Dry needling (DN) is one of the most hotly debated topics in physical therapy. It doesn’t take more than a quick look at any medical forum or message board to see that DN has both passionate supporters and detractors, and most well-intentioned attempts at discussing the topic quickly become an elementary school name-calling contest. It has even progressed to a legal debate between acupuncturists and other healthcare professionals that provide dry needling services.
Acupuncturists often claim that DN is the same as acupuncture, dressed up with a different name. Physical therapists, on the other hand, claim that DN is a completely different treatment paradigm. No matter where your thoughts lie, it’s important to know how they're similar, how they differ, and what the current research says on each.
The type of needle used for both dry needling and acupuncture is essentially the same. In the beginnings of DN as a form of treatment, hypodermic needles were used for trigger point stimulation. However, hypodermic needles are expensive, highly regulated, and cause more bleeding and greater tissue trauma than acupuncture needles. These issues resulted in DN practitioners switching to acupuncture needles because they are easily available, easy to use, cause less tissue trauma, and are less expensive.1
Example of a small filament needle.
Acupuncture needles are thin filament needles that range in length from 7mm to 150mm (¼” up to 6”). The diameter can also vary, with typical gauges ranging from 0.18mm to 0.30mm. There are needles specifically marketed for dry needling that are made with high-grade German steel and are said to be less painful during use, however they are essentially the same needle.
Intent and Philosophy
The intent of Traditional Chinese Acupuncture (TCA) is to open the body’s energy flow and improve one’s “Qi” in order to achieve homeostasis. The theories, procedures, and adjunct treatments (including the burning of herbs and aromatics) are all based on ancient Chinese and Eastern medicine. The various treatments of meridians all relate to specific physical, spiritual, and emotional dysfunctions. This is why acupuncture claims to treat many things outside of the musculoskeletal system including infertility, acne, illnesses, and even the malposition fetuses.
Dry needling, however, is rooted in Western medicine, physiologic responses, and addressing neuromuscular diagnosis. Through this, dry needling claims to decrease pain and muscle tightness while improving range of motion by altering anatomical and physiological processes. These processes can include the motor end plate function at a neuromuscular junction. The “neurological reset” in DN changes the bodies ability to perform certain activities, lessen pain, and improve movement quality.
In Traditional Chinese Acupuncture the usual depth of needle penetration is 3mm-10mm.2 The needles are most often superficial in placement and left in for a longer periods of time than they are for dry needling.
Dry Needling penetration is much deeper, as the needle must reach the proper area of target tissue. This can vary both by condition and by the relevant muscle. For example, the needle lengths used by Brennan et. al when comparing DN to cortisone injections for Greater Trochanteric Pain Syndrome ranged between 50mm all the way to 100mm.
One criticism regarding the depth of needle penetration during DN is the concern for safety and accuracy of needle placement, particularly in the areas near the spine. However, in a 2017 study, practitioners demonstrated a 100% accuracy of needle placement within the cervical and lumbar multifidus muscles.3,4
Location, Location, Location
Needle placement differs widely between the practices and is a focus of debate in the industry because locations tend to be more predetermined in acupuncture. Needles are placed in a specific location for the determined diagnosis. Each system, organ, or meridian has a reproducible treatment process.
In current dry needling practice there are not set locations for specific diagnoses. While there are specific techniques used when treating a desired muscle to maintain safety, the area being treated ultimately depends on the patient. The location can be determined by how the person’s symptoms present at that exact moment, where patients articulate their pain, and is based on the musculoskeletal movement evaluation.
Despite the differences in needle application location, research has produced mixed results. Two studies have reported high similarities in acupuncture and dry needling locations at 71% and 93.5%, but a third found a much lower correlation of 18% between needle locations.5 Unfortunately, all of the studies mentioned have limitations and are either dated or compare actual trigger points with the location of acupoints, not the process of dry needling itself.
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This also brings to question the general validity of trigger points which is a tensley debated topic all its own. Currently there are difficulties in defining trigger points, there is poor inter-rater reliability for palpating trigger points, and there are inconsistencies in the literature on treating trigger points. In the early stages of its development, dry needling relied heavily on the Trigger Point Model which is the method typically thought of when one hears the phrase “dry needling.” Yet the research and education is moving away from this model.
This practice as a whole is moving toward the Radicular and Spinal Segmental Sensitization Model (SSSM) but does still includes trigger point training. While trigger points are no doubt a part of dry needling, they should not be synonymous with the practice. There is ample research that encourages dry needling throughout the body at “non-trigger point sites for the purpose of reducing pain and disability in patients with neuromusculoskeletal conditions.” Unfortunately it seems that the debate over similarities in needle location between the treatments is currently unsettled and likely to continue into the foreseeable future.
Acupuncture is defined by the process of solely using needles to treat the patient. It often requires multiple sessions, promotes greater reliance on the provider to maintain the patient’s homeostasis, and by extension promotes an external locus of control on patients.
Dry needling is only part of a larger physical therapy treatment plan and only serves as an aid to achieving a greater overall treatment goal, and that means that dry needling is only performed for a segment of each treatment session. An advanced practitioner uses DN to help the patient achieve independence, and their rehab instruction, education, and performance of corrective exercises will then take the majority of the time. When administered correctly, and accompanied by proper education, DN should allow patients to maintain an internal locus of control and a way to achieve their own therapy goals.
Responses to Treatment
Risk and Adverse Events
One of the common concerns for the those that argue against dry needling is the safety of the practice. Any time that a sharp object is introduced into the body there is an inherent risk for an adverse event (AE). The frequency of AE have been found to be extremely similar between both DN and acupuncture. When looking at previous studies, the frequency of adverse events during acupuncture can range from 0.14% all the way to 11.4%!6,7,8,9 In studying DN and physical therapists, mild AE occurred in 19.18% of cases, and many of these AE were predominantly light bleeding and bruising at the needle insertion site, reported by the providers, not the patients. AEs can range from minor bleeding to major infections. Here are some examples of both major and minor AE:
Minor Adverse Events
- Pain during or following treatment
- Feeling faint
- General feeling of being “off”
Major Adverse Events
- Systemic infection
- Puncture of a vital organ
The most important conclusion to be drawn from these studies, is that there were no major AE. This is consistent with McCutcheon’s 2011 findings, that found the rate of a resulting pneumothorax from DN and acupuncture to be extremely rare (at <0.01%). This does not mean serious injuries have not occurred in both professions, but the rates remain comparably low.
While it may not seem so at first glance, dry needling is actually quite safe. DN is remains safer than taking NSAIDS which result in 16,500 deaths each year. Furthermore it has been highlighted that patients are 32% more likely to have a catastrophic accident while driving to the clinic than they are while receiving treatment.10
For more information on the rates of adverse events from both DN and acupuncture, check out this piece from Physiotherapy Alberta.
Post Needling Soreness
For anyone that has experienced both dry needling and acupuncture, they are likely to mention the difference in soreness after treatment, and in general, acupuncture causes less soreness and promotes more relaxation than DN. Based on cross sectional surveys, the most common short-term acupuncture reaction is a "relaxed" feeling (43.1%), followed by a decrease in pain (8.2%). Only 4.7% of those surveyed reported post treatment soreness.11
Patients receiving dry needling, especially those undergoing the “pistoning” technique (a process by which the needle is inserted in the same tissue multiple times in an attempt to elicit a local twitch response, or LTR), report higher levels of post-needle soreness compared to patients receiving acupuncture treatments. LTRs were once marked as an identifier of a successful dry needling treatment; despite reports of achieving greater short-term pain relief with an LTR, there appears to be no difference in long term outcomes with or without an LTR.12
That said, repeated needle insertion does result in more acute local tissue damage. There is also a positive correlation between the number of needle insertions, the number of local twitch responses achieved, and the amount of post-needle soreness experienced.13 It’s expected that DN produces greater soreness for 24-48 hours at the needle insertion sight.
Education and Training
Per the Council of Colleges of Acupuncture and Oriental Medicine (CCAOM), acupuncturists in the United States must first complete two years of undergraduate study before applying to school; some acupuncture programs may also require a Bachelor's degree. Once accepted, acupuncturists can choose a three year program to become an acupuncturist or a four year specialty program known as the Oriental Medicine Program that includes the acupuncture program and training in traditional Chinese herbal medicine. Graduates earn a masters degree through a total of 1,905 hours or 2,625 hours of education and training respectively.
“Prior to being able to take a dry needling course you must be a licensed physical therapist.”
The certification for dry needling varies slightly from state to state but requires attending a minimum of two credentialed courses. This totals around 46 hours of training and includes training in safe needle techniques, indications, contraindications, and overall patient safety. Prior to being able to take a dry needling course you must be a licensed physical therapist. In some states you must be a practicing PT for a minimum of two years before taking the certification courses.
A common argument presented against physical therapists performing DN is that they do not receive proper training and are unfit to perform DN after taking a few weekend courses. However, physical therapist’s have also had seven years of didactic training and are well-educated with regards to the human body and movement. Physical therapists receive extensive training in anatomy, physiology, and all things musculoskeletal. Per a study from BMC, physical therapists were the second most knowledgeable doctors when it came to managing musculoskeletal conditions, second only to orthopedic surgeons.
Hour for hour, the two specialties are actually quite comparable. Physical therapists obtain their education in seven years of education, and acupuncturists can complete their program in six years total. The education and training needed to perform each treatment are obviously very different, but it’s clear that both professions are specialists and well-equipped to perform their respective treatments.
The difference between acupuncture and dry needling is and will continue to be a commonly debated topic. The theories, intent, depth, standards, and education are vastly different between TCA and DN, but they make use of similar equipment to accomplish the same goal: patient wellness. There is still a great deal of research to be done on the effectiveness of each, but that’s a conversation for another time. All said and done, acupuncture and dry needling, even as distinctly different treatments, can play a role in helping patients.
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