General Practice Guidelines for Dry Needling

Dry Needling involves the insertion of a monofilament needle as thin as a strand of hair. These are the same needles used by acupuncturists.

Superficial dry needling, usually performed by acupuncturists, involves needles being placed into, but not beyond, the subcutaneous tissue approximately 10mm. Deep dry needling, used by Physical Therapists, involves the needles being placed beyond the subcutaneous tissue. The target of deep dry needling is into or around connective tissues, tendon, ligament, bone, and nerves. The length of the needle will vary and typically range from 15mm-75 mm. Deeper structures such as the hip or lumbar spine may require a larger needle depending on size of the patient.

Needles are commonly left in for 10-30 minutes. Deep needling may involve the needles being manipulated with winding, tenting, fanning, or coning. Patients will likely feel a dull, achy sensation. Twitch responses of muscle may be elicited but are not required for changes in the tissue to be made. Additionally, the needles are commonly coupled with electrical stimulation sending an electrical current directly into the target tissue through the needles.

The Physiological Effects of Dry Needling

  1. Stimulation of fibroblasts leading to changes in connective tissue and promoting healthy orientation of collagen fibers 1,2
  2. Reduction of myofascial pain by improving circulation of active ischemic trigger points 3
  3. Reduction of neuropathic pain by reversing the effects of central sensitization 4
  4. Promote healing and reduce joint pain by increasing microcirculation to the joint 5
  5. Promote tendon repair by improving oxygen saturation and blood flow 6
  6. General pain reduction by decreasing levels of cortisol and increasing beta endorphins
Dry Needling Image 1
Dry Needling Image 2

Common Conditions Treated

  • – Knee and Shoulder OA 8,9,10,11
  • – Tendinopathy 12,13,14
  • – Low back and neck pain 15
  • – Neuropathic conditions such as carpal tunnel 16
  • – Cervicogenic Headache

Adverse Responses

An autonomic response may occur leading to increased BP or heart rate. A patient may feel tired, drowsy, or faint. Risk of infection is extremely remote due to small diameter of the needle, but needs to be considered for individuals with compromised immune systems.

Relative Contraindications

  • – Recent Surgery
    • Avoid needling near surgical site if healing is incomplete (MD approval required if < 3 months)
  • – Diabetes
    • Careful assessment of patients with peripheral neuropathy/delayed wound healing is necessary before proceeding
  • – Bleeding Disorders
    • Patients with conditions like Hemophilia or those on mild anticoagulation therapy should be monitored for excessive bruising or bleeding
  • – Epilepsy
  • – Severe Osteoporosis
  • – Pregnancy

Absolute Contraindications

  • – Needle Phobia
  • – Metal Allergy (e.g Nickel)
  • – Active infection at the needling site
  • – Lymphedema
  • – Anticoagulant Therapy (e.g warfarin, heparin)
  • – Active cancer or tumor at the needling site
  • – Acute medical conditions (MI, CVA, Sepsis)
  • – Signs of poor circulation at the needling site (varicose veins, skin discoloration, swelling)

References

  1. Langevin HM, Bouffard NA, Badger GJ, Churchill DL, Howe AK. Subcutaneous tissue fibroblast cytoskeletal remodeling induced by acupuncture: evidence for a mechanotransduction-based mechanism. J Cell Physiol. 2006;207(3):767-774. doi:10.1002/jcp.20623
  2. 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. doi:10.1096/fj.01-0015hyp
  3. Shah JP, Danoff JV, Desai MJ, 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. doi:10.1016/j.apmr.2007.10.018
  4. Butts, Raymond, et al. “Peripheral and spinal mechanisms of pain and dry needling mediated analgesia: a clinical resource guide for health care professionals.” Int J Phys Med Rehabil 4.2 (2016): 2-18.
  5. Loaiza LA, Yamaguchi S, Ito M, Ohshima N. Electro-acupuncture stimulation to muscle afferents in anesthetized rats modulates the blood flow to the knee joint through autonomic reflexes and nitric oxide. Auton Neurosci. 2002;97(2):103-109. doi:10.1016/s1566-0702(02)00051-6
  6. Neal BS, Longbottom J. Is there a role for acupuncture in the treatment of tendinopathy?. Acupunct Med. 2012;30(4):346-349. doi:10.1136/acupmed-2012-010208
  7. 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):60-66. doi:10.1016/j.pain.2009.08.004
  8. Vickers AJ, Cronin AM, Maschino AC, et al. Acupuncture for chronic pain: individual patient data meta-analysis. Arch Intern Med. 2012;172(19):1444-1453. doi:10.1001/archinternmed.2012.3654
  9. Corbett MS, Rice SJ, Madurasinghe V, 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. doi:10.1016/j.joca.2013.05.007
  10. White A, Foster NE, Cummings M, Barlas P. Acupuncture treatment for chronic knee pain: a systematic review. Rheumatology (Oxford). 2007;46(3):384-390. doi:10.1093/rheumatology/kel413
  11. Manyanga T, Froese M, Zarychanski R, et al. Pain management with acupuncture in osteoarthritis: a systematic review and meta-analysis. BMC Complement Altern Med. 2014;14:312. Published 2014 Aug 23. doi:10.1186/1472-6882-14-312
  12. Neal BS, Longbottom J. Is There a Role for Acupuncture in the Treatment of Tendinopathy? Acupuncture in Medicine. 2012;30(4):346-349. doi:10.1136/acupmed-2012-010208
  13. Kubo, K., Yajima, H., Takayama, M. et al. Effects of acupuncture and heating on blood volume and oxygen saturation of human Achilles tendon in vivo. Eur J Appl Physiol 109, 545–550 (2010). https://doi.org/10.1007/s00421-010-1368-z
  14. Navarro-Santana MJ, Sanchez-Infante J, Gómez-Chiguano GF, et al. Effects of trigger point dry needling on lateral epicondylalgia of musculoskeletal origin: a systematic review and meta-analysis. Clinical Rehabilitation. 2020;34(11):1327-1340. doi:10.1177/0269215520937468
  15. Liu L, Huang QM, Liu QG, et al. Evidence for Dry Needling in the Management of Myofascial Trigger Points Associated With Low Back Pain: A Systematic Review and Meta-Analysis. Arch Phys Med Rehabil. 2018;99(1):144-152.e2. doi:10.1016/j.apmr.2017.06.008
  16. Yang CP, Wang NH, Li TC, et al. A randomized clinical trial of acupuncture versus oral steroids for carpal tunnel syndrome: a long-term follow-up. J Pain. 2011;12(2):272-279. doi:10.1016/j.jpain.2010.09.001
  17. Mousavi-Khatir SR, Fernández-de-Las-Peñas C, Saadat P, Javanshir K, Zohrevand A. The Effect of Adding Dry Needling to Physical Therapy in the Treatment of Cervicogenic Headache: A Randomized Controlled