Posted on by Kyle Ridgeway

What are the Issues with Therapeutic or Trigger Point Dry Needling? 9 Considerations to Ponder

Dry needling continues to garner increasing popularity within physical therapy. And, the focus is not just clinical, a pubmed search for “physical therapy” and “dry needling” illustrates an 8 fold increase of manuscripts from 2010 to 2015 (66) compared to 2000 to 2005 (8).1,2

The number of continuing education courses, certifications, and companies offering dry needling continues to rapidly expand. Further, there appears to be no shortage of anecdotal reports of the remarkable “power” of this intervention and clinical experiences suggesting it’s “the next big thing.” But, I have some questions, and justified concerns regarding the outpatient orthopaedic physical therapist’s most invasive intervention. Larry Benz has commented “trigger point dry needling is not #physicaltherapy.”3

Yes, while there is a paucity of evidence, TDN probably works in some instances-likely more to “meaning effect” and placebo than anything else (which of course is fine but in states with informed consent forms it probably works as a  nocebo).  My concern is the nocebo effect of TDN on our profession.

The irrational exuberance around TDN within the #physicaltherapy profession is ironic if not downright damaging.  We fight and defend for direct access, expanded scopes of practice, evidence as the core basis of our interventions, and being recognized in the healthcare chain as force multipliers within the musculoskeletal world yet state legislators in many states are hearing PT’s fight for the right to stick needles into patients. TDN is hardly a transformative intervention and regardless it does not define #physicaltherapy.

Like Larry, I am concerned and request that we as a profession take a moment to appraise this intervention, in terms of applicable clinical evidence and appropriate critical reasoning, before enthusiastically implementing dry needling, let alone recommending it to patients in professional publications.4 Further, the issues and assessments are not limited to dry needling specifically, as the approach can be applied to other interventions and concepts such as cupping.

Clinicians utilizing dry needling will exclaim “dry needling is not acupuncture!”, but the paradox is proponents continue to use acupuncture“evidence” (of both traditional Chinese medicine and biomedical flavors) to supposedly support their practice. Obviously, dry needling is not actually acupuncture. I’m not sure it even bears repeating that rarely is dry needling the sole intervention provided by a physical therapist. But, given the invasive nature and significant learning cost, in terms of both time and money, the addition of dry needling to a treatment plan as either an additive intervention or in replacement of other interventions, seems suspect without research supporting significant improvement in outcomes.5 And, this improvement should be specific to needling itself, not the byproduct of other non-specific mechanisms. Or, alternatively, needling must illustrate some measurable, or even highly plausible, physiologic effect known to improve a patient’s condition, main complaint, or medical diagnosis.

What issues with dry needling should be considered?

1) Acupuncture Literature Applies
2) Dry Needling Research is Underwhelming and Misrepresented
3) Poor Terminology Surrounding Needling, Trigger Points, and Myofascial Pain
4) Lessons from the Evolution of Manual Therapy: Manipulation
5) Treatment Targets and Proposed Mechanisms
6) Insights from the Study of Pain
7) Risk vs. Benefit and Invasiveness
8) Cost and Time
9) Bias in Research Interpretation and Conflicts of Interest

The Acupuncture Literature Applies

I contend that the acupuncture literature can provide us with some insights on the specific effects of inserting a needle into human flesh, be they physiologic, psychologic, perceptual, or otherwise.6 Of course, this is dependent on the assumption that any specific meaningful effects exist beyond transient, clinically irrelevant short term improvements in symptoms and subjective reports likely mediated by meaning response, expectation, context, non-specific effects, and placebo.7

In short, it is unambiguously clear from high quality investigations, systematic reviews, and meta analyses that acupuncture is nothing more than a “theatrical placebo.“8 The research illustrates:

  • Poorly designed smaller studies with high risk for bias showing promising results
  • Larger, well controlled studies show no meaningful clinical benefit
  • Needling location doesn’t matter
  • Needle depth doesn’t matter
  • Skin penetration doesn’t matter18
  • The needle doesn’t even matter, toothpicks work just as well

Interestingly, similar to potential mechanisms in manual therapy what does appear to modulate, or predict, small observed outcomes in select patients is expectation, patient beliefs, and individual practitioner factors among others.7,9-14 Specifically,

The individual practitioner and the patient’s belief had a significant effect on outcome. The 2 placebos were equally as effective and credible as acupuncture. Needle and non-needle placebos are equivalent. An unknown characteristic of the treating practitioner predicts outcome, as does the patient’s belief (independently). Beliefs about treatment veracity shape how patients self-report outcome, complicating and confounding study interpretation.

Whether studied as a means to move qi along meridians or under a more western and biomedical informed lens, acupuncture has consistently failed to show that is an effective treatment.15 Such results should not only give us pause regarding the recommendation of acupuncture to patients for the treatment of various painful problems, but should also raise serious questions regarding the enthusiastic implementation of dry needling into physical therapist practice, clinical research agendas, and post professional education.

If needle insertion, needle location, needle depth, or even using a toothpick do not seem to affect outcomes in acupuncture, I’m perplexed by those who propose dry needling is somehow, in some way profoundly physiologically different.16-18 And furthermore, how anyone can subsequently claim dry needling location, depth of penetration, and other specific factors relating to application technique can robustly impart some important physiologic effect or meaningfully impact on clinical outcomes. Physical therapists should likely temper claims of mechanistic specificity, or effect, and be cautious in citing acupuncture literature to support the practice of dry needling. For those seeking additional certifications in related healthcare fields, visit https://cprcertificationnow.com/products/bloodborne-pathogens-certification to explore valuable courses and enhance your knowledge in critical areas of healthcare.

Dry Needling Research is Underwhelming and Misrepresented

Many will claim the research around dry needling is growing, and promising results suggest broad applicability. Oddly, some will state that dry needling is not acupuncture and in the next breath cite flawed, or misinterpreted, acupuncture literature as a seemingly evidence base plea for the usefulness of dry needling. While the volume of manuscripts relating to dry needling continues to rise, the actual trial data is underwhelming at best, if not outright negative. Yet, articles in professional magazines, clinical perspectives, and (flawed) systematic reviews positively frame the intervention as effective.19-21 These assertions may mislead casual readers to conclude the data supporting dry needling is quite strong. This is not the case. Harvie, O’Connell, and Moseley at Body in Mind conclude:22

We contend that a far more parsimonious interpretation…is that dry needling is not convincingly superior to sham/control conditions and possibly worse than comparative interventions. At best, the effectiveness of dry needling remains uncertain but, perhaps more likely, dry needling may be ineffective. To base a clinical recommendation for dry needling on such fragile evidence seems rash and risks exposing patients to an unnecessary invasive procedure.

A more recent systematic review effectiveness of trigger point dry needling for multiple body regions concluded “The majority of high-quality studies included in this review show measured benefit from trigger point dry needling for MTrPs in multiple body areas, suggesting broad applicability of trigger point dry needling treatment for multiple muscle groups.”23 Unfortunately, that is not what the trials included indicated as only:

  • 47% showed a statistically significant decrease in pain when compared to sham or alternative treatments
  • 26% displayed a statistically significant decrease in disability
  • 42% did not include a sham or control intervention group
  • 32% investigated only the immediate effects (ranging from immediately post-intervention to 72 hours) of TDN which is a research design with remarkable limitations24
  • 3 assessed the quality of the blinding in the sham group
  • 1 was retracted at request of the journal editor

Specifically, one randomized trial effectiveness of trigger point dry needling for plantar heel pain found a number needed to harm (NNH) of 3 and a number needed to treat (NNT) of 4. So, for every 3 patients treated with needling 1 is likely to develop an adverse event while for every 4 patients treated only 1 is likely achieve a beneficial outcome. Or, in other words, patients in the treatment arm were more likely to experience an adverse event than a beneficial outcome. One of the most commonly reported adverse events, in addition to bruising, was an exacerbation of symptoms, which I will argue is only acceptable if intermediate and long term outcomes of dry needling are somehow superior. An invasive intervention that results in more adverse events, lacks long term benefit, or fails to measurably change an underlying physiologic derangement should likely not be employed. Subsequently, available interventions that are effective, less invasive, and less likely to result in symptom exacerbation such as graded exercise/activity/exposure, cardiopulmonary exercise, pain education/therapeutic neuroscience education, and non-invasive manual therapy should be preferentially implemented.

These are significant and specific concerns that require careful consideration.

Poor Terminology: Trigger Points, Myofascial Pain, and Needles

Unfortunately, dry needling is riddled with poor terminology and vague language. Admittedly, such an issue is not unique to dry needling, and thus this entire post is applicable to many interventions and trends within physical therapy: cupping, scraping the skin with instruments (instrumented assisted soft tissue mobilization), and trendy tools in the proverbial tool box.25,26 But, never the less language is a significant issue as researchers attempt to investigate and understand the intervention in greater depth and clinicians continue to broadly implement it into practice. It’s not just semantics, precision in language is an absolute necessity.28

What are the actual differences between trigger point dry needling, dry needling, therapeutic dry needling, intramuscular manual therapy, functional dry needling, systemic dry needling, integrative dry needling, or any other form of physical therapists poking patients with needles?

Regardless of the clinical trial data (which is actually weak), those utilizing a myofascial trigger point approach to dry needling need to acknowledge the current issues with regards to a lack of consistent criteria defining a trigger point, the questionable clinical importance (if any) of the proposed trigger point construct, and the poor reliability in trigger point identification. There are many foundational issues at the core of the trigger point theory including an absolute lack of established validity. John Quintner upon evaluating trigger points:29,30

The existence of such bands had never been demonstrated and it was therefore highly speculative and erroneous to attribute nerve entrapment to such a mechanism. Other weaknesses in their theory included the somewhat metaphysical concepts of “latent trigger points,” “secondary trigger points,” “satellite trigger points” and even “metastasising trigger points”. To further confuse matters, it was later shown that “experts” in MPS diagnosis could not agree as to the location of or even the presence of individual MTrPs in a given patient. The mind-boggling list of possible causative and perpetuating factors for MTrPs was completely devoid of scientific evidence and therefore lacked credibility…Finally, those who became “dry needlers” appeared to be unaware that when justifying their assault on MTrPs they were following the “like cures like” tenet of homeopathy. In their parlance, physical therapists (including physicians) were obliged to create a lesion in muscle tissue in order to cure (“desensitise”) a lesion (for which there was no pathological evidence)…

…subsequent literature was also notable for its failure to acknowledge that the underlying hypothesis was flawed – no one has ever succeeded in demonstrating nociceptive input from putative myofascial trigger points. All subsequent “research” simply assumed the truth of what started out – and remains – as conjecture.

Also, worth mentioning are the significant issues such as tautological reasoning inherent in not just trigger point theories and hypotheses, but also myofascial pain syndromes and fibromyalgia.30-33 I do agree with the term “Therapeutic Dry Needling.” I contend this language and nomenclature separates the technique from theoretical and mechanistic principles, thereby allowing continued growth and open discussion as the science evolves. In addition, the current terms, and many of the accompanying theories, are not fully encompassing of the state of the literature in regards to trigger points, myofascial pain, pain treatment, and possible treatment mechanisms. Lastly, some further perpetuate specific targets and theories of intervention that are quite frankly unreliable, and worse, invalid. Not to mention, understanding will inevitably change over time. Specifically, precise operational definitions are required for scientific inquiry. Vague language leads to vague reasoning and muddies research results. Geoffrey Maitland is credited with the insight “to speak or write in wrong terms means to think in wrong terms.”

In aggregate there is sufficient reason to not only doubt, but discard, the foundational premises  of trigger points, myofasical pain, and potential “needleable lesions” as clinically meaningful entities and necessary treatment targets.34-35

The Evolution of Manual Therapy: Manipulation

History, some may say, is our greatest teacher. A rearward glance into the evolution of manual therapy practice and mechanisms, specifically manipulation, appears eerily applicable to the current discussion. Specific derangements such as sacral nutations, ESRL, FSRL, sacral flares, leg length discrepancies, static posture position, and subtle biomechanical “faults” supposedly necessitated specifically matched techniques for proper symptom resolution. The minute differences between techniques such as angle, spinal level, specific joint mechanics, and other application factors such as speed were presented as highly important to garnering the proper effect. The tissues were hypothesized to be the primary dysfunction and treatment target. Concepts such as the “manipulatable lesion” were developed.

The paradigm of assessment and treatment attempted to mirror diagnostics in other segments of medicine, a laudable effort to be sure. Clusters of information, in the case of manual therapy the patient’s symptoms, palpable dysfunctions, and malalignments, were supposed to be aggregated into a specific diagnosis. Specific diagnoses warranted specific treatment at a specific dosage or speed or spinal level. Unfortunately, the fatal flaw with this diagnostic approach in manual and physical therapy is the overall lack of essential diagnoses, commonplace in medicine, and the high prevalence of nominal diagnoses.36 Outpatient orthopaedics is primarily characterized by pain complaints, often times absent of significant trauma, tissue injury, or diagnosable physiologic derangements. In a failed attempt to solve such a conundrum, nominal diagnosis or clinical syndromes such as patellafemoral pain syndrome or “pain on the front of the knee mostly when squatting or bending the knee with the foot on the ground” and shoulder impingement syndrome or “pain on the front of the shoulder mostly when raising the arm overhead that sometimes feels like a pinch” were created with the goal of improving the specificity of treatment and our ability to match interventions to patient presentation.

Proposed mechanisms included changing tissue length, loosening joint capsule, breaking adhesions, unsticking stuck joints, and improving tissue related joint mobility. Minute, subtle, questionably detectable, but in actuality irrelevant, biomechanical faults were pitched as the cause of patient symptoms. But, years of research now state otherwise.37

Matching a specific manual therapy technique to a specific, theoretical, but quite frankly imaginary, fault proved not only to be futile, but unnecessary.38 The amount of force provided through the hands lacks the speed, acceleration, and load to meaningful change tissue length and other material properties. Manual therapy techniques were shown to result in movement at many levels of the spine. And, the specific technique utilized didn’t seem to matter much. Overall, technique type, long lever vs. short lever, speed, and exact level of the spine didn’t seem to matter much either. Predictors of response to treatment did not include classical palpation and hands on motion testing. Fear avoidance beliefs and length of symptoms did however. The neurophysiologic mechanisms of manual therapy appeared similar to placebo mechanisms.9 Patient expectation of success was important as was therapeutic alliance.11,39,40 Clinician expectation was correlated with outcome. Framing of the intervention’s potential effects seemed to affect degree of analgesia.41

Manual therapy can now be conceptualized as a neurological input and patient interaction whose overall effect, in both direction and magnitude, appear to be related to host of a complicated interacting factors, most of which have little to do with the specific technique.10

Yet, those teaching and researching dry needling appear to be clearing an old trail. Peripheral derangements, specific techniques, and minute, likely minimally important dysfunctions as a root cause of a patient’s symptoms. Assumptions, in my opinion incorrect ones, are leading us down a long road, which if manual therapy and manipulation research is any indication, will require an even longer journey to reverse.

Treatment Targets & Proposed Mechanisms

In addition to vague language, the currently proposed treatment targets and purported mechanisms of dry needling fail to integrate understanding from the acupuncture literature and compose an incomplete consideration of potential mechanistic factors.

Trigger points, latent trigger points, twitch response, trigger point referral patterns, facilitated segments, neuro-trigger points, micro-tissue trauma, chronic local inflammation healed by needle induced inflammation, and the list goes on. The fact that a dense array of sensory receptors of various types, including nociceptors, exist in nearly every layer of tissue including the cutis and subcutis, suggests it is not only possible, but quite likely that stimulation of these receptors is sufficient to produce the proposed therapeutic benefits. This is anatomically and neurologically true regardless of needle depth. The clinical studies of acupuncture support such a claim as neither needle location nor depth nor skin penetration nor the needle itself appear to specifically contribute to outcomes. The skin contains dense array of free nerve endings, and other receptors. Those who present possible dry needling constructs should acknowledge the current, multi-factorial mechanisms of manual therapy and the various factors contributing to overall treatment responses.

  • Can we ascertain specifically which structures are needled?
  • Is it not likely we are needling a host of structures?
  • Can we ascertain the receptors that are stimulated during needling?
  • Is it not likely we are needling various receptors?
  • Can we actually target specific tissues or receptors?
  • Is targeting specific tissue necessary, or even sufficient, for symptom resolution or a positive clinical outcome?
  • Does specificity in anyway affect outcome?

There are many inherent issues with assuming, let alone presenting, specificity of a treatment target and subsequently proposed mechanism based on test/re-test assessments and clinical observations of benefit. Such an explanatory model assumes the underlying theoretical construct is accurate but also that:

1) The test is specific to that tissue, structure, or defined dysfunction (validity)
2) A positive, or negative, test (or test cluster) is accurately identifying the tissue, structure, or defined dysfunction (reliability, sensitivity and specificity)
3) The subsequent treatment intervention is specific to the identified dysfunctional structure and thus
4) The mechanism of effect specifically relies on treatment target, application, and location
5) Resolution of the symptom and clinical outcome is dependent on the preceding

A test/re-test approach, while clinically appropriate for assessing response to treatment, is inappropriate reasoning as a mechanistic explanatory model. So, we must further explore:

  • What is the premise of this intervention?
  • Is it more efficacious, effective, or efficient than other interventions?
  • Are the models of assessment and treatment plausible? Valid? Reliable?
  • Are there other explanations that may explain the observed effects, and thereby question the necessity of needling?
  • Is this intervention as specific to certain tissues or explanatory models as it is presented?
  • Is needling necessary, or even sufficient, for symptom resolution? Or, a positive outcome?

All approaches to and explanations of dry needling need to incorporate current, multi-factorial mechanisms of manual therapy and various factors contributing to overall treatment responses in pain. Such research would suggest that targets and mechanisms of many of our interventions for pain are not nearly as specific as previously assumed and currently presented. With this this in mind, one should be cautious in making claims of specificity. How can all the other potentially stimulated neuro-vascular structures, contextual factors, patient-practitioner interactions, and various other treatment effects be ruled out, or at least addressed as not only potential contributors to outcomes, but confounders to study results?

Pain Science and Complexity

Pain is now understood as a multifactorial, individualized, lived sensory and emotional experience much more profound than mere peripheral nociceptive signaling. The neurophysiologic, psychologic, environmental, contextual, as well as social factors present in the concept of pain are exceedingly complex. And, that is not inclusive of the profound philosophical and linguistic challenges of defining, studying, understanding, educating, and ultimately interacting with someone in pain. Attempting to accurately reconceptualize pain illustrates:42

 …the biology of pain is never really straightforward, even when it appears to be. It is proposed that understanding what is currently known about the biology of pain requires a reconceptualisation of what pain actually is, and how it serves our livelihood. There are four key points:

(i) that pain does not provide a measure of the state of the tissues;
(ii) that pain is modulated by many factors from across somatic, psychological and social domains;
(iii) that the relationship between pain and the state of the tissues becomes less predictable as pain persists; and
(iv) that pain can be conceptualised as a conscious correlate of the implicit perception that tissue is in danger.

These issues raise conceptual and clinical implications

And thus, it is worth mentioning not only a few of the myriad of factors that contribute to symptom severity, symptom report, and seeking medical treatment, but also the the swarm of interacting constructs that contribute to effect.43

Treatment Mechanisms in Pain
>Non-specific effects
>Placebo
>Nocebo
>Patient Expectation
>Provider Expectation
>Context
>Previous Experience
>Believability of the Intervention
>Psychologic State
>Framing and Language Surrounding the Intervention
>Regression to the Mean
>Naturally History
>and others

Obviously, such factors are not unique to dry needling. They are present in all treatments, especially those for pain. But, given the current understanding of pain stemming from a multitude of varied scientific disciplines, how can we assume, let alone propose, that sticking a human in pain with a fine needle contains sufficient and significant effect to be a primary contributor to relief and positive outcomes in both the short and long term? And, more importantly, why should we? It appears we’ve learned little from decades of research into the nature of pain, the mechanisms of treatment, passive vs. active approaches to care, acupuncture, “wet needling,” and manual therapy. Physical therapists, will rightly so I might add, critique the overuse of “wet needling” (and other interventions) by physicians, yet barely raise but a whimper of protest at the proliferation of dry needling. It may be time to refine our internal, smaller picture to facilitate crossing the chasm.44,45

Risk vs. Benefit and Invasiveness

The invasiveness of dry needling within the scope of physical therapist practice presents a unique and complicated challenge when attempting to assess risk vs. benefit in isolation, risk vs. benefit in comparison to other medical procedures, as well as risk vs. benefit in comparison to other physical therapist delivered interventions. It seems we over simplify, and potentially misunderstand risk versus benefit analysis as it applies specifically to physical therapy interventions. Sure, comparing dry needling adverse event types and rates to other medical interventions is tempting. It is an interesting health services inquiry. And, such an approach does hold some value for comparing intervention risks, benefits, and efficacy within the spectrum of the many possible health care interventions. Arguably, and quite plausibly, dry needling within the confines of a physical therapy treatment plan is safer than early imaging, prolonged NSAID use, delayed physical therapy referral, opiates, and of course spinal surgery. But, it seems to me this particular argument, even if compelling, even if true, is a weak and incomplete justification for needling. Although, please note even acupuncture may not be as safe as assumed.46-48

Comparisons regarding the risk, invasiveness, efficacy, and effectiveness of specific physical therapist delivered interventions are necessary.49 These comparisons are required in general, but also specifically within various conditions, complaints, diagnoses, and patient populations. Given the invasiveness, regardless of risk profile, to justify widespread utilization dry needling must illustrate robust effectiveness (or even significantly more efficacy) in relation to other physical therapist delivered interventions. And, any potential effectiveness must be assessed in the context of possible negative effects such as an exacerbation of symptoms and other more significant adverse events.

On the grounds of efficacy, effectiveness, risk, invasiveness, and potential benefit when compared to our other interventions for pain, I can’t understand an argument that currently justifies dry needling. Physical therapists must not merely claim superiority, or justify interventions, on the tenuous foundation that we are less invasive and less risky than other medical interventions. It’s not quite that simple. Physical therapists must provide the same internal scrutiny to comparing our own interventions in addition to comparing physical therapy interventions to physician practice patterns.44 Further, when taking into account the training cost and time it does not make sense to advocate for this intervention.

Training Cost & Time

An often undiscussed problem with dry needling is both the cost and time required to learn the technique. Currently, all states that allow physical therapists to practice dry needling require further training or even certification. So now, unfortunately, physical therapists are burdened not only with assessing the potential applicability, safety, risk and benefit of the intervention, but also the cost (time and money) required to even be granted permission to practice dry needling. Such a situation is quite acceptable for an intervention with robust effectiveness and broad applicability. But, for a single, questionably effective, invasive intervention this seems unnecessary if not wrong. For clinicians, what knowledge could be gained or other skills developed? For professional organizations, what other legislative challenges could be addressed? Who stands to benefit from such a scenario? Well, most obviously those who sell dry needling courses.

Bias in Research Interpretation and Conflicts of Interest

Similar to manual therapy, an alarming number of studies investigate immediate effects only which regardless of results is likely “much ado about nothing.”24 Many of the manuscripts pertaining to dry needling also contain overstated conclusions or even a misrepresentation of results.

In this regard, it is worth noting that many of those publishing positive systematic reviews, providing anecdotes and patient stories of success, and presenting on the potential favorable impact of dry needling teach or directly financially benefit from the teaching of dry needling.19, 20 For example, Kenny Venere and I observed that the authors of a highly positive viewpoint on acupuncture for knee osteoarthritis that was published in PT in Motion not only teach dry needling continuing education courses, but also offer a certification in dry needling.15,50 Oddly, this section and the subsequent statements were edited out of the final printed version of our letter. In any case, one of the authors is the “President of the Spinal Manipulation Institute and Dry Needling Institute of the American Academy of Manipulative Therapy” which offers a postgraduate diploma (which I’ve been openly critical regarding the name).51 The diploma is described as such:

an evidence-based post-graduate training program in the use of high-velocity low-amplitude thrust manipulation and dry needling for the diagnosis and treatment of neuromusculoskeletal conditions of the spine and extremities.

Now, other individuals and companies in the dry needling post-professional education business are all also at risk of being significantly influenced by financial incentives. For example, a program director for another dry needling continuing education company, continues to publish manuscripts defending the construct of myofascial trigger points which are, unsurprisingly, the foundation of their approach to dry needling.51 I’m sure many will contend I’ve unfairly singled out these individuals. But, I am by no means insinuating those financially vested in the dry needling continuing education business are insincere or intentionally misrepresenting trial data.

I do however wish to highlight the potential for interpretation bias of research evidence when significant (or even potential) conflicts of interest and financial incentives are present. Chad Cook, PT, PhD referring to manual therapy research poignantly states don’t always believe what you read:53

…there have been a number of manual therapy studies that were designed by clinicians who have a personal interest in the success of one intervention over another. These clinicians have either a vested interest in the applications that are part of the interventional model because they provide instruction of these techniques in continuing education courses in which they profit from (although it may seem minimal, it is not); or because the tools are part of a philosophical approach or a decision tool that was designed from their efforts or efforts from those they were affiliated with. In nearly all cases, the bias is not intentional and certainly not malicious…

I am concerned that new clinicians, passionate followers of selected manual therapy approaches, and in some occasions, seasoned clinicians, will be mislead because they lack expansive/formal research training with respect to study methodology. Certainly, once information is advocated within the clinical population, it takes years to diffuse its use, even after acknowledgement of its erroneous findings.

Dr. Cook’s concerns, which I urge you to consider, relate intimately to the surge in dry needling literature and clinical application. In physical therapy research the impact of potential conflict of interest and resulting bias of researchers also highly involved in continuing education companies is in a word: unknown. But, it is quite obvious that there is a potential conflict of interest and subconscious bias present for individuals who directly financially benefit from teaching a specific technique, or approach. And, this issue transcends dry needling. Regardless of intent, there is an incentive for positive conclusions surrounding that particular technique or school of thought. What and where are the incentives? I understand, and openly support, those who identify and ask difficult questions surrounding the possible unidentified conflicts of interest which have historically been neither discussed nor disclosed. It absolutely requires consideration. More disclosure within academia and the research literature regarding business relationships and continuing education ties is warranted.

In designing, or interpreting research conscientious checks and balances, for example blinding and proper study methods, must be executed. My sense is that it would be profoundly difficult to conclude an intervention is minimally effective, or even unnecessary, after designing, teaching, and selling courses founded upon the apparent diagnostic power and treatment effectiveness of a single intervention or specific treatment paradigm.

Summary & Conclusion

Unfortunately, I sense that dry needling is the new manipulation, which to be clear is not a compliment nor an endorsement. The intervention is not going away, and precious research dollars, cognitive space, and professional resources will undoubtedly be devoted in attempts to “prove it works” (or even “how does it work?”) which is in direct contrast to the true scientific method which is founded upon falsifiability, or “prove yourself wrong” (or even “does it even work?).

But, in getting to the point, the terminology is poor, the constructs questionable, and the current research underwhelming. Acupuncture literature suggests effects are small and non-specific to needling, and the current dry needling data demonstrates the same pitfalls in both design and interpretation. Note this is our most invasive intervention for pain, and it is technically quite passive. Additionally, many of the theoretical constructs and clinical explanations are myopic, vague, and appear invalid. Assessing risk vs. benefit of the intervention in isolation, and in comparison to other physical therapist delivered interventions, is an important, under discussed complexity of implementing needling into practice. Significant potential conflicts of interest and bias are present in the literature. As if that wasn’t enough, the time and cost to learn this intervention are astounding.

Yet, positive clinician experiences, professional publications, and overly optimistic reviews continue to escalate. Jason Silvernail, DPT, DSc, FAAOMPT asserts:

We should all – every one of us – be nothing but disturbed by our colleagues’ use of emotional anecdotes. I look forward to the day when mentioning an anecdote automatically makes our students shake their heads and turn away…Highly recommend people look into MJ Simmonds’ work on intolerance of uncertainty in our profession and how that anchors practitioners beliefs into concrete and wrong explanatory models loaded with nocebo and external loci of control.

Given the discussed issues, and likely others, the current unbridled enthusiasm and growing popularity of dry needling seems unwarranted, if not a mistake. I urge physical therapists, educators, clinicians, researchers, students, and professional leaders to re-consider.

History, it appears, has taught us little in this regard.

References & Resources

1. Pub Med Search. "Physical Therapy AND "Dry Needling" 2010-2015. Performed August 3, 2015

2. Pub Med Search. "Physical Therapy" AND "Dry Needling" 2000-2005. Performed August 3, 2015

3. Benz L. Trigger Point Dry Needling is Not #PhysicalTherapy. Evidence in Motion Blog. March 2014

 4. JOSPT perspectives for patients. Painful and Tender Muscles: Dry Needling Can Reduce Myofascial Pain Related to Trigger Points. J Orthop Sports Phys Ther. 2013;43(9):635

 5. Ridgeway K. Measuring Outcomes, Outcome Measures, and Treatment Effects. Physical Therapy Think Tank. December 13, 2014

 6. O'Connell N, Moseley GL. Acupuncture research – the path least scientific? The Conversation. October 30, 2012

 7. White P, Bishop FL, Prescott P, Scott C, Little P, Lewith G. Practice, practitioner, or placebo? A multifactorial, mixed-methods randomized controlled trial of acupuncture. Pain. 2012 Feb;153(2):455-62

 8. Novella S. Acupuncture Doesn't Work. Science Based Medicine. June 19, 2013

 8. Colquhoun D, Novella SP. Acupuncture is theatrical placebo. Anesth Analg. 2013 Jun;116(6):1360-3

 9. Bialosky JE, Bishop MD, George SZ, Robinson ME. Placebo response to manual therapy: something out of nothing? J Man Manip Ther. 2011 Feb;19(1):11-9

 10. Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Man Ther. 2009 Oct;14(5):531-8

 11. Bialosky JE, Bishop MD, Cleland JA. Individual expectation: an overlooked, but pertinent, factor in the treatment of individuals experiencing musculoskeletal pain. Phys Ther. 2010 Sep;90(9):1345-55

 12. Linde K, Witt CM, Streng A, et al. The impact of patient expectations on outcomes in four randomized controlled trials of acupuncture in patients with chronic pain. Pain. 2007 Apr;128(3):264-71

 13. Kong J1, Kaptchuk TJ, Polich G, et al. An fMRI study on the interaction and dissociation between expectation of pain relief and acupuncture treatment. Neuroimage. 2009 Sep;47(3):1066-76

 14. Bishop FL, Lewith GT. A Review of Psychosocial Predictors of Treatment Outcomes: What Factors Might Determine the Clinical Success of Acupuncture for Pain? J Acupunct Meridian Stud. 2008 Sep;1(1):1-12

 15. Venere K, Ridgeway KJ. Acupuncture Effect Not Clinically Meaningful. PT in Motion. 2015 Aug;7(7):6-7

 16. Chae Y, Lee IS, Jung WM et al. Psychophysical and neurophysiological responses to acupuncture stimulation to incorporated rubber hand. Neurosci Lett. 2015 Mar 30;591:48-52

 17. Bulley A, Thacker M, Moseley L. Against all reason- effects of acupuncture and TENS delivered to an artificial hand. Physiotherapy . 97 Supplement S1

 18. Cherkin DC, Sherman KJ, Avins AL et al. A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain. Arch Intern Med. 2009 May 11;169(9):858-66

 19. Ries E. Dry Needling: Getting to the Point. PT in Motion. 2015;5

 20. Dunning J, Butts R, Mourad F et al. Dry needling: a literature review with implications for clinical practice guidelines. Phys Ther Rev. 2014 Aug; 19(4): 252–265

 21. Kietrys DM, Palombaro KM, Azzaretto E et al. Effectiveness of dry needling for upper-quarter myofascial pain: a systematic review and meta-analysis. J Orthop Sports Phys Ther. 2013 Sep;43(9):620-34

 22. Harvie DS, O'Connell N, Moseley L. Dry needling for myofascial pain. Does the evidence make the grade? Body in Mind. July 4, 2014

 23. Boyles R, Fowler R, Ramsey D, Burrows E. Effectiveness of trigger point dry needling for multiple body regions: a systematic review. J Man Manip Ther. 2015. DOI: http://dx.doi.org/10.1179/2042618615Y.0000000014

 24. Cook C. Immediate effects from manual therapy: much ado about nothing? J Man Manip Ther. 2011 Feb; 19(1): 3–4

 25. Cotchett MP, Munteanu SE, Landorf KB. Effectiveness of trigger point dry needling for plantar heel pain: a randomized controlled trial. Phys Ther. 2014 Aug;94(8):1083-94

 26. Brence J. The Tools We Use. Forward Thinking PT. July 29, 2013
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 28. Ridgeway KJ. Precision in Language. Physical Therapy Think Tank. May 7, 2014

 29. PubMed Search for Author "Quintner JL[Author]."

 30. Quintner J. The trigger point strikes … out!. Body in Mind. January 20, 2015

 31. Quintner JL, Cohen ML. Fibromyalgia falls foul of a fallacy. Lancet. 1999 Mar 27;353(9158):1092-4

 32. Cohen M, Quintner J. The horse is dead: let myofascial pain syndrome rest in peace. Pain Med. 2008 May-Jun;9(4):464-5

 33. Cohen ML, Quintner JL. Fibromyalgia syndrome, a problem of tautology. Lancet. 1993 Oct 9;342(8876):906-9

 34. Quintner JL, Bove GM, Cohen ML. Response to Dommerholt and Gerwin: Did we miss the point? J Bodywork & Move Ther. July 2015;19(3):394–95

 35. Quintner JL, Bove GM, Cohen ML. A critical evaluation of the trigger point phenomenon. Rheumatology (Oxford). 2015 Mar;54(3):392-9

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 40. Fuentes J, Armijo-Olivo S, Funabashi M et al. Enhanced therapeutic alliance modulates pain intensity and muscle pain sensitivity in patients with chronic low back pain: an experimental controlled study. Phys Ther. 2014 Apr;94(4):477-89

 41. Bialosky JE, Bishop MD, Robinson ME, Barabas JA, George SZ. The influence of expectation on spinal manipulation induced hypoalgesia: an experimental study in normal subjects. BMC Musculoskelet Disord. 2008 Feb 11;9-19

 42. Moseley GL. Reconceptualising Pain According to Modern Pain Science. Physical Therapy Reviews. 2007; 12: 169–178. Accessed via Body in Mind

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76 Replies to “What are the Issues with Therapeutic or Trigger Point Dry Needling? 9 Considerations to Ponder”

  3. Great, sobering thoughts on what remains a relatively new western medical treatment modality. We don’t completely understand the mechanism of effect (or the reliability/validity of the intervention for that matter).

    I believe that we do have enough evidence, though, from the acupuncture and (albeit biased) PT literature, to use dry needling competently in the clinic as a component of a plan of care when indicated.

    Mostly though, I appreciate you advocacy for unbiased research regarding the interventions we use. May I re-post on my site?

  4. Great work here Kyle.

    I think Rothstein put it best in his PTJ editorial, so I’m putting it here:

    “When we generate concepts, we make meaningful research possible. When we try to do studies in the absence of well-developed concepts, we court disaster and fight isolated battles that can never lead to meaningful victories.”

  5. Kyle,

    you bring up many relevant issues. While in general, I am not a big fan of online discussions, I do want to acknowledge your invitation on Facebook to share some of my thoughts. I will follow the outline of your blog as much as possible, which implies that my reply will be fairly long, since your blog was quite extensive.

    For starters, I appreciate that you edited your blog and deleted my name and the names of others to avoid making it look like a personal attack even though I really did not experience your initial version as such. I understand that some may interpret my replying to your post as having a need to defend my work, but that is not why I accepted your invitation.

    You ended your blog with the conclusion that history has not taught us much. Let me start with my history with dry needling. When I started teaching dry needling courses in the US in 1997, there were no other course providers in North America other than Chan Gunn in Vancouver, BC, Canada. The Tri-State College of Acupuncture in New York had started including trigger point needling as part of its acupuncture curriculum, after its president, Dr. Mark Seem, met with Dr. Janet Travell and he published a book in which he recognized that trigger points were the missing part of his acupuncture practice (1). As far as I know, the school does not offer continuing education courses.

    In 1997, we introduced dry needling courses mostly based on our clinical experience and excellent, but yes, anecdotal, results. Our dry needling model evolved out of the practice of trigger point injections. Since Maryland allowed PTs to use trigger point injections, I learned the injection techniques before any dry needling techniques. Travell and Simons never used dry needling even though the first reports of dry needling date back to at least 1821 (2). We developed dry needling techniques through trial and error, anatomical study, experimentation of each other, etc. At that time, there was not much in the literature about dry needling and not too many physical therapists were concerned about the lack of scientific backing. There was little interest in what we were doing and we taught only about 4-6 courses a year to small groups of mostly physicians and physical therapists. In 2015, the world is quite different.

    You are right that all of a sudden dry needling seems to be the hottest thing in physical therapy and that is a concern I share with you. I am not convinced that all courses include a scientific basis for their teachings, realizing that there are some people who believe that my courses lack a scientific basis as well. It is curious though, that the folks, who criticize what I teach, have never attended any of my courses and really do not know what we cover in our courses. They have not struggled through 10 hours of home study modules that include a tremendous amount of pain sciences, information about the neuro-matrix, receptors, placebo, controversies, etc. They have not taken our challenging theoretical examinations requiring a thorough understanding of these topics. Some may have read a few of my many publications and commonly conclude that my co-authors and I have a need “to defend the construct of myofascial trigger points” even though that is not always the desire. The article you cited in support of this assumption was an attempt to explore what is known about peripheral and central mechanisms and trigger points. Sure, we took the position that trigger points can be studied and in that sense, you could interpret the article as a defense of the construct, but we feel that the article offers a lot more than a justification of our courses and publications. I do not believe that a few articles or book chapters give a complete perspective of what we teach as that is rarely the purpose of those publications.

    Feel free to ask anyone who has taken the time and effort to complete our courses about what we actually teach. If you have a look at my continuing education company’s Facebook page, you will see that the majority of the past many posts include not only your blog, but many studies and reports about rising costs of healthcare, recent papers from the journal Pain, kinesiotaping and placebo, musicians, and yes, a few articles about myofascial pain. Our dry needling courses have evolved since 1997.

    Back to your blog: You cited Larry Benz, who appears to be a rather confused person as the educational institute he is affiliated with offers dry needling courses, while he believes that dry needling is damaging for the profession. He got a lot of attention with his statements and maybe that was his objective, but I don’t understand that.

    Next, you mention that dry needling clinicians state that “dry needling is not acupuncture” but don’t hesitate citing acupuncture references. I share your concerns and disagree with some other dry needling course providers who cite many acupuncture references and suggest that ignoring randomized clinical acupuncture trials would limit the ability to optimally use dry needling in clinical practice (3). I don’t believe I have ever cited acupuncture references in support of dry needling, but I do recognize that others may have different points of view. There are multiple reasons why I have not included acupuncture references in my publications. I agree with you that “physical therapists should be cautious in citing acupuncture literature to support the practice of dry needling.”

    I do believe that dry needling is acupuncture when performed by an acupuncturist. It is not acupuncture, however, when performed by a physician, dentist, veterinarian, chiropractor, athletic trainer, occupational therapist, or physical therapist. In my humble opinion, dry needling is nothing but a technique that has little in common with traditional acupuncture other than the tool.

    I disagree that the acupuncture literature necessarily applies to the kind of dry needling I promote, but I do agree that certain aspects of acupuncture can possibly be applied to dry needling. One has to be careful with generalizations, as there are too many significant differences between the two approaches. You may be right that physiologically there are many similarities, but there is not good research to accept of reject that assumption. As a side note, in spite of several opinions to the contrary, I agree with acupuncturist Birch that there is little overlap between acupuncture points and trigger points (4, 5). Nevertheless, when I see online pictures of some dry needling techniques promoted in other courses in the US and abroad, and compare those to acupuncture references, it is clear that not everyone agrees with me given the many similarities.

    In 1997, there were only two schools of thought, namely Gunn’s school, which promoted a neuropathy model of myofascial pain, and our school, which promoted a trigger point model. It should be clear that in 2015 there are many different schools of dry needling, for example, some schools promote dry needling for tendinopathies, while others have developed specific dry needling protocols for certain clinical conditions. I question the validity of such protocols as there is very little scientific literature to base such approaches on. Therefore, talking about dry needling as a unified approach is no longer justified. The same applies to acupuncture. There are many entirely different schools of acupuncture and referring to acupuncture as one particular approach reflects ignorance. One could make the same argument for manual therapy. Manual therapy schools with a strict biomechanical focus are distinctly different from schools that integrate neurosciences in their teachings (6). In the current thinking many PTs would favor a neuroscience approach with manual therapy (7).

    By stating that “the acupuncture literature applies” combined with the notion that acupuncture is nothing but “theatrical placebo”, you also imply that dry needling is nothing but a good show celebrating “the power of the needle.” Although you seem quite certain that there are no acupuncture studies that demonstrate its efficacy, I do not believe that to be the case. A journal such as “Acupuncture in Medicine” aims to explore the field of acupuncture from an unbiased scientific perspective. Sample size is a problem throughout the field of medicine and physical therapy. Unfortunately, the funding of many universities is based on the number of publications and therefore, it may be more appealing for a program to publish three papers with 24 subjects rather than one study with 72 subjects. The dry needling literature suffers from this problem, as does the entire manual therapy field. Another issue in acupuncture and dry needling research is that it is very difficult to conduct randomized double-blind controlled studies. Sticking a needle in a subject makes it next to impossible. I am aware of only one double blind controlled dry needling study, which showed a dramatic improvement in favor of dry needling in patients undergoing a total knee replacement with a 6-month follow up. In this study, dry needling was performed with the patients under total or partial anesthesia (8).

    You stated that in acupuncture needle depth does not matter, but there are several dry needling studies that demonstrate that deeper needling is more effective than superficial needling (9, 10). I am not providing references for every study as I will likely be accused of overwhelming readers with too many references as has happened several times in the past in online exchanges. As stated before, some of those studies are of low quality or have very low sample sizes.

    You quote Harvey, O’Connell and Moseley who analyzed a 2013 dry needling review published in the JOSPT. Based on that study, they concluded that dry needling was possibly worse than comparative interventions. But the same Moseley wrote that “elimination of myofascial trigger points is an important component of the management of chronic musculoskeletal pain” and “we have found ischemic compression and dry needling to be the most effective” (11).

    I feel that you misrepresented the study on heel pain (12), when you stated that the patients in the treatment were more likely to experience an adverse event than a beneficial outcome. By definition, an adverse event is any outcome than is different from the therapeutically intended outcome. Dry needling is usually uncomfortable, which will be considered an adverse event. All adverse events in this study were considered mild and transitory. On the other hand, at “6 weeks, statistically significant differences in first-step pain (measured on a VAS) and foot pain (measured on the FHSQ) were found in favor of real dry needling.” In our study of adverse events associated with dry needling, the most common adverse events were bruising (7.55%), bleeding (4.65%), pain during treatment (3.01%) and pain after treatment (2.19%) (13). The risk of a serious adverse event, such as a pneumothorax was less than 0.04% (13). You state that non-invasive procedures should be preferred, which I seriously question. The adverse events of dry needling are transient and really not a big deal.

    You ask what the difference is between all the terms used for dry needling. That is an easy question to answer. These are all marketing terms developed by course providers. No course provider has all the answers. No course provider can claim superiority of one dry needling approach over another.

    Next, you cite Quintner and colleagues, but you did not mention the rebuttal Gerwin and I published (14). As we outlined, most of the arguments brought forward by Quintner et al are misleading, i.e., they misquoted many of the references in their most recent article (15). I find it interesting that you seem to value their biased opinion more than my biased opinion in favor of trigger points. You mentioned “poor interrater reliability” but apparently you are not aware of several recent intra- and interrater reliability studies. I am aware of a few papers that opponents of anything trigger points cite. The search for reliable criteria is ongoing. Rivers et al just released a paper in which they proposed a preliminary set of diagnostic criteria (16). In addition, the American Pain Society is conducting an international study on the validity of diagnostic criteria. Does that mean that no one would be able to identify myofascial pain? Did people not have migraine headaches before the International Headache Society developed diagnostic criteria?

    The idea that trigger points are “needleable leasions” is inconsistent with the current thinking about trigger points. In my interpretation, trigger points are not anatomical lesions, but represent peripheral sources of persistent nociceptive input, that are the result of tissue hypoxia and ischemia, which leads to a drop in pH, followed by an antidromic release of multiple chemicals, which in turn activate peripheral nociceptors. This is all part of the pain science background of trigger points, that have nothing to do with alleged lesions, but everything with neurological input that can be remedied by improving the local oxygen saturation, which will reverse the entire process. Your notion that “those teaching and researching dry needling appear to be clearing an old trail” is based on a misunderstanding of the current conceptual thinking promoted by Quintner et al and some others. As you mentioned, “understanding will inevitably change over time”, which is exactly why the content of our dry needling courses is being adjusted almost every year based on new research.

    Next, you provide a long list of what you consider “an incomplete consideration of potential mechanistic factors. Trigger points, latent trigger points, twitch response, trigger point referral patterns, facilitated segments, neuro-trigger points, micro-tissue trauma, chronic local inflammation healed by needle induced inflammation, and the list goes on.” You mention that the skin features “dense array of free nerve endings and other receptors” but you fail to consider that muscles also feature many nociceptors, including acid sensing ion channels, transient receptor potential vanilloid channels, and several other receptors, such as transient and short transient receptor potential cation channels (17-20). You seemed to dismiss the importance of the local twitch response, even though several electromyography and sonography studies have shown that eliciting local twitch responses significantly increases the effectiveness of at least trigger point dry needling (21-23). Of course, when a needle is inserted, multiple tissue are penetrated, including the skin, the superficial fascia, the deeper fascia, and muscle. All these tissues feature nociceptors and that is the important aspect. Dry needling should not be about which tissue is targeted, but how to decrease or eliminate peripheral nociceptive input.

    There is a lot more I could say in response to your blog, but due to family circumstances, I will have to leave it with this. I hope I met your expectation when you invited me to reply “to to encourage discussion.”

    1 Seem M. A new American acupuncture; acupuncture osteopathy. Boulder: Blue Poppy Press; 2007.
    2 Churchill JM. A treatise on acupuncturation being a description of a surgical operation originally peculiar to the Japanese and Chinese, and by them denominated zin – king, now introduced into European practice, with directions for its performance and cases illustrating its success. . London: Simpkins & Marshall; 1821.
    3 Dunning J, Butts R, Mourad F, Young I, Flannagan S, Perreault T. Dry needling: a literature review with implications for clinical practice guidelines. Phys Ther Rev. 2014 Aug;19(4):252-65.
    4 Birch S. Trigger point–acupuncture point correlations revisited. J Altern Complement Med. 2003;9(1):91-103.
    5 Birch S. On the impossibility of trigger point-acupoint equivalence: a commentary on Peter Dorsher’s analysis. J Altern Complement Med. 2008;14(4):343-5.
    6 Louw A. Treating the brain in chronic pain. In: Fernández de las Peñas C, Cleland J, Dommerholt J, editors. Manual therapy for musculoskeletal pain syndromes – an evidenced and clinical-informed approach. Edinburgh: Churchill Livingstone (Elsevier); 2016.
    7 Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy in the treatment of musculoskeletal pain: a comprehensive model. Manual therapy. 2009 Oct;14(5):531-8.
    8 Mayoral O, Salvat I, Martin MT, et al. Efficacy of myofascial trigger point dry needling in the prevention of pain after total knee arthroplasty: a randomized, double-blinded, placebo-controlled trial. Evidence-based complementary and alternative medicine : eCAM. 2013;2013:694941.
    9 Ceccherelli F, Rigoni MT, Gagliardi G, Ruzzante L. Comparison between superficial and deep acupuncture in the treatment of lumbar myofascial pain: a double-blind randomized controlled study. Clin J Pain. 2002;18:149-53.
    10 Itoh K, Katsumi Y, Hirota S, Kitakoji H. Randomised trial of trigger point acupuncture compared with other acupuncture for treatment of chronic neck pain. Complement Th r Med. 2007 Sep;15(3):172-9.
    11 Moseley GL. Pain: why and how does it hurt? Brukner & Kahn’s Clinical Sports Medicine. North Ryde, NSW: McGraw-Hill Australia Pty Ltd; 2012.
    12 Cotchett MP, Munteanu SE, Landorf KB. Effectiveness of trigger point dry needling for plantar heel pain: a randomized controlled trial. Phys Ther. 2014 Aug;94(8):1083-94.
    13 Brady S, McEvoy J, Dommerholt J, Doody C. Adverse events following dry needling: A prospective survey of Chartered Physiotherapists. J Manual Manipul Ther. 2014;22(3):134-40.
    14 Dommerholt J, Gerwin R, D. A critical evaluation of Quintner et al: Missing the point. J Bodyw Move Ther. 2015;19:193-204.
    15 Quintner JL, Bove GM, Cohen ML. A critical evaluation of the trigger point phenomenon. Rheumatology (Oxford). 2015 Mar;54(3):392-9.
    16 Rivers WE, Garrigues D, Graciosa J, Harden RN. Signs and Symptoms of Myofascial Pain: An International Survey of Pain Management Providers and Proposed Preliminary Set of Diagnostic Criteria. Pain Med. 2015 Jun 5.
    17 Hagberg H. Intracellular pH during ischemia in skeletal muscle: relationship to membrane potential, extracellular pH, tissue lactic acid and ATP. Pflugers Arch. 1985 Aug;404(4):342-7.
    18 Gerdle B, Ghafouri B, Ernberg M, Larsson B. Chronic musculoskeletal pain: review of mechanisms and biochemical biomarkers as assessed by the microdialysis technique. Journal of pain research. 2014;7:313-26.
    19 Sluka KA, Gregory NS. The dichotomized role for acid sensing ion channels in musculoskeletal pain and inflammation. Neuropharmacology. 2015 Jan 9.
    20 Walder RY, Rasmussen LA, Rainier JD, Light AR, Wemmie JA, Sluka KA. ASIC1 and ASIC3 play different roles in the development of Hyperalgesia after inflammatory muscle injury. The journal of pain : official journal of the American Pain Society. 2010 Mar;11(3):210-8.
    21 Hong CZ. Lidocaine injection versus dry needling to myofascial trigger point. The importance of the local twitch response. Am J Phys Med Rehabil. 1994;73(4):256-63.
    22 Hong CZ, Torigoe Y, Yu J. The localized twitch responses in responsive bands of rabbit skeletal muscle are related to the reflexes at spinal cord level. J Musculoskeletal Pain. 1995;3:15-33.
    23 Rha DW, Shin JC, Kim YK, Jung JH, Kim YU, Lee SC. Detecting local twitch responses of myofascial trigger points in the lower-back muscles using ultrasonography. Arch Phys Med Rehabil. 2011 Oct;92(10):1576-80 e1.

    1. Good discussion!

      My new strategy has everything to do with Gunn’s foundation.
      The idea of comparing a discipline to a “stable chemical” as in a RCT is illogical to me. Why?? Why try to prove something the is so improvisational. Gunn allows the practitioner to be more direct and targeted.

      Then with Gunn, Travell, Rachlin and Hackett extrapolation of the the pain receptions in muscles into that of hundreds of bizarre dysfunctions makes conventional diagnoses irrelevant and untrue. ie sciatic is not what the textbooks state. It is a problem in the muscles of the buttock. Treat the muscles and the pain goes away.

      Why compare and contrast bits and pieces of untruths and incompletenesses?

      Just apply the full forces of all that we as a scientific society have uncovered! So you can take his techniques and integrate them with Helms, Seems, Rapson, Travell, Rachlin, Pybus, Hackett + reinjury + unwinding + chiropractic adjustments + wellness + yoga + active isolated stretching to unlock the raw power of innate healing.

      The legality of incompleteness will nit these dilemmas in the buttock. Mis-informed consents may have to correct this wayward course.

    2. Jan, Thank you for taking the time to craft such a thoughtful reply and futher this discussion. I wish all online discussions could have the tenor of your reply! Eric

  6. Kyle, may I comment on Dr Dommerholt’s speculative contribution to the discussion?

    “In my interpretation, trigger points are not anatomical lesions, but represent peripheral sources of persistent nociceptive input, that are the result of tissue hypoxia and ischemia, which leads to a drop in pH, followed by an antidromic release of multiple chemicals, which in turn activate peripheral nociceptors.”

    The fact of the matter is that he and others have yet to demonstrate the existence of such nociceptive input. But if, as he maintains, no anatomical lesion actually exists, how then does he justify the practice of “dry needling” tender deep tissues?

    For the record, as it turned out, the rebuttal article by Dommerholt and Gerwin referenced above actually agreed with the main points of our argument.

    But the caravan has moved on since then.

    Here is an excerpt from my post on Fibromyalgia Perplex – “The Decline and Fall of the Trigger Point Empire”:

    A recent review by Shah et al. (2015) supports my impression that physical therapists who place “dry needles” into the tender muscles of their patients, and otherwise poke around there, have been “flying by the seat of their pants”.

    Shah et al. (2015) concede: “To date, the pathogenesis and pathophysiology of MTrPs and their role in MPS remain unknown” and that “It remains unknown whether the nodule is an associated finding, whether it is a causal or pathogenic element in MPS, and whether or not its disappearance is essential for effective treatment.”

    They also pose a number of rather embarrassing questions for researchers to answer:

    1. What is the etiology and pathophysiology of MPS?
    2. What is the role of the MTrP in the pathogenesis of MPS?
    3. Is the resolution of the MTrP required for clinical response?
    4. What is the mechanism by which the pain state begins, evolves and persists?
    5. Although the presence of inflammatory and noxious biochemicals has been established, what are the levels of anti-inflammatory substances, analgesic substances, and muscle metabolites in the local biochemical milieu of muscle with and without MTrPs?
    6. How does a tender nodule progress to a myofascial pain syndrome?
    7. Which musculoskeletal tissues are involved, what are their properties, and how do these change with treatment?

    Will ethical therapists now down needles, at least until these questions are properly answered? Will those who run courses in “dry needling” now admit that their teaching has been based upon flawed theory and many conjectures?

    Reference: Shah JP, Thaker N, Heimur J, et al. Myofascial trigger points then and now: a historical and scientific perspective. PM R 2015; available at http://dx.doi.org/10.1016/j.pmrj.2015.01.024

  7. I need to address this from Jan Dommerholt’s comment off the bat:
    “You seemed to dismiss the importance of the local twitch response, even though several electromyography and sonography studies have shown that eliciting local twitch responses significantly increases the effectiveness of at least trigger point dry needling (21-23).”
    First of all, the kappa coefficient measure of reliability for identification of the latent twitch response (LTR) by experienced examiners was found to be 0.36 for the upper trapezius by Gerwin et al (1997). This is not an impressive value. On top of that, the studies cited by Jan utilized either EMG or US to aid in the identification of the LTR. As far as I know, these methods are not being used clinically by dry needlers. Therefore, we have to conclude that the clinical identification of the LTR is fair, at best.

    Secondly, it’s inaccurate to use the phrase “increases the effectiveness” when referring to the results of these studies with respect to dry needling. Rha et al used “wet” needling in the classic “trigger point injection” fashion, which includes the injection of an active substance. Hong was a low quality trial that lacked a control or sham condition and blinding, no power analysis was performed, and there was no attempt to quantify the clinical meaningfulness of any pain reduction that was achieved. The Hong et al reference was a descriptive study performed on rabbits, so it’s misleading to include it in a list of studies claiming “effectiveness” of dry needling, particularly when it’s implied that we’re talking about treating human patients. The fact that Jan concludes his remarks with this very weak and over-stated argument about the relevance of the LTR, demonstrates the weakness of his overall argument. He’s leaving us with an easily dismissible argument while scolding Kyle for dismissing it. By all accounts the LTR is *not* an important feature of trigger point diagnosis and treatment based on currently available evidence and clinical practice. Kyle was right to dismiss it. What else could he do?

    My second point has to do with Kyle’s accurate juxtaposition of dry needling to manipulation/high velocity thrust technique. I’m in agreement that the progression from manipulation to dry needling represents a slouching of the PT profession away from the current extant evidence with respect to pain neurophysiology. The willingness to ignore what is happening even prior to when the clinician makes contact with the patient’s skin is just embarrassing. Bialosky’s model of manual therapy (2008) provides a graphic accounting for the effects and complex pathways involved as soon as contact his made with the patient’s skin. Yet, with needling, as a progression from the flawed explanatory models used to rationalize manipulation, PTs are barging right through the skin, completely ignoring the vast array of receptors embedded there and the profound effects of human to human touch. The skin as a social organ (see Morrison et al, Experiments in Brain Research. 2010;204:305-314) is utterly without consideration by the average manipulator or dry needling. This is a profound error.

    I think the references to Larry Benz’s position as a member of a dry needling continuing education provider company and to Lorimer Moseley’s previous position on treatment of trigger points are inaccurate and unfair. Larry is one of several owners of the company, and like any company, votes are typically taken on what is or isn’t going to be part of the company’s identity and/or product line. It’s apparent that Larry’s arguments against dry needling did not win out over the majority. That’s the way it goes. I don’t think he needs to be “confused” in order to have a difference of opinion with his business associates. With respect to Dr. Moseley’s prior advocacy of trigger point treatment, apparently his position has changed. He signed on with Harvie and O’Connell in the *more recent* analysis of the Kietrys et al review, which concluded that the evidence for dry needling did NOT reach a “grade A” level as claimed in that paper. A sign of a strong scientific thinker, in my view, is the willingness to change one’s mind in light of new evidence. Dr. Moseley has apparently done so. Kudos to him.

    Perhaps Jan will eventually as well.

  8. Hey Jan,

    I really enjoyed reading your perspective on Kyle’s post and have appreciated your contributions on this topic elsewhere.

    In regards to a few things you mention:

    “Although you seem quite certain that there are no acupuncture studies that demonstrate its efficacy, I do not believe that to be the case.”

    I would argue the contrary here. The systematic reviews (and even systematic reviews of systematic reviews) are unambiguous in their demonstrating acupuncture’s lack of efficacy in high quality, well controlled trials. See Madsen (2009), Derry (2006), Manheimer (2010) and others for reference.

    “Another issue in acupuncture and dry needling research is that it is very difficult to conduct randomized double-blind controlled studies. Sticking a needle in a subject makes it next to impossible.”

    We are in agreement here, but I think the presence of this issue serves more to illustrate the lack of acupuncture’s (and potentially dry needling’s) efficacy in treating painful conditions. The inability to adequately blind and produce a convincing sham intervention would serve to exaggerate the effect size of the experimental intervention (acupuncture or dry needling). Even with this potential limitation, the effect size of acupuncture is underwhelming and the PT driven dry needling literature illustrates this as well.

    “[The Mayoral trial] showed a dramatic improvement in favor of dry needling in patients undergoing a total knee replacement with a 6-month follow up. In this study, dry needling was performed with the patients under total or partial anesthesia (8).”

    I would hesitate to call the results of the Mayoral trial a dramatic improvement in favor of dry needling. This trial suffers from “small study bias” which you allude to earlier in your comment. It is well known that these small trials tend to favor and inflate the effect of the experimental intervention. The standard deviations are quite large for the mean VAS values, the difference between the two groups at one month was 8.5 on a 100 point scale, six people dropped out of the sham group with no mention of why or how their absence was handled and there was no effect on WOMAC scores. There is also the issue of MTrPs and myofascial pain syndrome which Kyle and John have discussed in their post and comments. I appreciate the novelty of the study design, but this is not a study to hang our hats on with the totality of evidence available in mind.

    “You quote Harvey, O’Connell and Moseley who analyzed a 2013 dry needling review published in the JOSPT. Based on that study, they concluded that dry needling was possibly worse than comparative interventions. But the same Moseley wrote that “elimination of myofascial trigger points is an important component of the management of chronic musculoskeletal pain” and “we have found ischemic compression and dry needling to be the most effective” (11).”

    I am not sure Moseley’s writing in a separate piece is relevant or takes away from the fact that the actual data in the JOSPT systematic review demonstrated a high level of heterogeneity and when the biggest outlier with the highest risk of bias was removed from analysis, the difference between groups failed to reach statistical significance, much less clinical significance.

    “I feel that you misrepresented the study on heel pain (12), when you stated that the patients in the treatment were more likely to experience an adverse event than a beneficial outcome. By definition, an adverse event is any outcome than is different from the therapeutically intended outcome. Dry needling is usually uncomfortable, which will be considered an adverse event. All adverse events in this study were considered mild and transitory. On the other hand, at “6 weeks, statistically significant differences in first-step pain (measured on a VAS) and foot pain (measured on the FHSQ) were found in favor of real dry needling.”

    I would disagree that Kyle misrepresented the study on heel pain, as these are direct numbers from the trial. The adverse events were minor, but were present none the less at a greater rate than those who achieved a “beneficial” outcome. I put beneficial in quotations because, despite you highlighting the statistical significance of the results, the actual effect size is questionably relevant. While there was a statistically significant difference found between dry needling and sham dry needling measured by the Foot Health Status Questionnaire, the results failed to achieve a previously determined minimally important difference per the authors. Further, the adjusted mean difference between dry needling and sham for first-step pain measured by a 100 millimeter visual analog scale barely met the minimally important difference and exhibited rather wide confidence intervals (mean -14.4 95%CI (-23.5 to -5.2), thus limiting the certainty of the results. You mention that “The adverse events of dry needling are transient and really not a big deal.” — It would seem that the Cotchett trial’s results suggest the actual effects of dry needling for heel pain are also transient and really not a big deal which would make the presence of any adverse events, however minor, unjustifiable.

    Thanks again for taking the time to share your thoughts

    Regards,
    Kenny

  9. Kyle, I had to smile when I read one of the comments made by Andy Kerk on the FB page of Myopain Seminars. He wants to have a face-to-face discussion with you to make sure that you are not a person in the category of “some freak who is out to undermine you personally.” His desire is for a “constructive yet challenging” exchange to take place outside of social media. But he and other “dry needling” proponents do not hesitate to make use of social media to advertise their “dry needling” courses of doubtful validity to gullible physical therapists and to offer this irrational treatment to their patients (as well as to dumb animals).

  10. A great read and very enjoyable discussion.

    Having had some ‘minor’ experience in the critique of trigger points and the therapies and therapists that are believed to treat them, and then the ‘major’ experience in dealing with the vitriol of those with vested interests in teaching said therapies and therapists, I applaud this excellent well, researched and diplomatic deconstruction of something that is nothing more than woo, that belongs in ancient rituals and ceremonies… Not in 21st century medicine, with all that we know and have learnt.

    In times like this when all the evidence has been presented rationally and robustly, yet still others continue to ignore, twist or simply try to bullshit their way around it, I like to say it as simply as I can… Not as diplomatically or politely as others have done here, but screw it, its what I do…

    Dry needling and trigger points are simply a load of bullshit!

    Come on, seriously, when and how did sticking a needle in someone, as near as damn it, completely at random become a ‘therapeutic’ option in the 21st century?

    Dry needling is nothing more than an unethical, opportunistic treatment, used on those most susceptible, most vulnerable and those in most pain.

    Ok some effects will be seen, but so would poking people with organic cucumbers if you did it long enough!

    If you dry needle, acupuncture, electroacupuncture or any other invasive needling technquie, Ask yourself this awkward question!

    If the effects were so good, why are we having this discusion and debate? Surely in the decades of research into dry needling you should be able to produce some robust evidence to make us critiques shut up, and not 104 half baked, glaringly flawed, obviously biased crap!

  11. Adam, I know you will enjoy reading our relevant Chapter in the soon to be released Oxford Textbook of Musculoskeletal Medicine, 2nd edition.

  12. I just had a few minutes to review the various comments and considered replying, but after reading Adam’s comments, I see no reason to spend any more time on this discussion. I was hopeful that finally we could have a meaningful discussion considering the tone of Kyle’s blog and the responses so far, but it did not last long. I rather spend my time with my son in his fight against cancer than engage in an exchange where respect for other opinions is not present.

  13. Jan, that is indeed sad news. However, there are others besides Adam who have contributed insightfully to this discussion. In my opinion, as a leading proponent of “dry needling” you do have a case to answer. I hope that you will be able to set aside some of your valuable time to do so.

  14. John, I agree in principle, but nearly every time I do participate in online exchanges, it gets out of hand very quickly. I had hoped that responses such as Adam’s would have been censored by Kyle. In my opinion, his words are insulting, insensitive and they do bot contribute anything. I welcome discussion as long as it is civilized. I will consider responding in more detail but at this point in time, I am really not sure about it.

  15. For the record, I agree with Adam. I think needling- in all of its forms- is BS. Furthermore, I think it’s a really bad move for the PT profession, and I’ve made my feelings clear on that in several different forums. However, I don’t necessarily think that all of the clinicians who choose to do it or teach it are necessarily full of BS. But, I do know that at least one of them is. James Dunning has taken to Twitter and essentially accused Kyle and Kenny Venere, who wrote a recent piece on needling that was published in the APTA’s magazine, PTinMotion, of having no leg to stand on to critique this practice because they haven’t attended a course. Well, how convenient a charge is that? It’s also incredibly obtuse since the very nature of scientific discourse encourages those who have no “dog in the hunt” to provide the most unbiased appraisal of the studies that have been on it. As long as the analysis is performed by individuals who have a firm grasp on how to appraise scientific studies, then their practical experience with the method is totally irrelevant (unless their critique is specifically related to the clinical application of the method, which in this case it is not.) Kyle and Kenny’s critique cited the relevant literature, as does Kyle’s piece here, showing that the effects of needling are modest at best, and not worth the time, effort and cost to learn nor the risk involved to the patient.

    In short, it’s BS.

    Jan, best wishes for your son’s recovery.

  17. That’s a fair question, Jan, and I’ll answer it. My state PT board spent over $16k from December 2013 to April 2015 on legal fees and communications to licensees on a recent challenge by the state Medical Board over PT’s incursion into “acupuncture”. While I have very low tolerance for allowing physicians to dictate our practice scope, I’m disturbed by the fact that my licensure dues are going to such a frivolous cause. Here in Louisiana we still lack full direct access to patients. Furthermore, due to the Governor’s decision to refuse the Medicaid expansion dollars tied to setting up a state health insurance exchange, access of Medicaid patients to PTs has been further restricted. Medicaid recipients can only receive outpatient services from a PT at a hospital-based clinic. This has resulted in serious delays and dramatic rationing of care for some of the most vulnerable citizens of our state. On top of that, Medicaid reimbursement for outpatient services provided by a PT remains ridiculously low. The most a PT can get from an hour long visit is $44. That barely pays the PT’s salary and benefits and doesn’t begin to cover overhead costs to operate a clinic. Where’s the effort in our state to improve access to PTs through direct access legislation and fair reimbursement for treatment provided to Medicaid recipients? The latter is an important ethical issue. But those issues can’t hold a candle to the lobbying efforts of the growing number of PTs who want to jab patients with needles based on decades of outcomes evidence that is on the whole unimpressive.

    I’m absolutely convinced, having spent many years on the front lines in legislative battles with chiropractors over manipulation, that needling is the new manipulation. It’s the “next big thing” that a relatively small number of vocal and politically active PTs are pushing hard to make a standard part of PT practice, just like they did manipulation during the previous couple of decades. Despite its ongoing popularity, the outcomes evidence for manipulation remains meager, at best. Instead of learning a lesson from the lack of effectiveness of passive and coercive methods, PTs ignore the growing body of basic science pointing to the importance of psychosocial factors in persistent pain problems and barge right through the skin with an even more invasive technique: needling. And in the process, they’re spending my licensure dues to do so.

    I’ve had enough of this wrong-headedness in the PT profession. I’ve had enough of the “death of thoughtfulness”, as the late Jules Rothstein put it. I’ve only got another 15 years to go in PT, and I’ll be damned if I’m going to spend it watching my colleagues bounce from fad to fad. While in the process spend my dues to justify it.

  18. Jan, I am still waiting for your straight-forward response(s) to my detailed comments of August 6, 2015 @ 12.49 am.

    Your argument, as presented above, is that: “Dry needling should not be about which tissue is targeted, but how to decrease or eliminate peripheral nociceptive input.” But no one has yet demonstrated such input arising from myofascial trigger points! Do you not see the huge credibility problem here?

    1. John,
      May I suggest that Jan’s argument that we should be concerned with reducing peripheral nociception by way of a needle is a “poke in the dark”?

  19. John, the “bottom line” is that the theory of “myofascial pain” has been comprehensively refuted. The practice of “dry needling” of “myofascial trigger points” is without a rational scientific foundation. At long last this sad chapter in the history of pain medicine is coming to a close.

    1. I seriously doubt that your 1994 and 2015 papers combined with your many comments on numerous websites managed to refute myofascial pain concepts and dry needling. You are really not as influential as you seem to believe. This chapter in pain medicine is still being written and the end is nowhere near.

  20. Reluctantly, I will try to provide some additional thoughts. I am reluctant, mostly based on previous experiences. In this medium, it is way too easy to focus on a less-than-optimal choice of words, a study that may not be perfect, etc. and before you know it, the discussion becomes a silly stabbing at each other without any intention of increasing understanding and knowledge. I realize that at this point in time, we will likely not agree and I hope that we can agree to disagree.

    Also based on previous experiences, I will not provide any references as I have been accused too many times of overwhelming readers with literature citations, which was interpreted as a weak argument rather than valued as an evidence-informed argument. As I have acknowledged before, I understand that many studies suffer from small sample sizes and that not all research is worth our while. I review papers for about 20 medical and physical therapy journals and reject over 95% of the papers. I understand the process…..

    I also maintain that the research into dry needling and for that matter of trigger points is still in its infancy even though trigger points have been described as early as the 16th century. I think that serious research by established and recognized labs and universities is really a new and welcome phenomenon. It is not uncommon that new developments start in clinical practice, require a critical mass, before scientists become interested. I think it is premature to throw out dry needling and trigger point concepts, and I do not accept the argument that I have to maintain this point of view just because I benefit financially from teaching dry needling courses. Better research may provide better answers. I appreciate the five levels of evidence so eloquently described by the late Sackett.

    John Ware:

    1. you are correct that a local twitch response (LTR) may not be necessary to improve clinical outcomes. But, I do believe that there is enough research to support that a LTR is an indication that the needle is indeed in a trigger point. Soliciting a LTR manually is quite difficult as the study by Gerwin et al (1997) demonstrated. There are many studies of the electromyographic characteristics of trigger points, which are likely linked to eliciting LTRs with a needle. In addition, I and others have done many experiments using EMG, US and even video fluoroscopy to study the nature of the LTR. In those days (around 1998), it never occurred to us that dry needling would become such a hot item and that perhaps we should do these studies more formally and publish our findings. At this time, I do think that it would be a good idea to revisit these studies, repeat the experiments and submit it to the literature.
    2. I do not agree that there are significant differences between trigger point injections and dry needling. The injectate is pretty much irrelevant for lidocaine, prilocaine, and most other “caines”, unless one would inject botulinum toxin, or a serotonin antagonist such as odansetron or tropisetron (which in the US has not been approved by the FDA, but has been studied in other countries, most notably Germany). Therefore, I do not agree with you that citing the study by Rha would be inaccurate.
    3. I do appreciate your comments about potentially bypassing the skin, but would like to assure you that in many cases, I do not use any dry needling with my patients and indeed, employ other approaches, including the skin, exercise, etc. As a side note, I recently posted a few videos on the Myopain Seminars Facebook page about our approach to exercise in one of my clinics, which you may appreciate. I cannot vouch for other “dry needlers” but it is certainly possible and perhaps even likely, that many are clinging to the needle as the silver bullet for anything dysfunctional in physical therapy. At the same time, as I stated before, I do not see any reason to limit physical therapy interventions to the skin. You stated that dry needlers are ignoring the vast array of receptors, but why would anyone want to ignore the many receptors in muscles and fascia? As I said, “of course, when a needle is inserted, multiple tissue are penetrated, including the skin, the superficial fascia, the deeper fascia, and muscle. All these tissues feature nociceptors and that is the important aspect.” There is a lack of good outcome studies on skin interventions and on validating the underlying thought process.
    4. Regarding Larry Benz, you are probably right. Personally, I would be concerned when the management of a company does not present as a “united front”, but I assume that there are different management styles. You are correct in pointing out that he does not have to be confused. Thank you for correcting me.
    5. It looks like I failed to explain what I meant with my comments about Moseley. I agree with Harvie, O’Connell and Moseley that the Kietry et al paper came up with conclusions that were not justified by the paper, which is one of the main points of the comments by Harvie, O’Connell and Moseley. I agree that the reviewers and editor of the JOSPT should have picked up on that and directed Kietrys et al to modify their paper and conclusions. I do not believe that the data presented by Kietrys et al justifies the Grade 1A rating. But, the commentary did not necessarily communicate the opinions by Moseley. You suggest that he may have changed his mind, which is possible, but perhaps, Moseley does see the value of considering what may be happening in peripheral tissues. The line “the issues are not in the tissues” is only partially correct, as Moseley recently acknowledged in “50 Shades of Pain with Lorimer Moseley: A lot of people mishear the work I do to mean I don’t think pain has anything to do with the tissues. That’s not true at all. I clearly think it does” (http://www.smertespecialisterne.dk/?p=108).
    6. You seem hopeful that one day I may change my mind. Glad to report that I have changed my mind many times since meeting Janet Travell in 1989. When I read some of my older publications, I am sometimes amazed and amused by what we thought to be the truth twenty years ago.
    7. I appreciate your insight that you “don’t necessarily think that all of the clinicians who choose to do it or teach it are necessarily full of BS.”
    8. Whether learning dry needling is worth the time, effort and cost is an individual choice. I understand that you will not be signing up anytime soon. Regarding the risk to the patient, I am convinced that the risks are marginal when properly educated. With close to 8,000 dry needling treatments, the risk of a significant adverse event was less than 0.04% for graduates of our Irish dry needling course program. Of course, that number does not necessarily transfer to graduates of other dry needling course programs, although many other providers did not hesitate citing the study. In my opinion, dry needling is an approach that fits well within the current pain science thinking, but requires an excellent appreciation of three-dimensional anatomy.
    9. About Louisiana, I understand your frustration, but I doubt that the 16k would have been spent on improving access to PT by the poor. You should be somewhat relieved that the PT profession in your state did not bribe the attorney general as the chiropractors in LA have been accused of…… (http://chiropractic.prosepoint.net/114308).

    I do share your concerns that needling may have become the next manipulation, but I disagree that there have been “decades of outcomes evidence.” The better quality research is less than 10-15 years old. You are right that for some aspects, we are poking in the dark, but that applies to the overall field of pain sciences, and physical therapy as a whole. There are so many unanswered questions about pain sciences, therapeutic neuroscience, the neuromatrix, etc., but that did not stop Butler and Moseley from publishing a new edition of the Explain Pain book and should not stop clinicians from applying what we know.

    John Quintner

    1. In this discussion and in other online venues, you have never addressed the many issues Gerwin and I pointed out in our reply to your paper published in Rheumatology. You did point out that we acknowledged several points of agreement, but to be fair, I think you should come off your high horse and acknowledge that at least part of your argumentation was based on citing several references inaccurately, among other problems, which by definition undermines your arguments. I made the same mistake in this forum and was immediately corrected. I posted your paper in the social media of Myopain Seminars, but all you managed to do, is point out where we more or less agreed, in addition to citing individual quotes from a wide variety of philosophers. For example, you and your colleagues cited Lewit’s 1979 paper as proof that referred pain patterns were arbitrary, although the Lewit paper never mentions referred pain. Lewit concluded that “immediate analgesia can be produced by needling precisely the most painful spot”, but you opted not to mention that. You cited a methodologically poor paper about botulinum toxin injections to critique the integrated trigger point hypothesis, etc. There is no point in repeating everything we stated in our paper, but it would have been nice if you and your co-authors would have been able to acknowledge that you made assumptions with improper citations.
    2. About nociceptive input:
    a. Some 25 years ago, German researchers established that trigger points are hypoxic, which was recently confirmed by researchers at the US National Institutes of Health.
    b. Anytime there is an hypoxic state, the pH of the tissues immediately decreases. A drop to a pH of 6.6 is sufficient to fully activate nociceptive acid sensing ion channels, transient receptor potential vanilloid channels, and several other receptors, such as transient and short transient receptor potential cation channels. Researchers at the NIH measured the pH at an active trigger point to be in around 4.5, as you acknowledged in your paper.
    c. Activation of acid sensing ion channels and other channels initiates myalgia and causes mechanical hyperalgesia, partially because of the antidromic release of multiple sensitizing substances, such as bradykinin, calcitonin gene-related peptide, substance P, tumor necrosis factor-α, interleukin-1β, serotonin, and norepinephrine, which have been confirmed in the immediate milieu of active trigger points.

    You suggested that the presence of these chemicals may be the result of tissue damage or altered peripheral nerve function, which are possibilities, but in trigger points there is little evidence of tissue damage. The researchers did not study peripheral nerve function and is unlikely that repeatedly they made such a grave error. In addition, other lines of research have confirmed the presence of chemical alterations in muscle tissue.
    d. Glutamate has not yet been identified specifically in the close environment of trigger points, but has been confirmed more generally in myofascial pain conditions.
    e. In mice, the onset of hypoxia led to an immediate increased acetylcholine release at the motor endplate.
    f. Trigger points are located in close proximity to dysfunctional motor endplates in well-defined innervation muscle zones.
    g. Recent studies have shown that the local pain at trigger points is due to sensitization of muscle nociceptors and to a lesser degree due to non-nociceptor activation.
    h. This can impair descending inhibitory pathways, which is an aspect of central sensitization.
    i. Australian researchers confirmed that the maintenance of referred pain depends on ongoing nociceptive input from the site of primary muscle pain.
    j. I believe that based on current literature, there is plenty evidence that trigger points function as peripheral sources of ongoing nociceptive input contributing to the propagation of central sensitization and widespread pain, including fibromyalgia, but also of whiplash-associated pain, migraines, tension-type headaches, post-mastectomy surgery, and temporomandibular disorders, among others.
    k. Of great clinical interest is that the treatment of trigger points can reverse and eliminate referred pain.

    3. In my opinion, your interpretation of the recent paper by Shah et al is a misrepresentation of the paper. Yes, they raised all the questions you accurately cited, but you have taken those out of the context of the entire paper. I do not agree with you that ethical physical therapists need to put down their needles. In my opinion, there is enough evidence that dry needling can play a role in the treatment of individuals with acute and persistent pain problems. Of course, we do disagree on this point, but that does not concern me all that much.

    I have spent much more time on this reply than I should have, but you raised a lot of questions. I will not be able to contribute for several days, but want to emphasize that I actually believe that such discussions are very useful and necessary as long as they are respectful. I refuse to pay any attention to comments that do not serve any purpose. I learn a lot from all of you and do modify my writings based on your valuable input. As I started off with, I do not anticipate that we will agree in the near future, but that should not distract us from learning. Thank you for your input and comments.

  21. “You are really not as influential as you seem to believe. This chapter in pain medicine is still being written and the end is nowhere near.”

    Jan, I have never claimed to be influential. But as it is said in Shakespeare’s Merchant of Venice – “… but at the length truth will out.”

    “I do not agree with you that ethical physical therapists need to put down their needles. In my opinion, there is enough evidence that dry needling can play a role in the treatment of individuals with acute and persistent pain problems.”

    Jan, I look forward to seeing the hard scientific evidence that might support your opinion. Until this happens, I must reaffirm my opinion that “dry needling” does not fall within the confines of ethical practice.

    I take your point about my being on a “high horse”. But at the very least I think I do have a good excuse under the circumstances.

  22. Addendum: Jan, here is the full quote from Lewit (1979): “When our table of pain spots and trigger zones is compared with those of Travell and Rinzler or Hansen and Schliack, or with the periosteal points of Vogler and Krauss, it is obvious that there are very many such points and that they are sometimes been chosen arbitrarily, there being no accepted standard.”

    I fail to see how any such “omission” weakens our argument.

    Lewit did indeed conclude: “immediate analgesia without hypesthesia (the needle effect) can be produced by needling precisely the most painful spot.” Indeed we did not specifically mention this. However, this phenomenon is explained later in our paper when we mentioned the possibility of “counter-irritation” or the application of a competing.

    So, if as seems likely, it turns out that the sole mechanism of action of “dry needling” is that of it being a temporary “counter-irritant,” I cannot see why it has any place in contemporary pain management.

  23. Jan,
    Thank you for that thorough and respectful reply.

    Your response to my issue with the LTR missed my point entirely. As far as I know, EMG and US are not being used clinically to confirm the presence of the LTR. Therefore, even if it is an important feature of “effective” dry needling intervention, since it’s not being used clinically (and hasn’t been described as a method of confirming the MTrP in recently published clinical trials), then whether or not it’s a sign of effective needling is moot. Until and unless a clinically accurate method of identifying the LTR is devised, its practical use as an indicator of isolating a trigger point is only speculative.

    I think a large gap in your argument, which pervades many of your arguments for this intervention, is your lack of appreciation for so-called non-specific effects, which if they’re beneficial are referred to as “placebo”, and if they’re negative then the term “nocebo” applies. I’ve recently come to prefer the term “contextual” effects. Many studies have shown that when patients believe that an active substance is being injected, then they show a stronger positive response to the intervention. A recent review by Oken (http://brain.oxfordjournals.org/content/131/11/2812) describes the complexity and range of placebo responses depending on many factors, including conditioning effects based on the subject’s previous experiences. In any case, your contention that “*several* electromyography and sonography studies have shown that eliciting local twitch responses significantly increases the effectiveness of at least trigger point dry needling” (emphasis added) overstates your case. Only one of those articles, Rha, supports your argument since Hong was very poor quality and the other study was done on rabbits.

    I appreciate that you are considering the skin, and your group is certainly unique in this regard. However, I think it’s both speculative and presumptive to target “issues in the tissues” in terms of nociception. *There is no way to measure nociception nor it’s level of influence over the emergent pain experience, so any argument that proceeds from an attempt to modulate a peripheral nociceptive source per se is impossible to defend.* This is really the heart of the argument for the use of conservative care for persistent pain problems, in my view, because it acknowledges the uncertainty inherent in treating people with non-pathological pain. I use the dictum “First, do no harm” liberally, which I think is appropriate for this patient population. What I mean by that is we should use the *least effective means necessary* to catalyze the patient’s descending modulatory system to help bring about pain resolution. Often, we will fail, which is when we must assist the patient in learning how to function better with the pain they have. The failure to respect and encourage self-autonomy and to build self-confidence through the use of well-intentioned interventions to alleviate pain has proven a financially unsustainable and wholly ineffective approach to treating patients with persistent pain problems. As providers of conservative care, the promotion of needling interventions utterly ignores the growing evidence of this failure in our modern healthcare systems.

    Therefore, the oft-cited adverse event statistic of 0.4% is misleading because it fails to address this more nuanced threat to self-efficacy that interventions like needling pose- interventions that draw on placebo effects of which the practitioner has little or no appreciation. That’s a recipe for medicalization, and I don’t want my profession to fall any farther into that trap than it already has.

    I was referring to the manipulation research, which goes back to the late ‘70s and ‘80s (see the systematic review by Keller et al in Eur Spine J. 2007;16:1776-1788), not the needling research.

    1. John Ware,

      Thank you again for your insightful comments and for elaborating on your thoughts on local twitch responses (LTR). In clinical practice, it is very easy to elicit these LTR with a needle and we have verified this multiple times. We teach this to our dry needling students and after 2-3 days in a course, every student can do this. As I mentioned, we have conducted many experiments without publishing the results, which is something I very much regret in retrospect. I do not think it will be difficult to demonstrate that eliciting LTRs with a needle can be done quite accurately. I will explore how this can be done. Thank you for bringing this to my attention.

      I don’t think I lack appreciation of contextual effects, but this aspect has not really come up before in our various online exchanges. I do not think that you can conclude anything about what I know and appreciate about these topics. Nevertheless, thank you for bringing this up in this discussion, as it is indeed a very important and under-appreciated topic.

      In our dry needling courses, we cover so much more than just dry needling. We include many hours of high level pain science education and as part of that, we review the work of Bandura on the importance of self-efficacy in some detail. We discuss the endogenous opioid mechanisms that Bandura reported in several of his papers. If we would do nothing but dry needling in our clinics, I would agree with you about the potential threat to self-efficacy.

      You may not realize that in my two physical therapy clinics, dry needling constitutes a relatively small part of what we do in our interactions with many of our patients. We routinely include self-efficacy training as part of our therapeutic neuro-education program. We work primarily with patients with persistent pain problems, but also with some specialty sub-groups including patients with Ehlers-Danlos Syndrome and musicians, among others.

      Although my practices are very small, approximately 40% of our patients come from out of state and many come from other countries. There is no question that many of those patients come in with very high, and very often very unrealistic expectations. The clinicians in my practices are very aware of these contextual expectations and almost all the time, we have to educate the patient that we do not have a magic bullet that will resolve all their problems, and that includes near ridiculous expectations of the “magic needle.” Many of my patients are seen by a psychotherapist affiliated with our practice, who routinely will ask the question “what are your plans when the PTs cannot help you?” Our practice administrator is trained to start the educational process when patients call to make their first appointment. During the very first appointment, we start the education process. In our dry needling courses, we spend a lot of time on these issues. Even in the clinical anatomy course I teach with Andry Vleeming, the biopsychosocial model plays a central role in our lectures.

      I am quite sure that most dry needling course providers do not have such an elaborate biopsychosocial approach. Some of those other providers have banned me from attending their courses; I was told that it was “unprofessional” of me to try to attend their courses, which is an interesting point of view, especially since many current course providers in the US have attended several of our courses….. Therefore I do not know firsthand what exactly is being taught, but judging by what appears in social media, I have my doubts. In my first entry in this forum, I mentioned that not all dry needling courses are the same.

      I think I mentioned that our dry needling students have to review over 10 hours of educational lectures that include many of these aspects of physical therapy. Of course, dry needling does not escape the placebo effect and that is always something to be aware of. I am sure that there are patients for whom the expectation of dry needling is the major reason they receive any benefit from coming to our office, but I do not believe that this is true for the majority of our patients. As you summarized, it is extremely complex to figure out what is due to placebo and what is not, but I believe that this is true for most contemporary physical therapy interventions, especially if they are new to the patient. Oken describes this in his article: “A patient’s expectancy of improvement may influence
      outcomes as much as some active interventions and this effect may be greater for novel interventions and for procedures.”

      When I see a patient who has been seen by 5 or more other PTs who offered nothing but outdated biomechanical approaches, i.e., correcting upslips of the ilium, spinal misalignments, rotations of the SI joint, impingement syndromes, and the list goes on, there has to be a huge placebo effect when we start educating the patient about pain sciences. One of our clinics features extremely advanced exercise equipment, which for most patients is novel and indeed very different than what they have experienced in other clinics. Is there a placebo effect in that clinic? Of course! But, patients have to work very hard in that clinic often without realizing that they are exercising. We incorporate the work of Wulf, Lohse, Williams, and others, which is a novel way to retrain the brain from the top down and from the bottom up. I agree with Oken when he writes “Maximizing this expectancy effect is important for clinicians to optimize the health of their patient.”

      I am not sure what you mean with “non-pathological pain.” All pain is a perception irrespective of whether there is associated pathology.

      I do not agree with you that the 0.04% risk of introducing a significant adverse event is misleading. It is a factual number based on nearly 8,000 treatments with dry needling. The purpose of that study was not to explore the potential threat of dry needling to self-efficacy.

  24. John, as one who is on the outside, I can see that the physical therapy profession has fallen into an abyss of ignorance. As Kyle correctly observed: “[T]he number of continuing education courses, certifications, and companies offering dry needling continues to rapidly expand.”

    It should now be clear to one and all that “dry needling” is not evidence-based practice. But the claim has been made that it does nevertheless fall into the valid category of evidence-informed practice. However, in my opinion a third category is necessary for “dry needling,” that of evidence-misinformed practice. This category could be defined as a consciously cultivated inability to accept overwhelming evidence that refutes the theory upon which “dry needling” is based.

    I sincerely hope that you and other like-minded therapists can restore the credibility of your profession.

    1. Just one comment here: I do not think the credibility of the entire profession is layed waste by the advancement in popularity of dry needling. It’s bigger and more profound than that.

  25. These are all of the predecessors I have discovered who have already answered all of our questions. I call them “The Masters of True Holistic Healing.” Baldry, Burke, Chaitow, Craig, Cyriax, DiFabio, Gokavi, Gunn, Hackett, Helms, Lennard, Hamm, B.J./D.D. Palmer, Pybus, Rachlin, Rapson, Seems, Simons, Travell, Wyburn-Mason.
    They all studied complex pain problems.
    They all used hands-on or needles, either hypodermic or thin acupuncture needles in their quest to find solutions for their suffering patients.
    They all had a different target for the needle. Whether it was the muscle, tendon ligament or nerve.
    Some use different substances in the syringe for injections or just used the action of the needles.
    They all realized that what was on X-rays was not the entire truth.
    They witness the failures of orthopedic and neurologic surgery to fix the human body.

    They will walk you thru a better understanding of what, where and how to treat everyday pain. Once you understand what pain is and is not, you will began to reformulate your logic.

    Gunn completed the 360 loop in his conceived mechanism of action that binds the entire spectrum of remedies which will remove pain from muscles: Stimulate and “electrically reboot” a stressed, strained and contracted muscle with a wire. Via Cannon’s Law. So the entire spectrum starts with 1) massage. ===> 2) thin needling ===>3) hypodermic stimulative needling.

    These are the words used to describe all of the SAME procedure: Acupuncture, medical or myofascial acupuncture, GunnIMS, dry wet needling, travell trp injections, prolotherapy, biopuncture, neuro-injection, sugar injections botox injections, joint injections, rooster comb injections, platelet rich plasma injection, stem cell injections ===> all use the same mecahian of action.

    The whole truth equation: A problem (within the muscle dynamics) + intramuscular stimulation via a metallic needle = reliable and consistent results.

    Everyday pain has been always will be in the muscle system.
    Everyday pain has been always will be remedied by the application of plain old massage, stretching and range of motion exercises.
    Muscle stress can not be detected with technology, only by history PE, hands on and needles.
    Muscles will store “stresses” and begin to contract and squeeze itself and surrounding structures.
    The disease is set in muscles and connective tissues.
    TrPs may or may not be present is a sick and needy muscle.
    Classic TrPs are rare.
    The source of the pain and thus the remedy is the muscle. NOT in TrPs.
    Whether the clinician finds a TrP or does not, he is still obligated to treat the key muscles.
    The pinhole invasive treatment of choice is “intramuscular stimulation” as per Gunn. One can use a thin or hypodermic needle.
    Everyday pain can not usually PRIMARILY be in the brain, spinal column, nerves, joints, skeleton, disc, cartilage or menisci.

    If you decide to stay in Convention, you may not be exposed to pain as these authors will explain. Not knowing these pain treatment masters may result in your miseducation leading to mismanagement, bewilderment, frustration and confusion. Stumbling over these authors saved me and my patients many years of being in miserable pain. Check them out!

  26. Jan says: “In clinical practice, it is very easy to elicit these LTR with a needle and we have verified this multiple times. We teach this to our dry needling students and after 2-3 days in a course, every student can do this.”
    Jan, certainly you can see the tautological problems with this. On the one hand the LTR is supposed to be an important criterion for identification of the MTrP, and then on the other you claim that it’s only identifiable after the needle is inserted into the proposed MTrP. So, your argument seems to be that the other criteria for identification of an MTrP (palpation of a tender taut band, reproduction of familiar pain, referred pain) are only provisional until these findings are confirmed by the insertion of a needle eliciting an LTR. Is that accurate? So if you get the first three, but fail to elicit the LTR with needle insertion, then you continue to poke around in the vicinity (which according to the review by Lucas et al [2009] is in a radius of anywhere from 3 to 6cm and then using the area of a circle calculation: The average radius of 4.5 [squared] x3.14=63.6cm squared). That’s a pretty large area to be poking around in to find the LTR. I’m sure someone with better math skill than I could determine how many insertions it would take on average, based on the available diagnostic accuracy literature, to actually insert the needle into the offending taut band that produces the LTR. It would seem that this would require more than one and likely several insertions; that is, if the diagnostic criteria are accurate and MTrPs exist as the have been defined. However, if they don’t exist as they have been defined by the palpatory criteria, then I would suspect that the rate of finding the LTR would be much higher. I suspect that by the end of the course, your student are eliciting LTRs on their very first try most of the time. Would that be accurate? So, you see how there’s an issue here with circular reasoning?

    Incidentally, in the recently published RCT by Llamas-Ramos et al (JOSPT. 2014;44(11):852-861), dry needling of MTrPs showed no significant benefit over manual therapy in patients with chronic mechanical neck pain. The authors included the LTR as a criterion for successful needle insertion. So, there is high quality evidence to suggest that your supposition of the importance of LTR elicitation is over-stated, particularly in patients with persistent mechanical pain.

    John Q, I am getting the sense that there is the beginning of a groundswell- albeit small- of grassroots opposition to dry needling in PT. We’ve got some very smart and dedicated therapists- as well as non-PTs like yourself- who are beginning to have an impact. The issue of bias on publication of clinical trials at JOSPT is gathering a head of steam. Even Jan has acknowledged that the assignation of “grade A” evidence in favor of dry needling from the Kietrys et al systematic review was unwarranted. In the study I just cited, which ironically won the 2014 “Excellence in Research” award from JOSPT, the authors were required to publish an apology for mis-reporting diagnostic reliability data in the February issue. That’s the same month they accepted the award at the professions most well-attend annual conference!

    The winds of change are gathering momentum.

    1. John Ware,

      1. eliciting a LTR is not a criterion for identifying a trigger point.
      2. eliciting a LTR with needling confirms that you are in the right place. Palpation is the most important aspect of dry needling.
      3. current criteria are taut band and tender spot. Eliciting referred pain and recognition of familiar pain are not required.
      4. there is no circular reasoning.
      5. I welcome the critical attitude to dry needling as it will push researchers to do a better job. But I also don’t think you should overstate the demise of PT. In the US, I estimate that less than 3% of all licensed PTs use dry needling. To conclude that “the physical therapy profession has fallen into an abyss of ignorance” reflects significant ignorance. Three percent of the PT population determine that the profession is in dire trouble? I don’t think so.

  27. Pingback: Come. Let us reason together « NAIOMT

    1. Based on my best estimate of the number of students who have attended dry needling programs. I know how many students attended my courses, have a good idea of the number of courses offered by other providers. No one has done a formal survey as far as I know. It may be as many as 4-5 percent.

  30. Jan says:
    “1. eliciting a LTR is not a criterion for identifying a trigger point.
    2. eliciting a LTR with needling confirms that you are in the right place. Palpation is the most important aspect of dry needling.
    3. current criteria are taut band and tender spot. Eliciting referred pain and recognition of familiar pain are not required.”

    According to Llamas Ramos et al (as cited above), the winner of the JOSPT Excellence in Research Award for 2014, the criteria for diagnosis of an MTrP in patients with chronic neck pain are:
    “(1) a hypersenstive spot in a palpable taut band, (2) palpable or visible local twitch on pincer palpation, and (3) reproduction of referred pain elicited by palpation of the tender spot.” They then go on to report kappa coefficients for these criteria of between 0.84 and 0.88, which, as I’ve already stated, are erroneous. They subsequently had to revise their data and publicly apologize in the February 2015 JOSPT.

    Mejuto-Vazquez et al reported the following criteria in their February 2014 article published in JOSPT [44(4):252-260]: “the presence of a palpable taut band in the upper trapezius muscle, the presence of a hypersensitive spot in the taut band, a palpable or visible local twitch on snapping palpation, and reproduction of referred pain elicited by palpation of the sensitive spot.” Both of these groups are associated with Dr. César-Fernández-de-las-Peñas, who is one of the most highly published and respected clinical researchers in the area of dry needling. If you have an issue with how he is defining MTrPs, then I think it would advance the science considerably for those promoting it to agree on how exactly one of these things is identified. The current different sets of criteria seem to be a bit of a mess. If you, as a leader in the dry needling research community, have made a public critique of these criteria, then I’d be interested in seeing it.

    Your argument on the one hand that “…[p]alpation is the most important aspect of dry needling” but then on the other to assert that the LTR is necessary after palpation to confirm “you are in the right place” doesn’t make any sense. We’re talking about literal needle-point accuracy. If the LTR confirms the “right place” then palpation is merely an approximation, and cannot be as important as the confirmatory LTR. If the clinician has palpated the tender taut band, but doesn’t get a confirmatory LTR with needle insertion, then they have to move on to find the “right place”, no?

    All this vagueness and confused criteria seems to come back to Dr. Quintner’s list of questions from up-thread, particularly the ones asking about the etiology and pathophysiology of the underlying condition, MPS, and the role of MTrPs in the pathogenesis of MPS. It seems that an intervention is being described and advanced for a condition that may not even exist. Or at least there aren’t any clear and agreed upon diagnostic criteria to match such interventional specificity. It appears to me that the cart is quite precisely, but nonetheless, very much positioned in front of the horse.

    We seem, in our modern healthcare systems, to have grown so accustomed to this mal-juxtapositioning of interventions prior to an adequate understanding of the condition that they’re intended to treat, that we just take the whole process for granted anymore. There are, however, two inescapable realities: 1) patients aren’t getting better and 2) we’re running out of money.

    1. John Ware,
      as I indicate before, I was not able to contribute to this exchange due to many other commitments including extensive travel.

      Regarding your questions about the LTR as a diagnostic criterion, I think we learned from the Gerwin et al study that the LTR is not a reliable indicator. The reliability of identifying a LTR varied a lot based on the muscle that was palpated. I have communicated with César-Fernández-de-las-Peñas about their frequent inclusion of eliciting a LTR in many of his research papers, and his response was that in research they prefer to include it, but not necessarily in clinical practice. I have shared with him that I do not think that that makes a lot of sense. I have not published that in a public format, other than in book chapters.

      Your interpretation of what I intended to say about the LTR suggests that I managed to express myself very poorly. Let me try again. I do not believe that eliciting a LTR is necessary for the identification of a trigger point. With dry needling, I don’t think it is essential either, and certainly not to confirm that a trigger point was identified, although I can see why you concluded that. With dry needling, eliciting a LTR only shows that a clinician managed to target the trigger point effectively with the needle. To target a trigger point with a needle after it has been manually identified is a skill that can be learned. Palpating with a needle is more or less comparable to the old-fashioned carpenter who’s hammer had become an extension of the carpenter’s arm and hand. The book Action in Perception by Noë (Cambridge, MIT Press, 2004) describes this process quite nicely as “enactive” approach to perception. I do not see any problem with moving the needle a few times to elicit LTRs. The degree of tissue damage is marginal and does not lead to further problems.
      I have acknowledged that the criteria need to be more solidified to avoid further confusion and to be able to compare studies more easily. It is true that many researchers use their own variation of what they seem to think are “good criteria.” That is once again not unique to trigger point research, but happens in many research areas. Developing techniques and approaches before having all the necessary research is the most common pathway new developments follow. It always takes a long time before academia catches on and starts exploring what a new development may be all about. Dry needling by itself may not get many patients better, but when combined with therapeutic neuroscience education and excellent exercise therapy preferably with an external focus of control beats everything I have learned.

      Regarding your reference to Quintner’s citation of the questions posed by Shah and colleagues, I already mentioned that the questions were referenced out of context of the rest of Shah’s article. Much is known about the etiology and pathophysiology, but much more can be learned. I understand that he, you and a few others continue to believe that the condition may not exist, but that is one area where we differ in opinion.

      I don’t think I will add much more to this exchange. I am currently in India, where I have a faculty position at a university, and need to focus on my responsibilities here.

      I would like to thank you for civilized participation. I hope that one day we will be able to meet in person and discuss these issues face to face.

  31. Regarding the popularity of needling, I think it’s safe to say that this intervention is the next “big thing” in PT, just as manipulation was in the 90’s and early 2000’s. Only a small percentage of PTs ever performed manipulative (high velocity thrust) techniques, but I don’t think that accurately reflects the resources that have been spent in terms of practice scope protection, research and continuing education. Many, many dollars and hours of lobbying legislators have been spent to advance the practice of manipulation by PTs. And now the same phenomenon seems to be recurring with needling. It’s like the next sequel to “Back to the Future”, just some of the players have changed- instead of chiros, we’re getting challenged by the acupuncturists and “integrative medicine” practitioners. The lawyers are still there, though, collecting their fees to help us protect our “scope of practice”.

    Lawyers are so helpful like that.

  32. John, the important questions posed above that are raised in the paper by Shah et al. [2015] cannot be answered by Jan Dommerholt and his followers. Moreover, they have steadfastly refused to acknowledge that there may be other more rational explanations for the clinical phenomena that have been attributed to the “myofascial trigger point”. By continuing to champion the cause of “dry needling” of tender muscles, one must reach the inescapable conclusion that the extreme position they have taken is an untenable one. But this has been said many times before in recent months, without any apparent effect.

    1. John Quintner,

      in my publications, I have reviewed many other possible explanations, including yours as well as the Central Modulation Hypothesis, the Neurogenic Hypothesis, the Neurophysiologic Hypothesis, the Radiculopathy Hypothesis, and the Mechanistic Hypothesis. None of these hypotheses have produced any credible scientific support and evidence. Once you deliver reasonable scientific support for your ideas, I will gladly consider your ideas. The students of our dry needling courses have to review all current hypotheses including yours.

  33. I can tell by reading some of these notes that a few of you have not read Gunn or Rachlin. I would suggest that you do so, you will help yourselves and your patients.

    The source of everyday pain is in the muscles system. NOT the brain, nerves, joints or joint structures. It is disrespectful to negate someone’s pain or state that it is in their brain. Of course it is but not just the brain. Doing this allows one to skate all of their responsibilities to help the patient.

    The aim of the entire treatment is the person who is crying in pain for help.
    The whole person is the focus of care.
    TrP are not “things” like a lipoma. They are in all stages of formation and deformation. So over time your will find that one that you have worked on is back. This is a dynamic dance of whack-a-mole. Your job is to whack. If you ally too much logic into a case you will waste a lot of their time and your effort. [been there]
    You may have to possible treat a quarter of the 200 muscles we all use in our daily lives. Yes this means 25-50 muscles per visit per week. You can not find a TrP or elicit a twitch in a 1″ rotator of the vertebra, a deep cervical paraspinal but you still are required to apply the correct remedy; IMS.
    All the associated muscles require IMS, not just a conceived TrP be they active, satellite, latent or dormant.
    Gunn talks about seeking out those TrP that will corrupt all of your work and reactive a TrP that you have thought you have eradicated.
    Stretching is vital to the rearranging of the muscle bundles.

    1. It is likely an error to claim that pain is IN any peripheral tissue or area. Our understanding has evolved immensely. Pain is individual, a lived experience, multi factorial, and an emergence. Your assertions are nothing but conjecture it not worse

  35. This is what happens when the patient does not get the proper therapy for a long time. Their skin turns to a leather-like state due to the engorgement of lymphatic fluids. The needle can not cut thru the dense fibrous kevlar-like threads within the tissues.

    This is a not so bad case. After a few visits, the kevlar tissues return back to human tissues again.
    https://youtu.be/Ew3sno3wLxQ

  36. Dr. Rodrigues, your perception of at least my conceptualization of how the pain experience comes to be is inaccurate and unsophisticated. First of all, I have no idea what is meant by “everyday pain”. If you’re talking about the predicaments associated with living a life- the stubbing of a toe, the straining of a back, the stiffness in a neck- then why on earth is medical attention of any kind being proposed for that?!

    All pain is OF the brain (not in it). Pain is a conscious experience- how could it be a product of anything else? Perhaps you’ve never heard about or read the interviews with Kevin Ware after he sustained a compound fracture of tib-fib during an NCAA tournament game a few years back? I suggest you google it. His description of his experience and that of his teammates is quite instructive. Certainly you’ve heard of the phantom limb pain experience. This phenomenon confirms that “nociception is neither sufficient nor necessary for the experience of pain.”

    All of your speculation about the various types, stages and locations of trigger points borders on anti-scientific nonsense. I wouldn’t blame the admin’s here if they removed the links to those silly videos. In fact, I’ll encourage it.

    1. We will keep the comments and links as an exposure for the readership. I think your comments John W have illustrated the issue contained. Happy viewing!

      1. Knowledge is power. Many human beings learn from watching an example. [may not be the best picture] “A picture is worth a thousand words.” The pictures and videos hopefully will help to concrete and personalize this academic discussion.

        Besides I sincerely hope the video helps you to see what your patients maybe are missing. It that not why we are here – to help patients who are in pain get out of pain??

    3. Those patient do not think that they are silly??!

      Dang do you not have compassion?
      Do you not have a passion for learning?

      Anyone can define pain in a thousand ways and words. Only one matters to the patient. The pain that keeps them awake at night.
      Blinding oneself to the needs of others is not a good ability for healthcare providers.

      K. Ware’s video is on my to do list.

      1. Dr. Rodrigues,
        I take exception to your charge that I lack compassion for my patients because I choose not to dry needle “trigger points”. That’s an emotional appeal and has no place in a rational discussion.

        Patients are not equipped with the knowledge to fully understand what is happening to them when they experience persistent pain. That’s our job as clinicians to educate them using an accurate and defensible explanatory model. I’m not aware of any evidence to support a predictable pain referral pattern when a tender spot is palpated. The findings of Travell and Simons were based on clinical observations, not tightly controlled clinical trials or reliability studies. If you have some quality evidence demonstrating that pain referral patterns upon palpation possess inter-examiner reliability, then please provide a citation.

        Jan has already acknowledged that referred pain upon palpation is not even a criterion his group uses to identify tigger points. I can assure you that if there were even marginal quality evidence to support this finding, he would’ve listed it by now.

        In terms of making a science-based argument for needling MTrPs, you’re not representing you side very well at all.

        1. ? My side? I have no side except what works in the office setting!

          These do NOT work: Back surgery for back pain is not natural and yields haphazard results. Same with knee, hip and shoulder replacement surgeries + the poor patient not only will still have pain but they will also have been robbed of a body part.

          It is not nice, logical, natural, ethical or humane to remove human body parts just for pain!!!

          You all are playing trick games with definitions and concepts which is intellectual dishonesty.
          Games of words or Master Manipulators: What is Acupuncture, needling or trp? What Acupuncture, a trp or needling is not?

          You say Acupuncture but “acupuncture” is not standardized so how can you study something that has no standard.
          A trp is not the cause of muscle pain.
          A trp is just a small and insignificant part of the totality of all muscle pain.
          Muscles are the exact cause of everyday pain.
          Muscle will always be the cause of everyday pain. Massage, stretching, range of motion of all joints will release the pain that lives in muscles the majority if the time.

          Delay in releasing this pain will simply cause more pain and dysfunctions; the treatment is the same but more of it! Then it will not work.

          The next tool to remove this pain are thin needles then finally hypodermic needles
          see C. Chan Gunn and Rachlin

          Withholding a remedy because to what you think, someone told you, what you read in a RCT or what is standard is illogical, unethical, disrespectful, misinformed consent, malpractice and will do harm to the patients who trust you to apply the correct remedy to their pain problem.

          What you believe is yours to do what you wish. When you apply your incomplete believes on a wounded soul in need of help that is the definition of a crime of omission. Misinform consent is a punishable crime.

          I sincerely hope that someone will see this travesty of justice and start suing for crimes against humanity!!

          http://archinte.jamanetwork.com/article.aspx?articleid=1357513

  37. Re: Kevin Ware video. You need to read the interviews with him after the injury, not just the video itself. It’s how he describes his experience that is so instructive.

  39. Kyle, you could add yet another issue in “therapeutic” dry needling, making 10 in all. It is the loss of scientific credibility of health professionals in general when zealots insist on promoting it as a panacea for all chronic musculoskeletal pain.

    1. Panacea is actually exactly the proper word to use in this case: A panacea is a possible solution or remedy for all difficulties or diseases.
      If you study muscles and connective tissues you will understand that sick muscles will first radiate only pain signals then after a few years of neglect then the muscle system will then begin to cause difficulties or dysfunctions. SO —
      I must say that human hands are the best tool to remove pain that is in muscles.
      I must also say that human hands with a slender stainless steel needles are the best tools to remove pain that is in muscles.

      Wow!!! Yes IMS is a panacea!!!

      1. Dr. Rodrigues – I’m interested in your comment about how muscles only first radiate “pain signals”, then after a few years they become dysfunctional. What is the evidence that supports this claim both by definition as well as timeline? Furthermore, are you equating nociceptive signals being sent from the periphery to a pain output? Thanks.

  40. There’s too much of trying to use evidence like a weapon here. Research does not develop to support the preconcieved notions of the clinician, and a little knowledge of how to read and critique the research is dangerous. Articles should be read without emotion.

    In that vein, let’s take a look at the following article. It’s open access (yet still peer reviewed) so everyone should be able to grab it online:

    Mayoral et al. Efficacy of Myofascial Trigger Point Dry Needling in thePrevention of Pain after Total Knee Arthroplasty: A Randomized, Double-Blinded, Placebo-Controlled Trial 2013

    ABSTRACT: The aim of this study was to determine whether the dry needling of myofascial trigger points (MTrPs) is superior to placebo in the prevention of pain after total knee arthroplasty. Forty subjects were randomised to a true dry needling group (T) or to a sham group (S). All were examined for MTrPs by an experienced physical therapist 4–5 hours before surgery. Immediately following anesthesiology and before surgery started, subjects in the T group were dry needled in all previously diagnosed MTrPs, while the S group received no treatment in theirMTrPs. Subjects were blinded to group allocation as well as the examiner in presurgical and follow-up examinations performed 1, 3, and 6months after arthroplasty. Subjects in the T group had less pain after intervention,with statistically significant differences in the variation rate of the visual analogue scale (VAS) measurements 1 month after intervention and in the need for immediate postsurgery analgesics. Differences were not significant at 3- and 6-month follow-up examinations. In conclusion, a single dry needling treatment ofMTrP under anaesthesia reduced pain in the first month after knee arthroplasty when pain was the most severe. Results show a superiority of dry needling versus placebo. An interesting novel placebo methodology for dry needling, with a real blinding procedure, is presented.

    There is an undenyable truth here — the therapist can get more neuromuscular re-education and strengthening out of a patient in reduced pain. Looking at the graphs, those patients dry needled under anesthesia achieved pain relief that it took the control group 3 months to achieve. Mechanisms and theories of trigger point development and reliability of palpaiton aside — shouldn’t a study like this give pause to even John Ware level critics?

    It’s more important to learn and to reflect than to be right.

    Andrew M. Ball, PT, DPT, PhD, OCS, CMTPT, PES

    1. Hi Drew,

      I commented on the Mayoral study previously when Jan mentioned it. I have copy and pasted it below:

      “I would hesitate to call the results of the Mayoral trial a dramatic improvement in favor of dry needling. This trial suffers from “small study bias” which you allude to earlier in your comment. It is well known that these small trials tend to favor and inflate the effect of the experimental intervention. The standard deviations are quite large for the mean VAS values, the difference between the two groups at one month was 8.5 on a 100 point scale, six people dropped out of the sham group with no mention of why or how their absence was handled and there was no effect on WOMAC scores. There is also the issue of MTrPs and myofascial pain syndrome which Kyle and John have discussed in their post and comments. I appreciate the novelty of the study design, but this is not a study to hang our hats on with the totality of evidence available in mind.”

      To expand, the treatment groups baseline pain went from 56.75 (22.31) to 23.80 (24.86) at one month on a 100 point scale. The sham groups baseline pain went from 50.37(16.76) to 32.30(25.72) on a 100 point scale. As stated before, this is an 8.5 point difference on a 100 point scale. Tubuch et al (2005) describe the minimal clinically important improvement for a 0-100 scale to be 19.9 in patients with knee osteoarthritis. These are underwhelming results at best.

      Kenny

    2. Andrew,
      I take exception to the implication you have made that I’m more interested in being right than learning about and reflecting on the evidence as it relates to trigger points and dry needling them. You can’t possibly know what my motives are for entering this debate on the side that questions both the 1) validity of the MTrP construct/MFP theory and 2) effectiveness of dry needling trigger points.

      Kenny has accurately critiqued the Mayoral et al study. There is nothing about this particular trial that hasn’t already been addressed in the needling research writ large, i.e. the study quality is often low, and when it isn’t the effect sizes of needling are unimpressive. If your argument is that there is more here to consider, then I’m willing to listen to it. Dr. Quintner and Dr. Cohen have offered an alternative hypothesis of counter-irritation analgesia to explain the meager short-term effects of needling. This, to me, seems to be the most plausible and parsimonious explanation for the effects we’re seeing in all these clinical trials.

      I recently came across a descriptive study of the injury associated with dry needling in an animal model (http://www.hindawi.com/journals/ecam/2013/260806/). It’s not surprising to find out that injury to both muscle and nerve fibers occur during dry needling, which is of course followed by an inflammatory response. Given the modest and short term effects on pain, I can’t see how any therapist who claims to offer the most scientifically defensible, conservative interventions can rationalize creating tissue injury. This is truly a departure for us as providers of conservative care for pain.

      Needling MTrPs is literally a stab into the darkness.

      1. “Needling MTrPs is literally a stab into the darkness.”

        This is true and not true or incomplete.

        Darkness is my every present nemesis. As practitioners of medicine we are always on the edge of uncertainty. Remember an assessment is a best guess. I’ll try not to ever say again, “I’m certain.” I now know I have to wait until the future proves or disprove my original assessment.

        If correct? – great. If not? – more work needs to be done.

        See p.28 of Gunn.
        Gunn uses the needle as a safe multi-tool, investigative, stimulative, electrical rebooting, examination and therapeutic. All in a single office visit – the perfect examination, surgical and medicinal tool. If the needle encounters a density change or change in sensational awareness — Done!! You can treat the area with simulation. If both feel or sense nothing – great trying. If you never look, touch, examine, or try you have not done your best to help the patient.

        In a complete muscle and connective tissue examination one must use your fingers, palms, thumbs, doohickeys and needles.
        What about inside the ALL the involved muscles???
        What about deep near the periosteum?
        What about behind the zygomatic arch or inside the mandible?
        What about the use of 4 inch needle to investigate the rotators of the hip?
        What about a 2” needle to examine ALL of the small rotators (dozens) of the ALL the vertebra?
        What about in in the occiput or axilla?

        If you do not examine all of the involved muscles with your hands or needles, your examination is incomplete and thus your assessment will be incomplete.

        Try being incomplete in a cancer case where the biopsy and or the post mortem proves you missed a cancer.

        NOT knowing, NOT doing, NOT helping, NOT trying, NOT thinking, NOT believing, NOT keeping up to date, NOT knowing your history, NOT being open minded, NOT trusting, NOT touching, NOT probing, NOT needling, NOT asking, NOT verifying, NOT confirming, NOT being flexible — in primary care medicine will do irreparable harm to your patients.

        For 15 yrs I had to practice without needles. Wow I surely did a lot of harm from my miseducation.

  41. Dr Rodrigues, nonsense remains nonsense, no matter how many times it is repeated. I was saddened but not surprised to learn that the Texas Commissioner of Worker’s Compensation was not swayed by your “dry needling” advocacy and has removed your right to provide health care services to injured workers: https://www.tdi.state.tx.us/wc/hcprovider/documents/corodrigues.pdf

    1. Thank you for bringing this up!! This is a snipet of what happened. The full version and more shocking version of the ignorance and dogma is in the TDI files.

      Someone who wanted to kill the messenger, me, found this on the web. They wanted to use something in an argument negating alternatives treatment options for pain by attacking me as a person.
      So here is a snapshot of what happened, 12/2014 in front of the Texas Department of Insurance, Division of Worker’s Compensation.
      This case centered around a poor lady who had to endure pain levels of 7 and may times up to 10! She suffered for more than 2 years. She suffered despite following Worker’s Compensation rules, regulation and standard of care options.
      The Texas WC Commision judged me out of bounds with my care of this lady who’s pain levels were dropping down to 6.
      I informed them that all I was using valid, vetted old school injection options as per with the Gunn-Travell Intramuscular Stimulation.
      I told them that she will need more therapy. Her case was one of the worse I had to manage. It was slow going due to the muscle sickness and the mental trauma that she had endured.
      They said, “You have no prove that what I was doing could help her.”
      I said, “why not call and talk to the her?”
      They said, “We do not talk to patients.”
      I said, “how can your discover the truth?” Crickets chirping.
      They said that my list of authors were not acceptable to them because books were using Science-Based Medicine.
      They said, “that my references were too old and not evidence based.”
      One of the specialist insinuated, “Janet G. Travell was a drug pusher from what he understood.” [Thus all of her work was invalid and my procedures were invalid too.]
      Here is my list of Masters of healing;
      Gunn, Travell & Simons’, Rachlin, Baldry, Seems, Helms, Starlanyl, Hackett, Cyriax, Craig, Gokavi, Lennard, Mann, Burke, DiFabio and Pybus, B.J./D.D. Palmer, Wyburn-Mason,and Chaitow.
      They ordered me to cease and desist treating all TXWC members!???

    2. Oh, yes this is called “killing the messenger” or “killing someone’s character” or “killing the credibility of the messenger” – all are the ways intellectual’s distract and betray valuable evidence and truth. Intellectual betrayers also want to use these tactics to distract from ALL of the evidence and ALL points of interest.

      I think it would helpful for many of you who are studying under Quinter tutelage to review their basic history of medicine, anatomy, biology, nomenclature, ethics, logic and human values. Then most importantly rethink medicine and what your are doing on your own.

  42. Dr Rodrigues, as I see it, the problem is not with the messenger, who no doubt faithfully delivered the message. The problem lies with the message itself, which was, in the opinion of the Texas Workers’ Compensation Commission, a false one. Undue reliance upon the opinions and speculations of past icons (“Masters of Healing”) did not advance your argument. On the other hand, Dr Dommerholt has indicated that “trigger point” research is still in its infancy. This opinion is arguable but if true offers no guarantee that the findings from such research will validate the current practice of inserting needles into “trigger points”.

    1. Dr. Master of Manipulation, Distraction, Diversion,

      Again you have betrayed the primary issues. What is pain? Where is pain? How best to remove each category of pain?

      1. Everyday aches, pains and stiffness has been and always will be in the muscle system.
      2. Everyday pain can not emanate from the skeleton, nervous, lymphatic or any other organ system.
      3. The best remedy to remove the pain that is the muscle system is with massage, stretching and ROM exercises.
      4. Any attempt to remove this pain in the operating room with a surgical blade is malpractice.
      5. Any attempt to place this pain in any other locations is disrespectful and malpractice.
      6. Any delay in the application of the corrective remedy is malpractice, disrespectful and a betrayal of the oaths that we have taken to do no harm.
      7. Any system wide acceptance and use of this falsity, breaking a natural law of biology, is racketeering.
      8. Any application of what you “think” that does irreparable harm is malpractice. IMO, many years in jail if it is the amputation of a body part like a natural joint.
      9. Any attempt to blame pain on a TrP is incomplete, disingenuous and intellectually dishonest. Punishable by any reasonable institution of knowledge and science grounded in integrity.

      1. Dr. Rodrigues,
        Can I assume, then, that you haven’t read the interviews with Kevin Ware after his injury?

        If by “everyday pain” you’re referring to pain that is mechanical in nature and therefore non-pathological, I’ll ask again: Why on earth would that need to be treated by a professional, in particular with needles? At what point, in your view, does “everyday pain” become a condition that requires treatment? Everyone who shows up in your clinic with an ache here or there- and red flags have been ruled out- has their muscles treated with needles, stretching, or some other intervention directed at the offending muscle?

        I just watched a very intriguing video by Dr. Kieran O’Sullivan (https://www.youtube.com/watch?v=DAKz10B9tXg&feature=player_embedded), who provided some compelling data on which patients fail to recover from I suppose what Dr. Rodrigues would refer to as “everyday pain”. It turns out that psychosocial factors, like confidence of recovery, and reports of pre-existing poor health status are the best predictors of persistent pain. So, unfit people with low self-efficacy don’t get well. I’ll tell you what, let’s stab them with needles and see what happens. Hey, look! people who are generally unfit and have low self-confidence say they feel better after some professional person in a white coat jabs their “dysfunctional muscle” with a needle! It’s amazing!!

        Please….stop.

        1. This is to dramatization of where the most common location of pain is located. Everyday pain as well as most ongoing pain syndromes can only be sourced in only 1 of the 10 organ systems: The Muscle System.

          If a person is experiencing everyday aches, pains and stiffness which come-n-go, wax-n-wane and sometimes will go away for months. Their pain moves around from lower spinal to mid thoracic areas with movements and will radiate into the gluts. It is true that they feel this pain in the brain. Just like the human body is designed to work. The brain is where awareness and consciousness is located.

          But by default the exact source or organ system this pain is located is in the muscles system. The source of muscle pain can never move into a nerve or the skeleton. That would be impossible by natural design.

          If this pain lingers longer that usually by nature we should apply remedy to restore the muscles back to a fully functional and peaceful state with: Hands-on tissue release. This remedy that must be applied externally to the muscles as in any hands-on therapies with manual labor. Massage. Balls, bars and doohickies. Joint Manipulations. Spinal Manipulations. Deep tissue manipulations. Cupping, scraping and brushing. Traction and inversion.

          The pain in muscles never leave the muscle system!! NEVER!! That is a law of nature.

          Do you know there are only 3 ways to remove the pain that is in muscles? as per Gunn-Travell-Hackett-Rachlin

          Extra muscular: 1) Hand-on options with manual labor and leverage.

          Intramuscular: 2) Thin slender filament (dry) needling 3) Tubulare and cutting hypodermic wet/dry/chemical needling.

  43. Did you ever wonder why joint and back surgeries fail?

    The skeleton can not produce pain primarily so you can not remove body parts to remove pain.

    So why do we as a scientific society put up with removing these natural organs like they are junk, worn out like a starter on a car, cancer or just throwaway?

    We can because we are easily tricked by cloaks and mirrors.

    I have stopped referring my patients for these barbaric procedures as I was told to do in the past. I have learned from my ignorance and errors.

    This is why I’m here attempting to change minds with what our predecessors had labored, learned and left for us to use.

  44. I just came up with a new term for trigger point dry needling that I think is more accurate, and I thought I would share it here. The new term is “motor point counter-injury” therapy. I’m basing this on the fact that it seems, according to the current research, that so-called “trigger points” are actually just symptomatic motor points, i.e. they are tender spots roughly over the motor point region of the muscle that reproduce the patient’s symptoms. The term “trigger point” is superfluous and, by all accounts, inaccurate. The term “dry needling” is euphemistic because it fails to accurately and specifically represent the intent of the intervention. Based on what I’ve read, disruption of both muscle and nerve tissue in the needled area is not only unavoidable, it is a necessary and desired effect of the “treatment”. All this nonsense we’re hearing about “intramuscular manual therapy”, and “trigger point dry needling” is just a bunch of useless and indecipherable babble. If you’re gonna do it, call it what it is and quit pussy-footing around.

    Now, all the motor point counter-injury proponents have to do is figure out why the outcomes from this intervention have the same marginal effects on pain and disability that jabbing needles into non-motor points achieve. Good luck with that.

  45. Pingback: Poking Holes in the Evidence for Acupuncture | Physiological

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