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.
APTA 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.
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.
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.