Andrea Furlan at the Institute for Work & Health in Canada looked over the scientific literature on dry needling and acupuncture for low back pain in English-language journals as well as Chinese and Japanese databases (acupuncture being an understandably popular research topic in Asian medical research).3

Though Furlan et al. did not find the bulk of the evidence strong enough for a ringing endorsement of dry needling or acupuncture, the authors did have a different conclusion about back problems.

There is some evidence of an effect for both acupuncture and dry needling, and that dry needling functions best as an adjunctive treatment, not as a standalone solution.

### Does dry needling help running injuries?

The scientific literature is more sparse when it comes to dry needling for athletic injuries, but there is some emerging evidence that it can be useful.

A 2010 report by Nichola Osborne and Ian Gatt described four elite female volleyball players with shoulder injuries who were successfully treated with dry needling treatments over the course of a month which included frequent competitions and tough training.4

Osborne and Gatt hypothesized that the needling treatments deactivated trigger points in the muscle, allowing the players to regain the ability to practice and compete while undergoing the treatment.

Likewise, a 2007 study by Steven James and colleagues published in the British Journal of Sports Medicine described how 44 patients were successfully treated for patellar tendonitis via dry needling and injection of the patients’ own blood into the tendon.5

In this case, the researchers used ultrasound imaging to insert a “dry” needle repeatedly into the degenerated area of the tendon.

This dry needling was followed by an injection of blood into the needled area.

## Why Does Dry Needling Work?

Here’s the deal:

While all of these studies show promise, they highlight one major problem with dry needling:

We don’t know how it actually works.

Some scientists hypothesize that it manipulates a mechanism called “gate control”—by focusing your nervous system’s response on the acute pain caused by the needle puncture, the chronic pain from your injury goes away.

Others propose that endorphins, mood-stimulating chemicals released in response to a painful stimulus like a needle wound, are responsible for alleviating pain.

Still another theory is that the needle deactivates muscular trigger points when inserted into the right location, relieving tension and referred pain.

Finally, the approach used by James et al. tries to take advantage of the direct trauma of the puncture, using the acute, local damage from the needle to kick-start the body’s healing process (aided in this case by a direct blood injection).

Clearly, much more research is needed on this front.

It’s likely that all of these responses play some part in how dry needling works.

The proper way to use dry needling may well depend on the injury it’s being used to treat.

### What injuries is dry needling most effective for treating?

A chronic, degenerative injury in tissue with poor healing capacity, like the Achilles tendon or the plantar fascia, might require the kind of repeated, direct trauma that was used in James et al.’s paper, possibly combined with external methods to boost healing, like autologous blood injections.

On the other hand, long-standing pain with nervous or muscular roots might benefit more from trigger-point targeted needling, or even just the rush of endorphins and redirection of pain that occurs in response to a needle wound.

### Is dry needling available everywhere?

Dry needling is available worldwide, but a few states in the US do not currently allow physical therapists and medical professionals other than licensed acupuncturists to use dry needling. This is because of an ongoing battle between physical therapists and acupuncturists.

This includes:

California, Utah, New York, Idaho, Hawaii and Florida.

In the remaining 44 states of the US, the argument has been settled, but if you live in any of the above states, you may need to seek alternative treatment.

Just keep this in mind:

There is no Procedural Terminology (CPT) code for dry needling itself, and many insurance carriers will not cover the treatment, so you have to decide if it is worth paying out of pocket for.

## What Does This Mean for the Injured Runner?

Here’s the bottom line:

Dry needling (or acupuncture) is best used as a tool to kick-start or speed up healing, not as a primary stand-alone treatment for running injuries.

You still need to get to the root of why you got hurt in the first place and how you can prevent that from happening again.

Further, it is best to seek dry needling from a medical professional you can trust with plenty of experience with the technique.

Even in the best case scenario, you can expect some significant soreness in the needled area, so you want to be sure the pain is worth it.

## What is Dry Needling?

Dry Needling is a treatment technique whereby a sterile, single-use, fine filament needle (acupuncture needle) is inserted into the muscle to assist with decreasing pain and improving function through the release of myofascial trigger points (knots in the muscle).

### What is the Difference Between Dry Needling and Acupuncture?

Dry Needling is a not the same as acupuncture, although there are similarities between the two techniques. The main difference between Dry Needling and acupuncture is the theory behind why the techniques work. Dry Needling is primarily focused on the reduction of pain and restoration of function through the release of myofascial trigger points in muscle. In comparison, acupuncture focuses on the treatment of medical conditions by restoring the flow of energy (Qi) through key points in the body (meridians) to restore balance.

### What is a Myofascial Trigger Point?

A myofascial trigger point, also known as a knot in the muscle, is a group of muscle fibres which have shortened when activated but have not been able to lengthen back to a relaxed state after use. A myofascial trigger point is characterised by the development of a sensitive nodule in the muscle (Simons, Travell & Simons, 1999). This occurs as the muscle fibres become so tight that they compress the capillaries and nerves that supply them (McPartland, 2004; Simons, et al., 1999). As a result, the muscle is unable to move normally, obtain a fresh blood supply containing oxygen and nutrients, or flush out additional acidic chemicals (McPartland, 2004; Simons, et al., 1999). In addition to this nodule, the remainder of the muscle also tightens to compensate (Simons, et al., 1999; Simons, 2002). The presence of a myofascial trigger point in a muscle can lead to discomfort with touch, movement and stretching; to decreased movement at a joint; and even a temporary loss of coordination (Simons, et al., 1999).

### What Causes a Myofascial Trigger Point?

A myofascial trigger point develops as part of the body’s protective response following:

• injury – the muscle will tighten in an attempt to reduce the severity of an injury;
• unexpected movements e.g. descending a step that is lower than originally anticipated;
• quick movements e.g. looking over your shoulder while driving;
• change in regular activity or muscle loading e.g. an increase in the number or intensity of training sessions for sport;
• sustained postures e.g. prolonged sitting for work or study;
• nerve impingement – the muscle will tighten to protect the nerve;
• stress;
• illness (bacterial or viral);
• nutritional deficiencies, or;
• metabolic and endocrine conditions.

(Simons, et al., 1999)

### How does Dry Needling Work?

Dry Needling assists with decreasing local muscular pain and improving function through the restoration of a muscle’s ability to lengthen and shorten normally by releasing myofascial trigger points.

When a fine filament needle is inserted into the center of a myofascial trigger point, blood pools around the needle triggering the contracted muscle fibers to relax by providing those fibers with fresh oxygen and nutrients, as well as by flushing away any additional acidic chemicals. This, in turn, leads to the decompression of the local blood and nerve supply.

### When is it Appropriate to Use Dry Needling as a Form of Treatment?

Dry Needling can be used in treatment:

• to help release myofascial trigger points (muscle knots);
• to assist with pain management, and;
• to restore movement at a joint if inhibited by myofascial trigger points.

### What Will You Feel During Dry Needling Treatment?

During a Dry Needling treatment, you may feel a slight sting as the needle is inserted and removed. However, this discomfort should last no longer than a second before settling.

A brief muscle twitch can also be experienced during a Dry Needling treatment. This may occur during treatment when the needle is inserted into a myofascial trigger point.

### Where Does Dry Needling Fit Within Your Rehabilitation Program?

Dry Needling is one of many techniques that can be utilised by your physiotherapist to assist with your rehabilitation. Dry Needling is often used in combination with other techniques including massage, manual therapy, and exercise prescription.

### What are the Side Effects of Dry Needling?

Every form of treatment can carry associated risk. Your physiotherapist can explain the risks and can determine whether Dry Needling is suitable for you based on your injury and your general health.

When Dry Needling is performed, single-use, sterile needles are always used and disposed of immediately after use into a certified sharps container.

### Is Dry Needling Safe?

Everybody is different and can respond differently to various treatment techniques, including Dry Needling. In addition to the benefits that Dry Needling can provide, there are a number of side effects that may occur, including spotting or bruising, fainting, nausea, residual discomfort or even altered energy levels. However, these symptoms should last no longer than 24 to 48 hours after treatment.

### Can You Exercise After Dry Needling?

It is recommended to avoid strenuous or high impact activities immediately after Dry Needling, to allow the body time to recover, and to maximise the benefits of the treatment.

At PhysioWorks, most of our physiotherapists are qualified and skilled in Dry Needling and would be happy to discuss your treatment options.

Call PhysioWorks

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### FAQs about Dry Needling & Acupuncture.

• What Conditions May Acupuncture Help?
• What is Dry Needling?
• What is a Trigger Point?
• What is Acupressure?
• Heat Packs. Why Does Heat Feel So Good?
• Non Attendance Policy
• What are the Early Warning Signs of an Injury?
• What is a TENS Machine?
• What is Chronic Pain?
• What is Nerve Pain?
• What is the Correct Way to Sit?

Acupuncture & Dry Needling

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### Related Information

• Early Injury Treatment
• Acupuncture and Dry Needling
• Gait Analysis
• Biomechanical Analysis
• Balance Enhancement Exercises
• Proprioception & Balance Exercises
• Medications?
• Real Time Ultrasound Physiotherapy
• Soft Tissue Massage
• Dry Needling
• Electrotherapy & Local Modalities
• Heat Packs
• Joint Mobilisation Techniques
• Kinesiology Tape
• Neurodynamics
• Physiotherapy Instrument Mobilisation (PIM)
• Running Analysis
• Stretching Exercises
• Supportive Taping & Strapping
• TENS Machine
• Video Analysis
• ## Research Studies Show Dry Needling Has No Long-Term Benefits

An increasing number of physical therapists (PTs), in the United States and throughout the world, are incorporating the dry needling (DN) technique to treat mainly musculoskeletal pain (MSP). So much so, the Federation of State Boards of Physical Therapy (FSBPT), in their most recent DN resource paper (1), dated July 2013 (pp2), state that “The volume of activity in the states from 2010-2013 regarding DN … has necessitated annual updates of the FSBPT original resource paper published in March 2010.”

Let me start by saying, researching this topic was kinda frustrating!! I like to understand a topic thoroughly before I even begin to think about writing about it. It wasn’t so easy, in this case. From clarifying the difference, if it exists, between the techniques of DN and acupuncture, to reviewing and comparing the available literature on DN with the varying methodologies (and conflicting commentaries among colleagues and professionals). It was even tricky clarifying in which U.S. states the DN technique is currently not considered within the practicing scope of PTs and, therefore, illegal.

I will take you through what I have managed to find out, though the ride may be a little “knotty”. The purpose of this article is to examine the current research on DN and whether it’s effective or to be avoided.

## What Is Dry Needling

The DN definition, according to the FSBPT (1) (pp4), is “a technique using the insertion of a solid filament needle, without medication, into or through the skin to treat various impairments including, but not limited to: scarring, myofascial pain, motor recruitment and muscle firing problems. Goals for treatment vary from pain relief, increased extensibility of scar tissue to the improvement of neuromuscular firing patterns.”

According to the FSBPT (1) (pp3), DN is known synonymously as intramuscular manual therapy (IMT), trigger point dry needling (TDN), or intramuscular needling (IN). The American Physical Therapy Association (APTA) had initially recommended using the term ‘IMT’. Since late 2011, though, it advocates using the term ‘DN’.

Interestingly, many groups still debate the proper term, and exact definition, to describe the technique.

Keeping up? 🙂

The ‘dry’ part refers to the fact that nothing is injected with the needle, as opposed to its opposite of “wet needling” which injects medications such as steroids, etc.

Mostly, it is used to treat MSP through the targeting of ‘myofascial trigger points’ (MTrPs). You’ll find this term used a lot in the DN literature. MTrPs are described as localized, hyper-sensitive, hyper-irritable spots in a taut band of muscle. They can be active MTrPs, when they produce spontaneous pain, or latent MTrPs that do not produce spontaneous pain and are only painful when touched.

DN can be divided into deep and superficial DN. Deep DN has allegedly been shown to inactivate MTrPs by eliciting local twitch responses, a.k.a. muscle contractions. This process is said to activate endogenous opioids, thereby relaxing the muscle.

MTrPs are often claimed to be a key cause of MSP. Problematic, however, is the finding (2) from a recent systematic review that “physical examination cannot currently be recommended as a reliable test for the diagnosis of trigger points” and that the reliability of MTrP diagnosis needs further investigation by high-quality studies!

## DN versus Acupuncture

Is there a difference, apart from the fact that one uses hand gloves during treatment? (that would be the PTs during DN, for a heads up).

Now this topic, I have discovered, seems to be quite a sensitive area. Understandably so – one has been around for centuries while the other is relatively new. Both seemingly perform a similar needling technique?! Will one potentially lose some of their clientele.. and mystique.. to the other?

In Team Acupuncture Corner. According to Fan et al (3), DN is being promoted “by simply rebranding (a) acupuncture as DN and (b) acupuncture points as trigger points.” Strike! DN touted as an “over-simplified” version of acupuncture except for “emphasis on biomedical language”, using English biomedical terms to replace their equivalent Chinese medical terms. Strike 2! “Trigger points belong to .. traditional Chinese acupuncture, and they are not a new discovery”. Strike 3! “For patients’ safety, DN practitioners should meet standards required for licensed acupuncturists and physicians.” .. and DN is out!

In Team DN Corner. The FSBPT paper (1) (pp4) states that the method by which acupuncture works is completely different, “based on a theory of energetic physiology”, focusing on the energy meridians or flows, and the unblocking of these pathways. Further, unlike acupuncture, the paper clarifies that PTs do not use DN to treat conditions such as fertility, smoking cessation, allergies, depression or other non-neuro-musculoskeletal conditions. They also identify an important distinction in that acupuncture is an entire discipline and profession, whereas DN is merely one technique which should be available to any professional with the appropriate background and training. Strike, strike, strike!

### Who wins this battle?

Taking the middle ground, the FSBPT (1) (pp6) finally state that, “the accepted premise must be that overlap occurs among professions. The question (for state licensing) … should only be whether or not DN is within the scope of practice of PT, not determining whether it is part of acupuncture.”

Fair enough, I guess.

## Is Dry Needling Legal Everywhere?

This brings us to the important topic of the legality of DN in the U.S.

Key organisations, such as the A.P.T.A., and other health professions claim that DN is within their “scope of practice”. However, each U.S. state has its own rules, regulations and guidelines concerning whether to permit the practice of DN. It is the responsibility of each therapist to be aware of these, and to practice within the grounds of their state, and professional, license.

The FSBPT paper (1) (pp9) specifies in which U.S. states DN is legally permitted, within the scope of practice for PTs, as at July 2013.

I have managed to source a more current map. At the time of writing, according to this information, the states that have made a ruling against DN being within the scope of practice for PTs (and therefore being illegal) are: California, Florida, Hawaii, New Jersey, New York, Pennsylvania, South Dakota, and Washington. According to my reading, this is “mainly due to verbiage in the practice act against puncturing the skin.” Notably, since the 2013 FSBPT paper, Utah has legalized the DN procedure in their state.

However, there are other categories indicating the practice is not necessarily yet legal in the state. They include the categories of ‘unclear or conflicting standards’ (Idaho, Michigan, Minnesota, Oregon, Texas) and ‘unknown’ (Connecticut, Massachusetts, Missouri, Oklahoma).

## How Much Research Is There on Dry Needling?

Not a great deal. A PubMed search of the terms, ‘dry needling’, ‘trigger point dry needling’, or ‘intramuscular needling’, limited to the English language, humans and spanning from the year 2000 to present, yields about 150 results. Of these, 12 are meta-analyses and 29 are systematic reviews.

The relatively low number, and overall quality, of studies reporting on DN performed by PTs, at this time at least, coupled with the high variability found in the results of the meta-analyses, made it challenging to piece this article together.

One 2015 systematic review (4) of “high-quality”, randomised, controlled trials (RCTs), concluded a “broad applicability of TDN treatment for multiple muscle groups”. Yet, it was swiftly challenged a couple of months later in a piece (5) entitled ‘TDN: the data do not support broad applicability or robust effect.’ stating “This strongly worded conclusion overstates the findings of the actual data and misleads casual readers into believing that the research supporting TDN is quite robust. We contend that it is not.” It then goes on to list seven potential limitations of the individual data, from the so-called high-quality RCTs, included in the said review.

Get the idea?!!

Compare it, say, to the amount of research on a better known form of physiotherapy, such as ‘hydrotherapy’, I retrieved over 300 results – double the amount. Of these, 54 are systematic reviews.

## What Has The Research Concluded?

### Does Dry Needling Help Facial Wrinkles?

Evan though DN may involve (6) the insertion of needles in to subcutaneous fascia, I was not able to find any credible research here. Not very biologically plausible, either, especially in the longer term. Skin wrinkling, as explained by the Mayo Clinic, is largely the result of a permanent breakdown of the skins connective tissue-collagen and elastin fibers.

Bottom Line: There is no evidence that DN improves facial wrinkles.

### Does Dry Needling Effect Scar Tissue?

Here, I could not find any research supporting DN in the treatment of scar tissue, even though it is known (6) to be used for such cases. One article (7) did suggest caution in applying DN in surgical patients, after the surgical scar of a recent patient showed signs of inflammation 2 weeks following DN treatment. Yikes.

Bottom Line: There is no evidence that DN improves scar tissue.

### Does Dry Needling Help Shoulder Pain or Frozen Shoulder?

There are a dozen or so research papers, of which one is a fairly recent (2015) meta-analysis (8) and systematic review. It reviews the topic of DN of the MTrPs associated with both neck and shoulder pain. Guess what? They found no longterm benefits, but stated that it “can be recommended … in the short and medium term”. However, wet needling was more effective than DN in the medium term.

The most recent research paper (9) (Jan 2017) is a RCT of 120 patients with non-specific shoulder pain. They found no benefit offered by DN, over other, personalized, evidence-based physical therapy treatment.

Bottom Line: There is weak evidence that DN may over short to medium-term benefits to shoulder pain.

### Does Dry Needling Help Back Pain or Sciatica?

Again, there are almost a dozen research papers investigating DN in this context. I found no meta-analysis papers and one systematic review (10), from 2005. Although it identified most of the studies were of low-quality, and highlighting the need for high-quality trials in this area, they concluded that “The data suggest that … DN may be useful adjuncts to other therapies for chronic low back pain (LBP)”.

The results of a more recent RCT (11), of a whole 12 patients, “suggest that MTrP DN was effective for improving pain, disability … and widespread pressure sensitivity in patients with mechanical LBP at short-term”.

Convincing??!

Bottom Line: There is weak evidence that DN may assist with LBP in the short-term.

### Does Dry Needling Help Plantar Heel Pain (Plantar Fasciitis)?

There is minimal, weak evidence supporting DN of MTrPs in the treatment of this condition. According to Cotchett et al (12), “in patients with plantar heel pain this technique is thought to improve muscle activation patterns, increase joint range of motion and alleviate pain.”

The same team conducted the first (and, at this time, only) RCT (13) of 84 patients with plantar heel pain, in a University health-sciences clinic setting. They concluded that DN “provided statistically significant reductions in plantar heel pain”, when compared to sham DN. This study was published in the peer-reviewed journal Physical Therapy, the official journal of the APTA. It currently has a low impact factor of 2.8.

A response (5) identified a number of issues with the findings of this particular RCT, making “the results’ clinical relevance questionable” and stating their conclusion to be “dubious at best”.Bottom Line: Evidence of benefits derived from DN in the treatment of plantar heel pain is weak, minimal and questionable.

### Does Dry Needling Induce Labor?

I was not able to find any evidence that DN assists with childbirth. As there is currently little high-quality evidence in support of DN, it is probably best avoided in this situation, at this point.

Bottom Line: No current evidence supporting DN to induce childbirth.

### Does Dry Needling Help Arthritis?

I was not able to find any credible evidence that DN assists with the pain associated with arthritis. It is not likely to be biologically plausible for DN to (a) minimize the joint inflammation associated with rheumatoid arthritis, nor (2) rebuild any of the cartilage ‘wear’n’tear’ contributing to the arthritic pain associated with osteoarthritis.

Bottom Line: No current evidence supporting DN in the treatment of arthritis.

### Does Dry Needling Help Tennis Elbow?

Credible evidence that DN assists with the pain associated with tennis elbow, yet again, eludes me here.

Bottom Line: No current evidence supporting DN in the treatment of tennis elbow.

## Precautions & Side Effects To Dry Needling

There are certain precautions to be considered with the use of DN:

1. Patients need to be able to give consent to the procedure.
2. Local skin lesions must be avoided.
3. Local or systemic infections are generally considered to be contraindicated.
4. Local lymphedema (note: there is no evidence that DN would cause or contribute to increased lymphedema, ie, postmastectomy, and as such is not a contraindication).
5. Severe hyperalgesia or allodynia may interfere with the application of DN, but should not be considered an absolute contraindication.
6. Some patients may be allergic to certain metals in the needle, such as nickel or chromium. This situation can easily be remedied by using silver or gold plated needles.
7. Patients with an abnormal bleeding tendency, ie, patients on anticoagulant therapy or with thrombocytopenia, must be needled with caution. DN of deep muscles may need to be avoided to prevent excessive bleeding.
8. Patients with a compromised immune system may be more susceptible to local or systemic infections from DN, even though there is no documented increased risk of infection with DN.
9. DN during the first trimester of pregnancy, during which miscarriage is fairly common, must be approached with caution, even though there is no evidence that DN has any potential abortifacient effects.
10. DN should not be used in the presence of vascular disease, including varicose veins.
11. Caution is warranted with DN following surgical procedures where the joint capsule has been opened. Although septic arthritis is a concern, DN can still be performed as long as the needle is not directed toward the joint or implant.

In terms of side-effects:

Brady et al (14), investigated the safety of the DN procedure performed by a sample of 39 physiotherapists. They found that while mild adverse-effects were commonly reported, no significant adverse-effects occurred.

The importance of a suitably qualified therapist is, of course, most important.

## Conclusion

Following a good few weeks of research, I would think that, at best, DN as a therapeutic treatment is somewhat dodgy! Wouldn’t you by now? There is currently no evidence (15) of any longterm benefit derived from DN, for a start. Whatever short-term benefit is suggested from DN generally comes from low to medium-quality evidence concluding that DN is better than “no treatment or sham needling.”

Now, in all honesty, would you be willing to go under the knife… or, should I say, the needle… for that?

YES NO

## Dry Needling FAQs – Southern Rehab & Sports Medicine

Dry needling has become increasingly popular over the years as a form of pain management. See if this technique is right for you.

#### Does dry needling hurt?

Dry needling uses very thin needles that are typically not painful. Because the needles do not contain medication, we are able to use very thin needles that are 8x smaller than those used for your vaccines with your medical doctor. While some areas may be more tender than others, dry needling typically does not cause more pain than your current symptoms.

#### Does dry needling make you tired?

Drowsiness, tiredness, or dizziness occurs after treatment in a small number of patients (1-3%). If this affects you, you are advised not to drive until you feel you are at your baseline.

#### How effective is dry needling?

Dry needling from a clinical perspective has proven to be an extremely useful tool, most notably in patients who have long-term or chronic muscle tightness that does not resolve with independent stretching or strengthening programs. Dry needling research supports its effectiveness in regards to relieving pain, muscle spasms, and muscle tightness by decreasing trigger points in the muscle.

#### How is dry needling different from acupuncture?

The purpose of acupuncture is to alter the flow of energy (“Qi”) along traditional Chinese meridians for the treatment of pain and dysfunction. Dry needling has an anatomy-specific focus as needles will be inserted directly into the tight muscle rather than up and down the path of its energy.

#### How long do dry needling benefits last?

Length of relief will vary from person to person. With initial treatments, results typically last several days. With each additional treatment, the goal is that we are able to increase the window of relief with each session meaning longer relief with each additional attempt.

#### How long does dry needling take to work?

Although you may have some soreness after a dry needling session, you will often notice some improvement in your symptoms within 24-48 hours. Again, the intensity of this improvement will ideally increase with each additional session. As you adjust to the treatment, post-treatment soreness will tend to decrease and your results will often be more noticeable directly after your session.

#### How many dry needling sessions do I need?

In acute pain situations, only one session may be needed. For more chronic pain situations, it may take several treatments to notice a change. Because dry needling can have a cumulative effect if you do not notice results after the first session we typically recommend 2-3 treatments before deciding to pursue other options. We tend to start your dry needling plan at 1x/week, with the goal of increasing the length between sessions as we go along. A therapist will discuss your individualized plan of care in regards to your dry needling plan at your first session.

#### How long is a dry needling session?

Dry needling alone is typically a 30-minute session.

#### What do you wear to a dry needling session?

Wearing loose-fitting clothes tends to be the best option when you are expecting to undergo dry needling. This will allow the therapist to access the muscles while allowing you to stay comfortable, as you are typically lying on a treatment table for 15-20 minutes. Shorts are easiest when attempting to access the muscles of the leg, and loose-fitting pants can help your therapist access the muscles of the low back and hips.

#### Is dry needling dangerous?

Dry needling is very safe with serious side effects occurring in less than 0.01% of treatments. Your therapist has undergone additional training after their doctorate degree to be certified in dry needling and is an expert in regards to anatomy and minimizing the risk associated with this intervention.

#### What does dry needling cost?

The cost will be based on your insurance plan, which our office will be happy to discuss after verifying your insurance. You will be provided with a handout prior to your session that will outline your expected costs. Dry needling sessions can also be purchased separately at a rate of \$65/session as a self-pay plan.

#### What is dry needling good for?

Dry needling can be used for a wide variety of conditions to treat pain and dysfunction of the musculoskeletal system. This includes but is not limited to: neck pain, back pain, shoulder impingement, tendinitis, tennis elbow, carpal tunnel, headaches, knee pain, arthritis, shin splints, and plantar fasciitis. Your therapist will be able to guide you in your first session as to whether or not dry needling will be beneficial for your symptoms.

#### Who benefits from dry needling?

Anyone experiencing pain can benefit from dry needling from athletes attempting to return to their sport, to those who have suffered from motor vehicle accidents. If you are unsure if dry needling will benefit you, feel free to call our office or reach out on our contact page for more information.

For further information, or to schedule your appointment please fill out the from below.

## Dry Needling: The Most Painful Thing I’ve Ever Loved

By AshleyJane Kneeland, Special to Everyday Health

Imagine you have pockets of a highly pressurized, toxic gas caught in your shoulders. Now imagine these painful pockets keep growing in size, every hour of the day, inflaming your muscles and pinching your nerves. And, as a result you’re miserable — grasping to keep your sanity.

Then imagine you find a medical professional willing to puncture your skin and release all that painful pressure — after which some soreness remains, although it’s nothing compared to the blessed relief you’re now feeling.

That procedure, dry needling, is what works best for me and the painful spasms that course through my shoulders. The needles deflate my muscle spasms, which feels like air rushing out of an overfilled balloon. It is, without a doubt, the most painful thing I’ve ever loved.

Prior to my relationship with dry needling, I had an on-again-off-again fling with trigger point injections. These injections provided six to eight weeks of relief. But the liquid injected contains a steroid, so the injections weren’t a viable long-term plan. Because what I’m dealing with is a long-term problem, my shoulders and I moved on to dry needling, which involves no injections, just a bit of brutal poking.

## Three Illnesses, All Causing Pain

A person must be pretty desperate to continually pursue such sharp methods of treatment, right? My despair stems from three illnesses that overlap each other in a Venn diagram kind of way. I made this diagram (left) to show how my lupus, fibromyalgia, and postural orthostatic tachycardia syndrome (POTS) symptoms overlap.

As a kid, I lived with chronic head and body aches. Assuming I was just wimpy and couldn’t handle the daily pressures of life, I carried ibuprofen around in my backpack and prayed for a morning math class, before the pain made it hard to concentrate. I played sports (not very well), competed in mock trials (deciding my true calling in life must be something involving dress suits and heels), and served as a U.S. Senate page (my crowning achievement, which I compulsively must mention when discussing the earlier years of my life). Chances are by now my fiancé and his daughter assume this part of my life is some kind of “Big Fish” story, but I swear, I really was Head Page. Twice. Which is one more than the number of friends I had.

Throughout all this I continued my reckless reliance on ibuprofen, which most definitely, explains why doctors later found three bleeding holes in my stomach. Then, during my senior year of college, extreme fatigue kicked in and I was no longer able to physically get myself to classes. In the 10 years since then, I’ve also experienced mouth and vulvar ulcers, joint stiffness, migraines, severe GI cramping, tachycardia, and an infuriating intolerance to regular amounts of daily activity.

## Why I Tried Dry Needling

What brought me to dry needling were muscle spasms in my neck and shoulders. Creams, patches, muscle relaxers, opiates and heated pool therapy sometimes help, at least temporarily; but new spasms are always appearing, seemingly triggered by everything and nothing at the same time. Of all of the treatments I’ve tried, dry needling has been the most effective.

The procedure goes a little something like this: After I lie down on a massage table, my physical therapy doctor inserts a thin-filament needle directly into the muscle that is currently tight or spasming. Then she jiggles the needle up and down until my muscle responds with a twitch. The purpose of this twitch is to disrupt the “neurological feedback loop” that keeps the muscle in a contracted state of pain. It’s almost like the spasm is treated with another spasm. However, this intentional spasm results in a release of pressure.

(Dry needling uses needles similar in size to the needles used for acupuncture treatments but, unlike acupuncture, dry needling is not a traditional Chinese medicine technique. Instead of inserting needles into the “energetic pathways” defined by traditional Chinese medicine, dry needling practitioners insert them directly into the muscles and nerve pathways causing the pain.)

In addition to muscle spasms like mine, dry needling has been used to treat conditions including headaches, lower back pain, sciatic pain, temporomandibular joint dysfunction (TMJ), and tendonitis. Dry needling hurts, but for me the hurt is worth it. Naturally, the amount of pain varies involved in the procedure varies for different people and their trigger points. Because the knots in my shoulders are so severe, I find dry needling extremely painful. I walk out of the office feeling like my nerve endings have been cut and exposed to air. A few hours later, that sensation passes, and my shoulders are noticeably more relaxed. Over time — two appointments a week for six weeks — most of my spasms, and their resulting headaches, fade away.

## 6 Things I’ve Learned About Dry Needling

Being desperate for pain relief, I’ve tried many things over the years. I recommend dry needling because, despite the discomfort, it produces long-lasting results. If you have severe pain and want a pleasant experience, get a massage. If you want results, commit to dry needling. Here are six things I’ve learned:

1. Schedule medications wisely. If you take Tylenol (or something stronger) at regular intervals, schedule a dosage for right before your appointment. I find the less I’m clenching my muscles, the more effective those helpful “twitches” are.
2. Keep it loose. After your appointment, resist the urge to curl into a ball like an overwhelmed hedgehog. The more you move around, the looser you will be, and the quicker the pain will dissipate.
3. Find a physical therapist who is good at the procedure. After shopping around, I was able to find a physical therapy practice that accepts my insurance and bills dry needling a specific way so that my insurance covers it in full. Don’t give up just because one practice tells you it isn’t covered. (Not all physical therapists can practice dry needling because PT license requirements vary from state to state, and the technique is not yet fully accepted. MDs, DOs, and acupuncturists can practice dry needling, but many are not trained.)
4. Plan your outfit accordingly. My particular impairment favors tube tops layered under a zip-up or button-down shirt. My outfit choice allows for easy access to my shoulders, and makes it easier to get dressed after the appointment.
5. Follow your doctor or therapist’s orders. Be diligent with the daily stretches your physical therapist assigns. These exercises can make the effects of dry needling last longer. Be gentle when exercising. Stretching aggressively can make things worse.
6. Make dry needling work for you, not against you. It’s okay to say, “I only want four needles today.” If you overdo it, your body will burn out, the pain will be overwhelming, and the process won’t be effective.

AshleyJane Kneeland, 32, lives in New Hampshire with her fiancé and his daughter. She works part-time as a bookkeeper and substitute teacher. She is the author of an Amazon Kindle book entitled, Living Incurably Despite Chronic Illness. You can follow her on Twitter and Instagram.

If the thought of lying on a table and being poked by tiny needles makes you feel uneasy, you’re not alone. But a growing number of people – from athletes to people with injuries or chronic pain – swear by its ability to provide sweet relief for intense muscle pain and mobility issues.

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Dry needling trigger point therapy has been used for decades, but it’s become an increasingly popular drug-free way to treat musculoskeletal pain.

It’s almost always used as part of a larger pain management plan that could include exercise, stretching, massage and other techniques, says clinical rehabilitation manager Adam Kimberly, PT, DPT, OCS. But it can play an important role in muscle recovery and pain relief.

How does dry needling work? It uses thin, dry needles — “dry” in the sense that they don’t inject anything into the body — that are inserted through the skin into the muscle tissue.

“Our main focus is muscle and connective tissue and trying to restore mobility,” he says.

It is performed by some physical therapists, acupuncturists, chiropractors or medical doctors who receive training in the technique.

### Triggering relief

When they’re overused or strained, muscles can develop knotted areas called myofascial trigger points that are irritable and cause pain.

“An overused muscle undergoes an energy crisis where, because of prolonged or inappropriate contraction, the muscle fibers are no longer getting adequate blood supply,” he says. “If it’s not getting that normal blood supply, it’s not getting the oxygen and nutrients that will allow the muscle to go back to its normal resting state.”

The tissue near the trigger point becomes more acidic, and the nerves are sensitized, which makes the area sore or painful.

Stimulating a trigger point with a needle helps draw normal blood supply back to flush out the area and release the tension, Kimberly says. The prick sensation can also fire off nerve fibers that stimulate the brain to release endorphins – the body’s own “homemade pain medication.”

To locate a patient’s trigger points, a therapist palpates the area with his or her hands. A trigger point map that notes common places in the body where trigger points emerge can be helpful, but every patient is a little different. “That’s where the clinician skill comes in – to palpate the area and locate the trigger point,” Kimberly says.

Once a trigger point is located, the therapist inserts a needle through the skin directly into it. He or she might move the needle around a bit to try to elicit what’s called a local twitch response, which is a quick spasm of the muscle. This reaction can actually be a good sign that the muscle is reacting.

Some patients feel improvement in their pain and mobility almost immediately after a dry needling session, Kimberly says. For others, it takes more than one session.

Regardless, it’s important to continue to keep the affected muscles loose by continuing to move them within their new range of motion after treatment, he adds. There can be some soreness for 24 to 48 hours afterward.

### Is it right for you?

Your provider can advise you on whether dry needling could be a helpful addition to your treatment plan for muscle recovery, mobility issues, or acute or chronic pain.

“Needling is just a component of the therapy process,” Kimberly says. “It’s not everything, and it’s not the be-all, end-all for everyone.”

Temporomandibular joint (TMJ) pain is a challenging diagnosis to manage. TMJ pain and dysfunction can be caused by an increase in tone to local mastication (chewing) muscles including the pterygoids and masseter as well as a dysfunction within the joint capsule and articular disc. People with TMJ dysfunction may have complaints of pain, clicking/popping, dull ache, headaches, or earaches.

The first steps to alleviating the pain may include reduction in excessive mastication (reducing hard foods or “chewy” foods from diet), wearing a night guard, and/or physical therapy. Physical therapy is a great resource for those who have not seen a reduction in pain with changes in daily routines.

As physical therapists, we are trained in proper techniques to mobilize immobile joints, stretch inflexible tissue, and strengthen weakened muscles. This applies to all joints including the TMJ.

During the evaluation, your physical therapist will assess both your TMJ and your cervical spine (neck). A lot of the time, the cervical spine plays a major role in the function of your TMJ. The upper cervical spine positioning can impact the position of your jaw when you are sitting and thus can impact your chewing. We will assess your cervical joints and TMJ mobility, range of motion in your neck and jaw, muscle strength and tenderness to palpation. As with any injury, we will treat the impairments that we find and focus our treatments around your goals. This may include joint mobilization to the upper neck and/or TMJ, strengthening exercises for the cervical stabilizers, stretching to muscles of upper neck and those that attach near the TMJ, and education. Your physical therapist may also include dry needling if it is prescribed by your dentist or physician.

Dry needling includes the insertion of fine needles into myofascial structures to help reduce hypertonicity, pain, and inflammation. For TMJ pain, your physical therapist may insert needles directly into the muscles of mastication which include pterygoids, masseter as well as the joint capsule. She/he may also insert them into the suboccipital muscles (upper neck). Depending on the level of severity, your physical therapist may hook the needles to an electrical stimulation unit to break down the tissue more. The side effects may include local soreness and redness. Dry needling is a safe and effective way to treat TMJ dysfunctions.

If you or someone you love is experiencing TMJ pain with little relief, call us today to schedule your appointment. We can treat most insurances for up to 30 days without a prescription. However, if you need dry needling, (which we recommend!) you will need a prescription from your dentist, family practitioner, or other referral source.

## Discussion

Temporomandibular pain of myofascial origin is a condition often referred for evaluation to outpatient clinics of Oral and Maxillofacial Surgery Departments. In more than 90% of cases no underlying cause is found, that is why they are diagnosed as nonspecific or uncomplicated pains, whose treatment is still under study (2,6,11).

Vazquez-Delgado et al. have reviewed the pathophysiologic, clinical and therapeutics aspects of the myofascial pain syndrome (12,13). Usual treatment of temporomandibular myofascial pain in our working environment is a combination of pharmacological and splint therapy, which produces a temporary relief. However, pharmacological treatments soon reach the limit of therapeutic efficacy and they are also associated with side effects (gastrointestinal disorders, drug interactions, and adverse reactions), so that the current trend is the search for alternative treatments (14-16).

Clinical guidelines and protocols about temporomandibular disorders recommend the management of myofascial pain from a multidisciplinary approach (3,4). However, within available treatments for muscle pain, there is a paucity of studies about the effectiveness of TP needling in masticatory muscles, and that is why we set the objective of studying the DDN of myofascial TP in the external pterygoid muscle. The mechanism of inactivation of a TP by needling is unknown, although we consider important the presence of a local twitch response during DDN, because it has a proven relationship with the desired therapeutic effect (6,17). Apparently, the tissular mechanical disruption caused by needle insertion constitutes the specific therapy, but the mechanism of action by which the TP is disabled is unknown. According to Travell, it would be by the mechanical disruption of the self-sustaining mechanism of the TP due to the membrane depolarization of the nerve fibers provoked by the intracellular potassium release and interruption of the central feedback mechanism (1,7). According to Hong, the most reasonable explanation seems to be a neurological mechanism (18), because pain relief after the DDN happens often in few seconds, as we also observed in our study. Probably, local mechanical disruption or reflex central interruption are the most likely mechanisms for breaking the vicious circle of the phenomenon of myofascial TP (11,14,16).

Since by stretching techniques and manual handling is difficult and complicated to access to the external pterygoid muscle, needling of TPs may be necessary. The critical importance of this muscle as origin of temporomandibular myofascial pain makes it worthwhile to develop the necessary skills for invasive treatment by TP needling. The external approach (extraoral DDN) allows the needling of the central TPs in the muscle bellies of the two divisions of the muscle and in the insertional TPs of posterior myotendinous junctions of both divisions. The correct location of the muscle mass is essential for the technique we use, so interference factors represented by the nearby bony structures (zygomatic arch, coronoid process, condyle and sigmoid notch of the mandible) must be eliminated. That is why there is no need to carry out the electromyographic control described in Koole et al. study (10), which is a complicated and uncomfortable technique that we do not think it is necessary in treating outpatients with DDN in which the TP can be detected by careful palpation and pressure sensitivity. Taut bands and TPs in the masseter muscle are other factors to consider as interference, since it can be difficult to recognize the pressure sensitivity on the external pterygoid muscle, which lies in a deeper layer. Masseter taut bands are more superficial and oriented almost perpendicularly to the fibers of the external pterygoid muscle making them easily distinguishable. Hypersensitivity of TPs in the masseter muscle must be inactivated before treatment of TPs in the external pterygoid muscle by DDN, as we did in 4 cases in our study.

In our patients we did not use a intramuscular puncture technique to inject local anesthetics, corticosteroids or botulinum toxin because DDN is just as effective in the myofascial pain caused by TPs in the pterygoid muscle, and this way myotoxic effects of infiltration with such drugs are avoided. Myotoxicity is strongly related to the concentration of anesthetic injected, especially by long-lasting anesthetics. The use of epinephrine in concentrations of 1:100,000 or more can increase muscle damage caused local anesthetics. The myotoxicity of the botulinum toxin type-A is irreversible by binding to the presynaptic cholinergic nerve terminals and interrupting any neurogenic contraction of muscle fibers mediated by the affected motor plates. This chemical denervation maintains the paralysis of the muscle for a period of 3 to 6 months until new axons sprout from a motor nerve and form new synaptic contacts to restore a normal neuromuscular junction function of affected muscle fibers (17).

For the treatment of symptoms associated with TPs, the DDN is a technique as effective as the infiltration of anesthetics if it causes local twitch response, which occurs when the needle had inserted in the muscular active loci of the TP. The reverse is also true and, if there is no local twitch response, the DDN or the infiltration of anesthetics are equally ineffective. Another reason to prefer the DDN before using local anesthetics is because dry needling allows the location of all TPs from one area by preserving pain reaction to palpation.

The results of our study have shown that the greatest reduction in the magnitude of pain was achieved when patients had started from a more unfavorable clinical situation with intense pain, so it was expected that pain improvement would be more evident in these patients. We have observed that in those patients who had significant pain before starting treatment (values 8 to 10 in visual analog scale), it was common that they had a reduction of 6 points, while those that started with mild pain (value less than 6) the expected reduction of pain was 4 points or less. These findings are consistent with the results published by other authors that performed intramuscular infiltrations after muscle needling (18,19). Fernández-Carnero et al. conducted a study with DDN in masseter muscle TPs in a group of 12 women obtaining a good therapeutic outcome measured by increase in the threshold of pain caused by pressure and measured with algometer (15). Bubnov examined the DDN guided by ultrasound to increase the accuracy of the TP needling under visual verification, and obtained a pain reduction in 93.3% of patients in a group of 91 patients with myofascial pain in different locations (20).

In conclusion, the results of our study suggest that patients with painful temporomandibular disease due to external pterygoid muscle involvement treated selectively with needles for dry needling showed a significant improvement in pain and, as consequence, an improvement of functional limitation which persisted up to 6 months after finishing the treatment. Pain reduction was greater the higher was the intensity of pain at baseline.

## Migraine / TMJ Treatment

### Elke’s Story

“When I first started therapy, I had achy pain and weakness in my back and shoulders, from being rear-ended in a car accident. Normal daily tasks such as driving and carrying groceries were uncomfortable and even painful. I didn’t feel like myself at all. The treatment I had at Fast Track included deep tissue work, muscle strengthening exercises, traction, laser and dry needling. In particular, the dry needling really helped release pent-up tension in my muscles from the accident. The most amazing difference I noticed was when I had dry needling on my jaw area for my TMJ issues that had resurfaced after the accident. The headaches that I had started having again stopped, and I almost felt as if I had a new jaw, as the tension was released and it didn’t feel tight and sore all of the time anymore. The muscle strengthening exercises were very helpful, too, and the traction felt like it helped realign my back and loosen it up. All of the therapy techniques worked really well together to help make my back and neck feel normal again. I mostly worked with Brian, who is extremely knowledgeable and thorough. He always took the time to do whatever was needed during my therapy sessions. Brian also has a very friendly and congenial manner, as did all of the therapists I worked with on the occasions that Brian wasn’t available. The entire staff, including the receptionists, were very pleasant and helpful. I would definitely recommend Fast Track to anyone needing physical therapy again. Thank you, Fast Track, for your excellent work!”

## Effectiveness of dry needling for improving pain and disability in adults with tension-type, cervicogenic, or migraine headaches: protocol for a systematic review

This systematic review will be performed in accordance with the PRISMA statement and principles outlined in the Cochrane Handbook for Systematic Reviews of Interventions . This protocol has been prepared with regard to the PRISMA-P 2015 guidelines and was registered on PROSPERO (International Prospective Register of Systematic Reviews, http://www.crd.york.ac.uk/PROSPERO/; #CRD42019124125) in 4 March 2019. Ethical approval and patient consent will not be required since this is a systematic review of previously published studies and no new data collection will be undertaken.

### Search strategy and study selection

A comprehensive electronic database search will be performed from inception to June 31, 2019 on the following databases: Medline (NLM) via the PubMed, Scopus, Embase®, PEDro, Web of Science, Ovid, AMED via the EBSCO, CENTRAL via The Cochrane Library, and Google Scholar. Electronic search strategies are constructed based on the combined keywords: tension-type headache, cervicogenic headache, migraine, and dry needling to identify human studies in the literature that investigated the effectiveness of dry needling in adult patients (≥ 18 years) with tension-type headache, cervicogenic headache, or migraine. A combination of MeSH (Medline), Emtree (Embase®) terms, and free text words in research equations with ‘OR’ and ‘AND’ Boolean operators will be used. Free text words will be selected from the indexed keywords of most relevant original studies and reviews in Scopus. To retrieve all possible variations of a specific root word, wildcards, and truncations will also be applied. The search strategy is customized according to the database being searched. In addition, if additional keywords of relevance are detected during electronic searches we will modify and re-formulate the search strategies to incorporate these terms. Three authors (M.R.P., M.A.M.B., and M.B.) will develop the sufficient search syntax, and after piloting and finalizing it, the search of the electronic databases will be conducted by one author (M.R.P.). Moreover, we will consult a biomedical librarian to review our search strategy using the PRESS 2015 guideline evidence-based checklist in order to minimize error in our search strategies. Details of PubMed/Medline (NLM) database search syntax are presented in Additional file 1. PubMed’s ‘My NCBI’ (National Center for Biotechnology Information) email alert service will be employed for identification of newly published systematic reviews using a basic search strategy.

Citation tracking and reference lists scanning of the selected studies and relevant systematic reviews will be searched for eligible studies. Manual search of keywords via internet will be also conducted. Additionally, the table of contents of the journal of Cephalalgia and the Journal of Bodywork & Movement Therapies will be reviewed. The key journals are identified within the research in the Web of Science and Scopus. To minimize publication bias, grey literature will be identified by searching for conference proceedings (via ProQuest, Scopus, and Web of Science Conference Proceedings Citation Index database), unpublished masters and doctoral theses (via ProQuest and OpenGrey; System for Information on Grey Literature in Europe), and unpublished trials (via US National Institutes of Health Ongoing Trials Register , WHO International Clinical Trials Registry Platform, and International Standard Randomized Controlled Trials Number . Abstracts from the annual meeting of American Headache Society and European Headache Federation congress in the last 5 years and abstracts from the congress of the International Headache Society in the last 4 years will also be searched. In addition, experts with clinical and research experience on the role of dry needling for headaches will be consulted. Finally, one author (M.R.P.) will complete the search process by manual searching in Google. We will not review content from file sources that are from mainstream publishers (e.g., BMJ, Sage, Wiley, ScienceDirect, Springer, and Taylor & Francis), as we expect these to be captured in our broader search strategy.

If a full text of a relevant article is not accessible, a contact will be made with the corresponding author(s). In addition, when unpublished works are retrieved in our search, an email will be sent to the corresponding author(s) to determine whether the work has been subsequently published. If no response received from the corresponding author(s) after three emails, the study will be excluded.

### Eligibility criteria

All publications identified by the searches will be imported into the EndNote reference management software (version X9.1; Clarivate Analytics Inc., Philadelphia, PA, USA), and duplicates will be removed automatically and double-checked manually. The titles and abstracts of each citation will be screened independently by three reviewers (M.R.P. M.A.M.B., and M.B.) according to a checklist that is developed for this purpose (Table 1) with the following criteria:

1. 1-

Study design should be clinical trials with concurrent comparison group(s) or comparative observational studies;

2. 2-

Study participants should have at least one of the three types of headache (tension-type headache, cervicogenic headache, and/or migraine);

3. 3-

Study participants should be ≥18 years of age;

4. 4-

The studies should have at least one of the primary outcomes (i.e., pain and disability) of this review; and,

5. 5-

Dry needling should be the main intervention in the study.

Table 1 PICOS criteria for the study

If a study meets all of the criteria, then the full-text of the study will be assessed for eligibility. In addition, a full-text review will be undertaken if the title and abstract do not provide adequate information. The selection process will be conducted strictly according to the inclusion and exclusion criteria by three independent reviewers simultaneously (M.R.P., M.A.M.B., and M.B.) (Table 1). The three reviewers are physical therapists with experience in performing systematic reviews. Disagreements will be resolved by discussion and if necessary, consultation with a fourth reviewer (A.A.K.). The eligibility criteria are based on the PICOS acronym (Table 1) and will be piloted prior to conducting the review proccess. The entire process of study selection is summarized in the PRISMA flow diagram (Fig. 1).

Fig. 1

Flow diagram of study selection process

### Data collection and analysis

#### Risk of bias

The risk of bias of each clinical trial will be evaluated independently by three reviewers (M.R.P., M.A.M.B., and M.B.) using the Cochrane Back and Neck Review Group 13-item criteria . The guideline examines six specific domains of bias, and the scoring criteria for each item in each of the domains are “Yes,” “No,” and “Unclear” if there is insufficient information to make an accurate judgment. We will categorize studies as “low risk” (at least six of the 13 criteria are met) or “high risk” (less than six criteria are met) . In addition, the risk of bias assessment of each comparative observational study will be judged independently by the same reviewers (M.R.P., M.A.M.B., and M.B.) on the basis of the NOS . The NOS is recommended by the Cochrane Non-Randomized Studies Methods Working Group to assess the quality of observational studies. The scale is based on the following three subscales: Selection (4 items), Comparability (1 item), and Outcome or Exposure (3 items) . A total score of 3 or less will be considered high, 4–6 will be considered moderate, and ≥ 7 will be deemed low risk of bias . Unacceptable bias will be defined as a zero score in any of the NOS subscales. The level of inter-rater agreement will be assessed using weighted Cohen’s kappa coefficient, with a method developed for comparing the level of agreement with categorical data along with their respective 95% confidence intervals (κ 0–0.20 = poor agreement; 0.21–0.40 = fair agreement; 0.41–0.60 = moderate agreement; 0.61–0.80 = good agreement; and 0.81–1 = very good agreement) . Disagreements will be resolved by discussion and where it is required with input from a fourth reviewer (A.A.K).

The graphical presentation of assessment of risk of bias will be generated by Review Manager Software (RevMan V.5.3.5) or Stata V.14 (Sata Corp., College Station, TX, USA).

#### Data extraction

Data extraction and abstraction from each eligible study will be performed independently by three reviewers (M.R.P., M.A.M.B., and M.B.), using a Microsoft Excel spreadsheet (Microsoft, Redmond, Washington, USA) which will be designed according to the Cochrane meta-analysis guidelines and will be adjusted to the needs of this review. The data-extraction form will be pilot-tested before its use. Pilot testing will be performed on two published studies which are not included in the present systematic review but are relatively similar to the eligible studies. During pilot-testing, we will assess the characteristic of the variables (e.g., categorical or continuous) and whether all pre-defined variables in the data-extraction form are useful for the systematic review and meta-analysis. Moreover, we will check if it is possible to include additional variables in the data-extraction form in order to perform further post-hoc sensitivity analyses. The following data will be extracted from all the eligible studies:

1. 1.

Study characteristics: first author’s name, journal’s name, publication year, country of study performance, study year, study design, single versus multicenter, size of the sample, and duration of follow-up.

2. 2.

Participants’ characteristics: ethnicity, age, gender, body mass, stature, BMI, and type of headache.

3. 3.

Intervention and comparator details: sample size for each treatment group, muscles name, features of dry needling treatment (such as type of dry needling , needle size, needling technique, and whether the technique elicited local twitch response), features of control interventions (sham/placebo methods or standard treatment details), duration of treatment session, frequency of treatment sessions per week or month, withdrawals, dropouts, and any other relevant detail.

4. 4.

Outcome measures: pain intensity, scales and questionnaires used to assess pain, total score of functional disability, disability questionnaires, cervical spine ROM, instruments used to measure cervical spine ROM, questionnaire used to measure health-related quality of life, and instruments used to assess TrPs tenderness. Primary and secondary outcomes will be documented at both baseline and endpoint.

Following the completion of this process, one author (M.R.P.) will double-check the extracted data to avoid any omissions or inaccuracies.

#### Dealing with missing data

If there are missing data or insufficient details in relation to the characteristics of the studies included in the meta-analysis, we will try to contact the study authors for further information. However, if the authors do not respond to queries, we will apply the following strategies to address missing data:

1. 1-

If ITT analyses were conducted in the eligible studies, we will use the ITT data instead of missing data as the first option.

2. 2-

For continuous missing outcome data, we will try to re-calculate mean difference, standard deviation, or effect size values when the test statistics, medians, p-values, standard errors, or confidence intervals are reported in the selected studies using the Campbell Collaboration effect size calculator (http://www.campbellcollaboration.org/escalc/html/EffectSizeCalculator-SMD-main.php).

3. 3-

If required data are presented only in graphs of the included studies, we will extract the data by using WebPlotDigitizer V.4.2 (https://automeris.io/WebPlotDigitizer/index.html).

4. 4-

If none of the above strategies can be implemented, we will try to estimate mean difference and standard deviation values from the most similar study .

#### Assessment of heterogeneity

Statistical heterogeneity among the included studies will be assessed using the I2 statistic and Q test (χ2) as recommended by the Cochrane Handbook for Systematic Reviews of Interventions . The I2 statistic will be interpreted using the following guide: 0–40% = no important heterogeneity; 30–60% = moderate heterogeneity; 50–90% = substantial heterogeneity; 75–100% = considerable heterogeneity . Heterogeneity will be considered before conducting pooled analysis. When I2 values are higher than 50% and there is overlap between the confidence intervals of the included studies with the summary estimate on the forest plot, the results of all eligible studies will be combined. The potential sources of heterogeneity will be explored by sensitivity and subgroup analyses/meta-regression.

#### Assessment of publication bias

Publication bias will be explored by constructing funnel plot and performing Begg and Mazumdar’s rank correlation and Egger’s linear regression tests . A p-value < 0.05 for Begg and Mazumdar’s rank correlation and Egger’s linear regression tests indicates significant statistical publication bias. However, the p-value will be set at 0.10 if the number of included studies is < 10. Moreover, Duval and Tweedie ‘trim and fill’ method will be conducted to explore the potential influence of a publication bias . Publication bias will not be assessed by constructing funnel plot when < 10 studies are available per primary outcome of interest, since the plot for publication bias yields unreliable results . Publication bias will be assessed using Stata V.14 (Stata Corp., College Station, TX, USA).

### Data synthesis

#### Statistical analysis

Pooled effects of continuous variables will be expressed as Morris’s delta (Morris’s dppc), if the same primary outcomes are used in the eligible studies. Morris described a pre-post control effect size as “the mean pre-post change in the treatment group minus the mean pre-post change in the control group, divided by the pooled baseline standard deviation of both the treatment and control groups” :

$${d}_{ppc}={c}_p\left$$

The pooled pretest standard deviation is calculated as :

$${SD}_{pre}=\sqrt{\frac{\left({n}_T-1\right){SD^2}_{pre,T}+\left({n}_C-1\right){SD^2}_{pre,C}}{n_T+{n}_C-2}}$$ T: treatment; C: control

The small sample size bias-correction is calculated as :

$${C}_P=1-\frac{3}{4\left({n}_T+{n}_C-2\right)-1}$$

Effect size (Morris’s dppc) will be calculated using Campbell Collaboration effect size calculator (http://www.campbellcollaboration.org/escalc/html/EffectSizeCalculator-SMD-main.php) and Psychometrica online tool (https://www.psychometrica.de/effect_size.html#cohc). If continuous outcomes measures are different between studies, we will also express pooled effects with Morris’s dppc, but we will first convert the different outcome measures to a 0 to 100 scale . For the measurement of effect sizes three levels are defined: small effect size (dppc < 0.40), medium effect size (0.40 ≤ dppc ≤ 0.70) or large effect size (dppc > 0.70). Although there are no available data for minimally clinically important differences (MCIDs) for pain and disability in adult patients with headache, a clinically important effect for the primary outcomes is considered when the magnitude of the effect size is at least medium . Meta-analysis will be done separately on studies with clinical trial design and on studies with comparative observational design. Additionally, meta-analyses will be conducted separately on tension-type headache, cervicogenic headache, and migraine within each study design. In the presence of a sufficient number of studies, we will also conduct a priori subgroup analysis based on the overall risk of bias score (high, moderate, and low risk of bias). All data from the meta-analyses with 95% confidence intervals will be reported in forest plots. The random-effect model with DerSimonian–Laird (D + L) method will be used to pool the data from individual studies. Stata V.11 and V.14 (Stata Corp., College Station, TX, USA) will be used for meta-analysis. Wherever applicable, NNT will be presented to help the reader better understand how the results can be applied to the individual patient. The Campbell Collaboration effect size calculator and Psychometrica online tool will be used to calculate NNT.

In addition, where a quantitative synthesis will not be deemed suitable due to low number of studies, a qualitative synthesis of results will be undertaken. We will conduct meta-analysis when ≥2 studies are available since “two” is the minimum number of studies required for meta-analysis . If meta-analysis is not possible, we will summarize study results as either statistically significant (p-value < 0.05) or nonsignificant and calculate the effect of intervention on the outcomes of this study.

#### Unit of analysis issues

The unit of analysis will be based on aggregated outcome data as individual patient data is not available for any study.

#### Analysis problems

If sufficient homogeneous studies are available for statistical pooling, a meta-analysis will be performed for the time points: short (< 3 months after the baseline measurements were taken), intermediate (at least 3 months but < 12 months after the baseline measurements were taken) and long-term (12 months or more after the baseline measurements were taken) follow-up. If multiple time points fall within the same category, the one that is closest to the end of the treatment, 6 and 12 months will be used .

#### Sensitivity analysis

Sensitivity analysis using the leave-one-out method will be performed to determine the effect of each individual study on the pooled results . Furthermore, sensitivity analyses will be conducted by using only high-quality studies in the meta-analyses to explore the robustness of conclusion. All sensitivity analysis will be performed using Stata V.14 (Stata Corp., College Station, TX, USA).

#### Summary of evidence

The overall quality of the evidence and strength of the recommendations for the primary outcomes will be assessed using GRADE . The ‘Summary of findings’ tables will be generated by the GRADE working group online tool (GRADEpro GDT (www.gradepro.org)). The downgrading process is based on five domains: study limitations (e.g., risk of bias), inconsistency (e.g., heterogeneity between studies results), indirectness of evidence (including other patient populations or use of surrogate outcomes), imprecision (e.g., small sample size) and reporting bias (e.g., publication bias). The quality of evidence is classified as the following: (i) high quality—further research is unlikely to change confidence in the estimate of effect; the Cochrane criteria and NOS identify no risks of bias and all domains in the GRADE classification are fulfilled. In addition, further research is unlikely to change confidence in the estimate of effect (ii) moderate quality—further research is likely to have an important impact on the confidence in the estimate of effect, and one of the domains in the GRADE classification is not fulfilled; (iii) low quality—further research is likely to have an important impact on the confidence and may change the estimate; two of the domains are not fulfilled in the GRADE classification; and (iv) very low quality—we are uncertain about the estimate; three of the domains in the GRADE classification are not fulfilled .

## Muscle Pain? 6 Things to Know About Dry Needling

Physical therapists have a variety of techniques they use to treat pain and conditions that inhibit a patient’s movement. One of those techniques, dry needling, utilizes a solid filament needle inserted into the muscle.

How does this work? Here are six things to know:

1. Dry needling is not acupuncture

Based in Eastern medicine, acupuncture focuses on the flow of Qi, or energy, along meridians for the treatment of diseases. Dry needling is a Western approach to treating pain and dysfunction in musculoskeletal conditions and serves as a reset button, breaking the pain cycle by resolving trigger points.

2. Dry needling can be used to treat a variety of conditions

Any patient that has pain and/or movement dysfunction due to a musculoskeletal condition can use dry needling to reduce pain. This includes any muscle where a trigger point is located, chronic pain, lumbar pain, neck pain, shoulder pain, headaches/migraines, whiplash and plantar fasciitis. Once a therapist deems a patient appropriate for dry needling, a prescription is obtained the patient signs a consent form.

3. Each patient receives personalized treatment

Treatment is personalized for each patient and can include a warm-up, dry needling, stretching and/or activation of the muscle to promote normal length (extensibility) and restore normal contraction and control of the muscle.”

4. The needles are targeted at trigger points

The patient starts by being placed in a safe position that exposes the desired area. The skin is wiped with alcohol to clean the surface layer. The therapist palpates the patient for tenderness and/or palpable trigger points, which are taut hyper-contracted nodules/bands within muscle tissue.

5. You may not even feel it

The patient may feel the needle enter the skin but sometimes it is not felt at all depending on the patient and the location of the needle. Needles are inserted and manipulated and removed or left in for a period of time. The needle elicits a local twitch response followed by the relaxation of the muscle. There may be a cramping, aching sensation or slight discomfort that lasts a few seconds. Electrical stimulation can be applied to the needles to bring even more blood flow to the tissues and relax the muscle tissue.

6. Pain relief may come after just one session

Some patients report 50% pain relief after just one session while others find relief after several sessions.

What’s Next?

Ready to find a personalized solution to your pain? Find an OrthoCarolina location near you.

This article was originally written on August 28, 2018, and updated on January 29, 2020.