Dry Needling
To many athletes and fitness enthusiasts, there is nothing worse than chronic pain or injury. It can impact their daily routines and quality of life as well as decrease performance. The negative impact to quality of life can then lead to depression, loss of motivation, and a decrease in self-confidence. Dry needling is a therapeutic procedure that has been used by some physical therapists since 1999. (Ott, et al., 2011) It is a procedure similar to acupuncture used to assist in muscle soreness or injuries through myofascial trigger points. Dry needling can be traced back to Europe in the 1970s. (Ott, et al., 2011) There have been multiple case studies and research conducted on the success of these treatments and a drastic reduction in pain for many patients. Of the studies conducted, there is still not substantial research to support or deny the claims of successful treatment results from dry needling.
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The purpose of this study is to understand and explore the effects of dry needling as a treatment plan for injured athletes. At this stage in the research, dry needling will be defined as a procedure similar to acupuncture used to assist in muscle soreness or injuries through myofascial trigger points. What are the differences in dry needling and acupuncture needle depth and location? What is the average success rate of dry needling versus acupuncture for injuries? Specific injuries will include shoulder, neck, back, and knees. How many treatments must a patient have of dry needling before they are able to return to normal activity or do not feel pain at the site of injury?
Previous case studies and statistical data will be used to develop answers to the above questions for this research study. The qualitative and quantitative data will be compared and contrasted; overall findings will be summarized within the research study results. In this study, data from previous research studies will be used to test the theory of dry needling having more success with injury healing than traditional acupuncture. The types of injury, diagnosis and experience level of the athlete are the independent variables. (Dommerholt, 2011) The experience level of the therapist administering the treatment and outcome measurements are dependent variables. Controlled variables will be the amount of treatment provided, level of activity of participant, and limit additional therapies in conjunction with dry needling, i.e. physical therapy, steroid injections, and massage therapy.
Case studies completed from 2012 to 2018, documented positive results. The procedure of dry needling is relatively simple and can be completed during a regular office visit to a physical therapist. The high success rates in dry needling treatment for chronic pain or injuries have resulted in a significantly higher quality of life and faster recovery time for many athletes. The question remains, how does it work? How can one treatment of dry needling make years of chronic pain cease? What is the difference between dry needling and acupuncture to treat pain in myofascial trigger points?
Doctors Susan Ott, Erik Adams, and Allyson Howe participated in an interview with Dr. Jeff Konen in 2011. (Ott, et. al, 2011) Dr. Ott stated that she had been using the procedure since 1999; however, she believes “the jury is out on it and more research is needed” (Ott, 2011, p. 256). In an article by Eric Ries, he discusses a patient who had experience pain for 15 years. She was misdiagnosed for fibromyalgia and prescribed pain medication for nearly 10 years. (Ries, 2015) This patient was then treated with dry needling by Dr. Tim Flynn. He stated her “gait is now fluid—there’s been about an 80% gain”. (Ries, 2015, p.14). He also stated that this treatment reduced her pain substantially. After such success with this case, Dr. Flynn expanded his use of dry needling as a dominant form of intervention and treatment for his patients. (Ries, 2015)
Dr. Shariat discusses one case of a patient with two years of pain from golfer’s elbow which was worsening for two months. The patient received one procedure of dry needling and his pain diminished shortly after. (Shariat, et al, 2018, p.138) The patient was a 40 year old male, retired athlete with 20 years of experience in wrestling and bodybuilding. He had a medical history of chronic lower back pain, scoliosis, and hypercholesterolemia. (Shariat, et al, 2018, p. 139) During the dry needling procedure, the needles were left in place for 20 minutes. He returned for a follow up appointment two days after the treatment and reported less pain. The patient was also able to do more activities with improved range of motion and flexibility; seven days post treatment, he resumed his exercise routine with zero pain. (Shariat, et al, 2018, p. 140)
In a double-blinded placebo-controlled trial by doctors Tekin, Akarsu, Durmus, Cakar, Dincer and Kiralp, the hypothesis that dry needling is more effective than sham dry needling in the treatment of myofascial pain syndrome was tested. Myofascial pain syndrome is defined as “a common form of pain that arises from muscles or related fascia” (Tekin, et al, 2012, p. 309). Myofascial trigger points are highly localized, hyperirritable spots within a taut band of skeletal muscle fibers. In 21 to 85% of individuals with pain complaints there is a prevalence of myofascial pain syndrome. (Tekin, et al, 2012, p. 309) The current treatment methods include physical therapy, exercise, ischemic compression, heat, stretch and spray, local injections, and acupuncture. Dr. Tekin found that dry needling is the most effective. (Tekin, et al, 2012, p. 309)
Thirty nine participants were selected over a period of six months and divided as follows; 22 in the study group and 17 in the placebo group. Participants were between the ages of 24 and 65, experienced pain for more than six months, and had the presence of at least one active trigger point. (Tekin, et al, 2012, p. 310) Patients who received physical therapy within the last three months were not included in the study. The treatment was composed of six sessions performed over six weeks. The first four sessions were given twice per week and the last two were reduced to once per week. (Tekin, et al, 2012, p. 311) During the treatment a dry needle was inserted perpendicularly through the skin. It was then moved forward until the trigger point was activated. Once activated the needle was withdrawn immediately. Participants that were part of the placebo group received sham needling. Sham needling is defined as a procedure where a blunted needle is placed against the skin at trigger points. It causes a prickling sensation that feels the same as the actual dry needling procedure. (Tekin, et al, 2012, p. 311)
After the treatments, the visual analog scale (VAS) was used to indicate current pain on a scale of “no pain” (0) to “worst pain possible” (10). During the first assessment, scores were the same on the visual analog scale between the placebo and study group. During the second and third assessment, the participants who received the actual dry needling procedure had significantly lower visual analog scale scores. Dr. Tekin’s study did reveal that dry needling was effective in relieving pain for the study group participants. He also stated that patients’ quality of life was improved by this procedure and the effects of dry needling reducing the pain experience from myofascial pain syndrome. Visual analog scale scores were as follows (Tekin, et al, 2012, p. 313):
Parameter
Before Treatment
After 1st Session
After 6th Session
Sham Needling
6.4+/- 1.6
5.4 +/- 1.6
5.3 +/- 1.8
Dry Needling
6.6 +/- 1.3
4.0 +/- 1.6
2.2 +/- 2.0
In June 2013, doctors Cagnie, Dewitte, Barbe, Timmermans, Delrue, and Meeus conducted a study on the physiological effects of dry needling. Within the article, it was stated that there is limited evidence that dry needling provided substantial treatment for pain when compared to other treatments. (Cagnie, et al, 2013, p. 1). Another cited resource stated “that despite positive results of individual studies, the level of evidence supporting the efficacy and effectiveness of dry needling for several conditions remains insufficient” (Cagnie, et al, 2013, p. 1-2). This was due to there being concerns of bias in the studies conducted as well as a lack of precision. There is currently no way to test the patients’ level of pain; the results are all based on word of mouth from the patient and the visual analog scale. Some of the most substantial differences between dry needling and acupuncture are that dry needling applies more needles, the movement of the needle is more aggressive, needles are inserted deeper into the tissue, there is an increase in the amount and force of stimulation, and the elicitation of a local twitch response is required. (Cagnie, et al, 2013, p. 3) Local twitch response is defined as “an involuntary spinal reflex resulting in a localized contraction of affected muscle fibers that are being manually stretched, injected or dry needled” (Cagnie, et al, 2013, p. 3).
During dry needling, the needle is inserted deeper into the band of skeletal muscle in order to relieve muscle pain. Dry needling can also increase the blood flow and oxygenation the muscle fibers. (Cagnie, et al, 2013, p. 3) Within myofascial trigger points, there is spontaneous electrical activity or endplate noise. This is the result of excess acetylcholine (Ach). Spontaneous electrical activity increases when there is pain. When dry needling is performed, it allows the excess acetylcholine to discharge, thus reducing spontaneous electrical activity which was causing the pain experienced. (Cagnie, et al, 2013, p. 3) Dr. Cagnie and colleagues’ study did conclude that the procedure of dry needling is highly complex. They believe it causes a physiological and psychological response because the central and peripheral nerve systems are activated. (Cagnie, et al, 2012, p. 7)
Doctors Kalichman and Vulfsons conducted research on dry needling for the management of musculoskeletal pain in 2010. These doctors highlighted two important clinical phenomena when myofascial trigger points are stimulated. They were the first to attribute activating a local twitch response to the success from treatment through dry needling. (Kalichman, et al, 2010, p. 640) Similar to Cagnie and colleagues’ research, this simulation of the local twitch response did reduce pain in patients; however, a lot of the research they discussed did not state that dry needling was the most successful treatment method. They did agree that activating the local twitch response made dry needling in myofascial trigger points more effective because this allowed for the rapid depolarization of muscle fibers. (Kalichman, et al, 2010, p. 641). Once the muscle is finished twitching, spontaneous electrical activity subsides decreasing pain dramatically. (Kalichman, et al, 2010, p. 641)
Kalichman stated that out of 96 patients, 74% had myofascial trigger points as the primary source of pain. (Kalichman, et al, 2010, p. 640) He also stated that out of the numerous noninvasive methods available for treatment such as acupressure, pharmacological treatment, massage, and stretching, no single strategy has been proven universally successful. (Kalichman, et al, 2010, p. 641) Kalichman also reviewed seven randomized clinical trial within his article. One study showed that dry needling myofacial trigger points were effective in reducing pain compared to no treatment at all. Contradictory results were found with two other trials and four other studies failed to show that dry needling in myofascial trigger points was the most effective treatment method available. (Kalichman, et al, 2010, p. 642) Dr. Kalichman also highlighted that the sample sizes were generally small within these studies and that could cause a false-negative result. He also stated that treatment interventions varied in the placement and depth of the needle during the procedure. (Kalichman, et al, 2010, p. 643)
One of the key points in Dr. Kalichman’s literature is deep tissue versus superficial needling. Superficial penetration is similar to acupuncture whereas deep needling will produce the local twitch response. A study by Naslund and colleagues was also discussed by Dr. Kalichman. This study was comprised of a group of 58 individuals with anterior knee pain. During this study, it was noted that there was no statistical difference between superficial and deep tissue dry needling. They also noted that pain decreased significantly in both groups and remained low during three and six month follow ups. (Kalichman, et al, 2010, p. 643) Another randomized clinical trial composed of elderly patients with lower back pain was divided into groups receiving deep dry needling and superficial dry needling. The difference in needle penetration was 17 millimeters and each group received two treatments. The treatments were each four weeks long with a three week interval in between. This study concluded that the group who received deep tissue dry needling reported less pain and an improved quality of life. The group receiving superficial dry needling reported a decrease in pain but not as improved as the deep tissue group. Dr. Kalichman also noted that overall the differences in pain improvement between superficial and deep tissue were not statistically significant. (Kalichman, et al, 2010, p. 644).
More recently, Doctors Lynn Gerber, Jay Shah, William Rosenberger, Kathryn Armstrong, Diego Turo, Paul Otto, Juliana Heimur, Nikki Thaker, and Siddhartha Sikdar (2015) conducted research on dry needling altering trigger points within the upper trapezius and shoulder girdle. During their study, 90 participants who were aged 18-65 years and had experienced pain for at least three months. (Gerber, et al, 2015, p. 712) Two clinicians performed the procedure that each had 20 years of experience with the technique. Participants received treatment once a week for three weeks. At the end of the study, 52 participants’ results were used; the other 56 were disqualified due to not finishing the treatment protocol or dropping out of the study. (Gerber, et al, 2015, p. 714) The visual analog score scale was used and the results are below (Gerber, et al, 2015, p. 715):
Baseline
Follow-Up
VAS on treated side
3.5+/-2.4
.9+/-1.6
Self-Reported Outcomes
Physical Functioning
88.5+/-14.3
91.4+/-11.3
Emotional
83.4+/-21.5
88.8+/-16.3
Physical Role
85.1+/-17
86.9+/-16.7
Vitality
58.7+/-17
60.7+/-16.9
The above results were used to outline the “self-reported results” of Dr. Gerber, et al’s study group. Dry needling treatments had a significant effect on their quality of life and their reported pain in the verbal analog scale (VAS). The major findings listed by Gerber from this study were that in all three assessments pain was reduced and is correlated with changing the status myofascial trigger points. (Gerber, et al, 2015, p. 716) Dr. Gerber’s study was not a randomized, placebo-controlled, blinded clinical trial and cannot prove effectiveness. (Gerber, et al, 2015, p. 716)
The only adverse effects of dry needling were discussed by Dr. Kalichman (2010) including soreness after needling, local hemorrhages at the needling site and syncopal responses. These adverse effects were experienced by 10.2 +/- 3.0 out of 229,230 patients in a prospective observational study. (Kalichman, et al, 2010, p. 644) No other studies discussed in this researched noted any adverse effects to dry needling procedures in myofascial trigger points.
There are many other stories and case studies similar to the ones above, unfortunately there is still much more research required to conclude the overall success of dry needling in myofascial trigger points. The results from the above studies did conclude that the procedure can be successful, but most feedback is word of mouth from the patient. Continued research on dry needling is a necessity. In some cases, dry needling was paired with other treatments such as steroid injections and traditional physical therapy. Overall, it remains the preferred treatment method to many doctors, but just as many disagree with the procedure. (Tekin, et al, 2013)
References
Chang-Zern, H. (2013). Needling therapy for myofascial pain control. Evidence – Based Complementary and Alternative Medicine, 2013 doi:http://dx.doi.org.ezproxy2.apus.edu/10.1155/2013/946597
Creswell, J.W. (2018). Research design: Qualitative, quantitative, and mixed methods approach (5th Ed.) Twelve Oaks, CA: Sage Publications.
Gerber, L., Shah, J., Rosenberger, W., Armstrong, K., Turo, D., Otto, P., Heimur, J., Thaker, N., & Sikdar, S. (May 2015). Dry Needling Alters Trigger Points in the Upper Trapezius Muscle and Reduces Pain in Subjects With Chronic Myofascial Pain. The American Academy of Physical Medicine and Rehabilitation. Volume 96, Issue 5. Pages 775-781. Retrieved from https://ac.els-cdn.com/S1934148215000520/1-s2.0-S1934148215000520-main.pdf?_tid=d187fe69-341c-4ae3-83d5-49ad257aeb90&acdnat=1543191531_f78639e2c7b80c94d397310233746143
Kalichman, L. & Vulfsons, S. (October 2010). Dry Needling in the Management of Musculoskeletal Pain. Journal of the American Board of Family Medicine (JABFM). Vol. 23, No. 5. Retrieved from http://www.jabfm.org/content/23/5/640.short
Ott, Susan M,D.O., F.A.C.S.M., Adams, E., M.D., & Howe, Allyson, MD, FAAFP,C.A.Q.Sports Medicine. (2011). Dry needling. Athletic Training & Sports Health Care, 3(6), 255-256. doi:http://dx.doi.org.ezproxy2.apus.edu/10.3928/19425864-20111028-04
Physiologic Effects of Dry Needling. (2013). Current Pain & Headache Reports, 17(8), 1–8. Retrieved from http://ezproxy.apus.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&AuthType=ip&db=mdc&AN=EPTOC89547499&site=ehost-live&scope=site
Ries, E. (2015). DRY NEEDLING: GETTING TO THE POINT. PT in Motion, 7(4), 12-13,15-19,21-22. Retrieved from https://search-proquest-com.ezproxy2.apus.edu/docview/1700342164?accountid=8289
Shariat, A., Noormohammadpour, P., Memari, A. H., Ansari, N. N., Cleland, J. A., & Kordi, R. (2018). Acute effects of one session dry needling on a chronic golfer’s elbow disability. Journal of Exercise Rehabilitation, 14(1), 138–142. http://doi.org/10.12965/jer.1836008.004
Tekin, L., Akarsu, S., Durmus, O., Çakar, E., Dinçer, Ü., & Kiralp, M. Z. (2013). The effect of dry needling in the treatment of myofascial pain syndrome: A randomized double-blinded placebo-controlled trial. Clinical Rheumatology, 32(3), 309-15. doi:http://dx.doi.org.ezproxy2.apus.edu/10.1007/s10067-012-2112-3
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