Download Agenda and Materials - The Iowa Physical Therapy Association

For the right touch,
See a physical therapist.©
Iowa Physical Therapy
Association & Foundation
Celebrating 65 Years as
a State Chapter of the
521 E Locust St, Suite 202 • Des Moines, IA 50309-1939
Phone 515-222-9838 • Fax 888-414-3183
[email protected] • www.iowaapta.org
Iowa Physical Therapy Association
Discussion on Dry Needling
Thursday, August 27, 2015
Nevada, Iowa
1. Welcome and Introduction
2. APTA power point updating current status and recent activity
3. FSBPT Document review/reference
4. 2015 Iowa Legislative activity review
5. Current Acupuncturist Activities
6. Chiropractic Position
7. General Overview of Strategy for 2016 Legislative year & rest of 2015
From: "Shuman, Angela" <[email protected]>
Date: August 19, 2015 at 11:00:31 AM CDT
To: "Shuman, Angela" <[email protected]>
Subject: FSBPT Dry Needling Competencies Report Now Available
Dear APTA State Advocate,
As you know, the issue of dry needling by physical therapists is one of the bigger PT scope of
practice challenges currently playing out in the states. Yesterday, the Federation of State
Boards of Physical Therapy (FSBPT) released its analysis of competencies for dry needling by
physical therapists. The FSBPT report – which can be found HERE – is the result of many months
of work by FSBPT and a task force comprised of physical therapists who perform and/or teach
DN. The FSBPT contracted with the Human Resources Research Organization (HumRRO) to
conduct the study in accordance with current best-practices in practice analysis procedures.
As noted in the report, more than four-fifths of what PTs need to know to be competent in dry
needling is acquired during the course of their entry-level education, including knowledge
related to evaluation, assessment, diagnosis and plan of care development, documentation,
safety, and professional responsibilities. Advanced or specialized training almost solely related
to the needling technique and the psychomotor skills, is required to make up the deficit.
The specific knowledge for competency in dry needling is noted in Table 2 on page 12 of the
report, which may be helpful if your state is currently looking at possible PT Board regulations
or legislation on this issue. Overall the report should assist in combating arguments made by
opponents related to education, training, and competency for dry needling.
Specific questions about the dry needling report can be directed to the FSBPT
at [email protected]. Please let me know if you have any questions.
Best,
Angela L. Shuman
Sr. State Affairs Specialist
American Physical Therapy Association
1111 N. Fairfax Street
Alexandria, VA 22314
703-706-3199
From: Federation of State Boards of Physical Therapy [mailto:[email protected]]
Sent: Tuesday, August 18, 2015 5:44 PM
Subject: Dry Needling Competencies Report Now Available
To view this email as a web page, go here
Dry Needling Competencies Report Now
Available!
August 18, 2015
For several years, U.S. jurisdictions have sought information from the Federation of State Boards
of Physical Therapy (FSBPT) regarding the ability of physical therapists to perform dry needling.
However, no publically available studies have explicitly examined what PTs must know and be able
to do to perform dry needling safely and effectively.
FSBPT contracted with the Human Resources Research Organization (HumRRO) to conduct the
study in accordance with current best-practices in practice analysis procedures.
HumRRO is a non-profit, social and behavioral science research and consulting firm dedicated to
the measurement and improvement of human and organizational performance. As an independent
contractor, HumRRO was instrumental in carrying out an objective, unbiased analysis.
More than four-fifths of what PTs need to know to be competent in dry needling is acquired during
the course of their entry-level education, including knowledge related to evaluation, assessment,
diagnosis and plan of care development, documentation, safety, and professional responsibilities.
Advanced or specialized training, almost solely related to the needling technique and the
psychomotor skills, is required to make up the deficit.
Read the report here: http://www.fsbpt.org/FreeResources/RegulatoryResources.aspx
For more information, contact [email protected].
American Physical Therapy Association - 1111 N. Fairfax Street, Alexandria, VA, 22314. 800-999-APTA (2782). To manage the types of email messages you receive from APTA, please visit www.apta.org/email
Dry Needling in Other States – APTA synopsis
Dry needling is now specifically recognized in the following PT practice acts: Georgia, Utah, Arizona,
Tennessee, and Delaware. All but Delaware pursued legislation because of a negative attorney general
opinion.
Not allowed (5): California, Hawaii, Idaho, South Dakota, New York
Questionable, under active challenge; use caution (7): Illinois, Florida, Michigan, Nebraska, Oregon,
Pennsylvania, Washington
No opinion from the state, use caution (11): Alaska, Arkansas, Indiana, Minnesota, Missouri, North
Dakota, Oklahoma, Connecticut, Rhode Island, New Jersey, Maine
Allowed - included in practice act, board rules, board opinion, board statement, attorney general
opinion (27 and DC): Arizona, Nevada, Montana, Wyoming, Utah, Colorado, New Mexico, Texas, Kansas,
Iowa, Louisiana, Mississippi, Alabama, Georgia, Tennessee, South Carolina, North Carolina, Kentucky,
Wisconsin, Ohio, West Virginia, Virginia, Maryland, Delaware, Massachusetts, New Hampshire, Vermont.
There have been several positive attorney general opinions in other states, and most if not all of them
have involved an interpretation of practice acts that includes dry needling as the use of “mechanical
devices”. Iowa’s practice act includes mechanical devices, so that could be helpful in making the
argument that dry needling is included in the Iowa practice act, but of course it’s not the only factor.
Dry Needling in Orthopaedic Physical Therapy Practice
Jan Dommerholt, PT, MPS
NOTE: Consistent with ethical guidelines,the author wishes to disclose that
he is co-founder and co-program director of the Janet G.Travell, MD Seminar
SeriesSM, the only US-based continuing
education program that offers courses
for physical therapists in the technique
of dry needling. Readers, check with
your own state practice acts on the use
of this technique.
offer academic programs that include dry
needling courses. The University of Castilla
- La Mancha offers a postgraduate degree in
conservative and invasive physical therapy.
At the University of Valencia, dry needling
is included in the curriculum of the master’s degree program in manipulative physical therapy. In Switzerland, dry needling
courses are offered via the accredited continuing education program of the
‘Interessengemeinschaft für Manuelle
Triggerpunkt Therapie’ (Society for Manual
Trigger Point Therapy). Physical therapists
in the UK are increasingly being trained in
joint injection techniques.2
In the United States,dry needling is not
included in physical therapy educational
curricula and relatively few physical therapists employ the technique. Dry needling
is erroneously assumed to fall under the
scopes of medical practice or oriental
medicine and acupuncture.
However,
physical therapy state boards of Maryland,
New Hampshire,New Mexico,and Virginia
have already ruled that dry needling does
fall within the scope of physical therapy in
those states. The Tennessee Board of
Occupational and Physical Therapy
recently rejected dry needling by physical
therapists. The general counsel of the
Illinois Department of Regulation advised
that dry needling would not fall within the
scope of practice of physical therapy but
should be covered by the board of
acupuncture. In the mean time, physical
therapists who are adequately trained in
the technique of dry needling are successfully employing the technique with a wide
variety of patients.
INTRODUCTION
Orthopaedic physical therapists employ
a wide range of intervention strategies to
reduce patients’pain and improve function.
From time to time, new treatment
approaches are being introduced to the
field of physical therapy. The arrival of manual therapy in the United States is a good
example. Although for several decades,
manual physical therapy was already an
essential part of the scope of orthopaedic
physical therapy practice in Europe, New
Zealand, and Australia, manual therapy did
not make its debut in the United States until
the 1960s.1 Initially many US state boards
of physical therapy opposed the use of
manual therapy. In spite of the early resistance,manual physical therapy has become
a mainstream treatment approach. Manual
therapy techniques are now taught in academic programs and continuing education
courses. During the past few years,physical
therapists,the APTA,and the AAOMPT even
have had to defend the right to practice
manual therapy especially when challenged by the chiropractic community! A
similar development is in progress with the
relatively new technique of dry needling.
While some physical therapy state boards
have already decided that dry needling falls
within the scope of physical therapy practice, others are still more hesitant. The goal
of this paper is to introduce the American
orthopaedic physical therapy community
to the technique of dry needling.
DRY NEEDLING TECHNIQUES
Several dry needling approaches have
been developed based on different individual theories, insights, and hypotheses.
The 3 main schools of dry needling are
presented: the myofascial trigger point
model, the radiculopathy model, and the
spinal segmental sensitization model.
DRY NEEDLING
Dry needling is commonly used by
physical therapists around the world. For
example, in Canada, many provinces allow
physical therapists to use dry needling
techniques. In Spain, several universities
Myofascial Trigger Point Model
Dry needling is used primarily in the
treatment of myofascial trigger points
(MTrPs), defined as “hyperirritable spots in
skeletal muscle associated with hypersensitive palpable nodules in a taut band.”3 The
Orthopaedic Practice Vol. 16;3:04
11
MTrPs are the hallmark characteristic of
myofascial pain syndrome (MPS). A recent
survey of physician members of the
American Pain Society showed general
agreement that MPS is a distinct syndrome.4
Throughout the history of manual physical
therapy,MPS and MTrPs have received little
or no attention, although several studies
have demonstrated that MTrPs are commonly seen in acute and chronic pain conditions,and in nearly all orthopaedic condiVecchiet and colleagues demontions.5
strated that acute pain following exercise
or sports participation is often due to
acutely painful MTrPs. Myofascial trigger
points are often responsible for complaints
of pain in persons with hip osteoarthritis,6
pain with cervical disc lesions,7 pain with
TMD,8 pelvic pain,9 headaches,10 epicondylitis,11 etc. Hendler and Kozikowski
concluded that MPS is the most commonly
missed diagnoses in chronic pain patients.12
A brief review of the current knowledge of
MTrPs and MPS is indicated to better understand the place of dry needling within
orthopaedic physical therapy.
Already during the early 1940s, Dr.
Janet Travell (1901-1997) realized the
importance of MPS and MTrPs. Recent
insights in the nature, etiology, and neurophysiology of MTrPs and their associated
symptoms have propelled the interest in
the diagnosis and treatment of persons
with MPS worldwide. The mechanism
that underlies the development of MTrPs
is not known, but altered activity of the
motor end plate, or neuromuscular junction, is most likely. Changes in acetylcholine receptor (AChR) activity, in the
number of receptors, and changes in
acetylcholinesterase (AChE) activity are
consistent with known mechanisms of
end plate function, and could explain the
changes in end plate activity that occur in
the MTrP. There is a marked increase in
the frequency of miniature end plate
potential activity at the point of maximum tenderness in the taut band in the
human, and in the neuromuscular junction end plate zone of the taut band in the
rabbit model and in humans.
Normally, ACh is broken down by
AChE. Preliminary results of studies by
Shah and associates at the National
Institutes of Health indicate that a number
of biochemical alterations are commonly
found at the active MTrP site using microdialysis sampling techniques.13 Among the
changes found are elevated bradykinin,
substance P, and calcitonin gene-related
peptide (CGRP) levels, and lowered pH
when compared to inactive (asymptomatic) MTrPs and to normal controls.13The
combination of increased levels of CGRP
and lowered pH suggest that the milieu of
a MTrP is too acidic for AChE to function
efficiently. The possible implications for
the development of MTrPs is outside the
scope of this article and will be addressed
in a future article.14 The administration of
botulinum toxin can block the release of
ACh, and is therefore now widely used in
the management of chronic and persistent
MPS.
Abnormal end plate noise (EPN) associated with MTrPs can be visualized with
electromyography using a monopolar
teflon-coated needle electrode and a slow
insertion technique.15,16 Active MTrPs are
spontaneously painful, refer pain to more
distant locations, and cause muscle weakness, mechanical range of motion restrictions, and several autonomic phenomena.
One of the unique features of MTrPs is the
phenomenon of the local twitch response
(LTR), which is an involuntary spinal cord
reflex contraction of the contracted muscle
fibers in a taut band following palpation or
needling of the band or trigger point.17 The
LTR can be visualized with needle electromyography and ultrasonography.18,19
To make a diagnosis of MPS, the minimum essential features that need to be
present are the taut band, an exquisitely
tender spot in the taut band, and the
patient’s recognition of the pain complaint by pressure on the tender nodule.20
Simons,Travell, and Simons add a painful
limit to stretch range of motion as the
fourth essential criterion.3 Referred pain,
the LTR, and the electromyographic
demonstration of end plate noise are confirmatory observations and not essential
for the clinical diagnosis.
From a biomechanical perspective,
National Institutes of Health researchers
Wang and Yu hypothesized that MTrPs are
severely contracted sarcomeres whereby
myosin filaments literally get stuck in titin
gel at the Z-band of the sarcomere
(Figures 1 and 2).21 Titin is the largest
known protein that connects the Z-band
with myosin filaments within a sarcomere. Approximately 90% of titin consists
of 244 repeating copies of fibronectin
I - Band
A - Band
I - Band
M Band
Actin
Titin
H Zone
Myosin
Z -line
Figure 1. Schematic representation of
a normal sarcomere.
Figure 2. Schematic representation
of a MTrP with myosin filaments literally stuck in titin gel at the Z-line
(after Wang K, Yu L. Emerging
Concepts of Muscle Contraction and
Clinical Implications for Myofascial
Pain Syndrome. Presented at Focus
on Pain 2000, Mesa, AZ: Janet G.
Travell, MD Seminar Seriessm.)
type III and immunoglobin domains,
which may contribute to the sticky nature
of titin once muscle fibers are contracted.
Histological studies have confirmed the
presence of extreme sacromere contractions, resulting in localized tissue
hypoxia.22 Brückle and colleagues established that the local oxygen saturation at a
MTrP site is less than 5% of normal.23
Hypoxia leads to the release of local
release of several nociceptive chemicals,
including bradykinin, CGRP, and substance
P,among others,which have been detected
in abnormal high concentrations at
MTrPs.13 Bradykinin is a nociceptive agent
that stimulates the release of tumor necrosing factor and interleukins, some of which
in turn can stimulate the further release of
bradykinin. Calcitonin gene-related peptide modulates synaptic transmission at the
neuromuscular junction by inhibiting the
expression of AChE,which is another likely
mechanism that contributes to the excessively high concentration of ACh.
Split fibers, ragged red fibers, type II
fiber atrophy, and fibers with a motheaten appearance have been detected in
MTrPs.22 Ragged red fibers and moth12
eaten fibers are also associated with muscle ischemia and represent an accumulation of mitochondria or a change in the
distribution of mitochondria or the sarcotubular system respectively.
Combining these various lines of
research, it can be concluded that MTrPs
function as peripheral nociceptors that
can initiate, accentuate, and maintain the
process of central sensitizaton.24
As a
source of peripheral nociceptive input,
MTrPs are capable of unmasking sleeping
receptors in the dorsal horn, resulting in
spatial summation and the appearance of
new receptive fields, which clinically are
identified as areas of referred pain. The
MTrPs are commonly associated with
other pain states and diagnoses, including
complex regional pain syndrome, and
should be considered in the clinical management.25 Treatment of MTrPs is only
one of the components of the therapeutic
program, and does not replace other therapeutic measures, such as joint mobilizations, posture training, strengthening, etc.
As MTrPs are easily accessible to trained
hands, inactivating MTrPs is one of the
most effective and fastest means to
reduce pain. Dry needling is the most
precise method currently available to
physical therapists.
Myofascial trigger points can be identified by palpation only. There are no other
diagnostic tests that can accurately identify an MTrP, although new methodologies
using piezoelectric shockwave emitters
are being explored.26 Excellent inter-rater
reliability has been established.20,27 Simons,
Travell, and Simons describe 2 palpation
techniques for the proper identification of
MTrPs. A flat palpation technique is used
for example with palpation of the infraspinatus, the masseter, temporalis, and
lower trapezius. A pincher palpation technique is used for example with palpation
of the sternocleidomastoid, the upper
trapezius, and the gastrocnemius.
Trigger point dry needling
Janet Travell pioneered the use of
MTrP injections that eventually led to the
development of dry needling. Her first
paper describing MTrP injection techniques was published in 1942, followed
by many others. Together with Dr. David
Simons she wrote the 2-volume Trigger
Point Manual.3,28 Many studies have confirmed the benefits of trigger point injections even though a recent review article
could not demonstrate clinical efficacy
Orthopaedic Practice Vol. 16;3:04
beyond placebo.5,29 In 1979 Lewit confirmed that the effects of needling were
primarily due to mechanical stimulation
of a MTrP with the needle.30 Dry needling
of a MTrP using an acupuncture needle
caused immediate analgesia in nearly 87%
of needle sites. In over 31% of cases, the
analgesia was permanent. Twenty percent
had several months of pain relief,22% several weeks, and 11% several days.
Fourteen percent had no relief at all.30
Dry needling an MTrP is most effective, when local twitch responses (LTR)
are elicited.31 A LTR has been shown to
inhibit abnormal end plate noise. Current
(unpublished) research strongly suggests
that a LTR is essential in altering the
chemical milieu of an MTrP (Shah, 2004,
personal communication). Patients commonly describe an immediate reduction
or elimination of the pain complaint after
eliciting LTRs. Once the pain is reduced,
patients can start active stretching,
strengthening, and stabilization programs.
Eliciting a LTR with dry needling is usually
a rather painful procedure. Post- needling
soreness may last for 1 to 2 days, but can
easily be distinguished from the original
pain complaint.
Patients with chronic
pain frequently report to have received
previous trigger point injections; however, many state that they never experienced LTRs. Accurate needling requires
clinical familiarity with MTrPs and excellent palpation skills.
Dr. Peter Baldry has adopted the Travell
and Simons trigger point model, but
prefers a gentler and less mechanistic
approach to needling MTrPs when possible. According to Baldry, using a superficial needling technique is nearly always
effective. With superficial dry needling,the
needle is placed in the skin and cutaneous
tissues overlying an MTrP. Baldry agrees
that both superficial and deep dry needling
have their place in the management of
MTrPs.32 A recent study confirmed that
both superficial and deep dry needling are
effective with dry needling having a
stronger and more immediate effect.33
Radiculopathy Model
In Canada,Dr.Chan Gunn developed his
‘radiculopathy model’ and coined the term
‘intramuscular stimulation’ instead of dry
needling.34 Gunn has expressed the belief
that myofascial pain is always secondary to
peripheral neuropathy or radiculopathy
and therefore, myofascial pain would
always be a reflection of neuropathic pain
Orthopaedic Practice Vol. 16;3:04
in the musculoskeletal system. Because of
muscle shortening, which in this model is
always due to neuropathy, ‘supersensitive
nociceptors’may be compressed,leading to
pain. The radiculopathy model is based on
Cannon and Rosenblueth’s “Law of
Denervation.” According to this law, the
function and integrity of innervated structures is dependent upon the free flow of
nerve impulses to provide a regulatory or
trophic effect. When the flow of nerve
impulses is restricted, the innervated structures become atrophic, highly irritable, and
supersensitive. Striated muscles are thought
to be the most sensitive innervated structures and according to Gunn, become the
“key to myofascial pain of neuropathic origin.” Because of the neuropathic supersensitivity, Gunn states that muscle fibers “can
overreact to a wide variety of chemical and
physical inputs including stretch and pressure.” The mechanical effects of muscle
shortening may result in commonly seen
conditions, such as tendonitis, arthralgia,
and osteoarthritis.
Shortening of the
paraspinal muscles is thought to perpetuate
radiculopathy by disc compression, narrowing of the intervertebral foramina,or by
direct pressure on the nerve root.
Gunn found that the most effective
treatment points are always located close
to the muscle motor points or musculotendinous junctions. They are distributed
in a segmental or myotomal fashion in
muscles supplied by the primary anterior
and posterior rami. In Gunn’s model,
MTrPs do not play an important role.
Because the primary posterior rami are
segmentally involved in the muscles of
the paraspinal region, including the multifidi, and the primary anterior rami with
the remainder of the myotome, the treatment must always include the paraspinal
muscles as well as the more peripheral
muscles. Gunn found that the tender
points usually coincide with painful palpable muscle bands in shortened and contracted muscles. He suggests that nerve
root dysfunction is particularly due to
spondylotic changes. He maintains that
relatively minor injuries would not result
in severe pain that continues beyond a
‘reasonable’ period, unless the nerve root
would already be in a sensitized state
prior to the injury.
Gunn’s assessment technique is based
on the evaluation of specific motor, sensory,and trophic changes. The main objective of the initial examination is to determine which levels of neuropathic dys13
function are present in a given individual.
The examination is rather limited and
does not include standard medical and
physical therapy evaluation techniques,
including common orthopaedic or neurological tests, laboratory tests, electromyographic or nerve conduction tests or radiologic tests, such as MRI, CT scan, or even
X-rays. Motor changes are assessed
through a few functional motor tests and
through systematic palpation of the skin
and muscle bands along the spine and in
the peripheral muscles of the involved
myotomes. Gunn emphasizes to assess
trophic changes in the paraspinal regions
segmentally corresponding to the area of
dysfunction. Trophic changes may include
orange peel skin (peau d’orange), dermatomal hair loss,differences in skin folds,
and moisture levels (dry vs. moist skin).34
Unfortunately, Gunn’s radiculopathy
model as a hypothesis to explain chronic
musculoskeletal pain has not really been
developed beyond its initial inception in
1973. Although Gunn has published
numerous interesting case reports and
review articles restating his opinions, most
components of the model have not been
subjected to scientific investigations and
verification. In fact,many of Gunn’s underlying assumptions are contradicted by
more recent research findings. For example, Gunn’s notion that persistent nociceptive input is uncommon contradicts many
recent neurophysiological studies confirming that persistent and even relative brief
nociceptive input can result in pain producing plastic dorsal horn changes.
The major contributions of Gunn to
the field of MPS and dry needling are the
emphasis on segmental dysfunction and
the suggestion that neuropathy may be a
possible cause of myofascial dysfunction.
Certainly with regard to motor dysfunction associated with MPS, the combined
impact of the primary anterior and posterior rami is an important consideration.
For example, from a segmental perspective, it would be likely to see dysfunction
of the C5-C6 paraspinal muscles when
MTrPs are present in the more peripheral
infraspinatus muscle.
The Spinal Segmental Sensitization
Model
The Spinal Segmental Sensitization
Model is developed by Dr.Andrew Fischer
and combines aspects of Travell and Simons’
trigger point model and Gunn’s radiculopathy model.35 Fischer proposes that the “pen-
tad of the vicious cycle of discopathy,
paraspinal muscle spasm and radiculopathy”consists of paraspinal muscle spasm frequently responsible for compression of the
nerve root, narrowing of the foraminal
space,and a sprain of the supraspinous ligament with radicular involvement. Fischer
advocates a comprehensive medical evaluation. According to Fischer, the most effective methods for relief of musculoskeletal
pain include preinjection blocks, needle
and infiltration of tender spots and trigger
points, somatic blocks, spray and stretch
methods, and relaxation exercises. Based
on empirical observations,Fischer routinely
infiltrates the supraspinous ligament,which
“inactivates tender spots/trigger points in
the corresponding myotome, relaxing the
taut bands,and increasing the pressure pain
thresholds as documented by algometry.”
The MTrP injections with Fischer’s needling
and infiltration technique are thought to
“mechanically break up abnormal tissue”
and “a layer of edema.” The main differences
between Fischer’s and Gunn’s approach are
the extent of the physical examination, the
use of injection needles by Fischer, and
acupuncture needles by Gunn, Fischer’s
recognition of the importance of MTrPs,
and the infiltration of the supraspinous ligament. Furthermore, Fischer’s model seems
more dynamic. He has integrated many new
research findings into his approach;for example,Fischer acknowledges that central sensitization is often due to ongoing peripheral
nociceptive input. Fischer’s proposed interventions use multiple injection techniques
and are therefore not that useful for physical
therapists. As far is known, the Maryland
Board of Physical Therapy Examiners is the
only physical therapy board that has ruled
that physical therapists may perform MTrP
injections.
MECHANISMS OF DRY NEEDLING
Although muscle needling techniques
have been used for thousands of years in
the practice of acupuncture, there is still
much uncertainty about their underlying
mechanisms. The acupuncture literature
may provide some answers, however, due
to its metaphysical and philosophical
nature, it is difficult to apply traditional
acupuncture principles to the practice of
using acupuncture needles in the treatment of MPS.
Mechanical Effects
Dry needling of an MTrP may mechanically disrupt the integrity of the dysfunc-
tional motor end plates. From a mechanical point of view, needling of MTrPs may
be related to the extremely shortened sarcomeres. It is plausible that an accurately
placed needle provides a localized stretch
to the contracted cytoskeletal structures,
which may disentangle the myosin filaments from the titin gel at the Z-band.
This would allow the sarcomere to
resume its resting length by reducing the
degree of overlap between actin and
myosin filaments.
If indeed a needle can mechanically
stretch the local muscle fiber, it would be
beneficial to rotate the needle during
insertion. Rotating the needle results in
winding of connective tissue around the
needle,which clinically is experienced as a
‘needle grasp.’ Comparisons between the
orientation of collagen following needle
insertions with and without needle rotation demonstrated that the collagen bundles were straighter and more nearly parallel to each other after needle rotation.36
Langevin and colleagues report that brief
mechanical stimulation can induce actin
cytoskeleton reorganization and increases
in proto-oncogenes expression, including
cFos and tumor necrosing factor and interleukins.36 Moving the needle up and down
as is done with needling of a MTrP may be
sufficient to cause a needle grasp and a
resultant LTR. As a result of mechanical
stimulation, group II fibers will register a
change in total fiber length, which may
activate the gate control system by blocking nociceptive input from the MTrP and
hence cause alleviation of pain.32
The mechanical pressure exerted via
the needle also may electrically polarize
the connective tissue and muscle. A physical characteristic of collagen fibers is
their intrinsic piezoelectricity, a property
that allows tissues to transform mechanical stress into electrical activity necessary
for tissue remodeling, possibly contributing to the LTR.37
Neurophysiologic Effects
In his arguments in favor of neurophysiological explanations of the effects
of dry needling, Baldry concludes that
with the superficial dry needling technique, A-delta nerve fibers (group III) will
be stimulated for as long as 72 hours after
needle insertion. Prolonged stimulation
of the sensory afferent A-delta nerve
fibers may activate the enkephalinergic
inhibitory dorsal horn interneurons,
which would imply that superficial dry
14
needling causes opioid mediated pain
suppression.32
Another possible mechanism of superficial dry needling is the activation of the
serotonergic and noradrenergic descending inhibitory systems, which would block
any incoming noxious stimulus into the
dorsal horn.The activation of the enkephalinergic, serotonergic, and noradrenergic
descending inhibitory systems occurs with
dry needle stimulation of A-delta nerve
fibers anywhere in the body.32 Skin and
muscle needle stimulation of A-delta and C(group IV) afferent fibers in anesthetized
rats was capable of producing an increase
in cortical cerebral blood flow, which was
thought to be due to a reflex response of
the afferent pathway, including group II
and IV afferent nerves and the efferent
intrinsic nerve pathway, including cholinergic vasodilators.38 Superficial needling of
certain acupuncture points in patients
with chronic pain showed similar changes
in cerebral blood flow.39
Gunn’s and Fischer’s techniques of
needling both the paraspinal muscles and
peripheral muscles belonging to the same
myotome, appear to be supported by several animal studies. For example,Takeshige
and Sato determined that both direct
needling into the gastrocnemius muscle
and into the ipsilateral L5 paraspinal muscles of a guinea pig resulted in significant
recovery of the circulation, after ischemia
was introduced to the muscle using tetanic
muscle stimulation.40 They also confirmed
that needling of acupuncture points and
non-acupuncture points involved the
descending pain inhibitory system,
although the actual afferent pathways
Acupuncture
were distinctly different.
analgesia involved the medial hypothalamic arcuate nucleus of the descending pain
inhibitory system, while non-acupuncture
analgesia involved the anterior part of the
In both
hypothalamic arcuate nucleus.
kinds of needle stimulation, the posterior
hypothalamic arcuate nucleus was
involved. There is no research to date that
clarifies the role of the descending pain
inhibitory system with needling of MTrPs.
Chemical Effects
The studies by Shah and colleagues
demonstrated that the increased levels of
various chemicals, such as bradykinin,
CGRP, substance P, and others, at MTrPs
are immediately corrected by eliciting a
LTR with an acupuncture needle.
Although it is not known what happens
Orthopaedic Practice Vol. 16;3:04
to these chemicals when a needle is
inserted into the MTrP, there is now
strong albeit unpublished data that suggest that eliciting a LTR is essential.13
STATUTORY CONSIDERATIONS
Whether from a legal or statutory perspective, physical therapists can perform
dry needling techniques, has not been
considered in most states. However, the
physical therapy state boards of
Maryland, New Mexico, New Hampshire,
and Virginia have officially determined
that dry needling falls within the scope of
physical therapy practice in those states.
Dry needling by physical therapists must
be regulated by state boards of physical therapy and not by state boards of acupuncture
or oriental medicine. Dry needling is not
equivalent to acupuncture and should not
be considered a form of acupuncture. For
example,the New Mexico Acupuncture and
Oriental Medicine Practice Acta defines
acupuncture as “the use of needles inserted
into and removed from the human body and
the use of other devices,modalities and procedures at specific locations on the body for
the prevention,cure or correction of any disease, illness, injury, pain, or other condition
by controlling and regulating the flow and
balance of energy and functioning of the
person to restore and maintain health.”
Obviously, dry needling involves the
use of needles inserted into and removed
from the human body; however, that is
the only similarity between dry needling
and acupuncture. Similarly, if a hammer
is associated with carpenters, do
plumbers become carpenters every time
they use a hammer? The objective of dry
needling is not to control and regulate
the flow and balance of energy and is not
based on Eastern esoteric and metaphysical concepts. The fact that needles are
being used in the practice of dry
needling does not imply that an acupuncture board would automatically have
jurisdiction over such practice. If so,
physicians and nurses would also need to
conform to the statutes of acupuncture,
as they also “insert and remove needles.”
Many boards of physical therapy in the
United States have adopted a variation of
the “Model Practice Act for Physical
Therapy” developed by the Federation of
State Boards of Physical Therapy
(http://www.fsbpt.org).
Neither the
Model Practice Act or any of the actual
state practice acts address whether dry
needling falls within the scope of physical
Orthopaedic Practice Vol. 16;3:04
therapy practice. However, based on the
definitions of physical therapy practice,
dry needling may well fall within the
scope of practice in nearly all states. The
respective statutes commonly include
statements like “the practice of physical
therapy means administering treatment
by mechanical devices,” “mechanical
modalities,” or “mechanical stimulation.”
Exclusions to the practice of physical therapy are frequently defined as “the use of
roentgen rays and radioactive materials for
diagnosis and therapeutic purposes, the
use of electricity for surgical purposes,
and the diagnosis of disease.” Most state
physical therapy acts do not specifically
prohibit the use of needles.
Whether physical therapists are legally
allowed to penetrate the skin has been
addressed in few statutes and usually only
in the context of performing electromyography and nerve conduction tests. The
Model Practice Act does include “electrodiagnostic and electrophysiologic tests
and measures.” For example, the Missouri
Revised Statutesb indicate that “physical
therapy [...] does not include the use of
invasive tests,” yet, the statutes state
specifically “physical therapists may perform electromyography and nerve conduction test” even though they “may not
interpret the results.”
The California
Physical Therapy Actc does address the
issue of “tissue penetration:” “A physical
therapist may, upon specified authorization of a physician and surgeon, perform
tissue penetration for the purpose of evaluating neuromuscular performance as
part of the practice of physical therapy
[...] provided the physical therapist is certified by the board to perform tissue pena
b
c
d
New Mexico Statutes Annotated
1978, Chapter 61, Professional and
Occupational Licenses, Article 14A,
Acupuncture and Oriental Medicine
Practice, 3, Definitions
Missouri Revised Statutes, Chapter
334, Physicians and Surgeons –
Therapists – Athletic Trainers, Section
334.500, Definitions
California Business and Professions
Code, Division 2, Healing Arts,
Chapter 5.7, Physical Therapy, Section
2620.5
The 2003 Florida Statutes, Title XXXII,
of
Professions
and
Regulation
Occupations, Chapter 486, Physical
TherapyAct,Section 486.021,Definitions,
11,Practice of Physical Therapy
15
etration and provided the physical therapist does not develop or make diagnostic
or prognostic interpretations of the data
obtained.” It is not clear whether the
California practice act would allow dry
needling at this time. In any case, it
appears that physical therapists would
need to be certified by the board to perform tissue perforation.
The definition of physical therapy practice in the 2004 Florida Statutesd includes
“the performance of acupuncture only
upon compliance with the criteria set
forth by the Board of Medicine, when no
penetration of the skin occurs.”The Florida
board does not indicate how acupuncture
or for that matter, dry needling, would be
performed without penetrating the skin
and this remains a mystery. Interestingly,
the physical therapy practice act in Florida
does include “the performance of electromyography as an aid to the diagnosis of
any human condition.”
In order to practice dry needling,
physical therapists would have to be able
to demonstrate competency or adequate
training in the examination and treatment of persons with MPS and in the
technique of dry needling. Many statutes
address the issue of competency by
including language like “a physical therapist shall not perform any procedure or
function for which he is by virtue of education or training not competent to perform.” Obviously, physical therapists
employing dry needling must have excellent knowledge of anatomy and be very
familiar with the indications, contraindications, and precautions.
In summary, most physical therapy
practice acts may allow dry needling,
according to the various definitions of
“practice of physical therapy.” Whether
individual state boards would interpret
their statutes in a similar fashion as the
Maryland, New Mexico, New Hampshire,
and Virginia physical therapy state
boards have, remains to be seen.
REFERENCES
1. Paris SV. A history of manipulative
therapy through the ages and up to
the current controversy in the United
States. J Manual Manip Ther. 2000;8
(2):66-77.
2. Baker R, et al. A Clinical Guideline for
the Use of Injection Therapy by
Physiotherapists.London:The Chartered
Society of Physiotherapy;2001.
3. Simons DG, Travell JG, Simons LS.
Travell and Simons’ Myofascial Pain
and Dysfunction; the Trigger Point
Manual. 2nd ed. Baltimore, Md:
Williams & Wilkins; 1999.
4. Harden RN, Bruehl SP, Gass S, Niemiec
C,Barbick B.Signs and symptoms of the
myofascial pain syndrome: a national
survey of pain management providers.
Clin J Pain. 2000;16(1):64-72.
5. Dommerholt J. Muscle pain syndromes. In:Myofascial Manipulation.
Cantu RI, Grodin AJ, ed. Gaithersburg,
Md:Aspen; 2001:93-140.
6. Bajaj P, et al. Trigger points in patients
with lower limb osteoarthritis. J
Musculoskeletal Pain. 2001;9(3):17-33.
7. Hsueh, TC, Yu S, Kuan TS, Hong CZ.
Association of active myofascial trigger
points and cervical disc lesions. J
Formos Med Assoc.1998;97(3):174-180.
8. Kleier DJ. Referred pain from a
myofascial trigger point mimicking
pain of endodontic origin. J Endod.
1985;11(9):408-411.
9. Ling FW, Slocumb JC. Use of trigger
point injections in chronic pelvic
pain. Obstet Gynecol Clin North Am.
1993;20(4):809-815.
10.Mennell J. Myofascial trigger points as
a cause of headaches. J Manipulative
Physiol Ther. 1989;12(4):308-313.
11.Simunovic Z. Low level laser therapy
with trigger points technique: a clinical study on 243 patients. J Clin Laser
Med Surg. 1996;14(4):163-167.
12.Hendler NH,Kozikowski JG.Overlooked
physical diagnoses in chronic pain
patients
involved
in
litigation.
Psychosomatics.1993;34(6):494-501.
13.Shah J, et al. A novel microanalytical
technique for assaying soft tissue
demonstrates significant quantitative
biomechanical differences in 3 clinically distinct groups: normal, latent
and active. Arch Phys Med Rehabil.
2003;84:A4.
14.Gerwin, RD, Dommerholt J, Shah J. An
expansion of Simons’integrated hypothesis of trigger point formation. Curr
Pain Headache Rep.In press 2004.
15.Simons, DG, Hong C-Z, Simons LS.
Endplate potentials are common to
midfiber myofascial trigger points. Am J
Phys Med Rehabil.2002;81(3):212-222.
16.Couppé C, et al. Spontaneous needle
electromyographic activity in myofascial trigger points in the infraspinatus
muscle: A blinded assessment. J
Musculoskeletal Pain.2001;(3):7-17.
17.Hong C-Z,Yu J. Spontaneous electrical
activity of rabbit trigger spot after
transection of spinal cord and peripheral nerve. J Musculoskeletal Pain.
1998;6(4):45-58.
18.Gerwin RD, Duranleau D. Ultrasound
identification of the myofascial trigger
point. Muscle Nerve. 1997;20(6):767768.
C-Z, Torigoe Y. Electro19.Hong
physiological characteristics of localized twitch responses in responsive taut
bands of rabbit skeletal muscle. J
Musculoskeletal Pain.1994;2:17-43.
20.Gerwin RD, Shannon S, Hong CZ,
Hubbard D, Gervitz R. Interrater reliability in myofascial trigger point examination. Pain. 1997;69(1-2):65-73.
21.Wang K,Yu L. Emerging Concepts of
Muscle Contraction and Clinical
Implications for Myofascial Pain
syndrome (abstract). In: Focus on
Pain. Mesa, Ariz: Janet G.Travell, MD
Seminar Seriessm; 2000.
22.Windisch A,Reitinger A,Traxler H,et al.
Morphology and histochemistry of
myogelosis. Clin Anat.1999;12(4):266271.
23.Brückle W, Suckfull M, Fleckenstein W,
Weiss C,Muller W.Gewebe-pO2-Messung
in der verspannten Rückenmuskulatur
(m. erector spinae). Z Rheumatol.
1990;49:208-216.
24.Mense S,Hoheisel U.New developments
in the understanding of the pathophysiology of muscle pain. J Musculoskeletal
Pain.1999;7(1/2):13-24.
25.Dommerholt J. Complex regional pain
syndrome; part 1: history, diagnostic
criteria and etiology. J Bodywork
Movement Ther. 2004;8(3):167-177.
26.Bauermeister W. The diagnosis and
treatment of myofascial trigger points
using shockwaves. In: Myopain.
Munich: Haworth; 2004.
27.Sciotti VM, Mittak VL, DiMarco L, et al.
Clinical precision of myofascial trigger point location in the trapezius
muscle. Pain. 2001;93(3):259-266.
28.Travell,JG, Simons DG. Myofascial
Pain and Dysfunction: The Trigger
Point Manual. Vol. 2. Baltimore, Md:
Williams & Wilkins; 1992.
29.Cummings TM, White AR. Needling
therapies in the management of
myofascial trigger point pain: a systematic review. Arch Phys Med
Rehabil. 2001;82(7):986-992.
30.Lewit K.The needle effect in the relief
of myofascial pain. Pain.1979;6:83-90.
31.Hong CZ. Lidocaine injection versus
16
dry needling to myofascial trigger
point. The importance of the local
twitch response. Am J Phys Med
Rehabil. 1994;73(4):256-263.
32.Baldry PE. Myofascial Pain and
Fibromyalgia Syndromes.Edinburgh:
Churchill Livingstone; 2001.
33.Ceccherelli F, Rigoni MT, Gagliardi G,
Ruzzante L. Comparison between
superficial and deep acupuncture in the
treatment of lumbar myofascial pain: a
double-blind randomized controlled
study. Clin J Pain.2002;18:149-153.
34.Gunn CC. The Gunn Approach to the
Treatment of Chronic Pain.2nd ed.New
York,NY:Churchill Livingstone;1997.
35.Fischer AA. Treatment of myofascial
pain. J Musculoskeletal Pain. 1999;7
(1/2):131-142.
36.Langevin HM, Churchill DL, Cipolla
MJ. Mechanical signaling through connective tissue: a mechanism for the
therapeutic effect of acupuncture.
Faseb J. 2001;15(12):2275-2282.
37.Liboff AR.Bioelectromagnetic fields and
acupuncture. J Altern Complement
Med.1997;3(Suppl 1):S77-S87.
38.Uchida S, Kagitani F, Suzuki A, et al.
Effect of acupuncture-like stimulation
on cortical cerebral blood flow in
anesthetized rats. Jpn J Physiol.
2000;50(5):495-507.
39.Alavi A, et al. Neuroimaging of
acupuncture in patients with chronic
pain. J Altern Complement Med.
1997;3(Suppl 1): S47-S53.
40.Takeshige C, Sato M. Comparisons of
pain relief mechanisms between
needling to the muscle, static magnetic field, external qigong and
needling to the acupuncture point.
Acupunct Electrother Res. 1996;21
(2):119-131.
Jan Dommerholt, Pain & Rehabilitation Medicine, Bethesda, MD. Jan can
be reached via email at dommerholt@
painpoints.com.
Orthopaedic Practice Vol. 16;3:04
Should Dry Needling for Myofascial
Pain be Within the Scope of Practice
for Physical Therapists?
Sinéad A. FitzGibbon, PT, MS
Doctoral Student, graduate program in Orthopedic and Sports Physical Therapy, Rocky Mountain University of Health Professions, Provo, UT &
Co-owner Manual and Sports Physical Therapy, Sag Harbor, NY
INTRODUCTION
Health care expenditure in the United
States reached $2.2 trillion in 2007, increasing 6.2% from the previous year, and
amounted to 16.2 % of the gross domestic
product.1 Professional services, including
physical therapy, accounted for $62 billion
of this cost.1 Myofascial pain is one of the
leading complaints of patients presenting in
general medical practice, with reported prevalence of 20% to 93% in general practice2,3
thus imposing significant financial burdens
on state and national health care budgets.3
With high prevalence and associated costs,
there is unrelenting pressure on insurers,
clinicians, and researchers to reduce costs
while optimizing outcomes. The physical
therapy profession is at the forefront of cost
containment by promoting comparisons of
the effectiveness of different interventions
in management of musculoskeletal pain.4
Physical therapists use nonsurgical, nonpharmaceutical modalities in the prevention and treatment of disability.5 Moreover,
the 2020 vision statement of the American Physical Therapy Association (APTA)
reflects the emerging priorities of the profession by emphasizing the provision of expert
care using evidence-based practice.6 With
44 states allowing direct access to physical
therapists (PTs) at a lower cost than physical therapy via physician referral,7 PTs are a
part of the vanguard of cost containment in
health care.
Physiotherapists began musculoskeletal
care in 1894 as a group of nurses practicing
remedial massage in the United Kingdom
(UK), and evolved into established professional organizations on both sides of the
Atlantic. Today there are 170,000 practicing
PTs in the United States and 36,000 chartered physiotherapists in the United Kingdom, with therapists recognized as expert
clinicians in management of musculoskeletal and myofascial pain.8,9
Physiotherapists practicing internationally in the United Kingdom, Australia, New
Zealand, and throughout Europe use dry
needling alongside traditional modalities
in management of myofascial pain.10-12 The
multimodal, direct access practice model
is beneficial to both the consumer and the
clinical practitioner, as well as cost effective
for all involved parties.7 There are growing numbers of national and international
courses in dry needling for physical therapists,13-15 with 5,500 physiotherapists in the
UK16 and over a thousand such therapists in
Australia17 now licensed to use needling in
physical therapy practice.
Direct access to physical therapy gives
patients suffering from myofascial pain
a gateway into a broad spectrum of pain
management techniques. Physical therapy
professionals are expert first-line clinicians
in delivery of pain management modalities. With inclusion of dry needling in the
battery of techniques available to skilled
clinicians, cost-effective nonsurgical pain
management options could improve patient
outcomes and contribute to containing
health care costs. In order to understand
how dry needling by physical therapists
can enhance pain management, knowledge
of its history and current use is warranted.
This paper will outline the background of
the trigger point theory and describe dry
needling as used in management of myofascial pain. It will then compare and contrast
the educational processes of acupuncturists
and physical therapists with regard to use of
needling. Finally, the case will be made for
broadening the physical therapist’s scope of
practice to include dry needling, with special
reference to use of evidence-based practice
in the current fiscally challenging medical
environment.
DRY NEEDLING: BACKGROUND
Dry needling, generally understood
as the insertion of filiform (fine filament)
needles without use of saline or other liquid
substances, has its roots in ancient practice
of acupuncture. Nearly 3,000 years of Chinese acupuncture has resulted in regional
Asian variations in technique and ideology.18,19 Development of modern Chinese
medical and therapeutic practices has com212
bined with western empirical medical practices to result in the practice of dry needling.
This is the use of filiform needles to treat
myofascial trigger points without reference
to oriental medicine philosophy and principles of practice. Dr. Janet Travell developed
and popularized the treatment of myofascial
trigger points (MTrP) using dry needling
techniques.20,21 This method of myofascial pain management has become popular among physical therapists and medical
doctors worldwide, especially over the past
3 decades. Histopathology, electrical activity, neurophysiology and clinical features of
MTrPs have been studied since the 1940s,
and though this body of knowledge continues to grow, the mode of efficacy of needling
MTrPs remains poorly understood.
Myofascial Trigger Points, Definitions,
and Mode of Efficacy
A MTrP is defined as a highly localized and hyper-irritable spot in a palpable
taut band of skeletal muscle tissue.22 The
main criteria used for diagnosis of MTrPs
are the following: a tender spot in a taut
band of contractile skeletal muscle, patient
pain report upon palpation of this point,
a predictable pattern of referred pain from
palpation of this point, and a local twitch
response elicited upon palpation.3 Despite
widespread use of these criteria, there have
been few studies that have examined interexaminer reliability and diagnostic sensitivity and specificity,3,23-24 nor has there been
standardization of the manner in which the
examination is conducted.21
TRIGGER POINT THEORY AND
NEEDLING RESPONSE
Trigger points are known to occur and
to be maintained at the level of a spinal segmental reflex.2 It is thought that excessive
local release of acetylcholine2 or calcium22
at the neuro-motor endplate results in
spontaneous electrical activity (SEA), with
sustained depolarization and shortening of
sarcomeres.21 The resultant prolonged local
muscle spasm is thought to impair blood
Orthopaedic Practice Vol. 23;4:11
flow, cause tissue damage, and perpetuate
an inflammatory cycle.2,21,22 To date, therapy
has been aimed at inhibiting muscle spasm
and reducing the pain of MTrPs using many
modalities, including spraying with ethyl
chloride followed by specific stretching, deep
massage, injection of various substances, and
dry needling.2,21,25 Elicitation of local twitch
response has been demonstrated to occur
with needle insertion into active MTrPs.2,21,26
Pain relief is associated with reduced electrical activity following needle insertion into
an MTrP in which a twitch response is
observed.21,22,26,27 Activation of spinal endogenous opioids is a likely factor in the effectiveness of many therapeutic interventions
in pain management. Direct stimulation of
peripheral nociceptors by needling may act
to desensitize the central nervous system
via SEA endplate inhibition and enhance
stimulation of opioid activity within spinal
wide-range dynamic neurons.22,28 While
acupuncture and dry needling are theorized
to have similar mechanisms of action, the
education, philosophy of practice, and techniques are quite dissimilar.
COMPARING ACUPUNCTURE AND
DRY NEEDLING
Acupuncture is one of the oldest forms of
therapy, and is based on Chinese philosophy,
namely that disease is an outward manifestation of internal imbalance of Yin and Yang
energetic forces.18 Although filiform needles
are used in both dry needling and acupuncture, the similarities are limited. Whereas
acupuncture is used to diagnose and manage
systemic conditions, dry needling of myofascial trigger points purportedly targets
specific tissue responses without reference to
energetic systems.22, 27 Acupuncture education entails 3 years of study with mentored
residency and competency examinations.
Dry needling certification is adjunctive to a
medical degree, or a physical therapy masters or doctoral qualification, which takes
5 to 7 years of study. Certification for dry
needling in the United States occurs after 50
hours of post-graduate coursework and 200
to 400 documented interventions. Competency examination is required in the United
Kingdom, Europe, and Australia with some
programs demanding rigorous dissertations
at the culmination of a full academic year of
acupuncture related physiotherapy.29 Such
competency exams are similar in depth to
APTA board certification areas such as orthopaedic sports, and women’s health physical
therapy certifications. Medical doctors and
Orthopaedic Practice Vol. 23;4:11
physical therapists practice dry needling
when it is determined to be within the scope
of practice by their relevant states. Available
evidence for efficacy of acupuncture and
dry needling in myofascial pain is limited,
and conclusive results are few.18,19,25,30 Most
studies have been limited by small sample
size, nonstandardization of techniques and
poor research design, with few high quality
studies or systematic reviews. The majority of published manuscripts investigating
the effects of acupuncture and needling
underscore the need for high quality clinical
research in this area.18,30-32
Dry Needling Within the Scope of
Physical Therapy Practice
Canada, the United Kingdom, Ireland,
the Netherlands, Norway, Switzerland, Belgium, Spain, Chile, South Africa, Australia,
and New Zealand, among other nations,
and some 18 states in the United States have
determined that dry needling techniques fall
within the scope of physical therapy practice.33,34 Other states such as California, New
York, North Carolina, Hawaii, and Tennessee have proscribed the practice outright.35
In order to understand the potential benefits
and risks of amending state practice acts, the
arguments of the stakeholders on both sides
need to be addressed.
ACUPUNCTURISTS
Acupuncturists have been licensed to
practice in the US since 197336 and many
programs obtained national certification in
1982,37 culminating in 16,000 acupuncturists currently in practice38 nationwide.
Forty-three states require certification for
licensure.39 Acupuncture practitioners
have been opposed to the inclusion of dry
needling in physical therapy practice acts
in Virginia and Colorado40,41 and other
states.35 Their objections are based on the
duration of the needling certification programs, concerns for the safety of patients
and encroachment on professional territory
by physical therapists.35,40,41 with resultant
specific criteria changes to the practice acts
in these states. Acupuncture professional
associations claim that physical therapists
can become certified in dry needling techniques with a course of only 54 hours, while
the majority of acupuncture certification
programs have requirements of 1,90542 to
3,000 hours of education from some 57
accredited programs.35,43 This claim disguises
the fact that dry needling certification is a
postgraduate course following graduation
213
from one of 200 masters or doctoral physical therapy programs that receive accreditation from the Commission on Accreditation
in Physical Therapy Education (CAPTE).44
Entry-level DPT programs typically comprise 2,676 hours of education33,45 and a
more extensive anatomy component than
acupuncture programs.33
Concern for patient safety is not without
merit, since skin penetration carries risk of
infection, disease transmission, and potential injury to soft tissue, nerve, and blood
vessels. However, there is no documented
evidence of increased litigation involving
therapists practicing dry needling or other
skin penetration techniques in states where
this is allowed.46,47 Regarding the territorial concerns, acupuncture practitioners
are concerned that the use of dry needling
by physical therapists encroaches on their
professional practice grounds. Dry needling has been identified as a component
of acupuncture practice, with acupuncturists invited to participate and teach on dry
needling courses.14,46 However, dry needling
practitioners limit their practice to management of MTrPs, with no claim to diagnosis
or management of systemic disease processes. Diagnosis and treatment of conditions using oriental medicine techniques
remains the domain of the acupuncture and
oriental medicine professions, and this is
affirmed by physical therapy practitioners
teaching courses in the United States and
internationally.46
PHYSICIANS
Physicians in particular, have been concerned about skin penetration by physical
therapists, objecting to the use of electromyography (EMG) by physical therapists
despite the inclusion of such procedures in
many state physical therapy practice acts for
decades.33,46,48 Several states license physical
therapists to use skin penetration in EMG
testing,33 and to date there has been no
documentation of any injuries or health
hazards for such therapists.33,46 Insurance
companies providing liability coverage for
physical therapists practicing dry needling
impose no additional requirements, other
than that they practice in a state that permits
the technique.47
CHIROPRACTORS
The Maryland chiropractic profession
took an interesting position towards dry
needling, initially opposing dry needling,
determining that it fell within the regulatory
practices of the state board of Acupuncture.
However, the Maryland Chiropractic Board
reversed its position in 2007 and allowed
chiropractors to use dry needling under their
physical therapy privileges, since the physical therapists in the state had been licensed
to do so since 1987. As in other states and
international communities, acupuncture is
determined to be “the use of oriental medical therapies for the purpose of normalizing
energetic physiological functions including
pain control, and for the promotion, maintenance, and restoration of health.36,41,49
The Maryland Chiropractic Board ruling
was based on the fact that acupuncture uses
needle insertion into fixed points and is
based on pre-scientific philosophies, whereas
dry needling into myofascial trigger points is
solely a local soft-tissue technique. Thus dry
needling is not based on Chinese philosophy of energetic systems, does not constitute
acupuncture, and is therefore not subject to
the regulation of the acupuncture licensing
boards.49
PHYSICAL THERAPISTS
The APTA is the national professional
organization of 72,000 physical therapists in
the United States.8 The APTA does not yet
have an official position on dry needling by
physical therapists, but recognizes that it is
a technique being used by some of its members.50 The APTA acknowledges that state
licensing boards, which have jurisdiction
over administration of each state’s PT act,
have been consulted regarding whether dry
needling falls within the scope of practice.
The answer across the states is mixed, with
5 states explicitly proscribing dry needling
(NV, NY, NC, ID, TN), stating that it is
not in the scope of practice. Fifteen boards
have interpretive opinions that it is within
the scope of practice in states allowing it,
and there have been no definitive statements
by the remaining 32. Arizona and Pennsylvania are legally prohibited from issuing
an interpretive statement. Statements by
physical therapy boards in the 18 states that
have amended the scope of PT practice to
include dry needling include language stipulating that neither the state medical board
nor the acupuncture board could rule on the
eligibility of appropriately trained physical
therapists to practice dry needling.51,52 Some
states issue contradictory statements. For
example, Florida proscribes “skin penetration” in dry needling by physical therapists,
but allows them to perform and analyze
EMGs, which by definition involves skin
penetration. Tennessee takes the position
that since no academic institutions in that
state teach dry needling to physical therapy
students, it should remain outside of the
scope of PT practice.33 This introduces the
dilemma of what to do once dry needling
is part of entry-level DPT programs, as it
is currently at Georgia State University,53
for example. It may be time to encourage
a national review of the scope of practice
for physical therapists. A recent report by
the Federation of State Boards of Physical
Therapy (FSBPT) outlines that there is a
historic basis, education and training, and
a scientific basis for use of dry needling by
physical therapists, provided competency
is determined to ensure safe practice.54 The
FSBPT conducts an analysis every 5 years
to determine actual practices within the profession. Also, the highly respected American
Academy of Orthopedic Manual Therapists
supports dry needling in the PT scope of
practice and indicates that research supports its use.55 As with any policy or practice
change, the process is likely to be slow and
piecemeal in nature, but gradual implementation of such changes can facilitate reflection and necessary critical analysis. In order
to reflect on the possibility of changing the
scope of practice of physical therapists, it
is important to understand the process by
which practice guidelines are determined.
Determining the Scope of Practice for
the Physical Therapists
In the United States, state physical
therapy boards determine the legal scope of
physical therapy practice in each state. The
Federation of State Boards of Physical Therapy (FSBPT) Model Practice Act provides
language to states for reference and consideration in the development of their individual
practice acts. In evaluating the current climate of health care practice and education,
the FSBPT recognizes the overlap of many
skills and procedures among professions,
stating that it is “no longer reasonable to
expect each profession to have a completely
unique scope of practice.”54 Devised with the
collaboration of the medical, nursing, social
work, pharmacist, occupational and physical therapy professional communities, the
FSBPT document provides a protocol for
state boards to use in decision making about
whether an intervention should be included
in the scope of practice. This protocol assists
in decision-making when considering practice act changes, with the primary focus on
whether the proposed changes “will better
214
protect and enhance consumers’ access to
competent health care services.”54 Proposed
changes to the scope of practice should
evaluate 4 critical areas: established history
of specific practices, adequate training, adequate evidence of benefit to public health,
and appropriate regulation. The FSBPT
maintains that adequate evidence in each
of these areas suggests that scope of practice
changes would be in the public’s best interest.54 This position echoes that of the Federation of State Medical Boards (FSMB), an
allied, parallel organization for physicians
and osteopaths. This group outlines the
multifactorial nature of scope of practice
decisions, including workforce needs and
availability, financial motivations, economic
circumstances, and consumer demand, with
the ultimate goal of protecting public health
and safety.56 In order for there to be a rational, useful approach to broadening the scope
of practice of a health care practitioner, there
must be judicious use of the guidelines that
have been developed for this purpose.
Guidelines for Changes to the Scope of
Practice
According to the FSBPT and the FSMB,
scope of practice should be reviewed when
the following factors have been considered:
where there exists a need for the proposed
scope of practice; when the existing scopes
of practice, if altered, will result in a positive change in public health and safety;
where there exists formal education, training, and accreditation processes for the
change in scope of practice; where appropriate evaluation and disciplinary procedures
are established; where accountability and
liability issues have been clarified and where
the effects on other practitioners have been
reviewed.54,56 Using these criteria, the broadening of the scope of practice for physical
therapists to include dry needling, would be
approved. First, more than a third of the US
physical therapy boards have issued interpretations that dry needling is within the PT
scope of practice. Such changes in physical therapy state practice acts parallel the
practices of Canada and many countries in
Europe, Asia, and South America. Second,
there has been no increased incidence of
injury to the health of patients when managed by physical therapists who use techniques that puncture the skin. Third, there
are 3 main US programs for accredited needling education programs, and reciprocity
already exists among the international programs for dry needling certification. Fourth,
Orthopaedic Practice Vol. 23;4:11
physical therapists practicing dry needling
are accountable under standard rules of
practice, and have the same requirements to
carry malpractice and liability insurance as
those who do not practice needling. Finally,
there is no documented adverse financial
effect on other practitioners when physical
therapists are licensed to practice dry needling. In fact, there may be an opportunity
for both acupuncturists and physical therapists to improve their position in the market
if both groups could market their nonsurgical, nonpharmaceutical approach to pain
management.
Planning or Policy Strategies that Might
Mitigate Differences
In negotiations, success results from collaborative efforts to resolve any impasse.57
The APTA and the American Association
of Acupuncture and Oriental Medicine
(AAAOM) could collaborate on combined
statements, with a unified marketing campaign for consumer education to differentiate between acupuncture and dry needling.
University programs for dry needling could
be developed in collaboration with all interested parties.33,58 Combined physical therapist and acupuncturist lobbying for third
party payor reimbursement could be more
successful than the current situation where
each professional community struggles for
reimbursement independently.59,60 Benefits could include improved teamwork of
medical doctors, physical therapists, and
acupuncturists to optimize patient care.
Reduced costs for the consumer could result
as all providers compete in the open market
for myofascial pain management services. As
continued research would determine best
practices, collaborating professionals would
be quick in adjusting their practice to reflect
new knowledge. The concept of an extended
scope of practice for physical therapists is not
an expansion of physical therapists interest
in needling therapy, but is a component of a
global shift in health care service utilization.
Extended Scope of Practice in Health
Care Professions
An international summit on advanced
scope of practice and direct access to physical therapy was held in Washington in October 2009 to examine current international
demands and practices, and to determine
the implications of increased practice scope
on interprofessional relationships, professional boundaries, and role definitions.61
National and international developments
Orthopaedic Practice Vol. 23;4:11
to alter the scope of practice of physical
therapists and other medical professionals
are underway, in order to mitigate the current stresses on the health care system.54,56,61
These scope of practice changes follow the
development of the nurse practitioner and
physician assistant professions, whose origins as legitimate medical professionals grew,
in the past 50 years, out of the financial and
workforce constraints on the general physician and medical community.62,63 Physical therapists are currently being trained in
joint injections,64 musculoskeletal triage in
emergency rooms,65 and first-line health care
management.66 The changing tide of clinical
practice is not likely to reverse, as increasing demands on finite financial resources
continue.1
SUMMARY
Current US and International Practice,
Recommendations for the Future
Dry needling is already within the scope
of physical therapy practice in many areas
(18 US states34); skin penetration by physical therapists for EMG is allowed in many
US states, and Canada, South America,
Europe, Asia, Australia, and New Zealand.
With minimal risk and increased benefits to
the majority of stakeholders, dry needling
practiced within an increased scope of PT
professionals will be of benefit to the public,
bringing American clinicians in-line with
their international colleagues.
The APTA’s “2020 vision” for physical therapy includes a commitment to lifelong learning with use of evidence-based
practice.6 Articles published in respected,
peer-reviewed journals underscore the continued need for expert clinicians to critically appraise and conduct research. The
current emphasis in physical therapy education is on research to support and challenge clinical practices. With increasing
use of dry needling by physical therapists,
the research emphasis should include dry
needling within efficacy and comparative
effectiveness studies. Doctoral level physical
therapists who acquire these skills as part of
their core curricula67 are well suited for such
215
analysis and research, and their dissertations
could explore the comparative effectiveness
of dry needling and other manual therapy
techniques.
Many techniques are not unique to a specific profession. There are ongoing battles for
territory between chiropractors and physical therapists over manipulation and joint
mobilization,68,69 between athletic trainers
and physical therapists over manual therapy
techniques,70 with physicians and physical
therapists performing EMG tests,71,72 and
physicians referral to in-house physical therapy practices.73,74 The global trends in health
care management are to look broadly across
the professional spectrum to determine
where patients can benefit from skilled care
provided by appropriately trained clinicians,
at the lowest cost. The future objective will
be to use best practices for best outcomes
and for the best financial value. The territorial battles are likely to continue, but will
diminish in intensity as adversaries compete
to demonstrate optimization of outcomes
and not compete over ownership of specific
techniques.
CONCLUSIONS
Physical therapists are positioned as
expert clinicians in the health care community with a broad spectrum of techniques
for nonsurgical management of musculoskeletal pain and dysfunction. Inclusion of
dry needling within the scope of PT practice will ensure further high-quality research
and clinical practice with better outcomes in
this field. Use of dry needling by qualified,
licensed physical therapists will bring American physical therapy professionals in line
with current international standards of practice, and provide patients with more options
for management of musculoskeletal pain.
In the costly arena of arthritis, movement
dysfunction, and pain management, extending the physical therapy scope of practice to
include dry needling will improve in consumer choice, increase evidence-based practice, and facilitate cost-containment.
REFERENCES
1. US Department of Health and Human
Services: National health expenditure
highlights 2007. http://www.cms.hhs.
gov/NationalHealthExpendData/downloads/highlights.pdf. Accessed October
1, 2009.
2. Wheeler AH. Myofascial pain disorders: theory to therapy. Drugs.
2004;64(1):45-62.
3. Tough EAM, White ARMD, Richards SP, Campbell JMD. Variability
of Criteria Used to Diagnose Myofascial Trigger Point Pain Syndrome-Evidence From a Review of the Literature.
Clinical Journal of Pain March/April.
2007;23(3):278-286.
4. American Physical Therapy Association. Federal Coordinating Council on
Comparative Effectiveness Research:
Priorities for Comparative Effectiveness Research in Physical Therapy.
http://www.apta.org/AM/Template.
cfm?Section= Advocacy&Template=/
MembersOnly.cfm&ContentID=57765
&Navmenuid=3218&Directlistcomboi
nd=D. Accessed October 1, 2009.
5. New York State Education Department: Office of the Professions: Physical Therapy http://www.op.nysed.gov/
article136.htm
6. American Physical Therapy Association:
Vision Statement for Physical Therapy 2020. http://www.apta.org/AM/
Template.cfm?Section=Vision_20201
&Template=/TaggedPage/TaggedPageDisplay. cfm&TPLID=285&Content
ID=32061. Accessed October 20, 2009.
7. Mitchell J, Lissovoy G. A comparison
of resourse use and cost in direct access
versus physician referral episodes of
physical therapy. Phys Ther. 1997;77:9.
8. American Physical Therapy Association: About APTA. http://www.apta.
org/AM/Template.cfm?Section=About_
A P T A & Te m p l a t e = / Ta g g e d P a g e / Ta g g e d P a g e D i s p l a y.
cfm&TPLID=41&ContentID=23725.
Accessed October 1, 2009.
9.Careers Research: Physiotherapist.
http://www.ca.courses-careers.com/
articles/physiotherapist.htm. Accessed
October 1, 2009.
10.Australian Physiotherapy Association:
Acupuncture and Dry Needling Group.
http://www.physiotherapy.asn.au/index.
php/groups/acupuncture-and-dry-needling. Accessed October 1, 2009.
11.New Zealand Society of Physiothera-
pists: Physiotherapy Acupuncture Association of New Zealand. http://www.
physiotherapy.org.nz/. Accessed October 12 2009.
12. Acupuncture Association of Chartered
Physiotherapists: Comment of new
“N.I.C.E.” guidelines for acupuncture.
http://www.aacp.uk.com/RelatedFiles//
Reports/PressRelease.pdf.
Accessed
October 20, 2009.
13. Global Education of Manual Therapists
GEMt: Advancing the art and science of
physical therapy: courses. http://www.
gemtinfo.com/. Accessed October 20,
2009.
14.Myopain Seminars: setting the standards for myofascial trigger point
education worldwide. http://www.myopainseminars.com/sponsoredcourses.
html. Accessed October 12, 2009.
15. Institute for the Study and Treatment of
Pain: iSTOP: courses. http://www.istop.
org/training.html. Accessed October 12,
2009.
16.Acupuncture Association of Chartered Physiotherapists: Clinical Interest
Group of the Chartered Society of Physiotherapists. http://www.aacp.org.uk/.
Accessed October 12, 2009.
17.Australian Physiotherapy Association:
Acupuncture and Dry Needling Group
(ADNG). http://www.physiotherapy.
asn.au/index.php/groups/acupunctureand-dry-needling Accessed September
29, 2009.
18. Furlan ADMD, van Tulder MP, Cherkin
DP, et al. Acupuncture and Dry-Needling for Low Back Pain: An Updated
Systematic Review Within the Framework of the Cochrane Collaboration.
Spine. 2005;30(8):944-963.
19. World Health Organization: Acupuncture; Review and analysis of reports on
controlled clinical trials. http://apps.
who.int/medicinedocs/en/d/Js4926e/.
Accessed October 11, 2009.
20.Pain Education: Dr. Janet G.Travell:
the mother of myofascial trigger point
knowledge. http://www.pain-education.
com/100143.php. Accessed October 20,
2009.
21. Travell J, Simons DG. Myofascial pain
and dysfunction: the trigger point manual.
2nd ed. Baltimore: Williams and
Wilkins; 1987.
22.Hong C-Z, Simons DG. Pathophysiologic and electrophysiologic mechanisms of myofascial trigger points. Arch
Phys Med Rehabil. 1998;79(7):863-872.
216
23.Hsieh C-YJ, Hong C-Z, Adams AH,
et al. Interexaminer reliability of the
palpation of trigger points in the trunk
and lower limb muscles. Arch Phys Med
Rehabil. 2000;81(3):258-264.
24.Gerwin RD, Shannon S, Hong C-Z,
Hubbard D, Gevirtz R. Interrater reliability in myofascial trigger point examination. Pain. 1997;69(1-2):65-73.
25. 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(1):3-10.
26.Chen J-TMD, Chung K-CP, Hou
C-RBSN, Kuan T-SMD, Chen
S-MMD, Hong C-ZMD. Inhibitory
Effect of Dry Needling on the Spontaneous Electrical Activity Recorded
from Myofascial Trigger Spots of Rabbit
Skeletal Muscle. Am J Phys Med Rehabil.
2001;80(10):729-735.
27. Gerwin RD. Neurobiology of the myofascial trigger point. Baillière’s Clin Rheumatol. 1994;8(4):747-762.
28.Fine PG, Milano R, Hare BD. The
effects of myofascial trigger point injections are naloxone reversible. Pain.
1988;32(1):15-20.
29. Physiotherapy Acupuncture association
of New Zealand Inc. 2011; http://www.
paanz.org.nz/mainmenu85/page104/
Certificate+in+Acupuncture+Qualificat
ion.html. Accessed February 18, 2011.
30. Irnich D, Behrens N, Gleditsch JM, et
al. Immediate effects of dry needling and
acupuncture at distant points in chronic
neck pain: results of a randomized,
double-blind, sham-controlled crossover
trial. Pain. 2002;99(1-2):83-89.
31. Gunn C, Milbrandt W, Little A, Mason
K. Dry Needling of muscle motor points
for chronic low back pain: a randomized
clinical trial with long term follow up.
Spine. 1980;5(3):13.
32. Gerwin R. Interexaminer-reliability and
myofascial trigger points. Arch Phys Med
Rehabil. 2000;81:2.
33.American Association of Acupuncture and Oriental Medicine: Qi Unity
Report: Dommerholt: Dry needling
response letter. http://www.bethesdaphysiocare.com/professionals/pdf/qiunity_dryneedlingissue08.pdf. Accessed
October 7, 2009.
34.Is dry needling within your scope of
practice? . 2011; http://www.kinetacore.
Orthopaedic Practice Vol. 23;4:11
com/physical-therapy/Is-Dry-NeedlingIn-Your-Scope-of-Practice/page63.
html. Accessed June 10, 2011.
35. American Association of Acupuncture
and Oriental Medicine: AAAOM Dry
Needling Letter http://www.aaom.info/
qiunity/07/10/dry_needling_letter.pdf.
Accessed October 1 2009.
36.Academy of Chinese Medicine USA:
history of acupuncture in the USA.
http://www.acmusa.org/acuhisty.htm.
Accessed October 19, 2009.
37. National Certification Commision for
Acupuncture and Oriental Medicine.
http://www.nccaom.org/about/about.
html. Accessed October 1, 2009.
38. American College of Acupuncture and
Oriental Medicine: FAQ’s. http://www.
acaom.edu/en/cms/?842.
Accessed
October 10, 2009.
39. National Certicication Commission for
Acupuncture and Oriental Medicine:
state licensure requirements. http://
www.nccaom.org/applicants/state_data/
State_sheet.htm. Accessed October 22,
2009.
40. American Association of Acupuncture
and Oriental Medicine: News alert:
Dry needling response letter. http://
www.aaaomonline.org/pressroom.
asp?pagenumber=48266.
Accessed
October 12, 2009.
41. Dry Needling and Acupuncture, Emerging Professional Issues. http://www.
aaaomonline.info/qiunity/07/10/2a.
html. Accessed October 1 2009.
42. Council of Colleges of Acupuncture and
Oriental Medicine: FAQ: duration of
program. http://www.ccaom.org/faqs.
asp#7. Accessed October 23, 2009.
43. Accreditation Commision for Acupuncture and Oriental Medicine: accredited programs. http://www.acaom.org/
accprgs.asp. Accessed October 21, 2009.
44.American Physical Therapy Association: CAPTE Accredited Physical Therapist Education Programs
http://www.apta.org/AM/Template.
cfm?Section=CAPTE3&Template=/
aptaapps/accreditedschools/acc_schools_map.
cfm&process=3&type=PT.
Accessed
October 20, 2009.
45.American Physical Therapy Association: Capte Accredited Physical Therapy
Education Programs. http://www.apta.
org/AM/Template.cfm?section=PT_
Pr o g r a m s & t e m p l a t e = / a p t a a p p s /
accreditedschools/acc_schools_map.
Orthopaedic Practice Vol. 23;4:11
cfm&process=3&type=PT.
Accessed
October 23, 2009.
46. Dommerholt J. Dry Needling in Orthopaedic Physical Therapy Practice. Orthop
Phys Ther Practice. 2004;16(3):6.
47. Herder T. Healthcare Providers Service
Organization: dry needling inquiry (personal communication) ed2009:1.
48. Guide to Physical Therapy Practice. 2nd
ed. Alexandria, VA: American Physical
Therapy Association; 2003.
49.Maryland Chiropractic Association:
Maryland Board of Chiropractic Examiners Now Approves Dry-Needling As
Being Within the Scope of Practice for
Chiropractors But… http://www.marylandchiro.com/index.php?file=index.
html. Accessed October 23, 2009.
50. Bradley B. American Physical Therapy
Association: Official Position on Dry
Needling for Physical Therapists. (personal communication) ed2009.
51.Oregon Physical Therapist Licensing
Board: Board Determines That Dry Needling Is Within PT Scope Of Practice.
http://www.oregon.gov/PTBrd/docs/
Publications/Newsletter.Summer.2009.
pdf Accessed October 23, 2009.
52.Oregon Physical Therapist Licensing Board: Board Discussion Regarding Use of Dry Needling. http://www.
oregon.gov/PTBrd/docs/Executive.
Minutes/07.17.2009.Board.Meeting.
Minutes.pdf. Accessed October 2, 2009.
53.Georgia State University: School of
Health Professions: graduate course
descriptions.
http://chhs.gsu.edu/pt/
docs/CourseDescriptions.pdf. Accessed
October 1, 2009.
54. Federation of State Boards of Physical
Therapy: Changes in Healthcare Professions’ Scope of Practice:Legislative Considerations. 2010; https://www.fsbpt.
org/download/ScopeOfPractice200908.
pdf Accessed February 17, 2011.
55.AAOMPT. Dry Needling: American
Academy of Orthopedic Manual Physical Therapists position statement. 2009;
http://www.aaompt.org/about/statements.cfm. Accessed Feb 19 2011.
56.Federation of State Medical Boards:
Assessing Scope of Practice in Health
Care Delivery:Critical Questions in
Assuring Public Access and Safety.
http://www.fsmb.org/pdf/2005_grpol_
scope_of_practice.pdf. Accessed October 21, 2009.
57. Fisher R, Ury W, Patton B. Getting to
“Yes”, negotiating agreement without
217
giving in. 2nd ed: Houghton Mifflin
Harcourt; 1992.
58. Georgia State University, Department of
Physical Therapy: Course Descriptions.
http://chhs.gsu.edu/pt/docs/CourseDescriptions.pdf. Accessed October 10,
2009.
59.American Association of Acupuncture and Oriental Medicine: Federal
Acupuncture Coverage Act of 2009.
http://www.aaaomonline.info/hinchey_
hr_646_fact_sheet.pdf. Accessed October 26, 2009.
60.
American Physical Therapy Association: Health Care Reform: Government Affairs Update. http://
www.apta.org/AM/Template.cfm?
S e c t i o n = A d v o c a c y & Te m p l a t e = /
C M / C o n t e n t Di s p l a y.
cfm&ContentID=64984.
Accessed
October 26, 2009.
61. International Summit on Direct Access
and Advanced Scope of Practice in
Physical Therapy. http://www.directaccesssummit.com/brochure.pdf Accessed
October 25, 2009.
62. American Association of Nurse Practitioners: Frequently Asked Questions:
Why Choose A Nurse Practitioner as
your Healthcare Provider? http://www.
aanp.org/NR/rdonlyres/67BE3A606E44-42DF-9008-DF7C1F0955F7/
0/09FAQsWhatIsAnNP.pdf Accessed
October 28, 2009.
63.Yale School of Medicine: Physician
Assistant program: History of the
Physician Assistant program. http://
medicine.yale.edu/pa/profession/history_profession.aspx Accessed October
28, 2009.
64.Chartered Society of Physiotherapy:
clinical guidelines for the use of injection therapy by physiotherapists. http://
www.csp.org.uk/uploads/documents/
csp_guideline_injection.pdf Accessed
October 20, 2009.
65. Anaf S, Sheppard LA. Physiotherapy as
a clinical service in emergency departments: a narrative review. Physiotherapy.
2007;93(4):243-252.
66.
Canadian
Physiotherapy
Association: Manitoba Branch:Physiotherapy
and Primary Health Care: Evolving
Opportunities.
http://www.manitobaphysio.com/pdf/FinalMBPHCReportJune_05_000.pdf. Accessed October
1, 2009.
67. American Physical Therapy Association:
2020 Vision Statement.
N
om
ina
tio
ns
68.
American Physical Therapy Association: Position on Thrust Joint
Manipulation Provided by Physical
Therapists. http://www.apta.org/AM/
Template.cfm?Section=State_Gov_t_
Affairs&Template=/CM/ContentDisplay.cfm&ContentID=56434. Accessed
October 23, 2009.
69. Virginia Board Of Medicine: Department Of Health Professions: Study
of Spinal Manipulation Pursuant
to Request from the Chair of the
Senate Committee on Education and
Health.
http://www.apta.org/AM/
Template.cfm?Section=State_Gov_t_
Affairs&Template=/CM/ContentDisplay.cfm&ContentID=54887. Accessed
October 23, 2009.
70.
National Athletic Trainers Association: Endorsed Model Legislative
Definitions/Terms.
http://www.apta.
org/AM/Template.cfm?Section=Top_
Issues2&Template=/MembersOnly.
cfm&ContentID=26425.
Accessed
October 23, 2009.
71.
American Physical Therapy Association: Electrophysiologic Examination
And
Evaluation
HOD
P06-96-20-04.
http://www.apta.org/
AM/Template.cfm?Section=Top_
Issues2&Template=/CM/ContentDisplay.cfm&ContentID=35129. Accessed
October 23, 2009.
72. American Physical Therapy Association:
letter to the American Medical Aassociation on EMG. http://www.apta.
org/AM/Template.cfm?Section=Top_
Issues2&Template=/MembersOnly.
cfm&ContentID=33478.
Accessed
October 23, 2009.
73.
American Physical Therapy Association: Position on PhysicianOwned Physical Therapy Services
(POPTS).
http://www.apta.org/
AM/Template.cfm?Section=Top_
Issues2&Template=/MembersOnly.
cfm&ContentID=26141.
Accessed
October 23, 2009.
74. American Physical Therapy Association:
Statement to the Federal Trade Commission/Department of Justice Joint
Hearings on Health Care Competition Law and Policy. http://www.apta.
org/AM/Template.cfm?Section=Top_
Issues2&Template=/MembersOnly.
cfm&ContentID=26146.
Accessed
October 23, 2009.
Orthopaedic
Section Awards
Now is the time to be thinking about and
submitting nominations for the Orthopaedic
Section Awards! There are many therapists in
our profession who have contributed so much,
and who deserve to be recognized. Please take
some time to think about these individuals and
nominate them for the Orthopaedic Section’s
highest Awards. Let’s celebrate the success of
these hard-working people!
• James A. Gould Excellence in Teaching
Orthopaedic Physical Therapy
• Outstanding Physical Therapy & Physical
Therapist Assistant Student Award
• Paris Distinguished Service Award
• Rose Excellence in Research Award
• Richard W. Bowling - Richard E. Erhard
Orthopaedic Clinical Excellence Award
Visit our Web site for more information about
the awards offered by the Orthopaedic Section
and the criteria for nominating an individual:
http://www.orthopt.org/awards.php.
218
Orthopaedic Practice Vol. 23;4:11
Narrative Review
Dry needling: a literature review with
implications for clinical practice guidelines1
James Dunning1,2, Raymond Butts3,4, Firas Mourad5, Ian Young6,
Sean Flannagan7, Thomas Perreault8
1
Alabama Physical Therapy & Acupuncture, Montgomery, AL, USA, 2American Academy of Manipulative
Therapy, Montgomery, AL, USA, 3University of South Carolina, Columbia, SC, USA, 4Palmetto Health Research
Physical Therapy Specialists, Columbia, SC, USA, 5Sportlife Physiotherapy, Montichiari, Italy, 6Spine & Sport,
Savannah, GA, USA, 7OneAccord Physical Therapy, Casa Grande, AZ, USA, 8Portsmouth-Newington Physical
Therapy, Portsmouth, NH
Background: Wet needling uses hollow-bore needles to deliver corticosteroids, anesthetics, sclerosants,
botulinum toxins, or other agents. In contrast, dry needling requires the insertion of thin monofilament
needles, as used in the practice of acupuncture, without the use of injectate into muscles, ligaments,
tendons, subcutaneous fascia, and scar tissue. Dry needles may also be inserted in the vicinity of
peripheral nerves and/or neurovascular bundles in order to manage a variety of neuromusculoskeletal pain
syndromes. Nevertheless, some position statements by several US State Boards of Physical Therapy have
narrowly defined dry needling as an ‘intramuscular’ procedure involving the isolated treatment of
‘myofascial trigger points’ (MTrPs).
Objectives: To operationalize an appropriate definition for dry needling based on the existing literature and
to further investigate the optimal frequency, duration, and intensity of dry needling for both spinal and
extremity neuromusculoskeletal conditions.
Major findings: According to recent findings in the literature, the needle tip touches, taps, or pricks tiny nerve
endings or neural tissue (i.e. ‘sensitive loci’ or ‘nociceptors’) when it is inserted into a MTrP. To date, there is
a paucity of high-quality evidence to underpin the use of direct dry needling into MTrPs for the purpose of
short and long-term pain and disability reduction in patients with musculoskeletal pain syndromes.
Furthermore, there is a lack of robust evidence validating the clinical diagnostic criteria for trigger point
identification or diagnosis. High-quality studies have also demonstrated that manual examination for the
identification and localization of a trigger point is neither valid nor reliable between-examiners.
Conclusions: Several studies have demonstrated immediate or short-term improvements in pain and/or
disability by targeting trigger points (TrPs) using in-and-out techniques such as ‘pistoning’ or ‘sparrow
pecking’; however, to date, no high-quality, long-term trials supporting in-and-out needling techniques at
exclusively muscular TrPs exist, and the practice should therefore be questioned. The insertion of dry
needles into asymptomatic body areas proximal and/or distal to the primary source of pain is supported by
the myofascial pain syndrome literature. Physical therapists should not ignore the findings of the Western or
biomedical ‘acupuncture’ literature that have used the very same ‘dry needles’ to treat patients with a
variety of neuromusculoskeletal conditions in numerous, large scale randomized controlled trials. Although
the optimal frequency, duration, and intensity of dry needling has yet to be determined for many
neuromusculoskeletal conditions, the vast majority of dry needling randomized controlled trials have
manually stimulated the needles and left them in situ for between 10 and 30 minute durations. Position
statements and clinical practice guidelines for dry needling should be based on the best available
literature, not a single paradigm or school of thought; therefore, physical therapy associations and state
boards of physical therapy should consider broadening the definition of dry needling to encompass the
stimulation of neural, muscular, and connective tissues, not just ‘TrPs’.
Keywords: Dry needling, Literature review, Trigger point, Practice guidelines, Physical therapy
Introduction
1
This paper should be attributed to: Alabama Physical Therapy &
Acupuncture, Montgomery, AL, USA.
Correspondence to: James Dunning, 1036 Old Breckenridge Lane,
Montgomery, AL 36117, USA. Email: [email protected]
252
ß W. S. Maney & Son Ltd 2014
DOI 10.1179/108331913X13844245102034
MORE OpenChoice articles are open access and distributed under the terms of
the Creative Commons Attribution Non-Commercial License 3.0
Local injection therapies, often referred to as ‘wet needling’, use hollow-bore needles to deliver corticosteroids,
anesthetics, sclerosants, botulinum toxins, or other
agents.1,2 In contrast, ‘dry needling’ refers to the
Physical Therapy Reviews
2014
VOL .
19
NO .
4
Dunning et al.
insertion of thin monofilament needles, as used in
the practice of acupuncture, without the use of
injectate.3–6 Dry needling is typically used to treat
muscles, ligaments, tendons, subcutaneous fascia,
scar tissue, peripheral nerves, and neurovascular
bundles for the management of a variety of neuromusculoskeletal pain syndromes.3,6,7 Given the broad
base of international literature presently available on the
technique, it is particularly concerning that the primary
US-based, National Physical Therapy Association8 and
several State Boards of Physical Therapy9–13 have
recently narrowed their definition of dry needling to
an ‘intramuscular’ procedure, i.e. the insertion of
needles into nodules within taut bands of muscle,
more commonly referred to as ‘trigger points’ (TrPs)
or ‘myofascial trigger points’ (MTrPs). More specifically, these professional organizations have equated
the procedure of dry needling with the term
‘intramuscular manual therapy’ (IMT) or ‘trigger
point dry needling’ (TDN). Certainly, IMT, or the
insertion of needles into TrPs within muscle bellies, is
one aspect of dry needling; however, IMT or TDN
should not be used synonymously with the term dry
needling. In addition to TrPs within muscular tissue,
an extensive body of literature, including both peerreviewed articles and randomized controlled trials,
supports the insertion of dry needles throughout the
body at non-TrP sites for the purpose of reducing
pain and disability in patients with neuromusculoskeletal conditions. Just as the Maitland,14 Kaltenborn,15
and McKenzie16 approaches are each unique brands of
manual therapy, ‘TDN’ and ‘IMT’ are individual
aspects of dry needling. Each describes a single
framework, paradigm, or approach that falls under
the much larger field of dry needling.5,6,9,10,17–25
Dry Needling Targets Neural, Muscular, and
Connective Tissues, Not Just TrPs
The first, peer-reviewed journal article on dry
needling published by a Western, medical physician6
did not limit needle insertion to muscular ‘TrPs’;
rather, the 241-patient study reported that only 2 of
the 14 target structures were muscular TrPs.6 The
other structures needled included ligaments, scar
tissue, tendons, bones, and teno-osseus insertion
sites, all of which are types of connective tissue.6 In
addition, ‘a high density of neurovascular structures’
has been found at dry needling target sites.26
As early as 1977, Melzack et al.27 stated that
‘Trigger points are firmly anchored in the anatomy of
the neural and muscular systems… and the stimulation of particular nerves or tissues by needles could
bring about an increased input to the central biasing
mechanism, which would close the gates to [pain]
inputs from selected body areas’.27 In a more recent
commentary titled ‘Treatment of Myofascial Pain
Dry needling
Syndrome’, Hong stated that the purpose of ‘the fastin and fast-out needle technique’26,28–30 in a fan or
cone shape is to ‘ensure that all or most sensitive loci
(i.e. tiny nerve endings) are encountered’.28 Widely
considered one of the world authorities on both dry
needling practice and experimental research, Hong
further reported that ‘high-pressure stimulation by
needling’26,28,31–33 or ‘mechanical irritation of the
needle’26,34 to ‘multiple sensitive loci or nociceptors
within the same MTrP’26,28,31–34 likely ‘elicits a local
twitch response that subsequently provides a very
strong neural impulse to the MTrP circuit to break the
vicious cycle so that MTrP pain is relieved’.26,28,33,34
Interestingly, ‘bilateral or mirror image evoked
potentials’ or ‘local twitch responses’34 (LTRs) have
been recorded in the contralateral trapezius during
unilateral dry needling stimulation of active TrPs on
the ipsilateral, symptomatic trapezius.34 Audette
et al.34 concluded, ‘the LTR is generated by inducing
a spinal reflex that involves sensory input to the spinal
cord by mechanical irritation of the needle at sensitive
loci in the TrP which then results in a motor, efferent
response of the alpha motor neuron pool’.34 The
presence of bilateral LTRs during unilateral dry
needling ‘argues strongly for a central abnormality
rather than a purely peripheral [muscular] abnormality
in patients with active MTrPs’.34
Thus, within the context of myofascial pain
syndromes, dry needles likely come in contact with
both muscle and connective tissue.6 It is held by several
research teams that needles inserted into MTrPs likely
touch, tap, or prick tiny nerve endings or neural tissue
for the purpose of pain reduction. Based on the most
recent literature,6,21,26,28–37 the definition of dry needling by the American Physical Therapy Association
(APTA) and State Boards of Physical Therapy
should therefore clearly articulate that dry needling
encompasses stimulation of neural,26,28–31,33,36,38–54
muscular,5,17,18,21,26,29,30,33,48,55–69
and
connective
tissues,6,48–54,70–72 and not just ‘TrPs’.73,74
2013 APTA Definition: Dry Needling Targets
Both Muscular and Connective Tissues
Page two of the January 2012 Resource Paper8 titled,
Physical Therapists & the Performance of Dry
Needling defined dry needling as ‘an invasive technique used by physical therapists (where allowed by
state law) to treat myofascial pain that uses a dry
needle, without medication or injection, which is
inserted into areas of the muscle known as trigger
points…’8 Notably, an updated February 2013 APTA
version of this document titled, Description of Dry
Needling in Clinical Practice: an Educational Resource
Paper, defines dry needling as including both
muscular and connective tissues, but not neural
stimulation.75 The paper reads, ‘dry needling is a
Physical Therapy Reviews
2014
VOL .
19
NO .
4
253
Dunning et al.
Dry needling
skilled intervention that uses a thin filiform needle to
penetrate the skin and stimulate underlying myofascial trigger points, muscular, and connective tissues
for the management of neuromusculoskeletal pain
and movement impairments’.75 Interestingly, the
2013 definition implies that only muscle and connective tissue may be targeted by dry needles in the
treatment of neuromusculoskeletal pain.26,28,31–34
Yet, nerve endings, referred to as ‘sensitive loci’ or
‘neurovascular bundles’ are clearly supported as
needle stimulation targets in the existing literature.26
How can physical therapists treat the ‘neuro’ in
neuromusculoskeletal with dry needles without placing needles near, beside, or onto neural tissue (i.e.
peri-neural needling)? By adding neural targets to the
position statement, the APTA would provide a
stronger and more evidence-based framework for
state boards to follow.
Narrowly Focused Position Statements by State
Boards of Physical Therapy
To date, a number of State Physical Therapy
Boards9–13 continue to have limited definitions of
dry needling. As a result, many physical therapists
believe that they are only able to treat patients by
targeting intramuscular TrPs with dry needles, as
their respective State Boards do not authorize them
to insert needles into connective tissues (e.g. ligaments, tendons, teno-osseus junctions, musculotendinous junctions, scar tissue) or to perform peri-neural
or peri-neurovascular needling. Several State Boards
of Physical Therapy have issued narrowly focused
position statements on dry needling:
N
254
Mississippi (Effective: 10 September 2012): The
Mississippi State Board of Physical Therapy updated
its regulations to read, ‘Intramuscular manual therapy is a physical intervention that uses a filiform
needle no larger than a 25-gauge needle to stimulate
trigger points, diagnose and treat neuromuscular pain
and functional movement deficits; is based upon
Western medical concepts; requires an examination
and diagnosis, and treats specific anatomic entities
selected according to physical signs’.10
N
North Carolina (Effective: 14 June 2012): The North
Carolina Board of Physical Therapy Examiners
revised its definition of dry needling to read,
‘Intramuscular Manual Therapy (IMT), which is
generally referred to as dry needling, is defined as a
technique to treat myofascial pain using a dry needle
(without medication) that is inserted into a trigger
point with the goal of releasing/inactivating the
trigger points and relieving pain’.9
N
Louisiana (Effective: 20 October 2011): Rule 311 of
the Louisiana Physical Therapy State Board uses the
terms ‘dry needling’ and ‘intramuscular dry needling’
interchangeably, and as a result, requires a physical
therapist to ‘successfully complete…no fewer than
50 hours of face-to-face instruction in intramuscular
dry needling treatment and safety’.11
Physical Therapy Reviews
2014
VOL .
19
NO .
4
N
Nebraska (Effective: 20 June 2011): The Nebraska
State Board of Physical Therapy opined, ‘Dry
needling is a mechanical modality technique used to
treat myofascial pain that uses a dry needle, without
medication, that is inserted into a trigger point with
the goal of releasing/inactivating the trigger points’.12
N
Colorado (Effective: 30 June 2012): The Colorado
State Physical Therapy Board opined, ‘Dry needling
(also known as Trigger Point Dry Needling) is a
physical intervention that uses a filiform needle to
stimulate trigger points, diagnose and treat neuromuscular pain and functional movement deficits; is
based upon Western medical concepts; requires an
examination and diagnosis, and treats specific anatomic entities selected according to physical signs.
Dry needling does not include the stimulation of
auricular or distal points’.13
Whether these State Boards of Physical Therapy9–13
will update their position statements and/or practice
acts to include both neural and connective tissue as
possible target structures for dry needling remains to
be seen. However, Arizona has recently provided a
reason to be optimistic. In January 2013, the Arizona
Physical Therapy Association set the standard by
becoming the first US-based, physical therapy association to explicitly recognize neural, muscular, and
connective tissue as target sites for dry needling.76 The
definition of dry needling that appears in the Arizona
position statement reads,
It is the position of the Arizona Physical Therapy
Association that dry needling for the management of
neuromusculoskeletal conditions is consistent with
the scope of practice of licensed physical therapists
in Arizona. Dry Needling is a skilled intervention
performed by a physical therapist that uses a thin
filiform needle to penetrate the skin and stimulate
underlying neural, muscular and connective tissues
for the evaluation and management of neuromusculoskeletal pain and movement impairments.76
Page two of the January 2012 APTA Resource
Paper8 titled, ‘Physical Therapists & the Performance
of Dry Needling’, also states, ‘Preliminary research
supports that dry needling improves pain control,
reduces muscle tension, normalizes biochemical and
electrical dysfunction of motor endplates, and facilitates an accelerated return to active rehabilitation’.
However, although the reference list of the 141-page
resource paper8 cited four systematic reviews,17,19,24,56
one clinical review,21 and one unpublished evidence
summary,77 the 23 randomized controlled trials that
were reportedly reviewed and rated by a single expert
on a 0–5 scale for quality and level of support for dry
needling, were not individually identified or specifically referenced in any way.8 Moreover, while the
‘median quality of the research was 4’ and the ‘median
support for dry needling was 3’, the specific studies
included in the analysis remains a mystery.8 This
resource paper8 also failed to describe available
Dunning et al.
literature on neuromusculoskeletal conditions that
supports the use of ‘TrP’ dry needling.
It is concerning that the APTA8,75 and several State
Boards of Physical Therapy9–13 continue to omit
neural and/or connective tissue as possible target
structures when defining dry needling in official
position statements. Perhaps position statements that
compartmentalize dry needling to ‘IMT’ – i.e. confine it
to muscle bellies, tight knots, or ‘myofascial TrPs’,8–11 –
fit better with the traditional physical therapy framework. Given that other professions continue to
question whether dry needling is within the scope of
practice of a physical therapist, declaratory statements by State Boards of Physical Therapy that
operationalize dry needling with an ‘intramuscular’9–13
framework may be a more defensible position.
Certainly, ‘nerve points’42,43 sound a little ‘Eastern’
to some, and may, at face value, be confused with
traditional Chinese acupuncture; however, dry needling neither attempts to move qi along meridians, nor
does it rely on diagnoses from traditional Chinese
acupuncture or Oriental medicine.78,79
TrP Needling is Only One Kind of Dry Needling
In 2009, the APTA recommended ‘IMT’ as the term
to be used by physical therapists to describe the
intervention of dry needling.8 The following excerpt
is from page two of the January 2012 Resource Paper
titled, ‘Physical Therapists & the Performance of Dry
Needling’:
Dry needling is an invasive technique used by
physical therapists (where allowed by state law)
to treat myofascial pain that uses a dry needle,
without medication or injection, which is inserted
into areas of the muscle known as TrPs. A TrP
describes a taught band of skeletal muscle located
within a larger muscle group. Trigger points can be
tender to the touch and can refer pain to distant
parts of the body. Physical therapists utilize dry
needling with the goal of releasing/inactivating the
TrPs and relieving pain.8
This definition seems to suggest that physical
therapists should only insert needles into muscle
bellies in an attempt to inactivate TrPs. This recommendation makes sense considering Itoh et al.80 found
that ‘TrP acupuncture’ of the splenius capitis, upper
trapezius, levator scapulae, sternocleidomastoid, suboccipitals, scaleni and paravertebrals was more effective in the short-term (i.e. at week 13) at reducing pain
and disability than classical or sham acupuncture in
patients with chronic, non-radiculopathic neck pain.
In contrast, Tough et al. concluded in a 2009 systematic review and meta-analysis that ‘there is limited
evidence deriving that deep needling directly into
myofascial trigger points has an overall treatment
effect when compared to standardized care’.24
Moreover, ‘the result of the meta-analysis of direct
Dry needling
dry needling [for myofascial trigger point pain]
compared to placebo control treatment did not attain
statistical significance’.24 There is a paucity of highquality evidence to underpin the use of direct dry
needling into myofascial TrPs for the purpose of short/
long-term pain and disability reduction in patients
with musculoskeletal pain syndromes.18,20,23,24,80
Rather, the vast majority of the dry needling literature
has demonstrated that targeting TrPs (i.e. muscle
tissue) and non-TrP structures (i.e. neural and
connective tissues) in combination, or non-TrP structures alone, is effective for the reduction of pain and
disability in knee osteoarthritis,50–51,81–83,85–90,166–168
hip osteoarthritis,53,91–94 piriformis syndrome,60 carpal
tunnel syndrome,36,37,40,41,44,45,47 migraine,95–101 tension type
headache,97,98,102 temporomandibular disorder,59,67,103–107
shoulder pain,108–110 neck pain,23,24,29,35,61,63–65,80,111–114 low
back pain,4,5,19,20,66,69,115–125 and plantar fasciitis.48,49,54,56,126,127
While many of these studies directly use the term
‘dry needling’,5,18,21,26,33,56,64,67,104,110 in their methodology, other studies use alternative terminology such
as ‘deep dry needling’,67 ‘superficial dry needling’,55,128
‘TrP acupuncture’,20,80 ‘paraspinal needling’,64 ‘intramuscular and nerve root needling’,65 ‘needle electrical
intramuscular stimulation’,129 ‘needle release’,113 ‘acupuncture needling’,63,113 ‘needling therapy’,17 ‘acupuncture’36–38,40,41,47,49–55,61,69,72,81–88,90,92,94–100,105–108,
112,115–117,119–123,130–135
and ‘electroacupuncture’.37,46,
93,126,127,136–139
Some studies have even chosen to use
both ‘acupuncture and dry needling’19,23,24,62,77 in
their titles. Importantly, none of the studies used
medicine and/or injectate in conjunction with their
needling procedure; therefore, all studies fit within the
strict definition of dry needling, regardless of
terminology. To our knowledge, no published randomized controlled trials, to date, have used the
words ‘IMT’ to describe a dry needling intervention
for any condition.
Interestingly, the most common term used to
describe dry needling is ‘acupuncture’. Physiotherapists and/or medical physicians114–116,119,171–174
within both government administered national health
services and mainstream university health systems53,90,
97–99,114,123,133,134,
in the UK,49,51,52,84,100,101,131,132
Canada,114 USA and Germany53,90,97–99,123,133,134 use
the term ‘acupuncture’ to describe dry needling
methodologies. The same is true of articles published
in mainstream, highly respected journals, including the
British Medical Journal,84,89,100,101,112,124 European
Journal of Pain,24,131 Archives of Physical Medicine
& Rehabilitation,17,22,60,109,140,141 Pain,6,44,87,111,123,125,
133,136,142
Annals of Internal Medicine,4,81,86,88,117,132
Headache,95,96 Rheumatology,35,51,82,85 Spine,5,19,66,114,
118,119,121,135
and Cochrane Database of Systematic
Reviews.62,108 Even the Physical Therapy Journal sponsored by the APTA has used acupuncture and
Physical Therapy Reviews
2014
VOL .
19
NO .
4
255
Dunning et al.
Dry needling
dry needling interchangeably in a recent publication.52
It would therefore be a mistake to ignore the
findings of high-quality, randomized controlled
trials,37,40,53,54,63,81,84,89,90,92,99,100,107,114,115,119,125,132,143 systematic reviews,17,19,23,56,83,97,121,144 meta-analyses,24,85
Cochrane reviews,62,108,145 the British practice
guidelines,124 the European practice guidelines,146,147
and the joint clinical practice guidelines from the
American College of Physicians and the American
Pain Society117 simply because they used the term
‘acupuncture’ instead of dry needling in their title and/
or methods section. Moreover, ignoring RCTs published by PhD and licensed acupuncturists (LAc) in
well-respected, peer-reviewed journals would be shortsighted. By disregarding these studies, physical therapists may limit their ability to support the use of dry
needling in clinical practice for treating knee osteoarthritis, shoulder pain, carpal tunnel syndrome,
migraine headache, tension type headache, hip pain,
low back pain, and neck pain.
Physical Therapists Should Not Ignore the
Findings of Western Acupuncture Trials
‘Acupuncture’ literally translates to ‘needle penetration’ (i.e. ‘acu’5needle; ‘puncture’5penetration), and
the vast majority of the ‘acupuncture’ trials are not
claiming to move qi along meridians or channels.
Furthermore, the vast majority of the so-called ‘acupuncture’ RCTs have used Western medical diagnoses
(not traditional Chinese or Oriental medicine78,79
diagnoses such as bi syndrome, qi, blood stagnation, and kidney yang deficiency143,148) such as
chronic neck pain,23,24,29,35,61,63–65,80,111–114 plantar fasciitis,48,49,54,56,126,127 knee osteoarthritis,50–52,81–90, and
carpal tunnel syndrome.36,37,40,41,44,45,47 These same
‘acupuncture’ trials have investigated the efficacy of
inserting thin filiform needles (without medicine) into
‘Ah-Shi points’ (Chinese for ‘auwh that’s where it hurts’
or ‘that’s it’; synonymous with trigger points57,58,154)
and/or non-trigger point locations. Thus, while the
terminology, theoretical constructs, and philosophies
are different, the actual procedure of inserting thin
monofilament needles, as used in the practice of
acupuncture, without the use of injectate is very similar
across professions.3 The use of McKenzie16 exercises
by a chiropractor does not make him or her a physical
therapist; likewise, the use of dry needles by a physical
therapist does not make him or her an acupuncturist.
Rather, these techniques are shared procedures among
a variety of healthcare professions. As an additional
comparison, physical therapist researchers do not
ignore or exclude studies published by MDs, DOs,
and DCs when citing references to support the use of
spinal manipulation treatments for a variety of
neuromusculoskeletal conditions simply because the
authors consider the techniques as ‘chiropractic’ or
256
Physical Therapy Reviews
2014
VOL .
19
NO .
4
‘osteopathic manipulations’. Physical therapists
should therefore not ignore the findings of large scale
randomized controlled trials available in the Western
or biomedical ‘acupuncture’ literature that use the
same ‘dry needles’ to treat patients with neuromuscular conditions.49,51–53,84,90,97–101,114,123,131–134
Poor Inter-Examiner Reliability for TrP Location
Barbero et al.150 reported ‘moderate to high’ intrarater reliability of an experienced physiotherapist for
determining the location of MTrPs within the upper
trapezius muscle. However, in a recent systematic
review on the reliability of physical examination for
the diagnosis of myofascial TrPs, Lucas et al.144
concluded, ‘There is no accepted reference standard
for the diagnosis of trigger points, and data on the
reliability of physical examination for trigger points
is conflicting’. In addition, a predictable pattern of
pain referral and the local twitch response are each
no longer considered to be sufficient or necessary
for the diagnosis of a TrP.22,25,144 After reviewing
nine studies on reliability, Lucas et al.144 further
concluded:
None of the nine studies in this systematic literature
review specifically reported inter-rater reliability
estimates for the identification of the location of
active trigger points in symptomatic participants….
At present, there is no data on the reliability of
pinpointing the exact location of active trigger
points…. The existing data on reliability pertain
only to agreeing if a muscle has the signs of a trigger
point and not the exact location of the taut band or
the nodule within the taut band.144
Lew et al.151 reported that the inter-examiner
agreement was only 21%, and Sciotti et al.142
reported error rates of 3.3–6.6 cm among examiners
attempting to identify the specific location of TrPs
in the upper trapezius muscle. In another recent
literature review, Myburgh et al.22 found poor interexaminer reliability of manual palpation of TrPs in
various muscle groups. Only ‘tenderness’ of the
upper trapezius, not the actual location of the TrP,
was found to be moderately reliable. In 2011,
Myburgh et al.152 similarly reported ‘good agreement between experienced practitioners’ for the
‘presence or absence’ of a clinically relevant TrP in
the upper trapezius muscle. However, this study,
like the many others,153–157 failed to investigate the
inter-rater reliability for determining the specific
location of the TrP within the target muscle. If
clinicians are not able to reliably identify TrPs, they
may not be able to consistently activate/deactivate
them by penetrating the nodule within the taught
band, as is commonly taught by Travell and
Simons.73,74 In fact, in a recent systematic review,
Tough et al.25 concluded, ‘There is a lack of robust
Dunning et al.
empirical evidence validating the clinical diagnostic
criteria [for TrP identification or diagnosis] proposed by both Travell and Simons (1999) and
Fischer (1997)’.
High-quality evidence suggests that manual examination for the identification of the specific location of
the ‘TrP’ is not a valid22,25,152 or reliable22,142,144,151
process between-examiners. Poor reliability of TrP
identification also makes it rather challenging, if not
impossible, for Physical Therapists to be in compliance with the APTA8 and several State Physical
Therapy Boards.9,10,11,12,13 As Lucas et al.144 summarizes, ‘It is not yet evident that examiners can
agree on the precise location of an active TrP; hence,
they cannot be relied upon to accurately insert the
needle into the nodule of the taut band’. Perhaps ‘TrP
dry needling’, or ‘IMT’,8–13 as performed by physical
therapists, does not meet the criteria of evidencebased practice (i.e. a valid and reliable diagnostic and
therapeutic intervention).
Ah-Shi Acupuncture Points and TrPs: Different
Theories, Similar Locations
Although ‘IMT’ or ‘TrP needling’ involves insertion
of needles into muscle bellies, Melzack et al.27
reported:
a high degree (71%) of correspondence between
MTrPs and acupuncture points, and it is very likely
that all MTrPs are Ah-Shi acupuncture points…
[however], trigger points are firmly anchored in the
anatomy of the neural and muscular systems, while
acupuncture points are associated with an ancient
conceptual but anatomically non-existent system of
meridians, which carry Yin (spirits) and Yang
(blood).27
Melzack et al.27 further concluded, ‘trigger points
and acupuncture points for pain, though discovered
independently, and labeled differently, represent the
same phenomenon and can be explained in terms of
the same underlying neural mechanisms’. More
recently, Dorsher and Fleckenstein,57 both medical
physicians, found that 238 (93.3%) of 255 common
MTrPs anatomically corresponded with classical
acupoints. Furthermore, ‘the marked correspondences of the pain indications (up to 97%) and
somatovisceral indications (up to 93%) of anatomically corresponding common MTrP-classical acupoint pairs provide a second, clinical line of
evidence that trigger points and acupuncture points
likely describe the same physiologic phenomena’.58
Dorsher further demonstrated a strong correspondence between the distributions of the myofascial
referred-pain patterns73,74 and acupuncture meridians78,79 of anatomically corresponding common
MTrP-classical acupoint pairs.
Dry needling
Biomechanical, Chemical, Endocrinological, and
Vascular Effects of Dry Needling
The biomechanical,70–72,158 chemical,141,159 and
vascular129,138,140,160–162 effects of needling either
superficial55 subcutaneous tissue (non-muscular) or
deep23,24,73,74 intramuscular tissue without injectate
have been well documented. Improved microcirculation around the knee joint has been demonstrated
following ‘dry’ needling into non-TrP locations,138 and
improved muscle blood flow has been found following
‘manual acupuncture’ in the lower extremities.163,164
Following needle electrical intramuscular stimulation
targeting MTrPs in patients with shoulder and cervical
myofascial pain syndrome, microcirculation above the
area of the MTrPs was found to have increased from
127.3 to 310.2 BPUs per Laser Doppler Flowmetry, a
greater than two-fold increase. Furthermore, low
blood flow seemed to correlate with pain intensity,129
suggesting that reduced microcirculation plays a
role in the pathophysiology of myofascial pain
syndrome.162,165 Electrical dry needling in patients
with knee osteoarthritis has also resulted in endocrinological changes, including increases in beta-endorphins and decreases in cortisol.136
Non-Trigger Point Dry Needling in Knee
Osteoarthritis and Carpal Tunnel Syndrome:
Highly Effective
Multiple studies have used dry needling of the
knee joint without targeting specific trigger points
to treat pain and disability in patients with
knee osteoarthritis.50–52,81–85,89,90,131 Recent systematic reviews and meta-analyses provide strong and
overwhelming evidence for the effectiveness of acupuncture in the treatment of knee osteoarthritis.166–168
According to the Cochrane Database systematic
review on acupuncture for peripheral joint osteoarthritis, Manheimer et al.167 found acupuncture to be
associated with a statistically significant and clinically
meaningful short term improvement in OA pain
when compared to a wait list control. Additionally,
this systematic review,167 which included 12 RCTs of
patients with knee OA and 4 trials of patients with
either knee or hip OA, reported statistically significant reductions in pain following acupuncture in
patients with knee OA at 6 months when compared
with sham acupuncture. Moreover, in an individual
patient data meta-analysis of 9 RCTs comparing real,
sham and no acupuncture for chronic pain conditions, Vickers et al.168 reported superior outcomes
using real acupuncture in the treatment of knee OA.
Additionally, a very recent meta-analysis166 of 11
high-quality RCTs concluded that real acupuncture
provides a significant reduction in pain immediately
following treatment compared to other physical
treatment methods, including sham acupuncture. In
contrast to the findings of the Cochrane Database
Physical Therapy Reviews
2014
VOL .
19
NO .
4
257
Dunning et al.
Dry needling
systematic review167 and two recent meta-analyses,166,168
it is noteworthy that an earlier trial84 found the
addition of real acupuncture to a course of advice and
exercise for the treatment of knee OA provided no
additional improvement in the WOMAC pain subscale at 6 months when compared to sham acupuncture. The data from Foster et al.84 also failed to
demonstrate a significant relationship between patient
treatment preferences and clinical outcomes or patient
expectations and pain at 6 and 12 months. However,
the results of Foster et al.84 should be viewed
cautiously due to the limited number of treatment
sessions in the acupuncture protocol compared to
other studies,53,81,88,90 which may have rendered the
true acupuncture intervention suboptimal, a concession that the authors independently made. More
importantly, unlike other trials,81,82,87–90 the subjects
in the Foster et al.84 trial did not have radiographically
confirmed knee osteoarthritis. Nevertheless, despite
the methodologic differences of the Foster et al.84 trial,
a cost-utility analysis of the Foster et al.84 data by
Whitehurst et al.52 concluded that advice and exercise
plus real acupuncture delivered by physical therapists
still provided a cost effective use of health care
resources.
Likewise, there is robust evidence that peri-neural
needling of non-trigger point structures helps reduce
pain and disability while improving sensory and
motor nerve conduction velocities.36,37,40,41,47 Perineural needling has also been shown to stimulate
microcirculation in patients with mild to moderate
carpal tunnel syndrome.36,37,40,41,47 Such findings
suggest that organizations that teach physical therapists a TrP ‘search and destroy’ method of dry
needling may not be evidence based. Rather, therapists may be much more effective treating conditions
such as osteoarthritis and carpal tunnel syndrome by
focusing on non-TrP locations such as neural,
connective, and muscle tissue.
Dry Needling for Tendinopathy, Not Just TrPs
Several recent studies7,158,161,164,169–171 support the
use of dry needling in the management of tendinopathy; more specifically, dry needling has been shown to
positively influence tendon healing by increasing blood
flow via local vasodilation161,163,164,169 and collagen
proliferation.158,170 It is theorized that the lack of
blood flow and subsequent hypoxic environment
contributes to ‘tendon dysrepair’172 and leads to the
pain and disability associated with chronic tendinopathy.7 In comparison to a superficial heating
modality, and following dry needling using ‘vertical
pecking’ between the tendon and its sheath, Kubo
et al.161 found statistically significant increases in
blood flow and oxygen saturation levels around the
Achilles tendon. Following dry needling to burninjured mice, and when compared with conventional
dressing, Lee et al.170 found significantly greater
basic fibroblastic growth factor and accelerated
tissue healing rates. Likewise, Langevin et al.158
reported significantly greater fibroblastic activity
following rotational needle manipulation in a
mouse model. Clearly, dry needling both superficial
and deep non-TrP locations results in significant
mechanical,70–72,158 chemical,141,159 endocrinological,136
microvascular,138,161,163,164,170 neural,36,41,47 and central
effects 38,39,44,46,130,137,160 (i.e. activation of the descending
pain inhibitory systems, cortex, hypothalamus, and
inactivation of the limbic system per recent fMRI, and
PET studies). As such, the physical therapy profession
must re-evaluate whether it is truly ‘best practice’ to limit
dry needling to muscle TrPs.
There is Limited Evidence Supporting the
Effectiveness of Deep TDN
Compared to sham or placebo treatments, a recent
systematic review and meta-analysis173 recommended
‘dry needling [directly into MTrPs] for decreasing
pain in patients with upper quarter myofascial pain
syndrome’; however, the data in this meta-analysis
was based on three ‘immediately after’ and two ‘at 4weeks’ post-treatment studies. More specifically,
although the findings of Kietrys et al.173 support the
immediate and short-term effectiveness of dry needling, it does not provide any evidence for the
long-term effects of direct TDN on pain or disability
in patients with upper quarter myofascial pain
syndrome.
There are three trials20,80,113 that seem to be
frequently cited by clinicians in support of deep
TDN; however, all three studies have significant
methodologic limitations. First, Ma et al.113 used a
‘mini-scalpel needle release’ surgical procedure
instead of monofilament dry needling in an effort
Table 1 Duration needles left in situ for neuromusculoskeletal condition.
Neuromusculoskeletal condition
Duration needles left in situ
10 minutes,20 15 minutes,68 20 minutes116,119,125,177 or 30 minutes.69,123,139
30 minutes,37,40,41 40 minutes47 or 60 minutes.36
5 minutes,56,178,179 15 minutes49 or 20 minutes.126,127
20 minutes51,81,82,87,88,136 or 30 minutes.88–90,138
5 minutes18 or 10 minutes.110
10 minutes,80 20 minutes61,132,174,180 or 30 minutes.111,112,133,181
20 minutes95 or 30 minutes.96,98–101
Low back pain
Carpal tunnel syndrome
Plantar fasciitis
Knee osteoarthritis
Shoulder pain
Neck pain
Headaches
258
Physical Therapy Reviews
2014
VOL .
19
NO .
4
Dunning et al.
to remove or disrupt a TrP within the upper trapezius.
As such, the study113 should not be cited in support
of ‘sparrow pecking’, ‘pistoning’, ‘fast-in fast-out’
intramuscular and deep TDN in patients with
myofascial pain syndrome. Second, although Itoh
et al.20 found that deep (20 mm) TrP acupuncture of
myofascial TrPs is more effective than either superficial (3 mm) TrP acupuncture or standard acupuncture, the conclusions should be cautiously considered
given the following methodological shortcomings: (1)
the sample contained just 35 patients that were further
split into three smaller groups, (2) the longest outcome measures for pain and disability were taken
just 4 weeks after the final needling session, (3) the
improvements in pain seen in the deep TrP acupuncture group was ‘reversed’ by the end of the 3-week no
treatment interval, (4) the between-group differences
for pain and disability were not statistically significantly different by week 13. Third, after comparing
TrP, standard, and sham acupuncture, Itoh et al.80
concluded that TrP acupuncture is more effective than
standard (traditional/classical) acupuncture and nonpenetrating sham acupuncture for reducing pain and
disability in patients with chronic, non-radiculopathic
neck pain. However, the 40-patient sample size was
divided among three smaller groups, and outcome
measures for pain and disability were taken only 3
weeks post-treatment.
Multiple Needles Should Be Left In Situ for 10–
30 minutes
Although the optimum dosage50,51,83,85,124 (frequency
of treatment sessions per week or month), duration
(length of time the needles should remain in situ), and
intensity (the number of needles used and degree of
manual manipulation or electrical stimulation) has
yet to be determined23,24,50,51,83,85,114,135,174 for many
neuromusculoskeletal conditions, the vast majority of
‘dry’ needling randomized controlled trials attempt to
elicit a deqi response.175,176 Deqi has been defined as a
dull ache, heaviness, distension, numbness, tingling,
cramping, pressure, fullness, spreading, warmth, or
coolness.175,176 In addition, most trials have left
multiple needles in situ for between 5 and 40-minute
durations; moreover, a recent systematic review and
meta-analysis19 within the framework of the
Cochrane collaboration concluded, ‘for low back
pain of any duration, needle retention for about
10 minutes is better than removal immediately after
insertion’.19 Table 1 provides the durations and
specific studies that multiple needles were left in situ
for a variety of neuromusculoskeletal conditions.
Even when ‘pistoning’, ‘sparrow pecking’, or ‘fastin-and-out’ maneuvers were used with the intent
of eliciting an LTR in muscular TrPs, multiple
needles were often left in place for ten minutes or
Dry needling
longer.20,80 While several studies29,35,59,63,64,67,102,104,182,183
have demonstrated immediate and/or short-term
improvements in pain and/or disability following ‘inan-out’ techniques, to date, there are no high-quality
long-term trials23,24 to support the practice of immediately removing the needles after pricking TrPs or
eliciting LTRs; therefore, this practice should be
questioned.
Local, Proximal, and Distal Needling
‘Regional interdependence’ has been defined as ‘the
concept that seemingly unrelated impairments in a
remote anatomical region may contribute to, or be
associated with, the patient’s primary complaint’;184
that is, the practice of examining and treating muscle,
joint or neural impairments that are not local, but are
distal or proximal to the patient9s symptoms, has
gained widespread acceptance in the orthopedic
manual physical therapy community.184-190 For
example, there are several trials that support the use
of thrust manipulation to the cervical, cervicothoracic, thoracic, and upper rib articulations in the
treatment of patients with the primary complaint of
shoulder pain185-190 or shoulder impingement191,192–
i.e. treating proximal structures to affect distal
symptoms. Likewise, patients with lateral epicondylalgia often seek conservative treatment by a physical
therapist. In addition to providing manual therapy to
the humero-radial joint and needling the forearm
extensor muscles,183 physical therapists often manipulate the neck and wrist based on supporting evidence
in the literature.193,194 That is, physical therapists
commonly deliver manual therapy both proximal193
and distal194 to the site of pain. The fact that the
Mississippi and Colorado State Boards of Physical
Therapy believe that IMT and dry needling, respectively, do not include the stimulation of distal points
seems misleading and clinically illogical.10,13 Based
on this line of reasoning, physical therapists in
Mississippi10 and Colorado13 are not allowed to
target TrPs in the adductor magnus muscle in
patients with ‘generalized internal pelvic pain…or
pain shooting up inside the pelvis’74 because the pain
is located ‘distal’ to the patient’s pain complaint. It is
worth noting that this clinical reasoning is directly
contrary to that recommended by Travell and
Simons. According to Travell and Simons, ‘deep
pain in the ipsilateral sacroiliac joint’74 may be caused
by a TrP in a very ‘distal’ location, namely the soleus
muscle. Interestingly, the most recent literature on
myofascial pain syndrome provides clear evidence for
needling distal sites, a finding analogous to the
acupuncture tradition of treating distal acupoints to
influence anatomically remote pain.149
More recently,33 ipsilateral or contralateral dry
needling to MTrSs (myofascial trigger spots) in the
Physical Therapy Reviews
2014
VOL .
19
NO .
4
259
Dunning et al.
Dry needling
distal gastrocnemius muscle (lower leg) was shown to
suppress spontaneous electrical activity (i.e. end plate
noise) in MTrSs within the more proximal biceps
femoris muscle. Furthermore, after either tibial nerve
transection or L5-6 spinal cord transection in rabbits,
Hsieh et al.33 found that the remote effects in the
bicep femoris disappeared. According to Hsieh
et al.,33 the physiologic basis for the remote and/or
distal effects of dry needling may be related to
activation of the diffuse noxious inhibitory control
(DNIC) system, as induced by noxious stimulation
provided by the needles. Simply put, ‘the pathway
for the remote effect appears to be a spinal reflex’.33
Such a finding implies that inserting a needle into
the left hand would potentially lead to pain relief in
the right hand. The recent findings of Hsieh et al.33
add support to the practice of needling contralateral to the side of pain and/or needling distal to
the site of pain in order to reduce end plate noise
and suppress activity of more proximal painful
TrPs.
In another recent experimental study,26 dry needling of primary MTrPs in patients with shoulder pain
was found to inhibit the activity of satellite or
secondary MTrPs situated in the shoulder, elbow,
or forearm. That is, the target MTrP was found either
proximal or distal to the patient’s site of discomfort.26 It follows then that the APTA8 and Physical
Therapy State Boards10,13 should consider that the
best practice for dry needling may require the
placement of needles both ‘local and/or distal’ to
the patient’s primary source of pain.
Physical therapists often deliver manual therapy and/
or orthotic interventions to the tarso-metatarsal,
subtalar, or talocrural joints in order to manage
patients with low back pain;195–199 likewise, the
insertion of needles without injectate into bodily areas
that are asymptomatic but distal or proximal to the site
of pain is supported by the myofascial pain syndrome
literature.149 As Melzack et al.27 points out:
The stimulation of particular nerves or tissues by
needles…would close the gates to [pain] inputs
from selected body areas. The cells of the midbrain
reticular formation are known to have large
receptive fields…. It is possible, then, that particular
[distant] body areas may project especially strongly
to some reticular areas, and these, in turn, could
bring about a complete block of inputs from
particular parts of the body.27
terms ‘TDN’ or ‘IMT’ should not be used interchangeably or synonymously with the term ‘Dry
Needling’. Dry needling encompasses the insertion of
needles without injectate3 into, alongside, or around
nerves,17,28,36,40,42,43,47,55,65,159 muscles,5,6,20,23,24,65,109 or
connective tissues6,7,48,49,70–72,126,170,172 for the management of pain and dysfunction in neuromusculoskeletal
conditions. Dry needling neither attempts to move
qi along meridians nor does it rely on diagnoses
from traditional Chinese or Oriental Medicine.78,79
Considering the mechanical,70–72,158 chemical,141,159
endocrinological,136
microvascular,138,161,163,164,170
36,41,47
neural,
and central effects38,39,44,46,130,137,160 of
both superficial and deep dry needling at TrP and
non-TrP locations, the position statements by the
APTA8,75 and many State Boards of Physical
Therapy9–13 do not seem to be consistent with the
existing literature.
Funding
None.
Conflicts of Interest
Dr. James Dunning is the President of the American
Academy of Manipulative Therapy (AAMT).
Through Spinal Manipulation Institute (SMI) and
Dry Needling Institute (DNI), AAMT provides postgraduate training programs in dry needling and spinal
manipulation to licensed physical therapists, osteopaths and medical doctors. Drs. James Dunning,
Raymond Butts, Thomas Perreault, and Firas
Mourad are senior instructors for SMI and DNI.
Academic Affiliation
The senior author, James Dunning, is currently a
PhD student at Nova Southeastern University, Fort
Lauderdale, FL, USA.
Ethics Approval
N/A.
Contributors
JD participated in the conception, design, initial
drafting and revision of the manuscript. FM participated in the design and revision of the manuscript. RB
participated in the conception, design, and revision of
the manuscript. IY participated in the drafting of the
manuscript and revision of the manuscript. SF and TP
participated in the revision of the manuscript. All
authors read and approved the final manuscript.
References
Conclusion
Just as the Maitland,14 Kaltenborn,15 and McKenzie16
approaches are unique brands of manual therapy, so is
‘TDN’ and ‘IMT’ to dry needling. They provide a
single framework or paradigm within the much
broader field of dry needling.5,17–25 Therefore, the
260
Physical Therapy Reviews
2014
VOL .
19
NO .
4
1 Speed CA. Injection therapies for soft-tissue disorders. Best
Pract Res Clin Rheumatol. 2003;17(1):167–81.
2 Speed CA. Injection therapies for soft-tissue lesions. Best
Pract Res Clin Rheumatol. 2007;21(2):333–47.
3 Casanueva B, Rivas P, Rodero B, Quintial C, Llorca J,
Gonzalez-Gay MA. Short-term improvement following dry
needle stimulation of tender points in fibromyalgia.
Rheumatol Int. Apr 23, 2013. [epub ahead of print]
Dunning et al.
4 Manheimer E, White A, Berman B, Forys K, Ernst E. Metaanalysis: acupuncture for low back pain. Ann Intern Med.
2005;142(8):651–63.
5 Gunn CC, Milbrandt WE, Little AS, Mason KE. Dry needling
of muscle motor points for chronic low-back pain: a
randomized clinical trial with long-term follow-up. Spine
(Phila Pa 1976). 1980;5(3):279–91.
6 Lewit K. The needle effect in the relief of myofascial pain.
Pain. 1979;6(1):83–90.
7 Neal BS, Longbottom J. Is there a role for acupuncture in the
treatment of tendinopathy? Acupunct Med. 2012;30(4):346–9.
8 APTA. Physical therapists & the performance of dry needling:
an educational resource paper. Alexandria, VA, USA: APTA
Department of Practice and APTA State Government Affairs;
2012.
9 NCBPTE. Position statement: intramuscular manual therapy
(dry needling). North Carolina Board of Physical Therapy
Examiners, June 14, 2012.
10 MSSBPT. Intramuscular manual therapy (dry needling) may
be performed by a licensed physical therapist. Mississippi State
Board of Physical Therapy, Part 3101 Rule 1.3c, September
10, 2012.
11 LAPTB. Louisiana Physical Therapy Practice Act: Treatment
with Dry Needling. Louisiana Physical Therapy Board, Rule
311, Page 29, October 20, 2011.
12 NEBPT. Minutes of the board of physical therapy: discussion
of board opinions. Nebraska Board of Physical Therapy, June
20, 2011:1–4.
13 SPTB. Requirements for physical therapists to perform dry
needling. Colorado Department of Regulatory Agencies: State
Physical Therapy Board, Rule 211, 2008:10–11.
14 Maitland GD. Vertebral manipulation, 2nd edn. London:
Butterworths; 1968.
15 Kaltenborn FM. Mobilization of the spine, 1st edn. Oslo,
Norway: Olaf Norlis Bokhandel; 1970.
16 McKenzie R, May S. The cervical and thoracic spine:
mechanical diagnosis and therapy, 2nd edn, Vol. 1.
Waikanae, NZ: Spinal Publications New Zealand; 2006.
17 Cummings TM, White AR. Needling therapies in the management of myofascial trigger point pain: a systematic review.
Arch Phys Med Rehabil. 2001;82(7):986–92.
18 DiLorenzo L, Traballesi M, Morelli D, Pompa A, Brunelli S,
Buzzi MG, et al. Hemiparetic shoulder pain syndrome treated
with deep dry needling during early rehabilitation: a prospective, open-label, randomized investigation. J Musculoskeletal
Pain. 2004;12(2):25–34.
19 Furlan AD, van Tulder M, Cherkin D, Tsukayama H, Lao L,
Koes B, et al. Acupuncture and dry-needling for low back
pain: an updated systematic review within the framework of
the cochrane collaboration. Spine (Phila Pa 1976).
2005;30(8):944–63.
20 Itoh K, Katsumi Y, Kitakoji H. Trigger point acupuncture
treatment of chronic low back pain in elderly patients–a
blinded RCT. Acupunct Med. 2004;22(4):170–7.
21 Kalichman L, Vulfsons S. Dry needling in the management of
musculoskeletal pain. J Am Board Fam Med. 2010;23(5):640–
6.
22 Myburgh C, Larsen AH, Hartvigsen J. A systematic, critical
review of manual palpation for identifying myofascial trigger
points: evidence and clinical significance. Arch Phys Med
Rehabil. 2008;89(6):1169–76.
23 Tough EA, White A. Effectiveness of acupuncture/dry
needling for myofascial trigger point pain–a systematic review.
Phys Ther Rev. 2011;16(2):147–54.
24 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(1):3–10.
25 Tough EA, White AR, Richards S, Campbell J. Variability of
criteria used to diagnose myofascial trigger point pain
syndrome–evidence from a review of the literature. Clin J
Pain. 2007;23(3):278–86.
26 Hsieh YL, Kao MJ, Kuan TS, Chen SM, Chen JT, Hong CZ.
Dry needling to a key myofascial trigger point may reduce the
irritability of satellite MTrPs. Am J Phys Med Rehabil.
2007;86(5):397–403.
27 Melzack R, Stillwell DM, Fox EJ. Trigger points and
acupuncture points for pain: correlations and implications.
Pain. 1977;3(1):3–23.
Dry needling
28 Hong C. Treatment of myofascial pain syndrome. Curr Pain
Headache Rep. 2006;10:345–9.
29 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(4):256–63.
30 Hong CZ, Kuan TS, Chen JT, Chen SM. Referred pain
elicited by palpation and by needling of myofascial trigger
points: a comparison. Arch Phys Med Rehabil. 1997;78(9):
957–60.
31 Hong C. Myofascial trigger points: pathophysiology and
correlation with acupuncture points. Acupunct Med.
2000;18(1):41–7.
32 Hong CZ, Simons DG. Pathophysiologic and electrophysiologic mechanisms of myofascial trigger points. Arch Phys Med
Rehabil. 1998;79(7):863–72.
33 Hsieh YL, Chou LW, Joe YS, Hong CZ. Spinal cord
mechanism involving the remote effects of dry needling on
the irritability of myofascial trigger spots in rabbit skeletal
muscle. Arch Phys Med Rehabil. 2011;92(7):1098–105.
34 Audette JF, Wang F, Smith H. Bilateral activation of motor
unit potentials with unilateral needle stimulation of active
myofascial trigger points. Am J Phys Med Rehabil.
2004;83(5):368–74.
35 Kamanli A, Kaya A, Ardicoglu O, Ozgocmen S, Zengin FO,
Bayik Y. Comparison of lidocaine injection, botulinum toxin
injection, and dry needling to trigger points in myofascial pain
syndrome. Rheumatol Int. 2005;25(8):604–11.
36 Khosrawi S, Moghtaderi A, Haghighat S. Acupuncture in
treatment of carpal tunnel syndrome: a randomized controlled
trial study. J Res Med Sci. 2012;17(1):1–7.
37 Kumnerddee W, Kaewtong A. Efficacy of acupuncture versus
night splinting for carpal tunnel syndrome: a randomized
clinical trial. J Med Assoc Thai. 2010;93(12):1463–9.
38 Hsieh JC, Tu CH, Chen FP, Chen MC, Yeh TC, Cheng HC,
et al. Activation of the hypothalamus characterizes the
acupuncture stimulation at the analgesic point in human: a
positron emission tomography study. Neurosci Lett.
2001;307(2):105–8.
39 Hui KK, Liu J, Makris N, Gollub RL, Chen AJ, Moore CI,
et al. Acupuncture modulates the limbic system and subcortical gray structures of the human brain: evidence from
fMRI studies in normal subjects. Hum Brain Mapp.
2000;9(1):13–25.
40 Yang CP, Hsieh CL, Wang NH, Li TC, Hwang KL, Yu SC,
et al. Acupuncture in patients with carpal tunnel syndrome: a
randomized controlled trial. Clin J Pain. 2009;25(4):327–33.
41 Yang CP, Wang NH, Li TC, Hsieh CL, Chang HH, Hwang
KL, et al. A randomized clinical trial of acupuncture versus
oral steroids for carpal tunnel syndrome: a long-term followup. J Pain. 2011;12(2):272–9.
42 Ma YT. Biomedical acupuncture for sports and trauma
rehabilitation: dry needling techniques. St. Louis, MO, USA:
Churchill Livingstone/Elsevier; 2011.
43 Ma YT, Ma M, Cho ZH. Biomedical acupuncture for pain
management: an integrative approach. St. Louis, MO, USA:
Elsevier Churchill Livingstone; 2005.
44 Napadow V, Kettner N, Liu J, Li M, Kwong KK, Vangel M,
et al. Hypothalamus and amygdala response to acupuncture
stimuli in Carpal Tunnel Syndrome. Pain. 2007;130(3):254–66.
45 Napadow V, Kettner N, Ryan A, Kwong KK, Audette J, Hui
KK. Somatosensory cortical plasticity in carpal tunnel
syndrome–a cross-sectional fMRI evaluation. Neuroimage.
2006;31(2):520–30.
46 Napadow V, Makris N, Liu J, Kettner NW, Kwong KK, Hui
KK. Effects of electroacupuncture versus manual acupuncture
on the human brain as measured by fMRI. Hum Brain Mapp.
2005;24(3):193–205.
47 Sim H, Shin BC, Lee MS, Jung A, Lee H, Ernst E.
Acupuncture for carpal tunnel syndrome: a systematic review
of randomized controlled trials. J Pain. 2011;12(3):307–14.
48 Imamura M, Fischer A, Imamura S, Kaziyama H, Carvalho
A, Salomao O. Treatment of myofascial pain components in
plantar fasciitis speeds up recovery: documentation by
algometry. J Musculoskelt Pain. 1998;6(1):91–110.
49 Tillu A, Gupta S. Effect of acupuncture treatment on heel pain
due to plantar fasciitis. Acupunct Med. 1998;16(2):66–8.
50 Vas J, White A. Evidence from RCTs on optimal acupuncture
treatment for knee osteoarthritis–an exploratory review.
Acupunct Med. 2007;25(1–2):29–35.
Physical Therapy Reviews
2014
VOL .
19
NO .
4
261
Dunning et al.
Dry needling
51 White A, Foster NE, Cummings M, Barlas P. Acupuncture
treatment for chronic knee pain: a systematic review.
Rheumatology (Oxford). 2007;46(3):384–90.
52 Whitehurst DG, Bryan S, Hay EM, Thomas E, Young J,
Foster NE. Cost-effectiveness of acupuncture care as an
adjunct to exercise-based physical therapy for osteoarthritis of
the knee. Phys Ther. 2011;91(5):630–41.
53 Witt CM, Jena S, Brinkhaus B, Liecker B, Wegscheider K,
Willich SN. Acupuncture in patients with osteoarthritis of the
knee or hip: a randomized, controlled trial with an additional
nonrandomized arm. Arthritis Rheum. 2006;54(11):3485–93.
54 Zhang S, Yip T, Li Q. Acupuncture treatment for plantar
fasciitis: a randomized controlled trial with six months followup. Evid Based Complement Alternat Med. 2009;20(11):1–10.
55 Baldry P. Acupuncture, trigger points, and musculoskeletal
pain. Edinburgh, New York, NY, USA: Churchill
Livingstone; 1989.
56 Cotchett MP, Landorf KB, Munteanu SE. Effectiveness of dry
needling and injections of myofascial trigger points associated
with plantar heel pain: a systematic review. J Foot Ankle Res.
2010;3:18.
57 Dorsher PT, Fleckenstein J. Trigger points and classical
acupuncture points: part 1: qualitative and quantitative
anatomic correspondences. Ger J Acupunct Relat Tech.
2008;51(3):15–24.
58 Dorsher PT, Fleckenstein J. Trigger points and classical
acupuncture points: part 2: clinical correspondences in treating
pain and somatovisceral disorders. Ger J Acupunct Relat
Tech. 2008;51(4):6–11.
59 Fernandez-Carnero J, La Touche R, Ortega-Santiago R,
Galan-del-Rio F, Pesquera J, Ge HY, et al. Short-term effects
of dry needling of active myofascial trigger points in the
masseter muscle in patients with temporomandibular disorders. J Orofac Pain. 2010;24(1):106–12.
60 Fishman LM, Dombi GW, Michaelsen C, Ringel S, Rozbruch
J, Rosner B, et al. Piriformis syndrome: diagnosis, treatment,
and outcome–a 10-year study. Arch Phys Med Rehabil.
2002;83(3):295–301.
61 Franca DL, Senna-Fernandes V, Cortez CM, Jackson MN,
Bernardo-Filho M, Guimaraes MA. Tension neck syndrome
treated by acupuncture combined with physiotherapy: a
comparative clinical trial (pilot study). Complement Ther
Med. 2008;16(5):268–77.
62 Furlan AD, van Tulder MW, Cherkin DC, Tsukayama H,
Lao L, Koes BW, et al. Acupuncture and dry-needling for low
back pain. Cochrane Database Syst Rev. 2005;(1):CD001351.
63 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(4):130–6.
64 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(6):617–24.
65 Ga H, Koh HJ, Choi JH, Kim CH. Intramuscular and nerve
root stimulation vs lidocaine injection to trigger points in
myofascial pain syndrome. J Rehabil Med. 2007;39(5):374–8.
66 Garvey TA, Marks MR, Wiesel SW. A prospective, randomized, double-blind evaluation of trigger-point injection
therapy for low-back pain. Spine (Phila Pa 1976).
1989;14(9):962–4.
67 Gonzalez-Perez LM, Infante-Cossio P, Granados-Nunez M,
Urresti-Lopez FJ. Treatment of temporomandibular myofascial pain with deep dry needling. Med Oral Patol Oral Cir
Bucal. 2012;17(5):e781–5.
68 Gunn CC. The Gunn approach to the treatment of chronic
pain: intramuscular stimulation for myofascial pain of
radiculopathic origin, 2nd edn. New York, NY, USA:
Churchill Livingstone; 1996.
69 Haake M, Muller HH, Schade-Brittinger C, Schäfer H, Maier
C, Endres HG, et al. German Acupuncture Trials (GERAC)
for chronic low back pain: randomized, multicenter, blinded,
parallel-group trial with 3 groups. Arch Intern Med.
2007;167(17):1892–8.
70 Langevin HM, Bouffard NA, Badger GJ, Churchill DL, Howe
AK. Subcutaneous tissue fibroblast cytoskeletal remodeling
induced by acupuncture: evidence for a mechanotransductionbased mechanism. J Cell Physiol. 2006;207(3):767–74.
71 Langevin HM, Bouffard NA, Badger GJ, Iatridis JC,
Howe AK. Dynamic fibroblast cytoskeletal response to
262
Physical Therapy Reviews
2014
VOL .
19
NO .
4
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
subcutaneous tissue stretch ex vivo and in vivo. Am J
Physiol Cell Physiol. 2005;288(3):C747–56.
Langevin HM, Churchill DL, Cipolla MJ. Mechanical signaling
through connective tissue: a mechanism for the therapeutic
effect of acupuncture. Faseb J. 2001;15(12):2275–82.
Travell JG, Simons DG. Myofascial pain and dysfunction: the
trigger point manual, Vol. 1. Baltimore, MD, USA: Williams
and Wilkins; 1983.
Travell JG, Simons DG. Myofascial pain and dysfunction: the
trigger point manual, Vol. 2. Baltimore, MD, USA: Williams
and Wilkins; 1992.
APTA. Description of dry needling in clinical practice: an
educational resource paper. Alexandria, VA, USA: APTA
Public Policy, Practice, and Professional Affairs Unit; 2013.
AZPTA. Definition and position statement for dry needling by
physical therapists in Arizona. Arizona Physical Therapy
Association, 2013.
Rathnayake T. Back pain (low): acupuncture and dry
needling. Evidence Summaries-Joanna Briggs Institute; 2009.
Deadman P, Al-Khafaji M, Baker K. A manual of acupuncture, 2nd ed. Hove, East Sussex, UK: Journal of Chinese
Medicine Publications; 2011.
O’Conner J, Bensky D. Acupuncture: a comprehensive text.
Seattle, WA, USA: Eastland Press; 1981.
Itoh K, Katsumi Y, Hirota S, Kitakoji H. Randomised trial of
trigger point acupuncture compared with other acupuncture
for treatment of chronic neck pain. Complement Ther Med.
2007;15(3):172–9.
Berman BM, Lao L, Langenberg P, Lee WL, Gilpin AM,
Hochberg MC. Effectiveness of acupuncture as adjunctive
therapy in osteoarthritis of the knee: a randomized, controlled
trial. Ann Intern Med. 2004;141(12):901–10.
Berman BM, Singh BB, Lao L, Langenberg P, Li H, Hadhazy
V, et al. A randomized trial of acupuncture as an adjunctive
therapy in osteoarthritis of the knee. Rheumatology (Oxford).
1999;38(4):346–54.
Ezzo J, Hadhazy V, Birch S, Lao L, Kaplan G, Hochberg M,
et al. Acupuncture for osteoarthritis of the knee: a systematic
review. Arthritis Rheum. 2001;44(4):819–25.
Foster NE, Thomas E, Barlas P, Hill JC, Young J, Mason E,
et al. Acupuncture as an adjunct to exercise based physiotherapy for osteoarthritis of the knee: randomised controlled trial.
BMJ. 2007;335(7617):436.
Kwon YD, Pittler MH, Ernst E. Acupuncture for peripheral
joint osteoarthritis: a systematic review and meta-analysis.
Rheumatology (Oxford). 2006;45(11):1331–7.
Manheimer E, Linde K, Lao L, Bouter LM, Berman BM.
Meta-analysis: acupuncture for osteoarthritis of the knee. Ann
Intern Med. 2007;146(12):868–77.
Mavrommatis CI, Argyra E, Vadalouka A, Vasilakos DG.
Acupuncture as an adjunctive therapy to pharmacological
treatment in patients with chronic pain due to osteoarthritis of
the knee: a 3-armed, randomized, placebo-controlled trial.
Pain. 2012;153(8):1720–6.
Scharf HP, Mansmann U, Streitberger K, Witte S, Krämer J,
Maier C, et al. Acupuncture and knee osteoarthritis: a threearmed randomized trial. Ann Intern Med. 2006;145(1):12–20.
Vas J, Mendez C, Perea-Milla E, Vega E, Panadero MD, León
JM, et al. Acupuncture as a complementary therapy to the
pharmacological treatment of osteoarthritis of the knee:
randomised controlled trial. BMJ. 2004;329(7476):1216.
Witt C, Brinkhaus B, Jena S, Linde K, Streng A, Wagenpfeil
S, et al. Acupuncture in patients with osteoarthritis of the
knee: a randomised trial. Lancet. 2005;366(9480):136–43.
Fink MG, Kunsebeck H, Wipperman B, Gehrke A. Nonspecific effects of traditional Chinese acupuncture in osteoarthritis of the hip. Complement Ther Med. 2001;9(2):82–9.
Haslam R. A comparison of acupuncture with advice and
exercises on the symptomatic treatment of osteoarthritis of the
hip–a randomised controlled trial. Acupunct Med. 2001;19(1):
19–26.
Stener-Victorin E, Kruse-Smidje C, Jung K. Comparison
between electro-acupuncture and hydrotherapy, both in
combination with patient education and patient education
alone, on the symptomatic treatment of osteoarthritis of the
hip. Clin J Pain. 2004;20(3):179–85.
Zhang W, Moskowitz RW, Nuki G, Abramson S, Altman
RD, Arden N, et al. OARSI recommendations for the
management of hip and knee osteoarthritis, Part II: OARSI
evidence-based, expert consensus guidelines. Osteoarthritis
Cartilage. 2008;16(2):137–62.
Dunning et al.
95 Allais G, De Lorenzo C, Quirico PE, Airola G, Tolardo G,
Mana O, et al. Acupuncture in the prophylactic treatment of
migraine without aura: a comparison with flunarizine.
Headache. 2002;42(9):855–61.
96 Coeytaux RR, Kaufman JS, Kaptchuk TJ, Chen W, Miller
WC, Callahan LF, et al. A randomized, controlled trial of
acupuncture for chronic daily headache. Headache. 2005;
45(9):1113–23.
97 Melchart D, Linde K, Fischer P, White A, Allais G, Vickers A,
et al. Acupuncture for recurrent headaches: a systematic
review of randomized controlled trials. Cephalalgia.
1999;19(9):779–86; discussion 765.
98 Melchart D, Linde K, Streng A, Reitmayr S, Hoppe A,
Brinkhaus B, Becker-Witt C, et al. Acupuncture Randomized
Trials (ART) in patients with migraine or tension-type
headache–design and protocols. Forsch Komplementarmed
Klass Naturheilkd. 2003;10(4):179–84.
99 Melchart D, Thormaehlen J, Hager S, Liao J, Linde K,
Weidenhammer W. Acupuncture versus placebo versus
sumatriptan for early treatment of migraine attacks: a
randomized controlled trial. J Intern Med. 2003;253(2):181–8.
100 Vickers AJ, Rees RW, Zollman CE, McCarney R, Smith CM,
Ellis N, et al. Acupuncture for chronic headache in primary
care: large, pragmatic, randomised trial. BMJ. 2004;
328(7442):744.
101 Wonderling D, Vickers AJ, Grieve R, McCarney R. Cost
effectiveness analysis of a randomised trial of acupuncture for
chronic headache in primary care. BMJ. 2004;328(7442):747.
102 Venancio Rde A, Alencar FG Jr, Zamperini C. Botulinum
toxin, lidocaine, and dry-needling injections in patients with
myofascial pain and headaches. Cranio. 2009;27(1):46–53.
103 Manolopoulos L, Vlastarakos PV, Georgiou L, Giotakis I,
Loizos A, Nikolopoulos TP. Myofascial pain syndromes in the
maxillofacial area: a common but underdiagnosed cause of
head and neck pain. Int J Oral Maxillofac Surg. 2008;37(11):
975–84.
104 McMillan AS, Nolan A, Kelly PJ. The efficacy of dry needling
and procaine in the treatment of myofascial pain in the jaw
muscles. J Orofac Pain. 1997;11(4):307–14.
105 Shen YF, Goddard G. The short-term effects of acupuncture
on myofascial pain patients after clenching. Pain Pract.
2007;7(3):256–64.
106 Shen YF, Younger J, Goddard G, Mackey S. Randomized
clinical trial of acupuncture for myofascial pain of the jaw
muscles. J Orofac Pain. 2009;23(4):353–9.
107 Smith P, Mosscrop D, Davies S, Sloan P, Al-Ani Z. The
efficacy of acupuncture in the treatment of temporomandibular joint myofascial pain: a randomised controlled trial. J
Dent. 2007;35(3):259–67.
108 Green S, Buchbinder R, Hetrick S. Acupuncture for shoulder
pain. Cochrane Database Syst Rev. 2005;(2):CD005319.
109 Ingber RS. Shoulder impingement in tennis/racquetball
players treated with subscapularis myofascial treatments.
Arch Phys Med Rehabil. 2000;81(5):679–82.
110 Osborne NJ, Gatt IT. Management of shoulder injuries using
dry needling in elite volleyball players. Acupunct Med.
2010;28(1):42–5.
111 Irnich D, Behrens N, Gleditsch JM, Stör W, Schreiber MA,
Schöps P, et al. Immediate effects of dry needling and
acupuncture at distant points in chronic neck pain: results of
a randomized, double-blind, sham-controlled crossover trial.
Pain. 2002;99(1–2):83–9.
112 Irnich D, Behrens N, Molzen H, König A, Gleditsch J, Krauss
M, et al. Randomised trial of acupuncture compared with
conventional massage and ‘sham’ laser acupuncture for
treatment of chronic neck pain. BMJ. 2001;322(7302):1574–8.
113 Ma C, Wu S, Li G, Xiao X, Mai M, Yan T. Comparison of
miniscalpel-needle release, acupuncture needling, and stretching exercise to trigger point in myofascial pain syndrome. Clin
J Pain. 2010;26(3):251–7.
114 Trinh K, Graham N, Gross A, Goldsmith C, Wang E,
Cameron I, et al. Acupuncture for neck disorders. Spine (Phila
Pa 1976). 2007;32(2):236–43.
115 Brinkhaus B, Witt CM, Jena S, Linde K, Streng A, Wagenpfeil
S, et al. Acupuncture in patients with chronic low back pain: a
randomized controlled trial. Arch Intern Med. 2006;166(4):
450–7.
116 Cherkin DC, Sherman KJ, Avins AL, Erro JH, Ichikawa L,
Barlow WE, et al. A randomized trial comparing acupuncture,
simulated acupuncture, and usual care for chronic low back
pain. Arch Intern Med. 2009;169(9):858–66.
Dry needling
117 Chou R, Qaseem A, Snow V, Casey D, Cross JT Jr, Shekelle
P, et al. Diagnosis and treatment of low back pain: a joint
clinical practice guideline from the American College of
Physicians and the American Pain Society. Ann Intern Med.
2007;147(7):478–91.
118 Eisenberg DM, Post DE, Davis RB, Connelly MT, Legedza
AT, Hrbek AL, et al. Addition of choice of complementary
therapies to usual care for acute low back pain: a randomized
controlled trial. Spine (Phila Pa 1976). 2007;32(2):151–8.
119 Giles LG, Muller R. Chronic spinal pain: a randomized
clinical trial comparing medication, acupuncture, and spinal
manipulation. Spine (Phila Pa 1976). 2003;28(14):1490–502;
discussion 1502–493.
120 Inoue M, Kitakoji H, Ishizaki N, Tawa M, Yano T, Katsumi
Y, et al. Relief of low back pain immediately after acupuncture
treatment–a randomised, placebo controlled trial. Acupunct
Med. 2006;24(3):103–8.
121 Johnston BC, da Costa BR, Devereaux PJ, Akl EA, Busse JW.
The use of expertise-based randomized controlled trials to
assess spinal manipulation and acupuncture for low back pain:
a systematic review. Spine (Phila Pa 1976). 2008;33(8):914–8.
122 MacPherson H, Thorpe L, Thomas K, Campbell M.
Acupuncture for low back pain: traditional diagnosis and
treatment of 148 patients in a clinical trial. Complement Ther
Med. 2004;12(1):38–44.
123 Molsberger AF, Mau J, Pawelec DB, Winkler J. Does
acupuncture improve the orthopedic management of chronic
low back pain–a randomized, blinded, controlled trial with 3
months follow up. Pain. 2002;99(3):579–87.
124 Savigny P, Watson P, Underwood M. Early management of
persistent non-specific low back pain: summary of NICE
guideline. Br Med J. 2009;338:1441–5.
125 Vas J, Aranda JM, Modesto M, Benı́tez-Parejo N, Herrera A,
Martı́nez-Barquı́n DM, et al. Acupuncture in patients with
acute low back pain: a multicentre randomised controlled
clinical trial. Pain. 2012;153(9):1883–9.
126 Ebrahim AHM, Ahmed GM, Elsayed E, Sarhan R. Effect of
electroacupuncture TENS, stretching exercises, and prefabricated insole in patients with plantar fasciits. Sci J Al-Azhar
Med Univ. 2007;28(3):1–10.
127 Perez-Millan R, Foster L. Low-frequency electroacupuncture
in the management of refractory plantar fasciitis: a case-series.
Med Acupunct. 2001;13(1):1–7.
128 Baldry P. The integration of acupuncture within medicine in
the UK–the British Medical Acupuncture Society’s 25th
anniversary. Acupunct Med. 2005;23(1):2–12.
129 Lee SH, Chen CC, Lee CS, Lin TC, Chan RC. Effects of
needle electrical intramuscular stimulation on shoulder and
cervical myofascial pain syndrome and microcirculation. J
Chin Med Assoc. 2008;71(4):200–6.
130 Biella G, Sotgiu ML, Pellegata G, Paulesu E, Castiglioni I,
Fazio F. Acupuncture produces central activations in pain
regions. Neuroimage. 2001;14(1 Pt 1):60–6.
131 Foster NE, Thomas E, Hill JC, Hay EM. The relationship
between patient and practitioner expectations and preferences
and clinical outcomes in a trial of exercise and acupuncture for
knee osteoarthritis. Eur J Pain. 2010;14(4):402–9.
132 White P, Lewith G, Prescott P, Conway J. Acupuncture versus
placebo for the treatment of chronic mechanical neck pain: a
randomized, controlled trial. Ann Intern Med. 2004;141(12):
911–9.
133 Witt CM, Jena S, Brinkhaus B, Liecker B, Wegscheider K,
Willich SN. Acupuncture for patients with chronic neck pain.
Pain. 2006;125(1–2):98–106.
134 Witt CM, Jena S, Selim D, Brinkhaus B, Reinhold T, Wruck
K, et al. Pragmatic randomized trial evaluating the clinical and
economic effectiveness of acupuncture for chronic low back
pain. Am J Epidemiol. 2006;164(5):487–96.
135 Yuan J, Purepong N, Kerr DP, Park J, Bradbury I,
McDonough S. Effectiveness of acupuncture for low back
pain: a systematic review. Spine (Phila Pa 1976). 2008;33(23):
E887–900.
136 Ahsin S, Saleem S, Bhatti AM, Iles RK, Aslam M. Clinical
and endocrinological changes after electro-acupuncture treatment in patients with osteoarthritis of the knee. Pain.
2009;147(1–3):60–6.
137 Almeida RT, Perez AC, Francischi JN, Castro MS, Duarte ID.
Opioidergic orofacial antinociception induced by electroacupuncture at acupoint St36. Braz J Med Biol Res. 2008;41(7):621–6.
138 Loaiza LA, Yamaguchi S, Ito M, Ohshima N. Electroacupuncture stimulation to muscle afferents in anesthetized
Physical Therapy Reviews
2014
VOL .
19
NO .
4
263
Dunning et al.
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
264
Dry needling
rats modulates the blood flow to the knee joint through
autonomic reflexes and nitric oxide. Auton Neurosci.
2002;97(2):103–9.
Yeung CK, Leung MC, Chow DH. The use of electro-acupuncture
in conjunction with exercise for the treatment of chronic low-back
pain. J Altern Complement Med. 2003;9(4):479–90.
Rha DW, Shin JC, Kim YK, Jung JH, Kim YU, Lee SC.
Detecting local twitch responses of myofascial trigger points in
the lower-back muscles using ultrasonography. Arch Phys
Med Rehabil. 2011;92(10):1576–80.e1.
Shah JP, Danoff JV, Desai MJ, Parikh S, Nakamura LY,
Phillips TM, et al. Biochemicals associated with pain and
inflammation are elevated in sites near to and remote from
active myofascial trigger points. Arch Phys Med Rehabil.
2008;89(1):16–23.
Sciotti VM, Mittak VL, DiMarco L, Ford LM, Plezbert J,
Santipadri E, et al. Clinical precision of myofascial trigger point
location in the trapezius muscle. Pain. 2001;93(3):259–66.
Brinkhaus B, Witt C, Jena S, Linde K, Streng A, Irnich D,
et al. Interventions and physician characteristics in a
randomized multicenter trial of acupuncture in patients with
low-back pain. J Altern Complement Med. 2006;12(7):649–57.
Lucas N, Macaskill P, Irwig L, Moran R, Bogduk N.
Reliability of physical examination for diagnosis of myofascial
trigger points: a systematic review of the literature. Clin J Pain.
2009;25(1):80–9.
Trinh KV, Graham N, Gross AR, Goldsmith CH, Wang E,
Cameron ID, et al. Acupuncture for neck disorders. Cochrane
Database Syst Rev. 2006;(3):CD004870.
Airaksinen O, Brox JI, Cedraschi C, Hildebrandt J, KlaberMoffett J, Kovacs F, et al. Chapter 4. European guidelines for
the management of chronic nonspecific low back pain. Eur
Spine J. 2006;15(Suppl 2):S192–300.
van Tulder M, Becker A, Bekkering T, Breen A, del Real MT,
Hutchinson A, et al. Chapter 3. European guidelines for the
management of acute nonspecific low back pain in primary
care. Eur Spine J. 2006;15(Suppl 2):S169–191.
Moffet H. Traditional acupuncture theories yield null outcomes: a systematic review of clinical trials. J Clin Epidemiol.
2008;61:741–7.
Dorsher PT. Myofascial referred-pain data provide physiologic
evidence of acupuncture meridians. J Pain. 2009;10(7):723–31.
Barbero M, Bertoli P, Cescon C, Macmillan F, Couts F, Gatti
R. Intra-rater reliability of an experienced physiotherapist in
locating myofascial trigger points in upper trapezius muscle.
J Man Manip Ther. 2012;20:171–7.
Lew PC, Lewis J, Story I. Inter-therapist reliability in locating
latent myofascial trigger points using palpation. Man Ther.
1997;2(2):87–90.
Myburgh C, Lauridsen HH, Larsen AH, Hartvigsen J.
Standardized manual palpation of myofascial trigger points
in relation to neck/shoulder pain; the influence of clinical
experience on inter-examiner reproducibility. Man Ther.
2011;16(2):136–40.
Al-Shenqiti AM, Oldham JA. Test-retest reliability of
myofascial trigger point detection in patients with rotator
cuff tendonitis. Clin Rehabil. 2005;19(5):482–7.
Gerwin RD, Shannon S, Hong CZ, Hubbard D, Gevirtz R.
Interrater reliability in myofascial trigger point examination.
Pain. 1997;69(1–2):65–73.
Hsieh CY, Hong CZ, Adams AH, Platt KJ, Danielson CD,
Hoehler FK, et al. Interexaminer reliability of the palpation of
trigger points in the trunk and lower limb muscles. Arch Phys
Med Rehabil. 2000;81(3):258–64.
Levoska S, Keinanen-Kiukaanniemi S, Bloigu R.
Repeatability of measurement of tenderness in the neckshoulder region by a dolorimeter and manual palpation. Clin J
Pain. 1993;9(4):229–35.
Njoo KH, Van der Does E. The occurrence and inter-rater
reliability of myofascial trigger points in the quadratus
lumborum and gluteus medius: a prospective study in nonspecific low back pain patients and controls in general
practice. Pain. 1994;58(3):317–23.
Langevin HM, Bouffard NA, Churchill DL, Badger GJ.
Connective tissue fibroblast response to acupuncture: dosedependent effect of bidirectional needle rotation. J Altern
Complement Med. 2007;13(3):355–60.
Shah JP, Phillips TM, Danoff JV, Gerber LH. An in vivo
microanalytical technique for measuring the local biochemical
milieu of human skeletal muscle. J Appl Physiol. 2005;99(5):
1977–84.
Physical Therapy Reviews
2014
VOL .
19
NO .
4
160 Almeida RT, Duarte ID. Nitric oxide/cGMP pathway
mediates orofacial antinociception induced by electroacupuncture at the St36 acupoint. Brain Res. 2008; 1188:54-60.
161 Kubo K, Yajima H, Takayama M, Ikebukuro T, Mizoguchi
H, Takakura N. Effects of acupuncture and heating on blood
volume and oxygen saturation of human Achilles tendon in
vivo. Eur J Appl Physiol. 2010;109(3):545–50.
162 Larsson R, Oberg PA, Larsson SE. Changes of trapezius
muscle blood flow and electromyography in chronic neck pain
due to trapezius myalgia. Pain. 1999;79(1):45–50.
163 Sandberg M, Lundeberg T, Lindberg LG, Gerdle B. Effects of
acupuncture on skin and muscle blood flow in healthy
subjects. Eur J Appl Physiol. 2003;90(1–2):114–9.
164 Shinbara H, Okubo M, Sumiya E, Fukuda F, Yano T, Kitade
T. Effects of manual acupuncture with sparrow pecking on
muscle blood flow of normal and denervated hindlimb in rats.
Acupunct Med. 2008;26(3):149–59.
165 Larsson R, Cai H, Zhang Q, Oberg PA, Larsson SE.
Visualization of chronic neck-shoulder pain: impaired microcirculation in the upper trapezius muscle in chronic cervicobrachial pain. Occup Med (Lond). 1998;48(3):189–94.
166 Corbett MS, Rice SJC, Madurasinghe V, Slack R, Fayter DA,
Harden M, et al. Acupuncture and other physical treatments
for the relief of pain due to osteoarthritis of the knee: network
meta-analysis. Osteoarthritis Cartilage. 2013;21(9):1290–1298.
167 Manheimer E, Cheng K, Linde K, Lao L, Yoo J, Wieland S,
et al. Acupuncture for osteoarthritis. The Cochrane database
of systematic reviews. 2010(1):CD001977.
168 Vickers AJ, Cronin AM, Maschino AC, Lewith G,
MacPherson H, Foster NE, et al. Acupuncture for chronic
pain: individual patient data meta-analysis. Arch Intern Med.
2012;172(19):1444–1453.
169 James SL, Ali K, Pocock C, Robertson C, Walter J, Bell J,
et al. Ultrasound guided dry needling and autologous blood
injection for patellar tendinosis. Br J Sports Med. 2007;
41(8):518–21; discussion 522.
170 Lee JA, Jeong HJ, Park HJ, Jeon S, Hong SU. Acupuncture
accelerates wound healing in burn-injured mice. Burns.
2011;37(1):117–25.
171 Pfefer MT, Cooper SR, Uhl NL. Chiropractic management of
tendinopathy: a literature synthesis. J Manipulative Physiol
Ther. 2009;32(1):41–52.
172 Cook J, Purdham C. Is tendon pathology a continuum? A
pathology based model to explain the clinical presentation of
load induced tendinopathy. Br J Sports Med. 2009;43(6):409–
16.
173 Kietrys DM, Palombaro KM, Azzaretto E, Hubler R, Schaller
B, Schlussel JM, et al. Effectiveness of dry needling for upper
quarter myofascial pain: a systematic review and metaanalysis. J Orthop Sports Phys Ther. 2013;43(9):620–634.
174 Ceccherelli F, Gioioso L, Casale R, Gagliardi G, Ori C. Neck
pain treatment with acupuncture: does the number of needles
matter? Clin J Pain. Nov-Dec 2010;26(9):807–812.
175 Bovey M. Deqi. Journal of chinese medicine. 2006;81:18–29.
176 Hui KKS, Nixon EE, Vangel MG, Liu J, Marina O, Napadow V,
et al. Characterization of the ‘‘deqi’’ response in acupuncture.
BMC Complement Altern Med. 2007;7:33.
177 Thomas KJ, MacPherson H, Thorpe L, Brazier J, Fitter M,
Campbell MJ, et al. Randomised controlled trial of a short
course of traditional acupuncture compared with usual
care for persistent non-specific low back pain. BMJ. 2006;
333(7569):623.
178 Cotchett MP, Landorf KB, Munteanu SE, Raspovic A.
Effectiveness of trigger point dry needling for plantar heel
pain: study protocol for a randomised controlled trial. J Foot
Ankle Res. 2011;4:5.
179 Cotchett MP, Landorf KB, Munteanu SE, Raspovic AM.
Consensus for dry needling for plantar heel pain (plantar
fasciitis): a modified Delphi study. Acupunct Med. 2011;
29(3):193-202.
180 Muller R, Giles LG. Long-term follow-up of a randomized
clinical trial assessing the efficacy of medication, acupuncture,
and spinal manipulation for chronic mechanical spinal pain
syndromes. J Manipulative Physiol Ther. 2005;28(1):3-11.
181 He D, Veiersted KB, Hostmark AT, Medbo JI. Effect of
acupuncture treatment on chronic neck and shoulder pain in
sedentary female workers: a 6-month and 3-year follow-up
study. Pain. 2004;109(3):299-307.
182 Fernandez-Carnero J, Fernandez-de-las-Penas C, Sterling M,
Souvlis T, Arendt-Nielsen L, Vicenzino B. Exploration of the
Dunning et al.
183
184
185
186
187
188
189
190
extent of somato-sensory impairment in patients with unilateral lateral epicondylalgia. J Pain. 2009;10(11):1179–85.
Gonzalez-Iglesias J, Cleland JA, del Rosario Gutierrez-Vega
M, Fernandez-de-las-Penas C. Multimodal management of
lateral epicondylalgia in rock climbers: a prospective case
series. J Manipulative Physiol Ther. 2011;34(9):635–42.
Wainner RS, Whitman JM, Cleland JA, Flynn TW. Regional
interdependence: a musculoskeletal examination model whose
time has come. J Orthop Sports Phys Ther. 2007;37(11):658660.
Bergman GJ, Winters JC, Groenier KH, Pool JJM,
Meyboom-de Jong B, Postema K, et al. Manipulative therapy
in addition to usual medical care for patients with shoulder
dysfunction and pain: a randomized, controlled trial. Ann
Intern Med. 2004;141(6):432-439.
Mintken PE, Cleland JA, Carpenter KJ, Bieniek ML, Keirns
M, Whitman JM. Some factors predict successful short-term
outcomes in individuals with shoulder pain receiving cervicothoracic manipulation: a single-arm trial. Phys Ther.
2010;90(1):26-42.
Sobel JS, Kremer I, Winters JC, Arendzen JH, de Jong BM.
The influence of the mobility in the cervicothoracic spine and
the upper ribs (shoulder girdle) on the mobility of the
scapulohumeral joint. J Manipulative Physiol Ther. 1996;
19(7):469-474.
Sobel JS, Winters JC, Groenier K, Arendzen JH, Meyboom de
Jong B. Physical examination of the cervical spine and
shoulder girdle in patients with shoulder complaints. J
Manipulative Physiol Ther. 1997;20(4):257-262.
Strunce JB, Walker MJ, Boyles RE, Young BA. The
immediate effects of thoracic spine and rib manipulation on
subjects with primary complaints of shoulder pain. J Man
Manip Ther. 2009;17(4):230-236.
Winters JC, Sobel JS, Groenier KH, Arendzen HJ, Meyboomde Jong B. Comparison of physiotherapy, manipulation, and
191
192
193
194
195
196
197
198
199
Dry needling
corticosteroid injection for treating shoulder complaints in
general practice: randomised, single blind study. BMJ.
1997;314(7090):1320-1325.
Bang MD, Deyle GD. Comparison of supervised exercise with
and without manual physical therapy for patients with
shoulder impingement syndrome. J Orthop Sports Phys
Ther. 2000;30(3):126-137.
Boyles RE, Ritland BM, Miracle BM, Barclay DM, Faul MS,
Moore JH, et al. The short-term effects of thoracic spine thrust
manipulation on patients with shoulder impingement syndrome. Man Ther. 2009;14(4):375-380.
Fernandez-Carnero J, Cleland JA, Arbizu RL. Examination
of motor and hypoalgesic effects of cervical vs thoracic
spine manipulation in patients with lateral epicondylalgia:
a clinical trial. J Manipulative Physiol Ther. 2011;34(7):432–40.
Struijs PA, Damen PJ, Bakker EW, Blankevoort L, Assendelft
WJ, van Dijk CN. Manipulation of the wrist for management
of lateral epicondylitis: a randomized pilot study. Phys Ther.
2003;83(7):608–16.
Brantingham JW, Lee Gilbert J, Shaik J, Globe G. Sagittal
plane blockage of the foot, ankle and hallux and foot
alignment-prevalence and association with low back pain. J
Chiropr Med. 2006;5(4):123–7.
Cambron JA, Duarte M, Dexheimer J, Solecki T. Shoe
orthotics for the treatment of chronic low back pain: a
randomized controlled pilot study. J Manipulative Physiol
Ther. 2011;34(4):254–60.
Cibulka MT. Low back pain and its relation to the hip and
foot. J Orthop Sports Phys Ther. 1999;29(10):595–601.
Dananberg HJ, Guiliano M. Chronic low-back pain and its
response to custom-made foot orthoses. J Am Podiatr Med
Assoc. 1999;89(3):109–17.
Williams AE, Hill LA, Nester CJ. Foot orthoses for the
management of low back pain: a qualitative approach capturing
the patient’s perspective. J Foot Ankle Res. 2013;6(1):17.
Physical Therapy Reviews
2014
VOL .
19
NO .
4
265