Do we need to stick everyone?

Dry needling (DN) is a manual therapy technique that is increasingly being incorporated by a variety of medical practitioners. Physical therapists, chiropractors, and physicians utilize this intervention for a variety of reasons. It has been suggested that DN produces local and central nervous system (CNS) responses that result in the reduction of both peripheral and central sensitization to pain (Gattie et al., 2017). There are benefits: it is relatively cheap and it is a quick intervention that requires little time. Many patients swear by it, reporting instant pain relief 1-2 days following the treatment session. The drawbacks? Some mild adverse effects include pain and bleeding. Other effects can be life threatening, such as pneumothorax and nerve injury (Brady et al., 2014). While it is well within the scope of practice for a physical therapist to practice DN, I firmly believe that it is being used too often. As a matter of fact, it seems as though many PT’s are using it for every single patient who walks into the clinic. Not only is it being used for every patient, but it is considered their first option treatment. Their “go to” move. Before exercise, physical activity and other manual therapy techniques (joint mobilization, joint manipulation, soft tissue mobilization, etc.).

Kietyrs et al. (2013) performed a systematic review and meta-analysis of the effectiveness of DN for upper quadrant myofascial pain. There was high heterogeneity with all the studies being compared. VAS was the primary outcome measure (self-reported disability, range of motion (ROM), pain pressure threshold (PPT) were not assessed). These were some of the major takeaway points:

1. DN compared to sham or control treatments: the authors concluded that more high-quality randomized controlled trials (RCT) were needed to further elucidate the effects of DN compared to sham or placebo on pain at 4 weeks.

2. DN compared to other treatments at approximately 4 weeks: in 6 studies, DN was not superior, in general, to the other treatments studied to reduce pain at 4 weeks. The authors noted the overall small effect size, expressing caution to the readers because of high heterogeneity with the subjects.

3. Some studies combined interventions, which may have influenced the results regarding the relative contribution of DN (ex. stretching exercises). That makes it even harder to extrapolate the true effects of DN for pain reduction.

4. Their conclusion was as follows: based on 3 RCT’s, the intervention was cautiously recommended—the overall effect of the 3 studies combined were ambiguous due to a large CI of the otherwise strong effect size.

If that study does not convince you, here is another one: Gattie et al. (2017) performed a systematic review and meta-analysis of dry needling for musculoskeletal conditions. The major points were as follows:

1. Very low-quality to moderate quality evidence suggested that DN was more effective than no treatment, sham DN, and other treatments for the reduction of pain and increasing pain pressure threshold (PPT) in the immediate to 12-week follow up period.

2. Low-quality evidence suggested superior outcomes with dry needling for functional outcomes when compared to sham or no treatment. No differences existed with functional outcomes when compared to other PT treatments.

I do not like it when therapists advertise DN benefits beyond what is stated in the literature. It has been my experience that therapists are quick to address some orthopedic surgeries that do not have significant evidence to support its use (myself included). However, that does not seem to be the case with DN. I am not against the use of DN: I use it myself and I have found success with the treatment. The neurophysiological effects of DN are likely similar to techniques such as joint manipulation (Bialosky, 2017). To further enhance manual therapy benefits, Bialosky (2010) discussed how we can influence treatment effects if we can shape their expectations. If patients have a strong belief that positive gains are to be made, analgesic effects may be further enhanced. In a sense, placebo analgesia is likely one of many mechanisms that results in pain reduction and improved clinical outcomes (Bialosky, 2017) . If that is the case, why do we use more invasive interventions to carry out the placebo effect?

There is a classic saying within the field of medicine: primum non nocere. That is, do no harm. If we recommend that patients trial conservative management prior to surgery, why do we immediately incorporate invasive techniques like DN before using less invasive interventions (joint mobilization, joint manipulation, instrument augmented soft tissue mobilization (ASTYM))? The naysayers may express that these two interventions are apples and oranges. Regardless, they are both inherently invasive, and invasive procedures have side effects that non-invasive techniques do not have (some being life-threatening, depending on the area of insertion (Brady et al., 2014).

We all know that best practice involves three dimensions: evidence-based research, patient preferences, and clinical experience. Before we stick anyone that moves, it is important to take into account the patient’s medical history and the previous treatments that have been used in the past. If passive modalities and treatments failed previously, it is well within the realm of possibility that DN (which is also passive) may be ineffective. However, if pain is limiting a patient from performing an activity, is it possible that DN may allow the patient to perform the exercise? Maybe. The point of the previous studies is that many other comparable treatments were equally effective. Why not try non-invasive manual therapy techniques first? At this point in time, there seems to be a larger body of evidence that supports other classic interventions that are less invasive. Consequently, it is imperative that our treatments are specifically tailored to the patient.

Resources:

Bialosky, J.E., Bishop, M.D., & Penza, C.W. (2017). Placebo mechanisms of manual therapy: a sheep in wolf’s clothing? Journal of Orthopedic and Sports Physical Therapy, 47(5), 301-304.

Brady, S., McEvoy, J., Dommerholt, J. & Doody, C. (2014). Adverse events following trigger point dry needling: a prospective survey of chartered physiotherapists. Journal of Manual and Manipulative Therapy, 22(3), 134-140.

Gattie, E., Cleland, J.A., & Snodgrass, S. (2017). The effectiveness of trigger point dry needling for musculoskeletal conditions by physical therapists: a systematic review and meta-analysis. Journal of Orthopaedic and Sports Physical Therapy, 47(3), 133-150.

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