Dry Needling in Florida?

By Dr. Sean M. Wells, DPT, PT, OCS, ATC/L, CSCS, Cert-DN

Dry needling (DN) can be described as the use of thin mono-filament needles inserted into and around muscles, tendons, ligaments, nerves, and connective tissues. Dry needling was originally published in 1979 with the focus of inserting a dry needle, a needle which contains no injectate, into trigger points of patients with myofascial pain. Dry needling is currently practiced by physical therapists in 34 states with Florida, hopefully, soon to be the 35th! Whether you are in Naples or Saint Augustine, Florida you might be wondering when your local PT can help you? Moreover, you might be wondering how's dry needling different than acupuncture and what's the evidence and safety of dry needling?

Dry needling differs from acupuncture in several ways both share many similarities. Those who dry needle operate from a Western, medically-driven approach to needling. Physical therapists’ curriculum is required to include medical pathophysiology and differential diagnosis, while acupuncturists are not required by a national mandate for such training. Some acupuncturists only perform needling based on Chinese Medicine and qi diagnosis, while many Western ones integrate medical terminology and concepts. Over the past decades Western acupuncturists have been involved in research and the practice of needling patients to treat Western medical diagnoses without the use of Eastern Chinese diagnoses (e.g. bi syndrome, qi restriction) (Dunning et al, 2014). Physical therapists performing DN use medical anatomical principles when inserting needles. Western acupuncturists are trained in anatomy; however, Eastern or strict traditional Chinese medicine acupuncturists may simply rely on meridians and points when needling. Some authors have shown that up to 80% of acupoints are associated with intermuscular or intramuscular connective tissue planes, suggesting TCM acupoints to be highly valuable targets for treatment (Langevin & Yandow, 2002). The safety of using only a meridian system or the educational rigor of acupuncturists' anatomical studies have not been directly compared to that of physical therapists’ or other providers; however, rates of adverse events have been compared between many providers and data show lower rates of adverse events in physical therapists versus acupuncturists with needling (Xu et al, 2013). Some physical therapy groups have pushed to differentiate DN from acupuncture by stating DN is the insertion of needles into trigger points only. Fortunately, the APTA, published literature, and practice guidelines have helped to demonstrate that DN involves needling in and around muscles, tendons, connective tissue, joints, and nerves (Dunning et al, 2014). A final departing difference between acupuncture versus DN are the complementary and other interventions provided. Acupuncturists’ mainstay focus for treatment is needling, while those performing DN may also utilize medications, exercise, manipulation, or other modalities in combination with needling. Similarities of acupuncture and DN can be seen in both nomenclature and in practice. The terms acupuncture and DN have been used interchangeably with researchers citing its overlapping use within professional organizations (e.g. APTA and British Journal of Medicine) (Dunning et al, 2014). Acupuncturists have cited that DN and acupuncture both share the same needles, locations, actions/mechanisms, and effects (Zhu & Most, 2016). As such, it is vital for physical therapists to be inclusive of Western acupuncture studies, while also exploring new evidence on DN and its integration with other physical therapy treatments (Dunning et al, 2014).

So what's the data show on DN and many physical therapy issues? Dry needling has strong and overwhelming evidence for effectiveness in the treatment of those with knee arthritis (OA), according to several systematic reviews (Dunning et al, 2014). A recent randomized controlled trial (RCT) showed individuals with knee OA receiving a combination of periosteal electrical DN, manual therapy, and exercise experience significantly greater improvements in disability, medication frequency, and the global rating of change (GROC) than those receiving only manual therapy and exercise alone (Dunning et al, 2018). The 2018 Dunning and other study is important for several reasons. The effect sizes were large (>0.82), 75% of DN patients improved their GROC by ≥5, and those getting the electric DN were nearly 2 times more likely to completely stop taking pain medication at 3 months (Dunning et al, 2018). The important thing is that the needling and electrification was done around the knee joint and not just into muscles.

Another promising area for DN is back pain. A recent systematic review and meta-analysis found that compared with other common treatments, DN was more effective in alleviating the intensity of low back pain (LBP) and functional disability (Liu et al, 2018).  DN helped to reduce, beyond minimal clinical differences (MCD), both pain and the Neck Disability Index (NDI) scores in patients with upper trapezius pain (Ezzati et al, 2018). Other areas of around the spine seem to benefit too, with DN studies showing beneficial outcomes for patients with headaches, TMJ dysfunction, and cervicogenic dizziness, albeit in a fewer number of studies (France et al, 2014; Butts et al, 2017; Escaloni et al, 2018).

There is some evidence for DN in the use of patients with extremity issues, such as plantar fasciitis, tennis elbow, and Achilles tendinitis. More research is needed to clearly see how these treatments can be best delivered to improve outcomes, although several studies highlight the need to insert needles in multiple locations around painful areas (not just muscles) and use electricity while needles are in place.

The risks of DN are minimal with appropriate training, education, and certification. Most common cited risks involve bruising, bleeding, headache, drowsiness, or nausea. Major adverse events include infections, pneumothorax, and punctured organs and sensitive tissues (e.g. spinal cord). In a Dunning 2018 trial, one patient (1.7% of the sample) experienced nausea, drowsiness, and headache, which resolved in several hours.  Halle & Halle  developed a 2-part article outlining cases and evidence for how to avoid adverse events in DN (2016). Major adverse events were noted when needling around the thorax, neck, and shoulder due to clinicians needling too deep and/or not observing appropriate anatomical features (Halle & Halle, 2016). The authors encourage clinicians to stay closer to midline when in the cervical spine, upper trapezius, and supraspinatus muscles, and utilize “bony backdrops” when appropriate (Halle & Halle, 2016). Boney backdrops are when a needle is inserted until a hard end feel is felt by tapping the needle onto a bony surface. Preventing infections can be achieved using a clean technique and once-only needles, especially around the abdomen and pelvis (Halle & Halle, 2016b). Gloves protect the physical therapist and offer little infection control to the patient. The earlier Liu et al 2014 article highlights that acupuncturists may have higher rates of adverse events than PTs -- perhaps this is due to PT's cadaver-based anatomy training and training to not insert needles deep into tissues.

In the end, physical therapists are skilled to perform dry needling and the data supports its use for many conditions. We are hopeful dry needling is passed in Florida, and after it is, our practices in St. Augustine and Naples will be implementing this evidence-based tool soon!

References available upon request.

This is an opinion piece and should be construed as practice information or medical advice. We are not liable for any and all actions taken related to this article. 

#Dryneedling #Naples #StAugustine #Pain #OA