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CLINICAL REVIEW
Dry Needling in the Management of
Musculoskeletal Pain
Leonid Kalichman, PT, PhD, and Simon Vulfsons, MD
Myofascial pain is a common syndrome seen by family practitioners worldwide. It can affect up to 10%
of the adult population and can account for acute and chronic pain complaints. In this clinical narrative
review we have attempted to introduce dry needling, a relatively new method for the management of
musculoskeletal pain, to the general medical community. Different methods of dry needling, its effec-
tiveness, and physiologic and adverse effects are discussed. Dry needling is a treatment modality that is
minimally invasive, cheap, easy to learn with appropriate training, and carries a low risk. Its effective-
ness has been confirmed in numerous studies and 2 comprehensive systematic reviews. The deep
method of dry needling has been shown to be more effective than the superficial one for the treatment
of pain associated with myofascial trigger points. However, over areas with potential risk of significant
adverse events, such as lungs and large blood vessels, we suggest using the superficial technique, which
has also been shown to be effective, albeit to a lesser extent.
Additional studies are needed to evaluate the effectiveness of dry needling. There also is a great need
for further investigation into the development of pain at myofascial trigger points. (J Am Board Fam
Med 2010;23:640 – 646.)
Keywords: Dry-needling, Myofascial Trigger Points, Pain, Connective Tissue, Musculoskeletal, Alternative Medicine
Myofascial pain is a common form of pain that arises from muscles or related fascia and is usually associated with myofascial trigger points (MTrP). An MTrP is a highly localized, hyperirritable spot in a palpable, taut band of skeletal muscle fibers.^1 When an MTrP is stimulated, 2 important clinical phenomena can be elicited: referred pain and a local twitch response. Epidemiologic studies from the United States have shown that MTrPs were the primary source of pain in 30% to 85% of patients
presenting in a primary care setting or pain clinic because of pain.2– 4^ MTrPs were the primary source of pain in 74% of 96 patients with musculoskeletal pain who were seen by a neurologist in a commu- nity pain medical center,^5 and in 85% of 283 pa- tients consecutively admitted to a comprehensive pain center.^2 Of 164 patients referred to a dental clinic for chronic head and neck pain, 55% were found to have active MTrPs as the cause of their pain,^3 as were 30% of those from a consecutive series of 172 patients who presented with pain at a university primary care internal medicine group practice.^4 Therefore, MTrP pain constitutes a sub- stantial burden for both individual patients and for society as a whole. Despite this, there is evidence that MTrPs that cause musculoskeletal pain often go undiagnosed by both physicians and physical therapists, which leads to chronic conditions.6 – 8 Numerous noninvasive methods—such as stretch- ing, massage, ischemic compression, laser therapy, heat, acupressure, ultrasound, transcutaneous electri- cal nerve stimulation, biofeedback, and pharmaco- logical treatments— have been used to alleviate chronic myofascial pain, but no single strategy has
This article was externally peer reviewed. Submitted 24 December 2009; revised 25 March 2010; accepted 29 March 2010. From the Department of Physical Therapy, Recanati School for Community Health Professions, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel (LK); and the Pain Relief Unit, Rambam Health Care Campus, Rappaport School of Medicine, Tech- nion, Haifa, Israel (SV). Funding: none. Conflict of interest: none declared. Corresponding author: Leonid Kalichman, PT, PhD, De- partment of Physical Therapy, Recanati School for Com- munity Health Professions, Faculty of Health Sciences, Ben-Gurion University of the Negev, P.O. Box 653, Beer Sheva 84105, Israel (E-mail: kleonid@bgu.ac.il or kalichman@hotmail.com).
640 JABFM September–October 2010 Vol. 23 No. 5 http://www.jabfm.org
proved to be universally successful.9,10^ Another way to treat myofascial pain is by dry needling (intra- muscular stimulation, Western acupuncture, med- ical acupuncture), which is a minimally invasive procedure in which an acupuncture needle is in- serted directly into an MTrP. Although an acu- puncture needle is used, the therapy is based on the traditional reasoning of Western medicine. The sites for needle insertion are located in skeletal muscles taught in any basic anatomy course. Dry needling is easy to learn, and a basic course usually lasts 2 to 4 days. The aim of this review is to introduce dry needling, a relatively new treatment modality used by physicians and physical therapists worldwide as a part of complex treatment of chronic musculoskeletal pain, to the wide audience of family physicians, rheumatologists, orthopedic surgeons, physiatrists, pain specialists, dentists, and physical therapists.
Dry Needling Methods
Injections into MTrPs were proposed by Travell and Simons,^1 the pioneering researchers who in- troduced the concept of MTrPs to the medical community. Dry needling methods were empiri- cally developed to treat musculoskeletal disorders. The wider use of dry needling started after Le- wit’s^11 publication, where it was emphasized that the needling effect is distinct from that of the in- jected substance. In addition, in numerous random- ized clinical trials (RCTs) and one systematic re- view, no difference was found between injections of different substances and dry needling in the treat- ment of MTrP symptoms.10,12– Several schools and conceptual models of dry needling have developed during the last 3 decades; most common are radiculopathy^15 and MTrP^1 models. The radiculopathy model is based on em- pirical observations by the Canadian physician Dr. Chan Gunn,^15 who was one of the pioneers of dry needling. To distinguish this approach from other methods of dry needling, Dr. Gunn named it in- tramuscular stimulation (IMS). The Gunn IMS technique is based on the premise that myofascial pain syndrome is always the result of peripheral neuropathy or radiculopathy, defined as “a condi- tion that causes disordered function in the periph- eral nerve.”^16 According to Gunn’s theory, based on Cannon and Rosenblueth’s^17 Law of Denerva- tion Supersensitivity, denervated tissues develop
supersensitivity. In the musculature, this manifests as muscle shortening, pain, and the development of taut bands with MTrPs. Shortening of the paraspi- nal muscles, particularly the multifidi muscles, leads to disk compression and narrowing of the intervertebral foramina, or direct pressure on the nerve root, which subsequently results in periph- eral neuropathy and the development of supersen- sitive nociceptors and pain. Thus, restricted flow of nerve impulses in all innervated structures—includ- ing skeletal muscle, smooth muscle, spinal neurons, sympathetic ganglia, adrenal glands, sweat cells, and brain cells—leads to atrophy, aggravated irri- tability, and sensitivity.^16 According to the MTrP approach,^1 an acupuncture needle is inserted di- rectly into an MTrP. In 1942, Dr. Janet Travell and colleagues^18 first published the method of in- jection into MTrPs. In 1979, Karel Lewit^11 pro- posed that the effect of injections were primarily cause by the mechanical stimulation of an MTrP with the needle. Since then, dry needling has been widely used for the treatment of MTrPs. Dry nee- dling an MTrP is most effective when local twitch responses are elicited,^14 probably because of rapid depolarization of the involved muscle fibers, which manifests as local twitches.^19 After the muscle has finished twitching, the spontaneous electrical activ- ity subsides and the pain and dysfunction decrease dramatically. A very similar method was developed in 7th century by Chinese physician Sun Ssu-Mo, who inserted needles at points of pain, which he called Ah-Shi points.^20 From the description of these points, it is clear that they are what are cur- rently referred to as MTrPs.^21 For family physicians and other health care pro- viders who are interested in a deeper understanding of myofascial pain, MTrPs, and methods of their management, we recommend the “classical” text- books: Travell and Simons’s^1 Myofascial Pain and Dysfunction: The Trigger Point Manual ; The Gunn Approach to the Treatment of Chronic Pain^15 ; and Baldry’s^22 Acupuncture, Trigger Points, and Musculo- skeletal Pain. Examples of dry needling application are shown in Figure 1.
Effectiveness of Dry Needling in the
Management of MTrPs
Effectiveness of dry needling in the management of MTrPs has been evaluated in numerous RCTs and 3 comprehensive systematic reviews.10,23,24^ Cum-
doi: 10.3122/jabfm.2010.05.090296 Dry Needling and Musculoskeletal Pain 641
the sole cause of pain. Secondly, sample sizes were generally small, which raises the possibility of type II error, where the likelihood of a study producing a false-negative result is increased.^25 Thirdly, treat- ment interventions varied considerably in the loca- tion of needle placement, the depth of insertion, individual treatment times, and overall number of treatment sessions. Until evidence of the possible mechanism of action of needling is available, or until different interventions have been compared directly, there is no logical basis for choosing the optimal intervention. Finally, the recent Cochrane systematic review of 35 RCTs^23 assessed the efficacy of acupuncture and dry needling for management of low back pain. It was concluded that there is evidence of pain relief and functional improvement of chronic low back pain with the use of acupuncture compared with no treatment or sham therapy. These effects were only observed immediately after the end of the sessions and at short-term follow-up. One paper, published by Gunn et al^26 approximately 30 years ago, showed that, in a long-term follow-up RCT of 56 patients treated at the Workers’ Compensation Board, the group that had been treated with nee- dling was found to be clearly and significantly bet- ter than the control group ( P .005). There was evidence that acupuncture in conjunction with other conventional therapies relieves pain and im- proves function better than the conventional ther- apies alone. However, the treatment effects were small. Dry needling seemed to be a useful adjunct to other therapies for chronic low back pain. Furlan and colleagues^23 also mentioned the low method- ologic quality of original studies. We agree with Cummings and White’s^10 con- clusion that because marked improvements oc- curred among patients who were treated with nee- dling, further research is required to investigate whether needling of MTrPs has an effect beyond placebo, with emphasis on the use of an adequate control for the needle.
Deep Versus Superficial Needling
In the early 1980s, Baldry^22 suggested inserting the needle superficially into the tissue immediately overlying the MTrP. He called this technique “su- perficial dry needling” and applied it to MTrPs throughout the body with good empirical results, even in the treatment of MTrPs in deeper muscles.
Baldry^22 recommended inserting an acupuncture needle into the tissues overlying each MTrP to a depth of 5 to 10 mm for 30 seconds. Because the needle does not necessarily reach the MTrP, local twitch responses are not expected. Nevertheless, the patient commonly experiences an immediate decrease in sensitivity after the needling procedure. If there is any residual pain, the needle is reinserted for another 2 to 3 minutes. Baldry^27 advocates the use of superficial dry needling over deep dry nee- dling because the procedure is very easy to carry out; in contrast to deep dry needling it is a painless procedure (other than an initial short, sharp prick); there is minimal risk of damage to nerves, blood vessels, and other structures; and there is a low incidence of soreness after treatment. We found only 2 small studies that evaluated the effectiveness of superficial dry needling. Edwards and Knowles^28 conducted a single-blind, prospective RCT in which participants received either superficial dry needling combined with active stretching exercises, stretching exercises alone, or no treatments. After 6 weeks, the superficial dry needling group had significantly less pain compared with the no-inter- vention group and significantly higher pressure threshold measures compared with the active stretching-only group. In a single-blind placebo- controlled trial of 17 participants with chronic lum- bar MTrPs, Macdonald et al^29 found that superfi- cial dry needling was significantly better than the placebo in reducing pain. Several studies have compared superficial to deep dry needling. Naslund and colleagues^30 com- pared the effect of deep versus superficial needling (which they considered to be placebo) in a group of 58 individuals with idiopathic anterior knee pain. The authors found no statistical difference between the 2 methods. Pain measurements decreased sig- nificantly in both groups and remained low at both 3 and 6 months. Ceccherelli et al^31 compared the therapeutic effects of superficial and deep dry nee- dling in a prospective, double-blind RCT of 42 patients with lumbar myofascial pain. In the first group, the needle was inserted into the skin above the MTrP to a depth of 2 mm; the second group received intramuscular needling (approximately 1. cm) at 4 arbitrarily selected MTrPs. There was no difference between the groups at the end of the treatment but, after 3 months, the deep dry nee- dling technique resulted in significantly better an- algesia than the superficial dry needling technique.
doi: 10.3122/jabfm.2010.05.090296 Dry Needling and Musculoskeletal Pain 643
In another RCT, the efficacy of standard acupunc- ture, superficial dry needling, and deep dry nee- dling was compared in the treatment of elderly patients with chronic low back pain.^32 The stan- dard acupuncture group received treatment at tra- ditional acupuncture points, with the needles in- serted into the muscle to a depth of 20 mm. The dry needling group received treatment at MTrPs in the quadratus lumborum, iliopsoas, piriformis, and gluteus maximus muscles, among others. In the superficial dry needling group, the needles were inserted into the skin over MTrPs to a depth of approximately 3 mm. There were 2 treatment pe- riods (4 weeks each), with a 3-week interval be- tween them. At the end of the study, the group that received deep needling to MTrPs reported less pain intensity and improved quality of life com- pared with the standard acupuncture group or the superficial needling group, but the differences were not statistically significant. In discussion of the re- sults Ceccherelli et al^31 suggested that muscular afferents are more important for the transmission of acupuncture analgesic signals than the skin af- ferents. They supported this theory by citing Chiang’s et al^33 observation that the blockade of nervous afferent fibers from the skin did not elim- inate the acupuncture analgesia, whereas the anes- thetic blockade in deep tissues did eliminate acu- puncture analgesia. Itoh et al^32 noted that MTrPs are supposed to be sites where nociceptors, such as polymodal-type receptors, have been sensitized by various factors. The polymodal-type receptors are also proposed as possible candidates for acupunc- ture and moxibustion because they respond to chemical, thermal, and mechanical stimulation, all of which can generate an analgesic effect. 34 Results of the 2 last studies suggest that acupunc- ture stimulation of MTrPs in muscle may pro- duce greater activation of sensitized polymodal- type receptors, resulting in stronger effects on pain relief. However, the polymodal receptors are distributed in the skin as well as the fascia and muscle, and the possibility that superficial nee- dling may activate polymodal receptors in the skin and produce analgesic effects should not be excluded. Additional and more well-designed studies are needed to evaluate the effectiveness of superficial dry needling. In the meantime we sug- gest the use of this method in “dangerous” areas, such as above the lungs and great vessels.
Needling With or Without Paraspinal
Needling
According to Gunn’s^15 approach, needling should be performed not only at the site of pain but also in the paraspinal muscles of the same spinal segment that innervates the painful muscles. In a single- blinded RCT, Ga and colleagues^35 compared the efficacies of dry needling of MTrPs with and with- out paraspinal needling in 40 elderly patients with myofascial pain syndrome. Eighteen patients re- ceived 3 weekly sessions of dry needling treatment of the upper trapezius MTrP, and 22 patients re- ceived similar treatment with additional paraspinal needling. At 4-week follow-up, the group that had received paraspinal dry needling had more contin- uous subjective pain reduction than the group that received dry needling alone; the paraspinal dry nee- dling group saw significant improvements of rat- ings on the geriatric depression scale, but the group who received dry needling alone did not; the paraspinal dry needling group saw improvements of in the cervical range of motions but the group that received dry needling alone did not see improve- ments in extensional cervical range of motion. The authors suggested that paraspinal dry needling is a better method than MTrP dry needling alone for treating myofascial pain syndrome in elderly pa- tients. This study was relatively small, included only an elderly population, and used insufficient blinding procedures. The results must therefore be confirmed in additional studies before paraspinal needling can be routinely recommended in addi- tion to MTrP needling.
Adverse Effects of Dry Needling
Several adverse effects associated specifically with dry needling have been reported. These include soreness after needling,^35 local hemorrhages at the needling site,^35 and syncopal responses.^36 Adverse effects of acupuncture, which are similar to those of dry needling, have been well described.37,38^ In a recent prospective observational study of 229, patients who received, on average, 10.2 3.0 acu- puncture treatments from 13,679 German physi- cians who had received acupuncture training,^37 8.6% of patients reported experiencing at least one adverse effect, and 2.2% reported one that required treatment. Common adverse effects were bleedings or hematoma (6.1% of patients, 58% of all adverse effects), pain (1.7%), and vegetative symptoms
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- Ga H, Choi JH, Park CH, Yoon HJ. Acupuncture needling versus lidocaine injection of trigger points in myofascial pain syndrome in elderly patients–a randomised trial. Acupunct Med 2007;25:130 – 6.
- Barbagli P, Bollettin R, Ceccherelli F. [Acupuncture (dry needle) versus neural therapy (local anesthesia) in the treatment of benign back pain. Immediate and long-term results]. Minerva Med 2003;94:17–25.
- Hong CZ. Lidocaine injection versus dry needling to myofascial trigger point. The importance of the local twitch response. Am J Phys Med Rehabil 1994;73: 256 – 63.
- Gunn CC. The Gunn approach to the treatment of chronic pain. 2nd Ed. New York: Churchill Living- stone; 1997.
- Gunn CC. Radiculopathic pain: diagnosis, treatment of segmental irritation or sensitization. J Musculo- skelet Pain 1997;5:119 –34.
- Cannon WB, Rosenblueth A. The supersensitivity of denervated structures: a law of denervation. New York, NY: MacMillan; 1949.
- Travell J, Rinzler S, Herman M. Pain and disability of the shoulder and arm: treatment by intramuscular infiltration with procaine hydrochloride. JAMA 1942;120:417–22.
- Chen JT, Chung KC, Hou CR, Kuan TS, Chen SM, Hong CZ. Inhibitory effect of dry needling on the spontaneous electrical activity recorded from myo- fascial trigger spots of rabbit skeletal muscle. Am J Phys Med Rehabil 2001;80:729 –35.
- Lu G-D, Needham J. Celestial lancets: a history and rationale of acupuncture and moxa. Cambridge, UK: Cambridge University Press; 1980.
- Hong CZ. Myofascial trigger points: pathophysiol- ogy and correlation with acupuncture points. Acu- punct Med 2000;18:41–7.
- Baldry PE. Acupuncture, trigger points and muscu- loskeletal pain. Edinburgh, UK: Churchill Living- stone; 2005.
- Furlan AD, van Tulder MW, et al. Acupuncture and dry-needling for low back pain. Cochrane Database Syst Rev 2005;(1):CD001351.
- Tough EA, White AR, Cummings TM, Richards SH, Campbell JL. Acupuncture and dry needling in the management of myofascial trigger point pain: a systematic review and meta-analysis of randomised controlled trials. Eur J Pain 2009;13:3–10.
- Sim J, Wright C. Research in health care. Concepts, designs and methods. Cheltenham, UK: Stanley Thornes, Ltd.; 2000.
- Gunn CC, Milbrandt WE, Little AS, Mason KE. Dry needling of muscle motor points for chronic low-back pain: a randomized clinical trial with
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- Baldry P. Superficial dry needling at myofascial trig- ger point sites. J Musculoskelet Pain 1995;3:117–26.
- Edwards J, Knowles N. Superficial dry needling and active stretching in the treatment of myofascial pain–a randomised controlled trial. Acupunct Med 2003;21:80 – 6.
- Macdonald AJ, Macrae KD, Master BR, Rubin AP. Superficial acupuncture in the relief of chronic low back pain. Ann R Coll Surg Engl 1983;65:44 – 6.
- Naslund J, Naslund UB, Odenbring S, Lundeberg T. Sensory stimulation (acupuncture) for the treat- ment of idiopathic anterior knee pain. J Rehabil Med 2002;34:231– 8.
- Ceccherelli F, Rigoni MT, Gagliardi G, Ruzzante L. Comparison of superficial and deep acupuncture in the treatment of lumbar myofascial pain: a double- blind randomized controlled study. Clin J Pain 2002; 18:149 –53.
- Itoh K, Katsumi Y, Kitakoji H. Trigger point acu- puncture treatment of chronic low back pain in el- derly patients–a blinded RCT. Acupunct Med 2004; 22:170 –7.
- Chiang CY, Chang CT, Chu H, Yang L. Peripheral afferent pathway for acupuncture analgesia. Scientia Sinica 1973;16:210 –7.
- Kawakita K. Polymodal receptor hypothesis on the peripheral mechanisms of acupuncture and moxibus- tion. Am J Acupunct 1993;21:331– 8.
- Ga H, Choi JH, Park CH, Yoon HJ. Dry needling of trigger points with and without paraspinal needling in myofascial pain syndromes in elderly patients. J Altern Complement Med 2007;13:617–24.
- Huguenin L, Brukner PD, McCrory P, Smith P, Wajswelner H, Bennell K. Effect of dry needling of gluteal muscles on straight leg raise: a randomised, placebo controlled, double blind trial. Br J Sports Med 2005;39:84 –90.
- Witt CM, Pach D, Brinkhaus B, et al. Safety of acupuncture: results of a prospective observational study with 229,230 patients and introduction of a medical information and consent form. Forsch Komplementmed 2009;16:91–7.
- White A, Hayhoe S, Hart A, Ernst E. Adverse events following acupuncture: prospective survey of 32 000 consultations with doctors and physiotherapists. BMJ 2001;323:485– 6.
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