To Needle or Not to Needle?

To Needle or Not to Needle?

In 2012, the American Physical Therapy Association (APTA) published an “educational resource paper” entitled “Physical Therapists & the Performance of Dry Needling”.

This important paper focused on the “dry needling” of tender muscles — a popular therapy for chronic pain being practiced around the world by a variety of physical therapists.

“The issue of whether the performance of dry needling (sometimes referred to as trigger point dry needling or intramuscular manual therapy) is within the professional and legal scope of physical therapist practice continues to be a question posed to state regulatory boards and agencies,” APTA states on its website.

bigstock-Accupuncture-3149299APTA considers that dry needling falls within the scope of acceptable physical therapy practice. In so doing, it divorced itself from the ancient theories, principles and tenets of traditional Chinese medicine.

In the words of APTA: “The performance of modern dry needling by physical therapists is based on western neuroanatomy and modern scientific study of the musculoskeletal and nervous systems.”

As this appears to be the case, it should be possible to determine if the currently available scientific evidence supports this claim.

The principle on which this paper is based can be found appears on page 2 of the document:

Dry needling (DN) is a skilled intervention used by physical therapists (where allowed by state law) 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.

A trigger point describes a taut band of skeletal muscle located within a larger muscle group. Trigger points can be tender to the touch and refer pain to distant parts of the body. Physical therapists utilize dry needling with the goal of releasing/inactivating the trigger points and relieving pain.

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.

A careful examination of this statement reveals that the entire edifice of dry needling has been erected upon circular argument: trigger points cause myofascial pain because the muscles thought to be at fault contain trigger points.

Research on animals and humans designed to show that trigger points are actual areas of muscle damage have been uniformly unsuccessful, which strongly suggests that the theory itself has no scientific basis.

Furthermore, because there is no consensus among “experts” on the definition and method of detecting trigger points and taut bands, inter-observer reliability for their detection has been uniformly poor. If they cannot agree on the actual location of trigger points, dry needling simply becomes a “hit or miss” exercise.

Not surprisingly, a number of meta-analyses of randomized control trials have shown that the outcomes of treatment founded on the presumed pathology within muscular tissues (trigger points) are no better or even worse than those expected from sham treatment.

Yet, physical therapists around the world are still being trained in dry needling technique and may not easily be dissuaded from practicing it upon their patients. After all, their income may depend upon it.

Why then does dry needling appear to work, at least in the short-term?

Is it possible for a treatment to be “accidentally” effective, despite it being based on false theoretical foundations? One explanation is that the treatments such as dry needling are rarely performed in an isolated fashion; that is, treatment is accompanied by manual therapy, home exercises, and stretching.

The apparent effectiveness of any treatment may be erroneously attributed to the natural history of the particular problem being treated (“good days” and “bad days”), the personality and status of the therapist, and the expectation of something being done to the area in question. This gives rise to the fallacy known as post hoc ergo propter hoc (“after this therefore because of this”) when the treatment offered in fact had nothing to do with the underlying nature of the condition to which the treatment is being directed.

A common factor shared by some manual therapies (including dry needling) is that they elicit pain at the site of their application; that is, they are potentially noxious (tissue-damaging) stimuli. If they do “work,” this similarity suggests a common mechanism of action, that of counter-irritation, or application of a competing noxious stimulus. It is not surprising that a noxious stimulus applied in the region where pain is experienced, whether or not there is local pathology present at that site, would elicit a short-lived reduction in pain intensity by recruiting those higher order brain regions responsible for anti-nociception. This phenomenon is called counter-irritation analgesia, a concept with which people who have ever hit their thumb with a hammer are familiar.

Unfortunately, physical therapists who conduct research in this complex area of pain medicine have not addressed the important issues that are outlined above. Until these matters are properly attended to, the scientific credibility of dry needling and similar “needling” approaches hangs by a slender thread.

Dr. John Quintner

Dr. John Quintner

John Quintner, MD, is a rheumatologist and pain medicine specialist in Australia who recently retired from clinical practice.

He has published numerous articles on chronic pain in Pain Medicine, Clinical Journal of Pain, The Lancet and other medical journals.

The information in this column is not intended to be considered as professional medical advice, diagnosis or treatment. Only your doctor can do that!  It is for informational purposes only and represents the author’s personal experiences and opinions alone. It does not inherently or expressly reflect the views, opinions and/or positions of National Pain Report or Microcast Media.

References:

APTA Department of Practice and APTA State Government Affairs. Physical Therapists & The Performance of Dry Needling. APTA, January 2012.

Cummings TM, White AR. Needling therapies in the management of myofascial trigger point pain: a systematic review. Arch Phys Med Rehabil 2001; 82:986-92.

Hartman SE. Why do ineffective treatments seem helpful? A brief review. Chiropr Osteopat 2009; 17:10. doi:10.1186/1746-1340-17-10.

Quintner JL, Cohen ML. Referred pain of peripheral nerve origin: an alternative to the “myofascial pain” construct. Clin J Pain 1994; 10:243-51.

Rickards LD. The effectiveness of non-invasive treatments for active myofascial trigger point pain: A systematic review of the literature. Int J Osteopathic Med 2006; 9:120-36.

Tough EA, White AR, Cummings TM, et al. Acupuncture and dry needling in the management of myofascial trigger point pain: a systematic review and meta-analysis of randomised controlled trials. Eur J Pain 2009; 13:3-10.

There are 36 comments for this article
  1. Nick Webborn at 4:44 am

    “Research on animals and humans designed to show that trigger points are actual areas of muscle damage have been uniformly unsuccessful, which strongly suggests that the theory itself has no scientific basis.”

    How sad that in the 21st century that some doctors still need to have a picture of an abnormality to believe that can cause pain! A dysfunctioning neural system causes pain without appearing abnormal on scan/biopsy etc. Not being able to show an abnormality on biopsy does not mean it doesn’t exist; you just didn’t do the right test.

    Dry needling can change muscle tone through its inter-relationship with its neural control system. Try a simple experiment of inducing increased muscle tone through e.g. downhill running. It’s sore and tight in your quads. Check your range of motion on prone knee bend. Now needle the rectus femoris. Re-measure your change in range on PKB and also see if it more comfortable.

    Try performing a sustained grip for 5 minutes and see if that is painful and your muscles feel tight and sore after. Abnormal pathology? No. Do it when you have a painful stiff neck and increased neural tension and it is worse and sustains for longer.

    22 yrs ago I couldn’t understand what my colleague was doing with his needles and why, but having tried and evolved dry needling/acupuncture/IMS over that time it is an invaluable part of assessment and management of many MSK conditions.

  2. Pat Anson, Editor at 4:29 pm

    With all due respect to Drs. Rodrigues and Quintner, this will be the last comment from either of you on this particular story. Let’s hear from others on dry needle therapy and whether it works or doesn’t work.

  3. Stephen S. Rodrigues, MD at 4:24 pm

    @Quintner
    You frightening me and you are being very deception. You disparage aspects of a holistic treatment, Myofascial Release Therapy that has been ubiquitous in society since the beginning of time. Why, because you have doubts about a word? Trigger Point. Those hand picked articles are to bolster your agenda and are weak representative of vast array of how needles are used today.

    Your present debate strategy which is an “ad hominem” is a form of criticism directed at the opponents person, intelligence or integrity. NOT the accumulated evidence, experiences or science facts. This attack is getting old and falling short.

    Myofascial release therapy has been ubiquitous in society since the beginning of time. Except in the last 15 years when the profiteer discovered a perpetual income source, you and your pain management. All the profiteers had to do is convince a few key players to ignore a few discoveries, turn everyone into a number and a code, lie about the past successes and promote only Conventional Medicine. Then sweep the poor outcomes under the rug.

    What’s the matter with using stretching and massage for sore achy muscles and stiffness?
    or using leverage, machines as in a Chiropractor’s office or using a needles as a tool to do the same? It is all the same treatments on a continuous spectrum from simple to invasive.

    My mission is to advocate for ALL pain treatment options, free and readily available to all. It will take a herculean effort and I figured at least 5 yrs to implement. I’m skeptical of the ability of today’s scientific and research community to look backwards before it can move forward to begin to help all those who need pain therapy. The human body and nature does not allow for large gaps in the knowledge stream as we advance forward in the biological sciences.

    Everyone here is a “Ms Rosa” in various stages. Ms Rosa was fortunate to find a CAM provider who took her insurance. Everyone should have this same opportunity. Agree or not, advocate for yourself or not, it is about ALL who suffer with long-term pain. This is the take home message of the petition.

  4. Johnna Stahl at 2:37 am

    Dr. Quintner said: “But surely one of the important roles of these associations is to protect the public from fraudulent and irrational practice.”

    I’m sorry, but I had to chuckle at that… As I think about the damage done by Big Pharma through its system of drug dealers (I mean, doctors).

    And when I think about the historical involvement of the AMA in the creation of the insurance industry.

    And when I think about the addiction and rehabilitation industry. Even when I think about the pain management industry.

    Gosh, I could go on and on…

    And I don’t think you can claim that “’dry needling of trigger points’ constitutes ‘The Greatest Masquerading Practice’ in our current health-care system.” (See above list.)

  5. John Quintner at 6:21 pm

    Johnna, the past icons of “trigger point” theory (Drs Travell, Gunn and Rachlin) were never part of what you refer to as the “medical establishment”. They were proponents of a now discredited construct, which my colleague Dr Rodrigues is trying to resurrect. Nonetheless, they did succeed in “getting things wrong”.

    I agree with you about doctors (and other health care professionals) relying unduly upon their professional associations. But surely one of the important roles of these associations is to protect the public from fraudulent and irrational practice.

    Better to rely upon the application of application of scientific methodology, which can be relied upon to move us closer to a better understanding of the phenomena we encounter in the clinical situation.

    To me, it appears that “The Greatest Masquerading Sickness” is being trotted out as a smokescreen to obscure the fact that “dry needling of trigger points” constitutes “The Greatest Masquerading Practice” in our current health-care system.

    As I have said in a previous comment, in this open forum Dr Rodrigues is attempting to defend the indefensible and pass off speculation as established knowledge. That of course is his choice.

  6. Johnna Stahl at 1:41 am

    Dr. Rodrigues: Why do you capitalize the word “masters,” as if you’re talking about a god? And why should I believe what these masters have to say, anyway? It’s not like you can trust the medical establishment to get things right.

    Also, I wanted you to know that I read your petition, which you linked in one of your other posts. And while I agree with some of what you said, I really disagree with quite a bit of it. But that’s not surprising, considering how long it is, and how much you covered in that one post.

    Dr. Quintner: Perhaps doctors should stop relying on their professional associations so much.

  7. Stephen S. Rodrigues, MD at 9:27 am

    Richard Feynman explains, “I would like to add something that’s not essential to the science, but something I kind of believe, which is that you should not fool the layman when you’re talking as a scientist. I am not trying to tell you what to do about cheating on your wife, or fooling your girlfriend, or something like that, when you’re not trying to be a scientist, but just trying to be an ordinary human being. We’ll leave those problems up to you and your rabbi. I’m talking about a specific, extra type of integrity that is not lying, but bending over backwards to show how you’re maybe wrong, that you ought to have when acting as a scientist. And this is our responsibility as scientists, certainly to other scientists, and I think to laymen.”

    My assertions are not mind but a compilation of past scientist with the utmost integrity. So attacking me, my type of practice and those Masters is said to be a form of blaming and shaming the messenger to discredit their contributions. 300 years of established knowledge is as credible as it can get in medicinal and biological sciences.

    The deceptive tactics of human beings with ignoble intents have disavowed what we already know! So if a person has off the chart very rare bizarre symptoms and weird diagnoses, doctors are baffled, confused, bewildered; medications do not work and your metabolic functions are broken. The immune system gets off track and starts to attack your our flesh which confuses the dickens out of every one.— you more than likely have the disease I call the “The Greatest Masquerading Sickness.” See Travell, Gunn, Rachlin.

    @Quintner
    An idea that is in someone’s mind which can not be tested in reality is just that, an idea.
    For an idea to grow you need fertile soil, water, the light of the sun — I would rethink this idea.

    Oh do you have the answer to the lower back pain question?

    http://neurotheory.columbia.edu/~ken/cargo_cult.html

  8. John Quintner at 3:15 pm

    “I think the problem is that medical science doesn’t understand chronic pain yet, so a lot of it is conjecture.”

    And as those who read National Pain Report may already have gathered, what a huge problem it is!

    In his 1972 Caltech lecture (Cargo Cult Science), the physicist Richard Feynman explains the first principle for maintaining one’s scientific integrity : “… you must not fool yourself, and you are the easiest person to fool. So you have to be very careful about that. After you’ve not fooled yourself, it’s easy not to fool other scientists. You just have to be honest in a conventional way after that.”

    His comments still ring true to me in this hugely complex and poorly understood area of Pain Medicine. We must all beware of passing off our conjectures as established knowledge!

    I do hope the American Physical Therapy Association is taking note!

  9. Johnna Stahl at 11:34 pm

    I think the problem is that medical science doesn’t understand chronic pain yet, so a lot of it is conjecture.

    Kinda like anti-depressants — no one really knows how they work. And, unfortunately, it turns out anti-depressants work only a little bit better than a placebo (which is not an insignificant percentage when we’re talking about treating depression). The medical science on depression is mostly conjecture too.

    But when we’re talking about the science of reproductive health, we are not talking about conjecture. So, my hope is that one day, medical science will figure out chronic pain and depression as well as it has figured out reproductive health.

    But I agree that the practice of medicine is both a science and an art form.

    A couple of years ago, I watched a very informative series on the Charlie Rose program about brain science. One episode was devoted to chronic pain, but I watched the whole series, as developments in other areas of brain science can sometimes be linked to chronic pain (or the comorbid conditions that accompany it). I won’t pretend that I understood it all, but it was this program that led me to the conclusion that the problem of chronic pain begins (and ends) in the brain.

    Yes, one must treat the body along with the mind… And I’d like for you to consider, Dr. Rodrigues, that trigger point treatments may have more to do with treating the psychological effects of chronic pain, more so than the physical. And if they do, then more power to them.

    If a psychiatrist can utilize hypnosis to help patients — a “treatment” that only a small portion of patients may have success with — then I don’t see why doctors can’t use trigger point injection therapies. If patients feel they receive benefits from seeing a chiropractor, then I say go for it; but again, I believe only a small portion of chronic pain patients obtain successful results with these treatments.

    A lot of treatments only work for a small number of pain patients (with the exception of opioids). Perhaps that is because pain is so unique to each person? Regardless of the reason, the goal should be to provide pain patients with as many options as possible. (Free the Leaf.)

  10. Stephen S. Rodrigues, MD at 8:07 pm

    1. How then does Dr Rodrigues know this?
    Questioning the authority, in this case it all of my past education, research, reading, set up trials, making errors, re-examining, experimentation and drawing conclusions. ALL in real encounters with the patients doing the grading. You have to touch people to draw these conclusions. I must trust that the patients has pain despite negative radiologic scans, inconclusive findings or unanimous verdicts from different specialist.

    I have a Question.
    If a radiologist had 10 age matched MRIs of 50 year old males, only one complains of lower back pain at level 5-8 for over 4 weeks. What are the odds of any radiologist being able to determine which case had the pain and which side the pain was on?
    Answer.
    https://www.facebook.com/notes/stephen-s-rodrigues/radiologic-question/925573214136736?ref=notif&notif_t=like

  11. John Quintner at 5:41 pm

    Once again I am indebted to Dr Rodrigues for assisting me in my task:

    “Pain starts in the invisible muscle and connective tissues which cannot be detected by technology.”

    This assertion raises three important questions:

    1. How then does Dr Rodrigues know this?

    2. He obviously believes he has gained access to an immutable truth, but why should anyone else believe him?

    3. Does not employing a needle to create a lesion in muscular tissue in order to heal an invisible lesion within that muscle defy common sense? Shades of homeopathy, where like is said to cure like?

  12. Stephen S. Rodrigues, MD at 9:03 pm

    Sorry! to me?? I’m sorry I brought God into the conversation. But if you think that medicine and religion do not mix, I would argue that they are inextricably mixed. Mixing political views, medicine and reproductive choices will stir up emotions.

    Proof in clinical medicine that is a fallacy. What can be proven?? Technically only the pure sciences can be proven in all circumstances. There is very little pure science in medicine although we use it to improve our outcomes which are in reality a function of logic, common sense, experience, conjecture, odds, fortune and plain old luck. Clinical medicine is both a science and an art. The art of knowing how to manage a case that has only subjective (word of the patient) and objective(the PE, labs and X-ray) data. ALL of which cannot be confirmed or refuted at that moment in time. So every doctor has to guess!

    “Anyway, it is my brain that heals my body when it is injured,”
    IMO this is an incomplete concept. It is the “whole you” that heals the “whole you.” If any aspect of the “whole you” is faltering your healing will also falter.

    “old stale trigger points”
    Gunn, Travell and Rachlin all note these complex types of trigger points, I will post a picture of a drawing in Gunn’s textbook. I certain that you can not fathom these treatments. If you like email me and I will link you with a video of a case I use for demonstrations.

    I do not cut patient’s off. Some I have been treating for 10 years. Do I stop? NO.

    Of course, unfortunately there are failures. These treatment are not like flipping a switch. Treatments of this type must accumulate over time, so you whittle the pain down until it’s gone or at a lower level.

    Great, I instruct my patients on self care at home too!

    “I don’t see how chronic pain can be treated via trigger points when the problem is in the brain.”
    IMO, this is wrong. Pain starts in the invisible muscle and connective tissues which can not be detected by technology. MF signals stresses the brain which set up the cycling each feeds off the other. You must treat the body to relieve the stress on the brain which is dependant on the body for survival so overtime both will settle down. If the brain is still neurotransmitter depleted, I add it in for a while.

    “But then, what do I know?” I would say that your know more that about 98% of the primary care docs!

  13. John Quintner at 6:25 pm

    “In the world of myofascial pain and dysfunction which is what chronic pain is caused by, these must be treated.”

    What a wonderful example of a circular argument – myofascial pain causes (myofascial) pain!

    Yet this is the very same logical error that gave rise to the practice of “dry needling” of muscles.

    I look forward to receiving a reasoned response from the APTA, but I am not going to hold my breath whilst waiting for it.

  14. Johnna Stahl at 4:31 am

    I’m sorry, Dr. Rodrigues, but it doesn’t matter which god you were talking about — medicine and religion do not mix. For a classic example of this, just look at the crisis in women’s health around reproductive choice. I prefer my medical providers to believe in things that can be proven, not ancient stories and myths.

    And look at the discrimination against women in the pain management industry. Don’t you think this is somewhat based in religious doctrine?

    Anyway, it is my brain that heals my body when it is injured, not some otherworldly, inexplicable source.

    Many of my injections included lidocaine — I don’t know why you would assume they didn’t. And for the cortisone and botox injections, I had to be sedated. Believe me, if these treatments had provided any relief, I would still be doing them.

    And I think I can tell the difference between the discomfort from a needle prick and the burning sensation I described. I’m guessing that your explanation of “old stale trigger points” is often given to patients when your treatments aren’t working. The point is, if these treatments don’t work on old stale trigger points — and what really does — then why continue? Because there’s a possibility that the treatment will work… some day?

    I’m curious, Dr. Rodrigues — when do you cut-off a patient? Have you ever told a patient that you can’t help them, say after 6 months or a year? Since patients have to pay for your treatment out-of-pocket, I’m guessing you don’t need to do that too often. Patients can’t afford treatments that don’t work, but many will continue on in the hope that someday they will.

    Patients deserve to know how well each treatment works before they open their wallets. According to my overall view of patient feedback for the different kinds of treatments for trigger points, these treatments haven’t proven themselves. But then, very few have.

    “In the world of myofascial pain and dysfunction which is what chronic pain is caused by, these must be treated.”

    I do treat the myofascial pain and dysfunction that I suffer from — at home, for free. My home treatment plan addresses these issues; it has to. But I don’t see how chronic pain can be treated via trigger points when the problem is in the brain.

    The side effects of the brain’s dysfunction include the different types of pain you are trying to treat, but I don’t see trigger points as the root cause of chronic pain. So, you’re really only treating the side effects of pain. Like taking anti-nausea medication for the side effects of opioids.

    But as I said earlier, if there are patients that obtain relief from these treatments, I don’t see the harm. As long as any negative side effects are not permanent…

    But then, what do I know? I’m not a doctor, just a patient who has lived with constant pain for a quarter of a century… Why would anyone listen to me?

  15. John Quintner at 5:57 pm

    Dr Rodrigues, I know my task is a hard one but it has been made a little easier as a result of your spirited defense of the indefensible. No matter how many times your wild speculation is repeated, it still remains a wild speculation!

  16. Stephen S. Rodrigues, MD at 7:43 am

    @Johnna
    Assumptions of a persons beliefs is not very constructive, all you had to do was ask for clarity. How did you know I was a type of Christian, most of us in the US are? Did you know there are hundreds of Christian ideologies. Where do you live? It is concerning that a person loses credibility if they believe differently than you.

    I use God is a metaphor for absolute certainty, not the emotional or belief God. The force that heals without any effort on our part as when you cut yourself. IMO, people have to have faith in “something” because we all prepare for the future with confidence and certainty. Yes?

    The pain associated with the needles can be seen as 2 varieties. The first is the stick from the point of the needle, which can be felt like a Q-tip on the skin to a sting or burn. Just a quick blip and it’s gone. If you take a 12 inch ruler and smack yourself – this is an example of a worse case.

    The second level of discomfort is where the action is and is assumed to be the action of the muscle tissues responding to the needle in a mechanical-electrical response. Some love this sensation like you are scratching an itch that has been bugging you for a while. This is a release signal that the muscle is responding and feels like an ache, pull, spreading or grab. In some this will evoke an “audible” like in football where they will tell you what to do. I just reset the needle.

    What happened to you in your treatments can be either. But I suspect that you have some old stale trigger points which have grown into a large masses of “OUCH.” These are very toxic and sensitive masses. Edward Rachlin, M.D. and Chan Gunn, MD noted this decades ago. Rashlin will pre-treat or pre-injection these hot TrPs with lidocaine, let the anesthetic settled in before he continues. I use laughing gas, IM sedation — these have not other treatments that I have found.

    In the world of myofascial pain and dysfunction which is what chronic pain is caused by, these must be treated.

    @quintner
    You have your work cut out for you, since you seem to have no recent real world hands-on clinical experience. Plus you reject all of the prior scientist work. One of the reason why we have progressed so rapidly in the science fields is that we build on prior confirmed work. You have no foundation?? I would suggest you rethink your arguments. Good luck.

  17. Johnna Stahl at 5:55 pm

    “These treatments once combined will unlock the full force of Mother Nature and thus unleash God’s Healing, which will restore that which is possible.”

    Okay, now we’ve brought the Christian god into the conversation… Which is fine for those who are religious and use prayer to treat pain.

    But when a doctor talks about his god, I tend to lose “faith” in any treatments he might recommend.

    My pain, and the treatments I choose, having absolutely nothing to do with religion.

  18. John Quintner at 2:07 pm

    Johnna, the American Physical Therapy Association made it quite clear that the treatment it was advocating on behalf of its membership had no basis whatsoever in Traditional Chinese Medicine. Therefore, “dry needling” is NOT simply an Americanised version of Chinese acupuncture.

    The sole intent of my article is to expose what I see as a deception being practiced upon so many people with persistent pain. The substance of my argument is contained within the article.

    Dr Rodrigues asks whether “we start all over from scratch on a new platform and build from there? Take what is known rearrange it into a new formulation?” My response is a resounding YES.

  19. Stephen S. Rodrigues, MD at 8:39 am

    @Quintner, you frightened me with that statement! You can not debunk 300 years worth of wisdom just by debunking an arbitrary term we use to describe something we can not see with modern technology.

    Do you own or have access to the textbooks? Have your read and applied the authors protocols in a real life setting? Those Masters meticulously and sincerely explain in fine detail ways to effectively treat chronic pain. They all evolved in isolation, so the plans and procedures are slightly different. If a provider today combines all the ideas in a seamless mission, one will cover for the other’s deficiency. These treatments once combined will unlock the full force of Mother Nature and thus unleash God’s Healing, which will restore that which is possible.

    So help me clarify your intent. Is it to codify a new term, name or concept? Start all over from scratch on a new platform and build from there? Take what is known rearrange it into a new formulation? What is your plan to treat chronic stubborn miserable pain? So please help me to understand your mission.

  20. Johnna Stahl at 7:39 pm

    Kudos to Dr. Rodrigues for finally mentioning the word “acupuncture.” When I read through this thread a couple of days ago, I wondered why the phrase “dry needling” was used. So, the dry needle technique is an Americanized version of Chinese acupuncture, right? And acupuncture is considered an “alternative” treatment by the medical industry, lacking in scientific evidence of its efficacy. Okay, now I understand what the problem with is.

    When I tried acupuncture awhile ago, no one had a problem with calling it by name. It was a GP who stuck me in the shoulders with dry needles — on one side, after 15 minutes or so, there was no effect. On the other side, within a few seconds, it started to burn and cause more pain, so I asked for that side to be removed. (And the burning sensation hung around for a few days, too.) An experience I was not willing to repeat, even though I understood that this GP was not really an expert in this treatment.

    I’ve also had trigger point injections in more than one area — some were dry needles, some with just saline, and some with steroids and other anti-inflammatories. None of these treated the pain — none reached that deep, dark place where chronic pain resides (probably because that place is in our brains). In fact, in my case, I think these treatments only caused more harm.

    I also did my share of research on trigger points, and my treatment experiences included manual manipulation too — just as painful as many other physical therapies. But, no pain, no gain, right? For a chronic pain patient, that’s not really how it works. After all, when you dread going to treatment, you know something is wrong.

    More pain often means a reversal in stability or progress. For me, these physical therapies just caused the referred pain to travel even further… all these trigger points (or whatever you want to call them) are connected, and very sensitive to pressure and invasive treatments.

    My pain levels eventually reached a point where I didn’t trust anyone else to touch me without causing more pain — I do my own therapy, including some light massage. The last time a doctor examined me, I requested that he not use his thumbs — hitting a bad spot (which is not hard to do) increases pain that can last for days.

    But… acupuncture is an ancient technique that is about more than just finding trigger points, and if it helps some people, this treatment should be made available and easy to access (including being covered by insurance). The problem in the pain management industry is the same as it’s always been — there are too many doctors who prey on the desperation of pain patients, stringing them along with promises of improvement that are never achieved (but only after a lot of money has been spent).

    So what are the actual success rates for acupuncture? How many people are being helped and how many are being harmed? It’s hard to believe self-reported success rates… I clearly remember my oral surgeon telling me I had a 70% chance for a reduction in pain with the surgery option. Since the surgery made the pain worse, I guess I was just one of his unlucky patients. But then, you can’t reverse surgery, and any negative effects from acupuncture are temporary… right?

  21. John Quintner at 5:26 pm

    Dr Rodrigues has “hit the nail on the head” when he affirms that a “trigger point” is “just a concept or description for something we can not detect with certainty with our advanced sophisticated technology or with a quorum of physicians.”

    Now that the central tenet of Myofascial Pain theory – the “trigger point” as a region of primary muscle damage – has been repeatedly questioned and found wanting, the elaborate “house of cards” upon which it was built has collapsed.

  22. Stephen S. Rodrigues, MD at 9:13 am

    Never in my wildest dreams.‏ 🙁
    I would have to justify why it is a tragic state in medicine that we allow and advocate the amputation of knee, hip, shoulder or ankle joints based on flawed forensic evidence, false pretense, and made it the standard care option by arbitrary rules and regulation.

    I never thought that as human being who can master some aspects of our environment, we must trash our ethical, moral foundation and sacrifice peoples lives to prove it.

    I never thought that medicine would separate out into 2 factions, one of science-based and the other of practical-based knowledge and that the science-base would overtake and overwhelm common sense.

    I never thought that the business community would undermine medicine and subvert the tenets of science and the ethics of Hippocrates losing all integrity and sanity.

    I never thought that I would have to explain to an erudite colleague that a “trigger point” is just a concept or description for something we can not detect with certainty with our advanced sophisticated technology or with a quorum of physicians. That a scientist and researcher would refer to an article that is the antithesis of a dry needling procedure..

    I would have thought that as a scientific community, we would have discovered that Fibromyalgia is a unique and unparalleled disease that has no singular or simple cause. That FM presentations are as diverse as each individual based on a much more complex set of circumstances such as genetics, environment, life and stresses. So each FM case is as unique as a snowflake and thus each person requires a personalized care plan.

    I never would imagine that in FM and chronic pain cases, that I could say with certainty, “that any care plan that does not include free access to myofascial release therapy with hands-on and needle options would be a dereliction of duty and a betrayal of the human spirit.”

    I never thought that a word or an image would instill and evoke such a visceral fear, hate, apprehension and rejection as does the word “acupuncture.” That modern intellect could not remove the surgical tool from the dialogue and witness “the most powerful set of tools in humanity.”

    In the clinical setting practical experience should be the guide to help patients in pain, so the scientific data takes the back seat. The beauty of the acupuncture needle is that it is an extension of your fingers. You can use the needle to reach into the tissues to “feel” what is there, invisible to the eye. So if you have a tender point, trigger point or an “ouch that hurts doc,” the needles can be used to further investigate. If it’s nothing there to behold, nothing happens except for the simple microscopic injury of the needle, which heals 100%. If there’s something questionable, the patient of the provider will acknowledge that evidence and continue with the investigation. Immediately, without any delays, further investigation will help determine if these areas are tender spots, sensitive spots, trigger point or whatever is present. If there is still uncertainty which is a certainty, the job has been done and the help is on the way as per Mother Nature.

    The beauty of the tool is that it’s like a 3 trick pony; it investigates, diagnose and treats all with one fell swoop. All within an office visit and a few pennies worth of needles.

  23. Geoffrey Bove, DC, PhD at 5:12 pm

    What a riot. As Forrest Gump said, “that’s all I have to say about that.”

  24. John Quintner at 3:14 pm

    I agree with Dr Rodrigues that there is a mass understanding of what a “trigger point” is and is not.

    According to Lucas et al. (2009): “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.”

    Until such time as these fundamental issues are properly addressed, physical therapists and others who practice dry needling are in the unenviable position of being unable to provide their patients and third party payers with a scientifically rational basis for their preferred intervention.

    Reference: Lucas et al. Reliability of physical examination for diagnosis of myofascial trigger points: a systematic review of the literature. Clin J Pain 2009; 25: 80-89.

  25. Stephen S. Rodrigues, MD at 11:54 am

    I fear there is mass misunderstanding of what a “TrP” is and is not. This is leading to many underdiagnosed, undertreated, neglected patients who have to suffer in pain. These patients need help NOW. The disconnect is rooted in the use of words, definitions, categories, separation of duties, rules and regulations.

    IMO every one is attempting to define what a VW bug is and how it is different from a Chevy Nova. What gets lost and is most important is the fact that they are both vehicles. Having a vehicle is important. Having access to a fleet of a wide variety of vehicles is even more important.

    The needle is the vehicle and the place to travel is dependent on the unique aspects of each case. In some folks, all you need to do is drive to the nearest 7-11. While in other cases you will need to venture off road and up hills. A VW bug is an inefficient tool to go off road, so you must get in the most appropriate vehicle. If the patient tells you the VW is not working listen and change the tool.

    Important! You will fail the patient if YOU insist that they will be fine with a VW and not a much needed SUV. You will also fail the patient if you insist that your VW can travel off road through a stream. You will do irreparable harm to a patient if you insist that your 18 wheeler will fit into a one car driveway.

    I would direct you all to the primary sources of all our modern day practices and procedure; Gunn, Travell & Simons’, Rachlin, Hackett, Lennard, Burke, DiFabio and Pybus, Baldry and Chaitow. These Masters of MF pain therapy have done all of the foundational work. All those authors advocate different modalities and tools to treat the same MF pain. Today we just need to implement all of their varied safe and effective protocols.

    TrPs start out as innocent “errors of repair”, them devolve into demons, from little ouchies or soreness, then into the classically described phase with a twitch, them they will further degrade into erratic muscle bundles, on to a dense hard beef jerky like effect. Each stage requires the appropriate tool from simple massage to more forceful hands-on manipulations and active release.

    There seems to be a critical level of TrP density within the muscle tissues where in which hands-on options will not fully release the muscles. Once this density is reached you must up the therapy to include the slim needles, NDing or GunIMS. As the density of trps increase the muscles will devolve and will require more aggressive tools, the hypodermic needles. Even at this level size matters too, so a 27g may work and at times you must go up to a 25g, and 23g is more appropriate.

    What is MF pain? Here is my simplified view of this pain which falls into 3 categories,
    Structural pain which can be visualized by technology as in cancer, aneurysms or tumors. This pain requires specific human intervention.
    Injury pain as in a fall youth contusion, sprains, pulls and breaks. Mother Nature does all the work and requires minimal or no human intervention.
    NONstructural pain which is what we are debating about. This MF pain is invisible to technology or analysis, has no structure because it is embedded within the flesh. It demands and requires therapy in the form of MF release therapy with hands-on and needle options. This pain requires customized human intervention.

    MF pain and dysfunction is a disease that will lead to secondary and tertiary complications like neuropathy, DJD, bone-on-bone effect, loss of joint spacing and collapsing disc. So when your doctor states that you have damaged joints structures on the X-Ray, MRI or CT scanner, these damaged findings are the secondary effects to the primary MF diseased tissues. Thus you can not honestly view these radiograph finding as the cause of the pain, they are of the secondary complications. It is illogical and unscientific to insist and promote the treatment of this MF pain with amputation and replacement of a joint or disc. You are using an erroneous concept, deceptions and misinformed consent. This is unethical and dishonest which will harm the patient irreparably.

    Ever wonder why back surgeries fails, patients continue to complain of pain after joint replacement surgery, Carpal Tunnel Syndrome release fails, frozen of a joint (shoulder) ruins peoples lives, face pain patients do not respond to open brain surgery, jaw pain options fail, vertigo is recalcitrant, Migraines become stubborn, diabetics complaint bitterly of pins and needles despite medications? This is why in a nutshell.

  26. John Quintner at 1:48 am

    Dear Foozieh, I omitted to provide the reference for my disparaging comments. Despite the authors’ attempt to put on a brave front, as I read their review, the conclusion seemed inescapable – that the entire practice of dry needling deserves to be relegated to the dust-bin of history where it will occupy a well deserved place alongside so many other failed “therapeutic” practices.

    Reference: Dunning et al. Dry needling: a literature review with implications for clinical practice guidelines. Phys Ther Rev 2014;,19: 252-265.

  27. John Quintner at 10:40 pm

    Dear Foozieh, I once had the opportunity to attend a workshop given by Dr C Chan Gunn and left it with the distinct impression that the theory upon which he based his technique known as IMS was insupportable. The evidence for benefit derived from this treatment does not appear to be convincing, to say the least. Again, anecdotal evidence cannot be relied upon as the sole arbiter of the value of such treatment. Is there more robust evidence in the relevant scientific literature that could guide us when evaluating IMS?

  28. Foozieh Ostowari at 10:03 pm

    Dear Dr. John
    In regards to whether the IMS is working, I must say yes. It does work.
    There are multifactors to patients presenting with improvements.
    Proper diagnosis
    Application of IMS
    Collaborating the IMS with strengthening and manual therapy.
    I must say I do not do dry needling. I treat with IMS. They may not look so different but when it comes to diagnosis, IMS taught by Gunn has a more detailed neuropathic assessment. It is also very limited to only safe spots. If practitioners try new areas, that is the practitioners’ initiative which also affects the outcome of the treatment.
    I treat individuals with IMS and most of the time they have tried IMS elsewhere. Most and almost all of them respond to the treatment and are very satisfied.
    I am also not sure if there is a slight difference between IMS and dry needling. All I know IMS is the main scientific approach. It is awesome. Dry needling started in USA and I can not tell much about it.
    I would be willing to continue this chat with you. Please contact me and I will speak with you about the numerous physicians who believe in this treatment approach.

  29. John Quintner at 1:53 pm

    Dear Giovanni. The evidence that you cite is not sufficient to justify invading tender muscles with needles under the guise of administering science-based therapy. You must surely know that anecdotal evidence alone, as has been drawn upon by others who have commented on this topic, is subject to considerable bias and cannot therefore be relied upon as justification for a therapeutic intervention.

    The altered biochemical milieu reported by Shah et al. is consistent with inflammation due either to tissue damage or to altered peripheral nerve function where the “pathology” is not necessarily in the site being sampled. Overall, the findings suggest that the phenomenon of tenderness (allodynia) is associated with an altered tissue environment. But Mense warned that because of their potential interactions, it was premature to conclude that any or all of these substances are responsible for localised pain.

    As for the EMG findings, it appears that “endplate noise” is characteristic of but not restricted to TrPs. An alternate interpretation of these findings is that the investigators were recording insertional and spontaneous activity (i.e. “end plate noise”) from single muscle fibers generated by the activation of intramuscular nerve terminals irritated by the needle.

    Yes, I agree that “dry needling” can be effective, but only as judged by anecdotal evidence. In my opinion, as I explained in my commentary, such effects are more likely to be due to contextual factors associated with the treatment than to the actual treatment being administered.

    Kory, the Titanic you mention has struck an iceberg and history tells us what happened to this outstanding example of human ingenuity. Dry needling will take much longer to disappear from the waters upon which it is currently trying to stay afloat.

    Rex, I enjoyed reading your thoughtful comments.

    References:

    Katirji B. Clinical electromyography. In: Bradley WG, Daroff, R.B., Fenichel, G.M., Jankovic, J. ed. Neurology in Clinical Practice. Philadelphia: Butterworth Heinemann, 2004: 491-520.

    Mense S. Algesic agents exciting muscle nociceptors. Exp Brain Res 2009; 196:89-100.

  30. Kory Zimney, PT at 8:32 am

    Dr. Quinter,

    Thanks for your thoughtful article. As I read some of the comments, I reflect on the Transtheoretical Model of Change. Some of us may be in the precontemplation stage, which is where we are when we are in denial and don’t see our behavior or beliefs as something that needs changing. People in this stage do not understand that their behavior or belief may be damaging or are under-informed about the consequences of their actions and thoughts. Somethings that can be helpful to move out of this stage is asking ourselves questions. Could there be an alternative explanation for the improvements that I see or feel in my patient or myself beyond my current understanding? How would I recognize research and evidence that refutes my current belief? What would happen if I changed my view point on my current belief and took the alternative view?

    As an APTA member, I am concerned about this movement within the profession. There is substantial marketing involved within the area of TDN and I wonder if the marking cart may be ahead of the research horse on this one. We have to consider that there are substantial non-specific effects that take place with an intervention such as TDN that may account for the improvement claims that are stated in testimonials. Unfortunately my concerns within our profession are probably a significant minority and this Titanic of a treatment intervention has already left port.

  31. Rex Fujiwara, MPT,OCS at 10:56 pm

    Dr. Quinter,

    Since physical therapists have yet to respond to your article. I would like to share some interesting things and respond to the previous comments.

    The first and most important question we (as clinicians) and the public need to know is: “what is a trigger point?”. Is it a taut band of microscopic muscle tissue? It is a site of hypertonicity due to a neurological protective mechanism? is it a knot?

    A couple of years ago I did a review of 82 articles trying to find research to validate and define a trigger point and palpation. Unfortunately, only 8 or 9 of them found validity and reliability of palpation itself. The remaining studies showed limited reliability and validity of palpation. Even top trigger point clinicians and instructors could not prove that they can consistently point out what a trigger point is or find the same exact spot on test subjects. This specific research study was discussed here: http://www.fmperplex.com/2013/02/14/travell-simons-and-cargo-cult-science/

    Studies show that hands on techniques work, but we assume that we are treating what we think we are treating. What this means is that hands-on techniques help patients with pain. But the explanatory model describing why patients improve may be incorrect. It doesn’t mean we do not do what we are doing, it means we have no idea why it works. We are only assuming.

    Many studies make conclusions that the reason why patients improve is strictly due to the intervention without assessing all other factors. here is an article on possible error and bias by researchers: http://www.nizkor.org/features/fallacies/post-hoc.html

    Studies by David Butler, Lorimer Moseley and other pain neurophysiologists are finding that we may actually be treating the nervous system.

    For example, if we tickle a child for a while, they will need a break to breath. Then all we have to do is wiggle our fingers and they start laughing and protecting their body without even touching them. Pain is the same. When there is a painful event, the body goes into protective mode. This increases tension in the body. It is real and it is neurological.

    If we put our hands on that child and assure them we will not tickle them, then they relax their body. How else can we explain why kissing a child’s knee decreases their pain? We are calming the protective mechanisms of the brain. If a child falls and we make facial expressions that give the child the perception that it is a serious fall, they will more likely cry and experience pain because we increase their threat value.

    Here is another example: why does potassium help with muscle cramps? Muscles do not need potassium, it is the nerves that need it because they have sodium/potassium pumps and calcium pumps that are required to send message from the brain to the muscle to contract. If there is a lack of potassium the nerves do not function properly causing abnormal contractions due to various reasons including those pumps and levels of chemicals in the extra-cellular matrix. It is the nervous system that may be in charge of the muscles.

    So by touch and movement, we may be changing how the body, through receptors on the skin is assessing its environment to increase or decrease protective mechanisms by giving positive feedback to the nervous system. By inserting a needle, it may do the exact same thing, but with more risk. It may also increase threat value which may increase protective mechanisms and pain. There are studies regarding needling involving piercing of the lungs by accident in humans and permanent nerve damage in mice and humans. here are some studies:

    http://www.practicalpainmanagement.com/treatments/iatrogenic-nerve-injury-following-dry-needling-foot-pain-case-challenge
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3638584/

    If trigger points are actually related to nervous tissue, Is the risk worth it? Even if it wasn’t related to nervous tissue, would it be worth it? I do not know, since there is a tremendous amount of variability in how our nerves travel in the body. How would I know that I will not cause nerve damage. This is one area where I would rather side with safety and “do no harm”

    I have learned many manual therapy treatment theories including pain neurophysiology education that have been very helpful to address parts of the body that are restricted, tense, and in a protective state without using needles (it is not part of my practice act here in California.)

    Respectfully,
    Rex Fujiwara,MPT,OCS

  32. Giovanni at 9:21 pm

    Dear Dr. John,

    As physiotherapist who tries to be evidence-based almost all the time. I have read some texts (no peer-reviewed papers) questioning the both the existence of myofascial trigger points (MTrP) as well as their role as peripheral pain generators.

    I Agree with your statement that MTrP has strong face validity, since we can palpate hyperirritable spots within taut bands, which are painful to compression and can reproduce the patients’ main complaint. I’m confused, however, with your statement that “there is little in the way of evidence to support it”. Could you please provide more comprehensive arguments? There is experimental evidence associating the presence of MTrP to endplate disturbance; there is experimental evidence that needle insertion on MTrP elicit several biochemical reactions (Jay Shah et al and their biochemical ‘millieu’), as well as there is some recent meta-analytic evidence demonstrating that trigger point dry needling can be effective (Kietrys et al. J Orthop Sports Phys Ther, 2014).

    I would be please to hear from you about this fascinating theme.

    Looking forward!

  33. Michael G Langley, MD at 4:11 pm

    It is interesting that the woman who replied here is saying her physician could identify trigger points with ultrasound! Is that something new that has developed over the last ten years? Or, is it just another example that sham medicine is helpful in decreasing the pain of the trigger points? In my own injections. I would use lidocaine, usually about 5cc in my trigger point. It caused immediate relief because the entire TP was anesthetized. (It hurt like the devil, too! It was much less painful when injecting into areas that were not in spasm) I was able to inject the ones in my upper back and neck. I was, even, able to teach my non-medically trained wife to hit them! I wonder if those tiny trigger point injections, used by others, did not really affect enough of the muscle tissue to give the relief. At times, I used decadron in the lidocaine, but did not do that more than two times in six weeks, to avoid and cortisone related side effects. With concomitant use of Prozac, I had pretty good control of the disease. I was able to pull my hunting bow back, easily at the start of each hunting season. Before treatment, I had been having increasing pain when trying to pull the 50lb weight of the bow.

    Interestingly, after I was started on gabapentin and for my neuropathy and tizanadine for the muscle spasms associated with my post-traumatic cauda equina syndrome, the trigger points have vanished! Then again, it could be the sedentary lifestyle the spinal cord injury has given to me! Who knows? I did shoot my hunting bow, yesterday, without any pain! My accident…I fell from a tree, about twenty feet, when a weld broke on the tree stand! I was no threat to the deer after that, for about a year!

    The other thought is how much of this is stress related. I have been disabled and no longer work. Could my relief be from retirement, and not swimming with the sharks any more?! Who knows?!

  34. Stephen S. Rodrigues, MD at 11:21 am

    The references that you cite are confirmation to my therapy that I have been using for a decade. Myofascial release therapy is the only treatment for these invisible pain syndromes. When I say only I mean just that -only. These options are taken off the table and now we have a chronic pain epidemic. I love the fact that non-MDs will have these tools to help fight pain. I would order up thousands of them to put them to work immediately. I’ve always said that a MD does not need to do these treatments and they don’t. Patient can even do them at home!

    I am sadden that you are the antithesis of what a true scientist is suppose to be. A scientist’s collects data for analysis, formulates concepts and test these ideas in the real word for repeatability and validity. They do not or should not question a patient feelings, especially the feeling of pain or discounts a testimony from a real person who states what they feel. Then they do not hangs on to old stale, faulty opposing views. They let failures and flaws go and hopefully learn from the ordeal.

  35. John Quintner, Physician in Pain Medicine at 5:34 pm

    Thanks for your response, Celeste. It supports my thesis that there is little if any scientific basis for the passive treatment you received.

    Without going into detail, in my opinion the logic behind your reasoning is that known as confirmation bias, which connotes the seeking or interpreting of evidence in ways that are partial to existing beliefs, expectations, or a hypothesis in hand.

    The trigger point theory of “myofascial pain” certainly has high face validity but there is little in the way of evidence to support it. As I mentioned (and referenced), treatment predicated on this theory has been shown not to work.

    To continue to perpetuate the mythology initially promulgated by Travell & Simons in the 1980s flies in the face of the evidence that there are other more rational and scientific explanations for the clinical phenomena that have been associated with and attributed to trigger points.

    The idea that trigger points are “peripheral pain generators” has certainly been canvassed by some researchers in fibromyalgia but they have muddied the waters by passing off speculation as established knowledge.

    In any case, my commentary is directed at the APTA’s 2102 publication. Doubtless to say, a response will be forthcoming from this august body.

    Reference: Nickerson RS. Confirmation bias: a ubiquitous phenomenon in many guises. Review of General Psychology. 1998; 2: 175-220.

  36. Celeste Cooper at 2:52 pm

    Not only can my advanced trained physical therapist locate myofascial trigger points using his skilled fingers, he successfully uses another technique call active release therapy to treat them. He has gotten me from using a cane to ambulate, to walking without a limp because of MTrPs that have developed from SI joint arthritis and deformity.

    My integrative pain MD in Arizona, uses ultrasound guidance to locate and treat myofascial trigger points, which are my greatest peripheral pain generator. He uses ultrasound so that he can also use dry needling when lidocaine along with a biotanical antiinflammatory, called sarapin (which is covered by medicare here in the US) to get into the belly of trigger point when injection does not sufficiently release them.

    I had severe debilitating pain from myofascial trigger points in my neck secondary to severe, diffuse, inoperable disease, including splondylosis. No epidurals worked. One pain doctor wanted to implant a neurostimulator because a TENS unit helps. I only wish I could find a pain doctor year round to treat me because ultrasound guided trigger point injections are a Godsend to me, and if my PT could use dry needling, I would do it in a heart beat!

    As anyone with myofascial pain syndrome knows, it is difficult to maintain a normal muscle resting length, but it is possible and then one can work on strengthening. It requires perpetual care, identification of contributing factors, such as poor posture, ill fitting shoes, a purse that’s too heavy, one leg shorter than the other, etc.

    To hear that I am thrilled about this study would be an understatement.