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620 | september 2013 | volume 43 | number 9 | journal of orthopaedic & sports physical therapy
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research report
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Myofascial pain syndrome
(MPS) is a common
condition associated
with myofas cial trigger
points (MTrPs).27 MTrPs are a
common source of pain in patients pre-
senting to primary care or pain clin-
ics.13,25,37 MTrPs are localized areas of taut,
band-like hardness in muscle that typi-
cally contain hyperalgesic zones.19,32,36,42
MTrPs may develop anywhere in the
body in response to sudden injury, muscle
overload, or repetitive microtrauma.36,42
Chronic upper-quarter pain, tension-type
headaches, and orofacial pain have all
been commonly associated with MPS.25
Poor posture, as well as certain physi-
cal and social conditions, can activate
MTrPs.44
When compressed, MTrPs can cause
local and/or referred tenderness and
pain, aggravation of existing pain, mo-
tor dysfunction, and/or autonomic phe-
STUDY DESIGN: Systematic review and meta-
analysis.
BACKGROUND: Myofascial pain syndrome
(MPS) is associated with hyperalgesic zones in
muscle called myofascial trigger points. When pal-
pated, active myofascial trigger points cause local
or referred symptoms, including pain. Dry needling
involves inserting an acupuncture-like needle into
a myofascial trigger point, with the goal of reducing
pain and restoring range of motion.
OBJECTIVE: To explore the evidence regarding
the eectiveness of dry needling to reduce pain in
patients with MPS of the upper quarter.
METHODS: An electronic literature search
was performed using the key word dry needling.
Articles identified with the search were screened
for the following inclusion criteria: human subjects,
randomized controlled trial (RCT), dry needling
intervention group, and MPS involving the upper
quarter. The RCTs that met these criteria were
assessed and scored for internal validity using
the MacDermid Quality Checklist. Four separate
meta-analyses were performed: (1) dry needling
compared to sham or control immediately after
treatment, (2) dry needling compared to sham or
control at 4 weeks, (3) dry needling compared to
other treatments immediately after treatment, and
(4) dry needling compared to other treatments at
4 weeks.
RESULTS: The initial search yielded 246
articles. Twelve RCTs were ultimately selected.
The methodological quality scores ranged from
23 to 40 points, with a mean of 34 points (scale
range, 0-48; best possible score, 48). The findings
of 3 studies that compared dry needling to sham
or placebo treatment provided evidence that
dry needling can immediately decrease pain in
patients with upper-quarter MPS, with an overall
eect favoring dry needling. The findings of 2 stud-
ies that compared dry needling to sham or placebo
treatment provided evidence that dry needling can
decrease pain after 4 weeks in patients with upper-
quarter MPS, although a wide confidence interval
for the overall eect limits the impact of the eect.
Findings of studies that compared dry needling
to other treatments were highly heterogeneous,
most likely due to variance in the comparison
treatments. There was evidence from 2 studies
that lidocaine injection may be more eective in
reducing pain than dry needling at 4 weeks.
CONCLUSION: Based on the best current
available evidence (grade A), we recommend dry
needling, compared to sham or placebo, for de-
creasing pain immediately after treatment and at 4
weeks in patients with upper-quarter MPS. Due to
the small number of high-quality RCTs published to
date, additional well-designed studies are needed
to support this recommendation.
LEVEL OF EVIDENCE: Therapy, level 1a–.
J Orthop Sports Phys Ther 2013;43(9):620-634.
Epub 11 June 2013. doi:10.2519/jospt.2013.4668
KEY WORDS: dry needling, myofascial pain
syndrome, randomized controlled trial
1School of Health Related Professions, Rutgers, The State University of New Jersey, Stratford, NJ. 2Institute of Physical Therapy Education, Widener University, Chester, PA.
3NovaCare Rehabilitation, Philadelphia, PA. 4NovaCare Rehabilitation, Sewell, NJ. 5Comber Physical Therapy, Williamsburg, VA. 6SportsCare of America, Bridgewater, NJ. The
authors certify that they have no aliations with or financial involvement in any organization or entity with a direct financial interest in the subject matter or materials discussed
in the article. Address correspondence to Dr David Kietrys, 40 East Laurel Road, UEC Suite 2105, Stratford, NJ 08084. E-mail: kietrydm@shrp.rutgers.edu Copyright ©2013
Journal of Orthopaedic & Sports Physical Therapy®
DAVID M. KIETRYS, PT, PhD, OCS1 • KERSTIN M. PALOMBARO, PT, PhD, CAPS2 • ERICA AZZARETTO, PT, DPT3
RICHARD HUBLER, PT, DPT4 • BRET SCHALLER, PT, DPT5 • J. MATHEW SCHLUSSEL, DPT • MARY TUCKER, PT, DPT6
Eectiveness of Dry Needling
for Upper-Quarter Myofascial Pain:
A Systematic Review and Meta-analysis
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journal of orthopaedic & sports physical therapy | volume 43 | number 9 | september 2013 | 621
nomena.8,19,36,41 MTrPs can contribute to
impaired range of motion and increased
sensitivity to stretch.13,16,18,33,36,42 Active
MTrPs can cause spontaneous pain,
whereas latent MTrPs elicit symptoms
when compressed.13,16,18,20,33,36,42 Palpat-
ing an MTrP or inserting a needle into
an MTrP may elicit a localized twitch
response, defined as a brisk contrac-
tion of muscle fibers in or around the
MTrP.13,16,18, 33,36,42 Localized twitch re-
sponses are more easily elicited when
sensitive loci within an MTrP are identi-
fied and targeted.16-19
Dry Needling
Trigger-point dry needling is a procedure
in which an acupuncture-like needle is
inserted into the skin and muscle in the
location of an MTrP.11 Needles are re-
moved once the trigger point is inactivat-
ed. Dry needling is typically followed by
stretching exercises.14 The actual mecha-
nism of eect of dry needling is still being
debated. The localized twitch response
that often occurs may interrupt motor
end-plate noise, eliciting an analgesic
eect.10 Eliciting a localized twitch re-
sponse and stretching exercises relax the
actin-myosin bonds in the tight bands.4
Some studies have suggested that pain re-
lief and range-of-motion restoration are
greater when a localized twitch response
is elicited during dry needling.16,18,19 It
has been suggested that the gate control
theory of pain may play a role.14 Dry nee-
dling causes stimulation of alpha-delta
nerve fibers, thus activating the enkepha-
linergic inhibitory dorsal horn interneu-
rons and causing opioid-mediated pain
suppression.2 Dry needling may correct
levels of several chemicals in the aected
muscles, including bradykinin, calcito-
nin gene-related peptide, and substance
P.10 Needling of MTrPs is also theorized
to disrupt reverberatory central nervous
system circuits.30
A previously published systematic
review of 7 studies of acupuncture/dry
needling for the management of MTrPs
in various body regions (including the
upper quarter, low back, and lower ex-
tremity) found limited evidence in 1 study
that dry needling had an overall eect
compared to standardized care.41 Meta-
analysis of 4 studies comparing dry nee-
dling to a sham (placebo) treatment did
not show statistical significance between
interventions but noted that, overall, the
results suggested a positive treatment ef-
fect of dry needling for MTrP pain.
The purpose of this systematic review
and meta-analysis was to determine the
immediate and longer-term eectiveness
in pain reduction of dry needling, specifi-
cally in patients with upper-quarter MPS,
and to make a recommendation for clini-
cal practice based on the best available
evidence.
METHODS
The studies included in this sys-
tematic review and meta-analysis
had human subjects, were random-
ized controlled trials (had a control or
comparison group), had a dry-needling
intervention group, included partici-
pants with upper-quarter myofascial
symptoms, and were in the English lan-
guage. An electronic search of the term
dry needling was performed on the fol-
lowing databases: OvidSP MEDLINE
(1946-2012), HealthSTAR, and PubMed.
Search results are illustrated in FIGURE 1.
After removal of duplicates, articles that
were not randomized controlled trials
were excluded. Next, articles that did
not involve subjects with upper-quarter
myofascial pain and articles that did not
include dry needling as an intervention
group were excluded.
Our initial search produced a sys-
tematic review and meta-analysis re-
garding dry needling and acupuncture
in the management of MTrP pain.41 A
hand search of that review produced 2
articles that met our inclusion criteria
that were not previously identified with
our electronic search. All other key refer-
ences,1,4,9,15,17,20-23,26,43 as well as 1 other sys-
tematic review8 on the topic, were hand
searched but did not yield any additional
articles. One article39 published online
(ahead of print) in November 2012 was
added to the review.
Retained articles were scored inde-
pendently for internal validity using the
evaluation guidelines for rating the qual-
ity of an intervention study (the Mac-
Total articles found, n = 246
• Medline (1946-July 2012), n = 81
• PubMed (1946-July 2012), n = 93
• Healthstar (1975-July 2012), n = 71
Keyword: dry needling
Total articles
excluded, n = 82
• Not a RCT, n = 66
• Of remaining, not
related to UQ
MPS, n = 11
• Of remaining, did
not include DN as
an intervention
group, n = 5
Articles remaining after duplicates
removed, n = 91
Retained for literature review, n = 12
Total articles added after hand
searching, n = 2
Recent article published online
(ahead of print), n = 1
FIGURE 1. Flow diagram of search strategy and results. Abbreviations: DN, dry needling; MPS, myofascial pain
syndrome; RCT, randomized controlled trial; UQ, upper quarter.
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Dermid Quality Checklist).28 This tool
assesses 7 domains of internal validity
(study question, study design, subjects,
intervention, outcome, analysis, and
recommendations) and has been used
in other published reviews.3,24 The Mac-
Dermid Quality Checklist consists of 24
items, each scored from 0 to 2, with a
highest possible score of 48 points.28 In
this review, each article was scored by at
least 3 dierent evaluators. Any dier-
ences in scores or ratings were discussed
by the reviewers until they reached a con-
sensus score. If the reviewers could not
reach a consensus score to within 1 point,
an additional reviewer was used to adju-
dicate the score. If a consensus could still
not be reached, the lower score was as-
signed. In addition, the studies reviewed
were assigned a level-of-evidence rating
as described by Sackett et al.34 All authors
(except K.M.P.) participated in extraction
of relevant data related to MacDermid
Quality Checklist scoring.
Two of the authors (D.M.K. and
K.M.P.) worked as a team to extract
relevant data related to meta-analyses.
Meta-analyses were performed with
MetaAnalyst Version Beta 3.13 (Tufts
Medical Center, Boston, MA), with a
continuous-variable random-effects
model. Four separate meta-analyses were
performed, with pain on a visual analog
scale (VAS) as the outcome measure: (1)
dry needling compared to sham or con-
trol, immediate eects; (2) dry needling
compared to sham or control at 4 weeks;
(3) dry needling compared to other treat-
ments, immediate eects; and (4) dry
needling compared to other treatments
at approximately 4 weeks. All studies that
compared dry needling to other treat-
ments provided data at 4 weeks, with the
exception of the study by DiLorenzo et
al,9 which measured outcomes at 21 days.
These data were used in the comparisons
at approximately 4 weeks. Outcomes at
times other than immediately after and
approximately 4 weeks after treatment
were not considered in this review, due
to variability across studies in other
times to outcomes. The VAS pain scores
reported by Itoh et al23 were measured on
a 100-point scale (mm), and were con-
verted to a 10-point scale (cm) before
entering the data for the meta-analysis.
The data from Chu4 were not reported
such that they could be included in the
meta-analysis, thus the study was exclud-
ed from meta-analysis. In the meta-anal-
ysis of dry needling compared to other
treatments (immediate eects), 2 dier-
ent data sets from the study by Hong17
were entered separately, because the data
were not reported such that they could be
combined. In a meta-analysis, Kamanli et
al26 and Itoh et al23 both assessed the ef-
fects of dry needling in comparison to 2
dierent treatments at 4 weeks. The data
for each of these other treatments were
entered separately; therefore, these 2
studies are each represented twice in the
meta-analysis of dry needling compared
to other treatments at approximately 4
weeks.
We used 2 points on a 0-to-10 VAS
as a conservative cuto value for clini-
cal meaningfulness of change in pain for
between-group comparisons. Various
studies have reported a range of minimal
clinically important dierence values for
numeric or visual analog pain scales for
patients with upper-quarter pathologies,
including 1 point for patients with chron-
ic musculoskeletal pain,35 1.3 points for
neck pain,5 1.7 points for chronic pain,12
2.17 points for shoulder pain,31 and 3.0
points for patients with neck/upper ex-
tremity/lower extremity pain.38
RESULTS
Twelve studies that met our in-
clusion criteria1,4,9,15,17,20-23,26,39,43 are
listed in chronological order in
TABLES 1 through 6. Inclusion and exclu-
sion criteria for participants in the re-
viewed studies are described in TABLE 1.
In all studies, subjects had symptoms at-
tributed to upper-quarter MPS, typically
involving the neck or shoulder region.
Etiology of pain was not consistent across
studies. For example, DiLorenzo et al9
included subjects with shoulder pain fol-
lowing cerebrovascular accident, where-
as other studies included chronic neck,
shoulder, or trapezius myofascial pain,
often of ambiguous origin.1,4,15,17,20-23,26,39,43
Exclusion criteria varied across studies
but generally included alternative mus-
culoskeletal diagnoses and contraindica-
tions for needling.
TABLE 2 presents the participants’ age
range and duration of symptoms where
these data were provided by the authors.
In general, participants were adults, and
in 4 studies9,15,20,23 they were primarily
adults over 60 years of age. Duration of
symptoms varied among studies; par-
ticipants in 8 of the studies had chronic
symptoms ranging from 3 months23 to
63 months39 in duration. One study9
included participants whose shoulder
symptoms started following a stroke. The
study by Ilbuldu et al21 included only fe-
male participants, whereas all other stud-
ies appear to have included individuals of
both genders.
Intervention groups (independent
variables), outcome measurements (de-
pendent variables), and times to out-
comes are summarized in TABLE 3. Six of
the studies used a true control (placebo
or sham) group.4,21-23,39,43 One study used
the contralateral side of the participants
as the control.20 Eight studies utilized
a variety of comparison groups (groups
that received interventions other than dry
needling to MTrPs). Comparison groups
included lidocaine injection,1,17,26 botuli-
num toxin injection,26 laser,21 nonlocalized
acupuncture,22,23 and standard rehabilita-
tion (external support, positioning, exer-
cise) for hemiparetic shoulder pain.9 The
comparison group in the study by Ga et
al15 received a treatment (intramuscular
stimulation) that, technically, is a dry-
needling technique, with subtle dier-
ences in technique between the authors’
operational definitions of dry needling
and intramuscular stimulation. Times to
outcomes ranged from immediate4,17,20,22,43
to 6 months,21 with 4 studies17,20,22,43 re-
porting only immediate eects.
TABLE 4 describes the key findings,
MacDermid Quality Checklist scores, and
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level-of-evidence ratings. Scores for each
of the 24 items on the MacDermid Qual-
ity Checklist are provided in TABLE 5. The
criteria and description of the scoring
system for this tool have been previously
published.3 Levels of evidence34 ranged
from 2b4 to 1b.1,9,15,17,20-23,26,39,43 Internal va-
lidity scores (MacDermid Quality Check-
list) ranged from 234 to 40,39 with a mean
of 34. The articles with the strongest in-
ternal validity, as evidenced by relatively
higher scores on the MacDermid Quality
Checklist, were those by Tekin et al,39 Ga
et al,15 and Irnich et al.22 The studies with
the weakest internal validity were those
TABLE 1 Inclusion and Exclusion Criteria by Study
Study Inclusion Criteria Exclusion Criteria
Hong17 • MPS (tender spots in palpable taut bands, typical pattern of referred
pain, LTR with snapping palpation of MTrP, restricted ROM of CS for
lateral bending to opposite side)
• At least 1 active MTrP in upper trapezius
• MTrP injection in prior 6 mo
• CS or shoulder surgery in prior year
• Narcotic medication in prior month
• Fibromyalgia
• CS radiculopathy or myelopathy
• Severe disc or skeletal lesion
• Hyperesthesia in shoulder or CS
• Cognitive deficit
• Inadequate cooperation
Chu4• Neck or UE pain
• Referred for electrodiagnostic studies
• Evidence of peripheral neuropathy (via nerve conduction study)
Irnich et al22 • Chronic pain of greater than 2 mo in duration
• Limited ROM in CS
• Diagnosis of cervical MPS (pain and limited ROM associated with
MTrPs) or “irritation syndrome” (diuse intense pain and irritated
soft tissues with prolonged aggravation after motion and pressure)
• CS radicular syndrome, segmental instability, fracture, or surgery
• Contraindications to acupuncture
• Drug treatment, physical therapy, or manual treatment in prior 4 wk
Ilbuldu et al21 • MTrP in upper trapezius
• Diagnosis of MPS (local pain, pain and sensory changes referred
from MTrP, palpable taut band, extreme sensitivity in 1 point in band,
limited ROM)
• Tumor
• Infectious disease
• Stage 3 or 4 osteoarthritis
• Pregnancy
• Scoliosis
• Bleeding diathesis
• Chronic obstructive lung disease
DiLorenzo et al9• Patients 4 to 8 wk post-CVA who had undergone at least 3 wk of
physical therapy
• Shoulder pain (at least 6/10 on VAS) on aected side
• Pain due to CVA aecting spinothalamic pathways in brain stem with sensory deficit
• Primary depression
• Hemiparesis due to neurosurgical procedure
• Cerebral tumor
• Head injury
• Congenital cerebral palsy
• Worsening or pre-existing internal derangement of shoulder ligaments or tendons
• Adhesive capsulitis
• Peripheral neuropathy
• Complex regional pain syndrome
• Shoulder fractures
• Neglect syndrome
• Decline participation
Kamanli et al26 • At least 1 MTrP on CS, back, or shoulder muscles with disease of at
least 6 mo in duration
• Treatment in prior 8 wk
• MTrP injection within prior 2 mo
• Cardiovascular or respiratory disease
• Allergies
• CS or shoulder surgery in prior year
• Fibromyalgia
• CS radiculopathy or myelopathy with severe disc or skeletal lesions
• Uncooperative
• Use of medications that prevent neuromuscular transmission
• Motor neuron or neuromuscular junction disease
• Pregnancy
Table continues on page 624.
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by Hsieh et al,20 Chu,4 and Hong.17 As in-
dicated in TABLE 4, all studies reported sig-
nificant decreases in pain in the groups
receiving dry needling. In many cases,
comparison groups also realized an im-
provement in pain.
Meta-analysis: Dry Needling Compared
to Sham or Control, Immediate Eects
Four studies compared dry needling to
sham or control and assessed immedi-
ate eects on pain (FIGURE 3).20,22,39,43 The
overall eect size (standardized mean dif-
ference) of 1.06 (95% confidence interval
[CI]: 0.05, 2.06) suggests a large eect7
favoring dry needling over sham or con-
trol. Heterogeneity was high (I2 = 86.3%).
Three of the 4 studies entered into this
meta-analysis favored dry needling.
The study with the largest treatment
eect20 used the same subject’s unin-
volved side as the control, and reported a
raw between-group eect size of 4.0 VAS
points, which is clinically meaningful.
The other 2 studies that favored dry nee-
dling39,43 had large treatment eects (0.88
and 0.75, respectively), but their raw be-
tween-group eect sizes (1.4 and 1.2 VAS
points, respectively) were of questionable
clinical meaningfulness.
TABLE 1 Inclusion and Exclusion Criteria by Study (continued)
Abbreviations: CS, cervical spine; CVA, cerebrovascular accident; DN, dry needling; LTR, localized twitch response; MPS, myofascial pain syndrome; MTrP,
myofascial trigger point; ROM, range of motion; UE, upper extremity; VAS, visual analog scale.
Study Inclusion Criteria Exclusion Criteria
Ga et al15 • Chronic MPS of upper trapezius based on physical examination and
interview
• MTrP injection, intramuscular stimulation, or DN in prior 6 mo
• CS or shoulder surgery in prior year
• Narcotic medication in prior month
• Fibromyalgia
• CS radiculopathy or myelopathy
• Severe cardiovascular or respiratory disease
• Cognitive deficit
• Diculty with communication
• Inadequate cooperation
Hsieh et al20 • Bilateral shoulder pain with active MTrPs in the infraspinatus
• No significant dierences in clinical presentation between 2 sides
• Treatment other than oral medication in past 3 mo
• Contraindication for DN, such as local infection, serious medical problems, recent
multiple trauma, or pregnancy with threatened abortion
• Condition that might interfere with pain/pain threshold assessment
• CS or UE surgery
Itoh et al23 • Neck pain for 6 mo or longer with no radiation
• Normal CS nerve function
• Aged 45 y and older
• Major trauma or systemic disease
• Other conflicting or ongoing treatments, except medication with uniform dosage for 1 mo
or longer
Ay et al1• Clinical diagnosis of MPS (regional pain, taut band[s], referred trig-
ger point pain and sensory change, extreme sensitivity in taut band,
decreased ROM)
• At least 1 active trigger point in upper trapezius
• Symptom duration for at least 1 mo
• Fibromyalgia
• Systemic disease
• Cervical disc lesion
• History of MTrP injection
• Physical treatment in past 6 mo
• Pregnancy
• Neck or shoulder surgery
• Drug allergies
• Abnormal lab results
Tsai et al43 • Unilateral shoulder pain caused by digital compression of MTrP
in the upper trapezius (MTrP diagnosed as tenderness and pain
reproduction with palpation of a tight band)
• Contraindication for DN, such as local infection or trauma
• Anticoagulant medication
• Pregnancy with threatened abortion
• Problem that might interfere with pain/pain threshold assessment
• Cognitive deficit
• Needling treatment in past
Tekin et al39 • MPS (local spontaneous pain, referred pain or sensory changes
from MTrP, palpable taut band, localized tenderness, reduced ROM)
• At least 1 active MTrP
• Symptom duration at least 6 mo
• Physical therapy or local injection within prior 3 mo
• Fibromyalgia
• Pregnancy
• Cervical nerve root irritation
• Abnormal lab results
• Thoracic outlet syndrome
• Upper-limb entrapment syndromes
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Meta-analysis: Dry Needling Compared
to Sham or Control at 4 Weeks
Three studies compared the eects of
dry needling to sham or control on pain
at 4 weeks (FIGURE 4).21,23,39 The overall ef-
fect size (standardized mean dierence)
of 1.07 (95% CI: –0.21, 2.35) suggests a
large eect favoring dry needling over
sham treatment or control; however, the
95% CI crosses the line of no dierence,
suggesting that caution should be used
when making conclusions based on over-
all eect size. Heterogeneity was high (I2
= 84.2%). Two of the 3 studies23,39 in this
meta-analysis favored dry needling over
the sham or control at 4 weeks, and both
had large eect sizes (1.95 and 1.55, re-
spectively). Both had raw between-group
eect sizes at 4 weeks that were clinically
meaningful (3.6 and 3.1 VAS points, re-
spectively). The most recent study39 had
the highest internal validity score of any
study in this review.
Meta-analysis: Dry Needling Compared
to Other Treatments, Immediate Eects
Two studies compared dry needling to
other treatments and assessed immediate
eects on pain (FIGURE 5).17,22 Hong17 used
lidocaine injection (with or without local-
ized twitch response), whereas Irnich et
al22 used nonlocalized acupuncture as the
other treatment. Hong17 reported results
separately for subjects who had a local-
ized twitch response and those who did
not, and these data were entered sepa-
rately into the meta-analysis because
the results could not be combined. The
overall eect size (standardized mean dif-
ference) of –0.64 (95% CI: –1.21, –0.06)
suggests a moderate eect7 favoring other
treatment over dry needling. Hetero-
geneity was high (I2 = 90%). Although
both studies entered into this meta-anal-
ysis favored other treatment, the raw be-
tween-group eect sizes (0.58-1.69 VAS
points for Hong17 and 1.01 VAS points for
Irnich et al22) were of questionable clini-
cal meaningfulness.
Meta-analysis: Dry Needling Compared
to Other Treatments at Approximately
4 Weeks
Six studies compared the eects of dry
needling to other forms of treatment on
pain at 4 weeks (FIGURE 6).1,9,15,21,23,26 Two
of the studies included 2 other treat-
ment groups, and the results from each
of these treatments were entered sepa-
rately into the meta-analysis, such that
8 data sets were entered. The overall ef-
fect size (standardized mean dierence)
of –0.07 (95% CI: –1.39, 1.26) suggests a
small overall eect favoring other treat-
ment, with the 95% CI crossing the line
of no dierence. Heterogeneity was high
(I2 = 95%). Two of the studies9,23 entered
into this meta-analysis favored dry nee-
dling over other treatment at 4 weeks,
and both had large7 eect sizes (2.26
TABLE 2 Participant Characteristics by Study
*Values are mean SD where those data were provided by the authors.
†Reported age and duration of symptoms based on occurrence of a localized twitch response; the sub-
group that experienced a localized twitch response is listed first.
‡Dry-needling group.
§Comparison group(s).
║Reported age and duration of symptoms based on pain relief outcome; subgroup experiencing pain
relief listed first.
¶Control (placebo or sham) group.
Study Sample Size, n Age, y* Duration of Symptoms*
Hong17† 58 41.7 14.4‡7.6 4.7 mo‡
42.1 10.2‡9.1 4.2 mo‡
42.2 12.2§10.2 5.6 mo§
39.9 9.6§11.7 6.7 mo§
Chu4║164 44.2 14.0‡10.9 12.2 mo‡
40.1 11.5‡13.9 17.6 mo‡
40.5 13.7¶11.3 13.3 mo¶
40.9 12.8¶17.1 20.4 mo¶
Irnich et al22 36 51.9 36.7 mo
Ilbuldu et al21 60 35.3 9.2‡38.5 31.9 mo‡
33.9 10.4§32.9 28.6 mo§
32.3 6.9¶36.5 33.6 mo¶
DiLorenzo et al9101 69.6 6.2‡3.53 wk
67.4 9.1§
Kamanli et al26 29 37.2 8.1‡32.5 22.0 mo‡
37.3 9.8§49.2 35.0 mo§
38.3 5.3§50.7 19.9 mo§
Ga et al15 40 79.2 6.8‡…
76.3 8.6§…
Hsieh et al20 14 60.2 13.2 …
Itoh et al23 40 62.3 10.1‡2.9 2.7 y‡
62.3 11.0§3.2 3.1 y§
65.0 10.5§3.3 3.9 y§
65.0 10.5¶2.3 1.5 y¶
Ay et al180 38.1 9.8‡34.3 40.9 mo‡
37.2 10.1§30.6 37.2 mo§
Tsai et al43 35 46.4 12.2‡7.5 3.9 mo‡
41.5 10.4¶6.8 4.5 mo¶
Tekin et al39 39 42.9 10.9‡63.5 50.7 mo‡
42.0 12.0§57.9 48.3 mo§
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TABLE 3 Summary of Intervention Groups and Outcome Measures by Study*
Abbreviations: CS, cervical spine; DN, dry needling; IMS, intramuscular stimulation; MTrP, myofascial trigger point; ROM, range of motion; SF-36, Medical
Outcomes Study 36-Item Short-Form Health Survey; VAS, visual analog scale.
*Unless otherwise noted, DN and injections were performed at MTrP sites and were done at 1 session.
Study Intervention Group Outcome Measure Time to Outcomes
Hong17 • DN
• Lidocaine injection
• Both groups received spray and stretch technique and
“home program”
• Pain (0-10 numeric pain rating scale)
• Pressure pain threshold (algometry)
• CS ROM (lateral bending) (goniometry)
Immediate
Chu4• DN
• Control: DN to random points
• Pain (VAS)
• Pain relief duration
• Number of MTrPs
• CS ROM (goniometry and tape measure)
• Shoulder ROM (goniometry)
Immediate, 2 wk
Irnich et al22 • DN
• Acupuncture (nonlocalized; needles inserted at distant
points)
• Sham laser acupuncture
• Pain with motion (VAS)
• CS ROM (custom device)
• Change of general complaints (–5 to +5 scale)
Immediate (15-30 min)
Ilbuldu et al21 • DN (once per wk for 4 wk)
• Laser (12 times over 4 wk)
• Sham laser (12 times over 4 wk)
• All groups did stretching exercises
• Pain (VAS) (at rest and with activity)
• Pressure pain threshold and pain tolerance (algometry)
• Analgesic use
• CS ROM (goniometry)
• Nottingham Health Profile
1 mo, 6 mo
DiLorenzo et al9• DN (4 times, every 5-7 d)
• Rehabilitation (external support, positioning, exercise)
• Pain (VAS)
• Rivermead Mobility Index
9, 15, and 21 d
Kamanli et al26 • DN
• Lidocaine injection
• Botulinum toxin injection
• Pain score (0-3 numeric pain rating on palpation)
• Pressure pain threshold (algometry)
• Pain (VAS)
• Fatigue (VAS)
• Work disability (VAS)
• CS ROM (goniometry)
• Nottingham Health Profile
• Hamilton Anxiety Scale and Hamilton Depression Inventory
1 mo
Ga et al15 • DN
• IMS (modified DN technique) of MTrPs and C3-5 multifidi
• Both groups treated once per wk over 3 wk
• Pain (VAS; Wong-Baker FACES scale)
• Pressure pain threshold (pain rating on palpation)
• Geriatric Depression Scale (short form)
• CS ROM (goniometry)
Prior to treatment on 4 dates over
4 wk, Geriatric Depression
Scale (short form) at wk 0
and wk 4
Hsieh et al20 • DN
• Control: contralateral side of same subjects
• Shoulder internal rotation ROM (goniometry)
• Pain (VAS)
• Pressure pain threshold (algometry)
Immediate
Itoh et al23 • DN
• DN on nontender points
• Traditional acupuncture
• Sham acupuncture
• All groups treated 6 times over 7 wk
• Pain (VAS)
• Neck Disability Index
Weekly over 12 wk
Ay et al1• DN
• Lidocaine injection
• Both groups did stretching exercises
• Pain (VAS)
• CS ROM (goniometry)
• Beck Depression Inventory
4 wk, 12 wk
Tsai et al43 • DN (of extensor carpi radialis MTrP)
• Sham needling
• Pain (0-10 numeric scale)
• Pressure pain threshold (algometry)
• CS ROM (goniometry)
Immediate
Tekin et al39 • DN
• Sham needling
• Pain (VAS)
• Quality of life (SF-36)
After first session (immediate),
4 wk
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TABLE 4 Summary of Key Findings, Quality Scores, and Level of Evidence by Study
Abbreviations: CS, cervical spine; DN, dry needling (directed to MTrP); IMS, intramuscular stimulation; LTR, localized twitch response; MTrP, myofascial
trigger point; NDI, Neck Disability Index; QoL, quality of life (measured with Turkish version of Medical Outcomes Study 36-Item Short-Form Health Sur-
vey); ROM, range of motion.
*MacDermid Quality Checklist score (range, 0-48), with higher scores reflecting greater internal validity.28 Level-of-evidence ratings were assigned as described
by Sackett et al.34
Study Key Findings Quality/Level of Evidence*
Hong17 • Decreased pain immediately and at 2 wk in both groups (when an LTR was elicited), and immediately in lidocaine injection group even
if no LTR was elicited (P<.05). Between groups, greater decrease in pain in lidocaine injection group at 2 wk (P<.05)
• Improved pressure pain threshold immediately and at 2 wk in both groups (when an LTR was elicited) (P<.05)
• Improved CS ROM immediately and at 2 wk in lidocaine injection group (when an LTR was elicited) and in DN group immediately
(when an LTR was elicited) (P<.05)
30/1b
Chu4• Greater percentage of subjects with pain relief in DN group compared to control (treatment of distal-site DN) group (P<.0001)
• Decreased number of tender MTrPs in DN group compared to control (treatment of distal-site DN) group immediately after treatment
23/2b
Irnich et al22 • Decreased pain in nonlocalized acupuncture group (P<.001)
• Improved CS ROM in DN group (P<.05) and nonlocalized acupuncture group (P<.05)
• Improvement in rating of general complaints in nonlocalized acupuncture group compared to DN group or sham laser group
39/1b
Ilbuldu et al21 • Improved CS flexion in DN group compared to laser group at 1 mo
• Improved CS extension and lateral flexion in laser group compared to DN group (P<.001 for both) or sham laser group (P<.001, P<.01,
respectively) at 1 mo
• Decreased pain in laser group at rest (P<.05) and with activity (P<.001) compared to DN group or sham laser group at 1 mo
• Improved pressure pain threshold in laser group compared to DN group or sham laser group (P<.001 for both) at 1 mo
• Improved health profile scores in laser group compared to DN group or sham laser group (P<.05 for both) at 1 mo
36/1b
DiLorenzo et al9• Decreased shoulder pain in both DN and rehabilitation groups on day 9, 15, and 21
• Greater decrease in pain in DN group compared to rehabilitation group at day 9 and 21
35/1b
Kamanli et al26 • Improved pain score (all groups) (P<.05)
• Improved pressure pain threshold (all groups) (P<.05); greater decrease in lidocaine injection group (P<.016)
• Improved fatigue and work disability in lidocaine injection and botulinum injection groups (P<.05)
• Improved CS ROM (all groups) (P<.05)
• Improved health profile score in lidocaine injection and botulinum toxin groups (P<.05)
• Improved anxiety and depression scale scores in botulinum toxin group (P<.05)
37/1b
Ga et al15 • Decreased pain (both groups) at 28 d (P<.001)
• Improved pressure pain threshold (both groups) at 28 d (P<.001)
• Improved depression scale score at 28 d in IMS group (P = .024)
• Improved CS ROM (both groups, except extension in DN group) at 28 d (P<.012)
39/1b
Hsieh et al20 • Improved shoulder ROM compared to untreated side (P<.01)
• Decreased pain compared to untreated side (P<.001)
• Improved pressure pain threshold compared to untreated side (P<.01)
26/1b
Itoh et al23 • Decreased pain in DN group at 3 wk and subsequent intervals compared to pretreatment (P<.05)
• Less pain in DN group compared to other groups at wk 9-12 (P<.01)
• Improved NDI score in DN group at wk 3-12 (P<.01)
• Improved NDI in DN compared to other groups at wk 9 and 12 (P<.01)
35/1b
Ay et al1• Decreased pain (both groups) at 4 wk and 12 wk (P<.001)
• Improved CS ROM (both groups) at 4 wk and 12 wk (P<.05)
• Improved depression scale scores (both groups) at 4 wk and 12 wk (P<.001)
• No significant dierences between groups
34/1b
Tsai et al43 • Decreased pain in DN group (P<.05) compared to sham needling
• Improved pressure pain threshold in DN group (P<.05) compared to sham needling
• Improved CS ROM sidebending in DN group (P<.05) compared to sham needling
37/1b
Tekin et al39 • Decreased pain in DN group compared to sham needling after first treatment (immediate) (P = .034) and at 4 wk (P<.001)
• Improved QoL scores at 4 wk in DN group
• Less medication use (paracetamol) in DN group at 4 wk (P<.01)
40/1b
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and 1.48-2.15, respectively). In the study
by DiLorenzo et al,9 in which dry nee-
dling was compared to rehabilitation,
the raw between-group eect size at ap-
proximately 4 weeks approached clini-
cal meaningfulness (1.81 VAS points).
The raw between-group eect size be-
tween groups at 4 weeks was clinically
meaningful (2.73-3.98 VAS points) in
the study by Itoh et al,23 where dry nee-
dling was compared to dry needling of
nontender points or to acupuncture. In
the studies that favored the comparison
(“other”) treatment, only Kamanli et al26
reported clinically meaningful raw be-
tween-group eect sizes at 4 weeks (2.44
VAS points favoring botulinum toxin
injection and 3.17 VAS points favoring
lidocaine injection), with corresponding
large7 treatment eect sizes (0.83 and
1.08, respectively). Ay et al1 also reported
a large eect favoring lidocaine injection
over dry needling (3.30), but the raw
between-group eect size of 1.55 VAS
points (at 4 weeks) was of questionable
clinical meaningfulness.
Ilbuldu et al21 reported statistical
significance and a moderate7 eect size
(0.71) favoring laser over dry needling
at 4 weeks, but meta-analysis results
TABLE 5 MacDermid Quality Checklist Scores for the Individual Items
Study 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Total
Hong17 2 2 1 2 1 1 1 2 1 2 0 1 2 0 2 1 2 1 1 1 1 1 0 2 30
Chu41 1 1 2 1 1 1 0 1 1 0 0 2 1 1 1 1 0 2 1 2 0 1 1 23
Irnich et al22 2 1 2 2 2 1 1 2 1 2 0 2 2 2 2 2 1 0 2 2 2 2 2 2 39
Ilbuldu et al21 2 2 2 2 1 1 1 2 1 2 0 2 1 0 2 2 2 2 2 1 1 2 2 1 36
DiLorenzo et al92 2 2 2 1 1 1 0 1 2 0 2 2 0 2 2 2 1 2 1 2 1 2 2 35
Kamanli et al26 2 2 2 2 1 1 1 0 1 2 0 2 2 1 2 2 2 1 2 2 1 2 2 2 37
Ga et al15 2 2 2 2 1 2 1 0 1 2 0 2 2 1 2 2 2 2 2 2 1 2 2 2 39
Hsieh et al20 2 0 2 2 0 1 1 0 1 1 0 2 1 0 0 2 1 1 2 1 2 2 0 2 26
Itoh et al23 2 2 2 2 1 2 1 2 1 2 0 1 2 0 2 2 1 2 2 1 1 0 2 2 35
Ay et al12 2 2 2 2 1 1 0 1 2 0 2 2 0 2 1 1 2 2 2 2 2 0 1 34
Tsai et al43 2 2 1 2 2 2 1 2 1 2 0 2 2 0 2 2 2 0 2 2 1 2 1 2 37
Tekin et al39 2 2 2 2 2 2 1 2 1 2 1 1 2 2 2 2 2 1 2 2 1 1 1 2 40
Item
TABLE 6 Summary of Key Methodological Issues and Outcomes by Study
Abbreviations: DN, dry needling; MCID, minimal clinically important dierence.
*Authors did not provide adequate information for reviewers to assess whether the examiner was blinded to group allocation.
†Hsieh et al20 used the contralateral side of the same subjects as a “control group”; there was not a separate control group of participants.
Study
True Control Group (Sham or
Placebo)
Examiner Blinded to Group
Allocation
Sample Size Justified by
Power Analysis
DN Group: Eectiveness for
Pain Reduction (Statistical
Significance)
Clinical Meaningfulness of
Magnitude of Pain Reduction
(MCID) Discussed in Article
Hong17 No No No Yes No
Chu4Yes ?* No Yes No
Irnich et al22 Yes Yes No Yes Yes
Ilbuldu et al21 Yes ?* No Yes No
DiLorenzo et al9No No No Yes No
Kamanli et al26 No ?* No Yes No
Ga et al15 No Yes No Yes No
Hsieh et al20 No†?* No Yes No
Itoh et al23 Yes ?* No Yes No
Ay et al1No ?* No Yes No
Tsai et al43 Yes Yes No Yes No
Tekin et al39 Yes Yes Yes Yes No
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showed a wide 95% CI that crossed the
line of no dierence. The raw between-
group eect size at 4 weeks was 1.66 VAS
points (favoring laser), which approaches
clinical meaningfulness. Ga et al15 found
no dierence between dry needling and
intramuscular stimulation. However, in-
tramuscular stimulation is very similar
to dry needling, and therefore the lack of
dierence was expected.
Publication Bias
Funnel plots (FIGURE 2) were created to
determine the risk of publication bias
for the 4 separate meta-analyses. The
funnel plots for dry needling compared
to sham or control for both immediate
eects and at 4 weeks, as well as the
funnel plot for the immediate eects of
dry needling compared to other treat-
ments, were asymmetrical, demonstrat-
ing a risk for publication bias. The funnel
plot for dry needling compared to other
treatments at 4 weeks was symmetrical,
demonstrating a lower likelihood for
publication bias.
DISCUSSION
Interpretation of the collective
body of results of the studies reviewed
is complicated due to the variance in
comparison groups, control conditions,
dosage of intervention, outcomes, out-
come measurement tools, times to out-
comes, and internal validity (quality) of
the studies. The studies that have been
published to date were conducive to the
4 meta-analyses described, but the high
heterogeneity for all analyses performed
requires special consideration.
Dry Needling Compared to Sham
or Control, Immediate Eects
In studies that compared dry needling
to sham or control, high heterogeneity
of pooled results (I2 = 86.3%) was likely
attributable to the small number of stud-
ies, variance across studies in the condi-
tions for the sham or control group, and
dierences in inclusion criteria. Hsieh
et al20 used the same subject’s unin-
volved side as the control, Irnich et al22
used sham laser acupuncture, and Tsai
et al43 and Tekin et al39 used sham nee-
dling. Despite the high heterogeneity, 3
of the 4 studies provided evidence of a
large7 eect of dry needling compared to
sham or control. However, such results
should be interpreted with caution, as
raw between-group dierences in pain
scores in 2 of these studies were of ques-
tionable clinical meaningfulness.39,43 The
data by Chu4 were not included in the
meta-analysis because they could not be
extracted in a way conducive to inclusion
in the meta-analysis. Chu4 reported a
greater percentage of subjects with pain
relief for the dry-needling group com-
pared to the control group (P<.0001).
However, the internal validity of that
study was the weakest of the 12 stud-
ies reviewed, with a score of 23 points
on the MacDermid Quality Checklist.
Additional high-quality randomized
controlled trials are needed to further
elucidate the immediate eects on pain
of dry needling compared to a sham or
placebo.
Dry Needling Compared to Sham
or Control at 4 Weeks
At 4 weeks, 2 studies23,39 provided evi-
dence of a strong eect of dry needling
compared to a sham or control, with clini-
cally meaningful raw between-group ef-
fect sizes. Although the overall eect was
strong, it was confounded by a wide 95%
CI due to the equivocal findings of the
study by Ilbuldu et al.21 It was unclear if
the examiners in the Ilbuldu et al21 study
were blinded, and a low number of sub-
jects (n = 40) without a priori power anal-
ysis might have contributed to the finding
of a lack of dierence between groups
(type II error). The high heterogeneity for
this meta-analysis (84.2%) may, in part,
be explained by the small number of stud-
0.5
–1 0 1 2 3 4 5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
Precision
Eect
1.0
–0.5 0.0 0.5 1.0 1.5 2.0 2.5
1.5
2.0
2.5
3.0
3.5
Precision
Eect
A B
1.0
–2.0 –1.5 –1.0 –0.5 0.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
Precision
Eect
1.0
–4 –3 –2 –1 0 1 2 3
1.5
2.0
2.5
3.0
4.0
3.5
Precision
Eect
C D
FIGURE 2. Funnel plots for meta-analyses showing (A) dry needling compared to sham or control immediately
after treatment, (B) dry needling compared to sham or control at approximately 4 weeks, (C) dry needling
compared to other treatment immediately after treatment, (D) dry needling compared to other treatment at
approximately 4 weeks. The diameter of the circles represents the standardized mean dierence of each study,
with larger diameters corresponding to larger standardized mean dierences.
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ies and the variance in sham or control
conditions (eg, Ilbuldu et al21 used sham
laser, Itoh et al23 used sham acupuncture,
and Tekin et al39 used sham needling). In
addition, there were dierences in the
inclusion criteria of these studies. More
high-quality randomized controlled tri-
als are needed to further elucidate the
eects of dry needling compared to sham
or placebo on pain at 4 weeks and other
clinically relevant time points.
Dry Needling Compared to Other
Treatments, Immediate Eects
Based on 2 studies,17,22 dry needling is
not superior to lidocaine injection or
nonlocal acupuncture to decrease pain
immediately after treatment. One study17
provided evidence that a lidocaine in-
jection had a greater eect on pain, ap-
proaching clinical meaningfulness, when
the treatments did not induce a localized
twitch response. When a localized twitch
response was associated with the treat-
ments, the dierence between lidocaine
injection and dry needling was neither
significant nor clinically meaningful.
This finding supports the theory that a
localized twitch response is an important
component of eective dry needling. The
high heterogeneity (90%) in this meta-
analysis is partly explained by the small
number of studies and the variety in
comparison treatments: Hong17 used li-
docaine injection and Irnich et al22 used
nonlocal acupuncture. In addition, there
were some dierences in the subject in-
clusion criteria between these studies.
Dry Needling Compared to Other
Treatments at Approximately 4 Weeks
Based on 6 studies, dry needling is not
superior, in general, to the other treat-
ments studied to reduce pain at 4 weeks.
However, the overall small7 eect (–0.07,
favoring other treatment) must be viewed
with caution because of the high hetero-
geneity (95%) attributable to the vari-
ety of other treatments, dosages of dry
needling, and diagnoses of the subjects.
Two studies1,26 provided evidence that a
lidocaine injection or botulinum toxin
injection had a greater eect than dry
needling on reducing pain, with raw be-
Immediate Eects
Study n Mean SD* n Mean SD* Weight Treatment Eect, Random†
Irnich et al22 33 2.92 2.19 34 2.8 1.94 49.2% –0.06 (–0.53, 0.42)
210 3 4
Favors
control Favors dry
needling
Hsieh et al20 14 2.8 1.1 14 6.8 1.3 4.5% 3.64 (2.05, 5.22)
Tsai et al43 17 5.2 1.6 18 6.4 1.00 22.3% 0.75 (0.04, 1.46)
Tekin et al39 22 4.0 1.6 17 5.4 1.6 24.0% 0.88 (0.19, 1.56)
Total 86 83 100% 1.06 (0.05, 2.06)
*Values are pain scores immediately posttreatment. Outcome measure was pain rating on a 0-to-10 visual analog scale.
†Values are standardized mean dierence (95% confidence interval). In the plots, the squares represent point estimates of treatment eect; bigger squares
indicate larger samples; the diamond represents the pooled treatment eect; the horizontal lines are 95% confidence intervals; and the vertical line represents
no dierence. Tests for heterogeneity: τ2 = 0.855, df = 3.0 (P<.001), I2 = 86.3%.
FIGURE 3. Forest plot for dry needling compared to sham or control.
Control/Sham
Dry Needling
Approximately 4 Weeks
Study n Mean SD* n Mean SD* Weight Treatment Eect, Random†
Ilbuldu et al21 20 3.71 2.33 20 3.65 2.03 55.4% –0.03 (–0.65, 0.59)
210 3
Favors
control Favors dry
needling
Itoh et al23 8 1.86 1.85 7 5.46 2.0 10.3% 1.95 (0.51, 3.38)
Tekin et al39 22 2.2 2.0 17 5.3 1.8 34.3% 1.55 (0.76, 2.34)
Total 50 44 100% 1.07 (–0.21, 2.35)
*Values are pain scores immediately posttreatment. Outcome measure was pain rating on a 0-to-10 visual analog scale.
†Values are standardized mean dierence (95% confidence interval). In the plots, the squares represent point estimates of treatment eect; bigger squares
indicate larger samples; the diamond represents the pooled treatment eect; the horizontal lines are 95% confidence intervals; and the vertical line represents
no dierence. Tests for heterogeneity: τ2 = 1.042, df = 2.0 (P = .002), I2 = 84.2%.
FIGURE 4. Forest plot for dry needling compared to sham or control.
Control/Sham
Dry Needling
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tween-group eect sizes that were clini-
cally meaningful. When dry needling was
compared to standard rehabilitation in
subjects with shoulder pain following
a cerebrovascular accident,9 dry nee-
dling was favored (with a strong eect)
over rehabilitation, with a raw between-
group eect size that approached clini-
cal meaningfulness. In another study of
patients with neck pain,23 dry needling
was favored (with a large7 eect) over dry
needling of nontender points or acupunc-
ture, with a raw between-group eect size
for pain scores that was clinically mean-
ingful. Despite the high heterogeneity of
this meta-analysis, the mixed results, and
lack of overall eect, close inspection of
the design of individual studies suggests
that dry needling may be superior to oth-
er treatments, depending on the other
treatment and patient diagnoses. How-
ever, when dry needling is compared to li-
docaine injection in patients with MTrPs
in the neck, upper back, or shoulder,26
lidocaine injection may be superior.
In some cases, combined interven-
tions might have influenced the results
regarding the relative contribution of dry
needling (or other interventions) to treat-
ment eects. For example, in the studies
by Ay et al1 and Ilbuldu et al,21 subjects
in all groups performed stretching exer-
cises. In these studies, it is possible that
the stretching exercises contributed to
the treatment eects.
Importance of the Localized Twitch
Response in Dry Needling
Many descriptions of dry-needling
Immediate Eects
Study (Comparison Group) n Mean SD* n Mean SD* Weight Treatment Eect, Random†
Hong17 (lidocaine with LTR) 15 1.00 1.46 26 0.42 0.49 33.4% –0.40 (–1.05, 0.26)
–1–2–3 0
Favors other
treatment Favors dry
needling
Hong17 (lidocaine without LTR) 8 7.13 0.93 9 5.44 0.83 7.8% –1.82 (–3.16, 0.47)
Irnich et al22 (nonlocal acupuncture) 33 2.92 2.19 34 1.91 1.61 58.7% –0.46 (–0.95, 0.03)
Total 56 69 100% –0.64 (–1.21, –0.06)
Abbreviation: LTR, localized twitch response.
*Values are pain scores immediately posttreatment. Outcome measure was pain rating on a 0-to-10 visual analog scale.
†Values are standardized mean dierence (95% confidence interval). In the plots, the squares represent point estimates of treatment eect; bigger squares
indicate larger samples; the diamond represents the pooled treatment eect; the horizontal lines are 95% confidence intervals; and the vertical line represents
no dierence. Tests for heterogeneity: τ2 = 1.633, df = 3.0 (P<.001), I2 = 90.0%.
FIGURE 5. Forest plot for dry needling compared to other treatments.
Other TreatmentDry Needling
Approximately 4 Weeks
Study (Comparison Group) n Mean SD* n Mean SD* Weight Treatment Eect, Random†
DiLorenzo et al9 (rehabilitation) 54 3.15 0.8 47 4.96 1.12 24.1% 2.26 (1.68, 2.84)
–1 1 2 3–2–3–4 0
Favors other
treatment Favors dry
needling
Ilbuldu et al21 (laser) 20 3.71 2.33 20 2.05 1.43 18.7% –0.71 (–1.37, 0.05)
Kamanli et al26 (lidocaine) 10 5.12 2.94 10 1.95 1.67 8.0% –1.08 (–2.09, 0.07)
Kamanli et al26 (botulinum) 10 5.12 2.94 9 2.68 1.04 8.5% –0.83 (–1.81, 0.15)
Itoh et al23 (dry needling nontender) 8 1.86 1.85 8 5.84 1.89 3.7% 2.15 (0.66, 3.65)
Itoh et al23 (acupuncture) 8 1.86 1.85 8 4.59 1.75 5.2% 1.48 (0.23, 2.72)
Ga et al15 (intramuscular stimulation) 18 3.82 2.47 22 3.11 2.01 20.5% –0.29 (–0.92, 0.34)
Ay et al1 (lidocaine) 40 3.82 0.47 40 2.27 0.98 11.2% –3.30 (–4.15, 2.45)
Total 168 164 100% –0.07 (–1.39, 1.26)
*Values are pain scores immediately posttreatment. Outcome measure was pain rating on a 0-to-10 visual analog scale.
†Values are standardized mean dierence (95% confidence interval). In the plots, the squares represent point estimates of treatment eect; bigger squares
indicate larger samples; the diamond represents the pooled treatment eect; the horizontal lines are 95% confidence intervals; and the vertical line represents
no dierence. Tests for heterogeneity: τ2 = 3.417, df = 7.0 (P<.001), I2 = 95.0%.
FIGURE 6. Forest plot for dry needling compared to other treatments.
Other TreatmentDry Needling
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techniques emphasize the potential im-
portance of a localized twitch response
during treatment. Often, the definition
of MPS includes the phenomenon of a
localized twitch response in response to
stimulation of an MTrP. Of the 12 studies
we reviewed, 8 clearly described whether
a localized twitch response was desired or
elicited upon dry needling of a subject’s
MTrP.1,15,17,20,22,23,39,43 In general, provoca-
tion of a localized twitch response was
described as a necessary component of
the dry-needling technique. In a study
comparing dry needling with lidocaine
injection, Hong17 noted that a lack of lo-
calized twitch response in either group
was associated with little change in pain,
tenderness, or range of motion. Ga et al15
compared dry needling with intramus-
cular stimulation, a variation of dry nee-
dling that involves “grasping and winding
up” of the muscle (by the needle) and a
“stronger stimulation” response. Local-
ized twitch response rates were not dif-
ferent between the groups, with nearly
all participants demonstrating localized
twitch responses during treatment. Both
groups had decreased pain and improved
pain pressure threshold at 4 weeks. Fur-
ther research is needed to clarify wheth-
er a localized twitch response is a valid
predictor of success or a necessary com-
ponent of dry-needling treatment in pa-
tients with upper-quarter MPS. However,
it does appear that provocation of a local-
ized twitch response is common with the
dry-needling technique.
Limitations
The limitations of this review include the
use of only 1 search term (dry needling).
However, based on the hand search of
references from 2 other systematic re-
views,8,41 it is unlikely that any relevant
articles were overlooked. Our methods
did not permit us to calculate concor-
dance statistics for data extraction. The
authors recognize the value of this infor-
mation in retrospect but cannot adjust
for this aspect of the methodology.
Other tools, such as the PEDro scale,29
are available to rate the internal valid-
ity of randomized controlled trials. The
MacDermid Quality Checklist28 aorded
us the opportunity to closely analyze the
design and methods of the studies; how-
ever, the reliability of the MacDermid
Quality Checklist has not been well de-
scribed in the literature, which may be
a limitation. The interpretation of study
findings was based on meta-analysis
results and consideration of raw dier-
ence in pain scores between groups. Any
potential instability of the MacDermid
Quality Checklist, in terms of reliability,
did not have an eect on our conclusions
or recommendations. Of great concern
was the high heterogeneity in each of the
4 meta-analyses we performed. In gen-
eral, such high heterogeneity may bring
into question whether it is even appropri-
ate to perform a meta-analysis. However,
our discussion of likely reasons for this
high heterogeneity and our consideration
of findings of individual studies provide
a rationale to pursue the meta-analyses.
Another limitation of this review is
the evidence of publication bias in the
asymmetrical funnel plots (FIGURE 2) for
dry needling compared to sham or con-
trol for both immediate eects and at 4
weeks, as well as dry needling compared
to other treatments for immediate eects.
Publication bias may result from a lower
publication rate of negative results, exclu-
sion of publications in foreign languages,
or an inability to access work not submit-
ted for publication.6 The authors did not
attempt to locate unpublished research or
research in foreign languages examining
the impact of dry needling on patients
with upper-quarter MPS. However, fun-
nel-plot asymmetry can be influenced by
the heterogeneity of studies included in
a meta-analysis40 and can be challenging
to interpret when the number of studies
included is small.6 Thus, the asymmetri-
cal funnel plots in this study cannot be
interpreted conclusively due to the small
number of studies included (range, 3-4)
as well as the heterogeneity of those stud-
ies (range, 84.2%-90%).
Because most studies of longer-term
eects described outcomes at approxi-
mately 4 weeks, we chose that time point
for meta-analysis. However, 2 studies re-
ported outcomes up to 12 weeks.1,23 Ay et
al1 found no between-group dierences
at 12 weeks, whereas Itoh et al23 report-
ed less pain in the dry needling group
at 12 weeks. Although further study of
the long-term eects of dry needling is
needed, we feel that the time points ad-
dressed in this review (immediate and
4 weeks) are of great value, as the goal
of dry needling is rapid relief of pain so
that patients can be progressed to other
forms of therapy, such as exercise and
postural correction. Several studies in
this review reported statistical superi-
ority of dry needling compared to sham
or other outcomes, including pain pres-
sure threshold,17,43 range of motion,17,22,43
self-reported disability,23 and number of
tender MTrPs.4 A limitation of this sys-
tematic review was that it did not provide
analyses of these secondary variables.
All studies reviewed had methodologi-
cal limitations, which were extensive in
some cases. Key methodological limita-
tions of the studies are summarized in
TABLE 6. Only 1 study22 provided a cursory
interpretation of pain reduction from
the perspective of minimal clinically im-
portant dierence. The parameters of
dry-needling treatment technique var-
ied across studies. The studies by Chu4
and Ga et al15 referred to intramuscular
stimulation as a consideration in dry nee-
dling, with Ga et al15 actually using intra-
muscular stimulation as a comparison
group. Times to outcomes varied across
studies, with 4 reporting only immediate
eects.17,20,22,43 The immediate eects on
pain are of interest, but longer-term ef-
fects on a comprehensive group of func-
tional and clinically relevant measures
should be considered when designing
future studies. In general, future stud-
ies should be carefully designed to avoid
many of the methodological limitations
found in the studies published to date.
The external validity of several of the
studies is limited due to the age ranges
and gender bias of the sample. Four stud-
ies9,15,20,23 focused on an older sample,
43-09 Kietrys.indd 632 8/20/2013 3:35:05 PM
journal of orthopaedic & sports physical therapy | volume 43 | number 9 | september 2013 | 633
while Ilbuldu et al’s21 sample of 18- to
50-year-old adults was composed of fe-
male subjects only. Furthermore, there
was variance in the causes or diagnoses
explaining the upper-quarter myofascial
pain in the studies reviewed (as described
under the inclusion criteria in TABLE 1).
For example, the findings of DiLorenzo
et al9 are relevant only for patients with
shoulder pain who have suered a recent
stroke.
CONCLUSION
Based on the studies published
to date, we recommend (grade A)34
dry needling, compared to sham
or placebo treatment, for immediate re-
duction of pain in patients with upper-
quarter MPS, based on the results of 3
individual randomized controlled tri-
als20,39,43 included in the meta-analysis
of 4 studies and on the overall eect
size derived from that meta-analysis.
We cautiously recommend (grade A)34
dry needling, compared to sham or pla-
cebo treatment, for reduction of pain at
4 weeks in patients with upper-quarter
MPS, based on results of 2 individual
randomized controlled trials23,39 included
in a meta-analysis of 3 studies. However,
it must be noted that the overall eect
of the 3 studies combined is ambiguous
due to a large CI of the otherwise strong
eect size. Future studies should be criti-
cally reviewed to inform the evolution
of these recommendations. Additional
research with high-quality study design
and appropriate choices of comparative
treatments will aid in developing more
conclusive evidence for dry needling.
More evidence is needed to establish ef-
ficacy of dry needling compared to other
interventions for upper-quarter MPS.
However, it appears that injection with
lidocaine may be superior to dry needling
for pain reduction both immediately after
treatment and at 4 weeks. t
KEY POINTS
FINDINGS: A large immediate effect of dry
needling compared to sham or placebo
to decrease pain in individuals with up-
per-quarter MPS was found in 3 of the 4
studies, with raw between-group effect
sizes ranging from 1.2 to 4.9 points on
a pain VAS. At 4 weeks, a large effect
favoring dry needling was tempered by
a large CI, but findings from 2 cohorts
showed a large effect favoring dry nee-
dling, with clinically meaningful raw
between-group effect sizes ranging from
3.1 to 3.6 points on a pain VAS. Several
studies have compared dry needling to
other treatments, with outcomes varying
from no difference to a difference either
favoring dry needling or the alternate
intervention.
IMPLICATIONS: We recommend (grade A)34
dry needling for immediate reduction
of pain in patients with upper-quarter
MPS, and cautiously recommend (grade
A)34 dry needling for reduction of pain
at 4 weeks in patients with upper-quar-
ter MPS.
CAUTION: The limited number of stud-
ies performed to date, combined with
methodological flaws in many of the
studies, prompts caution in interpret-
ing the results of the meta-analyses
performed here. Variance in study fac-
tors, such as control conditions and
comparison treatments, contributed to
high heterogeneity in the results of the
meta-analyses.
REFERENCES
1. Ay S, Evcik D, Tur BS. Comparison of injec-
tion methods in myofascial pain syndrome: a
randomized controlled trial. Clin Rheumatol.
2010;29:19-23. http://dx.doi.org/10.1007/
s10067-009-1307-8
2. Baldry PE. Myofascial Pain and Fibromyalgia
Syndromes: A Clinical Guide to Diagnosis and
Management. Edinburgh, UK: Churchill Living-
stone; 2001.
3. Brudvig TJ, Kulkarni H, Shah S. The eect of
therapeutic exercise and mobilization on pa-
tients with shoulder dysfunction: a systematic
review with meta-analysis. J Orthop Sports
Phys Ther. 2011;41:734-748. http://dx.doi.
org/10.2519/jospt.2011.3440
4. Chu J. Does EMG (dry needling) reduce myo-
fascial pain symptoms due to cervical nerve
root irritation? Electromyogr Clin Neurophysiol.
1997;37:259-272.
5. Cleland JA, Childs JD, Whitman JM. Psycho-
metric properties of the Neck Disability Index
and numeric pain rating scale in patients with
mechanical neck pain. Arch Phys Med Rehabil.
2008;89:69-74. http://dx.doi.org/10.1016/j.
apmr.2007.08.126
6. Cleophas TJ, Zwinderman AH. Meta-analysis.
Circulation. 2007;115:2870-2875. http://dx.doi.
org/10.1161/CIRCULATIONAHA.105.594960
7. Cohen J. Statistical Power Analysis for the
Behavioral Sciences. 2nd ed. Hillsdale, NJ: Law-
rence Erlbaum Associates; 1988.
8. Cummings TM, White AR. Needling therapies
in the management of myofascial trigger point
pain: a systematic review. Arch Phys Med Reha-
bil. 2001;82:986-992. http://dx.doi.org/10.1053/
apmr.2001.24023
9. DiLorenzo L, Traballesi M, Morelli D, et al. Hemi-
paretic shoulder pain syndrome treated with
deep dry needling during early rehabilitation: a
prospective, open-label, randomized investiga-
tion. J Musculoskelet Pain. 2004;12:25-34.
10. Dommerholt J. Dry needling in orthopedic
physical therapy practice. Orthop Pract.
2004;16:15-20.
11. Dommerholt J, del Moral OM, Gröbli C. Trig-
ger point dry needling. J Man Manip Ther.
2006;14:E70-E87.
12. Farrar JT, Young JP, Jr., LaMoreaux L, Werth
JL, Poole RM. Clinical importance of changes
in chronic pain intensity measured on an
11-point numerical pain rating scale. Pain.
2001;94:149-158.
13. Fricton JR, Kroening R, Haley D, Siegert R.
Myofascial pain syndrome of the head and
neck: a review of clinical characteristics of
164 patients. Oral Surg Oral Med Oral Pathol.
1985;60:615-623.
14. Furlan AD, van Tulder M, Cherkin D, et al. Acu-
puncture and dry-needling for low back pain: an
updated systematic review within the framework
of the Cochrane Collaboration. Spine (Phila Pa
1976). 2005;30:944-963.
15. Ga H, Choi JH, Park CH, Yoon HJ. Dry needling
of trigger points with and without paraspinal
needling in myofascial pain syndromes in
elderly patients. J Altern Complement Med.
2007;13:617-624. http://dx.doi.org/10.1089/
acm.2006.6371
16. Hong CZ. Considerations and recommendations
regarding myofascial trigger point injection. J
Musculoskelet Pain. 1994;2:29-59.
17. Hong CZ. Lidocaine injection versus dry nee-
dling to myofascial trigger point. The importance
of the local twitch response. Am J Phys Med
Rehabil. 1994;73:256-263.
18. Hong CZ. Myofascial trigger point injection. Crit
Rev Phys Rehabil Med. 1993;5:203-217.
19. Hong CZ, Simons DG. Pathophysiologic and
electrophysiologic mechanisms of myofas-
cial trigger points. Arch Phys Med Rehabil.
1998;79:863-872.
20. Hsieh YL, Kao MJ, Kuan TS, Chen SM, Chen
43-09 Kietrys.indd 633 8/20/2013 3:35:06 PM
634 | september 2013 | volume 43 | number 9 | journal of orthopaedic & sports physical therapy
[ research report ]
MORE INFORMATION
WWW.JOSPT.ORG
@
JT, Hong CZ. Dry needling to a key myofas-
cial trigger point may reduce the irritability
of satellite MTrPs. Am J Phys Med Rehabil.
2007;86:397-403. http://dx.doi.org/10.1097/
PHM.0b013e31804a554d
21. Ilbuldu E, Cakmak A, Disci R, Aydin R. Com-
parison of laser, dry needling, and placebo
laser treatments in myofascial pain syndrome.
Photomed Laser Surg. 2004;22:306-311. http://
dx.doi.org/10.1089/1549541041797878
22. Irnich D, Behrens N, Gleditsch JM, et al. Im-
mediate eects of dry needling and acupuncture
at distant points in chronic neck pain: results of
a randomized, double-blind, sham-controlled
crossover trial. Pain. 2002;99:83-89.
23. Itoh K, Katsumi Y, Hirota S, Kitakoji H. Ran-
domised trial of trigger point acupuncture
compared with other acupuncture for treatment
of chronic neck pain. Complement Ther Med.
2007;15:172-179. http://dx.doi.org/10.1016/j.
ctim.2006.05.003
24. Iversen MD, Choudhary VR, Patel SC. Thera-
peutic exercise and manual therapy for persons
with lumbar spinal stenosis. Int J Clin Rheuma-
tol. 2010;5:425-437. http://dx.doi.org/10.2217/
ijr.10.29
25. Kalichman L, Vulfsons S. Dry needling in the
management of musculoskeletal pain. J Am
Board Fam Med. 2010;23:640-646. http://
dx.doi.org/10.3122/jabfm.2010.05.090296
26. Kamanli A, Kaya A, Ardicoglu O, Ozgocmen S,
Zengin FO, Bayik Y. Comparison of lidocaine
injection, botulinum toxin injection, and dry
needling to trigger points in myofascial pain
syndrome. Rheumatol Int. 2005;25:604-611.
http://dx.doi.org/10.1007/s00296-004-0485-6
27. Lavelle ED, Lavelle W, Smith HS. Myofas-
cial trigger points. Med Clin North Am.
2007;91:229-239. http://dx.doi.org/10.1016/j.
mcna.2006.12.004
28. MacDermid JC. An introduction to evidence-
based practice for hand therapists. J Hand Ther.
2004;17:105-117. http://dx.doi.org/10.1197/j.
jht.2004.02.001
29. Maher CG, Sherrington C, Herbert RD, Moseley
AM, Elkins M. Reliability of the PEDro scale for
rating quality of randomized controlled trials.
Phys Ther. 2003;83:713-721.
30. Melzack R. Myofascial trigger points: relation
to acupuncture and mechanisms of pain. Arch
Phys Med Rehabil. 1981;62:114-117.
31. Michener LA, Snyder AR, Leggin BG. Respon-
siveness of the numeric pain rating scale in
patients with shoulder pain and the eect of sur-
gical status. J Sport Rehabil. 2011;20:115-128.
32. Perez-Palomares S, Oliván-Blázquez B, Arnal-
Burró AM, et al. Contributions of myofascial
pain in diagnosis and treatment of shoulder
pain. A randomized control trial. BMC Mus-
culoskelet Disord. 2009;10:92. http://dx.doi.
org/10.1186/1471-2474-10-92
33. Rosen NB. The myofascial pain syndrome. Phys
Med Rehabil Clin N Am. 1993;4:41-63.
34. Sackett DL, Straus SE, Richardson WS.
Evidence-Based Medicine: How to Practice and
Teach EBM. 2nd ed. Edinburgh, UK: Churchill
Livingstone; 2000.
35. Sala F, Stancati A, Silvestri CA, Ciapetti A,
Grassi W. Minimal clinically important changes
in chronic musculoskeletal pain intensity mea-
sured on a numerical rating scale. Eur J Pain.
2004;8:283-291. http://dx.doi.org/10.1016/j.
ejpain.2003.09.004
36. Simons DG, Travell JG, Simons LS. Travell &
Simons’ Myofascial Pain and Dysfunction: The
Trigger Point Manual Volume 1: Upper Half of
Body. 2nd ed. Philadelphia, PA: Lippincott Wil-
liams & Wilkins; 1998.
37. Skootsky SA, Jaeger B, Oye RK. Prevalence of
myofascial pain in general internal medicine
practice. West J Med. 1989;151:157-160.
38. Spadoni GF, Stratford PW, Solomon PE, Wishart
LR. The evaluation of change in pain intensity: a
comparison of the P4 and single-item numeric
pain rating scales. J Orthop Sports Phys Ther.
2004;34:187-193. http://dx.doi.org/10.2519/
jospt.2004.1157
39. Tekin L, Akarsu S, Durmuş O, Çakar E, Dinçer U,
Kiralp MZ. The eect of dry needling in the treat-
ment of myofascial pain syndrome: a random-
ized double-blinded placebo-controlled trial.
Clin Rheumatol. 2013;32:309-315. http://dx.doi.
org/10.1007/s10067-012-2112-3
40. Terrin N, Schmid CH, Lau J, Olkin I. Adjusting for
publication bias in the presence of heterogene-
ity. Stat Med. 2003;22:2113-2126. http://dx.doi.
org/10.1002/sim.1461
41. Tough EA, White AR, Cummings TM, Richards
SH, Campbell JL. Acupuncture and dry needling
in the management of myofascial trigger point
pain: a systematic review and meta-analysis
of randomised controlled trials. Eur J Pain.
2009;13:3-10. http://dx.doi.org/10.1016/j.
ejpain.2008.02.006
42. Travell JG, Simons DG. Myofascial Pain and
Dysfunction: The Trigger Point Manual Volume
2: The Lower Extremities. Media, PA: Williams &
Wilkins; 1992.
43. Tsai CT, Hsieh LF, Kuan TS, Kao MJ, Chou LW,
Hong CZ. Remote eects of dry needling on the
irritability of the myofascial trigger point in the
upper trapezius muscle. Am J Phys Med Reha-
bil. 2010;89:133-140. http://dx.doi.org/10.1097/
PHM.0b013e3181a5b1bc
44. Venâncio RA, Alencar FGP, Jr., Zamperini C. Dif-
ferent substances and dry-needling injections in
patients with myofascial pain and headaches.
Cranio. 2008;26:96-103.
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43-09 Kietrys.indd 634 8/20/2013 3:35:07 PM
journal of orthopaedic & sports physical therapy | volume 43 | number 9 | september 2013 | 635
jospt perspectives for patients
Painful and Tender Muscles
Dry Needling Can Reduce Myofascial Pain Related to Trigger Points
Trigger points are irritable, hard “knots” within a muscle
that may cause pain over a large area, leading to di-
culty performing everyday tasks. When a trigger point is
touched, it hurts and can also cause pain in nearby areas
(see illustration). When a person has painful muscles and trigger
points, it is sometimes called myofascial pain syndrome. Common
locations for these problems are the arm and neck. Dry needling is
a treatment that involves a very thin needle being pushed through
the skin to stimulate a trigger point. Dry needling may release the
tight muscle bands associated with trigger points and lead to de-
creased pain and improved function. In a study published in the
September 2013 issue of JOSPT, a group of researchers analyzed
the results of the best clinical studies that have been conducted thus
far to determine if dry needling helps to reduce neck and arm pain.
NEW INSIGHTS
After reviewing many sources of information and
evaluating both the quality and results of the relevant
studies, the researchers determined that dry needling can
be eective in providing pain relief. These studies noted
that a “twitch” often occurs when a needle is inserted into
the trigger point, and this “twitch” may be a sign that the
treatment will be helpful. The authors of the JOSPT article
also found that the eects of dry needling varied across
studies and that more research needs to be done to
determine whether dry needling is better for this condition
than other treatment options.
Myofascial pain syndrome, or trigger points, can be
a source of pain and limit function. Dry needling is a
specialized treatment for trigger points provided by
some physical therapists. It is one possible treatment
option, usually combined with other techniques
including exercises, to manage myofascial pain. Your
physical therapist can perform a thorough evaluation
to help determine if you are a good candidate for this
treatment as part of a program designed to reduce your
pain and improve your function. For more information on
the treatment of myofascial pain, contact your physical
therapist specializing in musculoskeletal disorders.
For this and more topics, visit JOSPT Perspectives for
Patients online at www.jospt.org.
This JOSPT Perspectives for Patients is based on an
article by Kietrys DM et al titled “Eectiveness
of Dry Needling for Upper-Quarter Myofascial Pain:
A Systematic Review and Meta-analysis,” J Orthop
Sports Phys Ther 2013;43(9):620-634. Epub 11 June
2013. doi:10.2519/jospt.2013.4668.
This Perspectives article was written by a team of
JOSPT’s editorial board and sta, with Deydre S. Teyhen,
PT, PhD, Editor, and Jeanne Robertson, Illustrator.
PRACTICAL ADVICE
JOSPT PERSPECTIVES FOR PATIENTS is a public service of the Journal of Orthopaedic & Sports Physical Therapy. The information and recommendations
contained here are a summary of the referenced research article and are not a substitute for seeking proper healthcare to diagnose and treat this condition.
For more information on the management of this condition, contact your physical therapist or healthcare provider specializing in musculoskeletal
disorders. JOSPT Perspectives for Patients may be photocopied noncommercially by physical therapists and other healthcare providers to share with
patients. The ocial journal of the Orthopaedic Section and the Sports Physical Therapy Section of the American Physical Therapy Association (APTA),
JOSPT strives to oer high-quality research, immediately applicable clinical material, and useful supplemental information on musculoskeletal and
sports-related health, injury, and rehabilitation. Copyright ©2013 Journal of Orthopaedic & Sports Physical Therapy®
J Orthop Sports Phys Ther 2013;43(9):635. doi:10.2519/jospt.2013.0505
NEEDLING TRIGGER POINTS. Trigger points, often a component of myofascial pain syndrome, are irritable, hard
“knots” within a muscle that may cause pain over a large area (A). A potential treatment option is dry needling, which
consists of a very thin needle that your therapist pushes through the skin to stimulate the trigger points, muscles, or
connecting tissues (B). Dry needling may release the tight muscle bands and decrease pain (C).
Contraction knot
Normal fibers
Taut band
Nodule
Trigger point complex
A
B
C
43-09 Perspectives.indd 635 8/20/2013 3:36:24 PM
