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Although Western medical acupuncture (WMA) is commonly practised in the UK, a particular approach called dry needling (DN) is becoming increasingly popular in other countries. The legitimacy of the use of DN by conventional non-physician healthcare professionals is questioned by acupuncturists. This article describes the ongoing debate over the practice of DN between physical therapists and acupuncturists, with a particular emphasis on the USA. DN and acupuncture share many similarities but may differ in certain aspects. Currently, little information is available from the literature regarding the relationship between the two needling techniques. Through reviewing their origins, theory, and practice, we found that DN and acupuncture overlap in terms of needling technique with solid filiform needles as well as some fundamental theories. Both WMA and DN are based on modern biomedical understandings of the human body, although DN arguably represents only one subcategory of WMA. The increasing volume of research into needling therapy explains its growing popularity in the musculoskeletal field including sports medicine. To resolve the debate over DN practice, we call for the establishment of a regulatory body to accredit DN courses and a formal, comprehensive educational component and training for healthcare professionals who are not physicians or acupuncturists. Because of the close relationship between DN and acupuncture, collaboration rather than dispute between acupuncturists and other healthcare professionals should be encouraged with respect to education, research, and practice for the benefit of patients with musculoskeletal conditions who require needling therapy.
Dry needling versus acupuncture:
the ongoing debate
Kehua Zhou,
Yan Ma,
Michael S Brogan
Department of Health Care
Studies, Daemen College,
Amherst, New York, USA
Daemen College Physical
Therapy Wound Care Clinic,
Daemen College, Amherst,
New York, USA
Division of Interdisciplinary
Medicine and Biotechnology,
Beth Israel Deaconess Medical
Center, Harvard Medical School,
Boston, Massachusetts, USA
Internal Medicine and Sleep
Center, Eye Hospital, China
Academy of Chinese Medical
Science, Beijing, China
Department of Physical Therapy,
Daemen College, Amherst,
New York, USA
Correspondence to
Dr Kehua Zhou, Department of
Health Care Studies, Daemen
College, 4380 Main Street,
Amherst, NY 14226, USA;
Accepted 18 September 2015
Published Online First
6 November 2015
To cite: Zhou K, Ma Y,
Brogan MS. Acupunct Med
Although Western medical acupuncture (WMA)
is commonly practised in the UK, a particular
approach called dry needling (DN) is becoming
increasingly popular in other countries. The
legitimacy of the use of DN by conventional non-
physician healthcare professionals is questioned
by acupuncturists. This article describes the
ongoing debate over the practice of DN between
physical therapists and acupuncturists, with a
particular emphasis on the USA. DN and
acupuncture share many similarities but may
differ in certain aspects. Currently, little
information is available from the literature
regarding the relationship between the two
needling techniques. Through reviewing their
origins, theory, and practice, we found that DN
and acupuncture overlap in terms of needling
technique with solid filiform needles as well as
some fundamental theories. Both WMA and DN
are based on modern biomedical understandings
of the human body, although DN arguably
represents only one subcategory of WMA. The
increasing volume of research into needling
therapy explains its growing popularity in the
musculoskeletal field including sports medicine.
To resolve the debate over DN practice, we call
for the establishment of a regulatory body to
accredit DN courses and a formal, comprehensive
educational component and training for
healthcare professionals who are not physicians
or acupuncturists. Because of the close
relationship between DN and acupuncture,
collaboration rather than dispute between
acupuncturists and other healthcare professionals
should be encouraged with respect to education,
research, and practice for the benefit of patients
with musculoskeletal conditions who require
needling therapy.
Western medical acupuncture (WMA) is a
therapeutic modality involving the inser-
tion of solid filiform needles. It is a
modern adaptation of traditional acu-
puncture (TA) using current biomedical
understanding and research evidence.
WMA is widely practised by convention-
ally trained healthcare providers includ-
ing physicians, chiropractors, and
physical therapists (PTs).
WMA is relatively commonplace in the
UK and Sweden,
a particular approach
called dry needling (DN), which is
mainly practised by PTs, is becoming
increasingly popular in other major
western countries.
WMA, DN and TA
are all needling procedures that involve
penetration of the skin with solid filiform
needles with therapeutic intent. DN is a
technique that PTs and other healthcare
professionals use to treat various painful
conditions of the musculoskeletal system,
usually myofascial pain syndrome,
whereas TA is a technique used by profes-
sional acupuncturists. Compared with
DN, both TA and WMA have a broader
range of indications including muscu lo-
skeletal pain, and gastrointestinal and
neurological disorders.
Patients and
healthcare professionals may be confused
about the relationship between DN and
acupuncture as they seem to share simi-
larities and yet may differ in certain
aspects. Currently, little information is
available from the literature regarding the
similarities and differences between these
two needling techniques. In this article,
we aim to: (1) explore the professional
controversies surrounding the practice of
DN; (2) review the origins, theory, and
practice of DN and acupuncture; and (3)
seek potential solutions in response to
the ongoing debate.
The dispute about the legitimacy of DN
practice by healthcare professionals who
are not physicians or acupuncturists has
been ongoing now for more than a
decade, particularly in the USA. Here, we
focus on the debate between acupunctur-
ists and PTs regarding DN practice.
Acupuncturists oppose the practice of
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DN by PTs because they perceive DN to be a form of
acupuncture, which they feel should not fall into the
scope of practice of PTs and other practitioners, such
as chiropractors. They also argue that, with minimal
training, PTs are unlikely to be able to master the
technique and thus may endanger patient safety and
In response, PTs claim that DN is not acu-
because, although both acupuncture and
DN are needling techniques, DN is base d on modern
biomedical science rather than TA theories or
However, DN and acupuncture clearly overlap to
some extent in view of their most common indication
(musculoskeletal pain) and their use of solid filiform
Additionally, with the single exception of
cases of pneumothorax due to inappropriate and/or
unlawful practice, which is also reported in acupunc-
ture practice,
no significant patient safety events
have been reported in relation to the practice of DN.
Thanks to accumulating evidence for its applicability,
utility, and lack of side effects (which are minimal to
none), the practice of DN is becoming increasingly
popular among conventionally trained healthcare pro-
viders around the world, especially among PTs in the
DN is the de facto practice of PTs in many
countries and states across the USA, yet it is unavail-
able in others, which further convolutes the debate of
who can and should practise DN.
The other argument lies in the training of PTs in
The practice of acupuncture by trained clini-
cians requires enhanced experience. In most states and
countries, the practice of acupuncture requires hun-
dreds and often thousands of hours of acupuncture
education in specialised educational programmes. In
the USA, the practice of acupuncture requires state
licensure, which is based on passing national level
examinations and maintaining good professional
records. The practice of acupuncture is governed by
the acupuncture or medical board of the state educa-
tion department in most states across the USA.
By contrast, current training of DN for PTs in the
USA is done only through continuing education or
certificate programmes, which are not strictly regu-
lated and have few (if any) standards that need to be
complied with.
With these non-formal training pro-
grammes in DN, acupuncturists argue that PTs expos-
ure, experience and skills in needling therapy are
likely to be limited.
Additionally, evaluation systems
for the practice of DN by PTs are currently unavail-
able, and standards for healthcare governing adminis-
trations and policymakers are not yet established.
History of DN
DN, subtypes of which include related techniques
known as intramuscular stimulation or trigger point
needling, refers to the use of either solid filiform
needles or hollow-core hypodermic needles for the
treatment of muscular pain. Although some PTs claim
that DN was first developed in the 1940s by Janet
Travell, little evidence exists to support this state-
In Myofascial pain and dysfunction: the
trigger point manual, Travell and Simons
marised the key elements of the DN technique as: (1)
use of a needle of sufficient length to reach the con-
traction knots in the trigger points without any prefer-
ence for needle diameter (range 0.33.4 mm); and (2)
use of an aseptic technique via careful cleansing with
a suitable antiseptic (usually alcohol wipes). Travell
and Simons
did not mention any specific type of
needle used in DN when they proposed that it was as
effective as local lidocaine injection in relieving
trigger point pain; however, they did mention that
DN would induce post-injection soreness, which
might be more severe and last for a longer period of
time than the injection of lidocaine. Thus, the needle
that they were referring to is more likely to have been
a hypodermic needle, rather than an acupuncture
Further evidence that the origin of DN involved the
use of hypodermic needles for the treatment of myo-
fascial pain is provided by findings of a review of DN
history. The earliest reference to DN, as per Legge,
was in an article about low back pain in 1947 when
reported that DN and injecting saline both
relieved pain. In 1952, Travell and Rinzler
the origins of myofascial pain, and commented that
effective treatment of myofascial pain might include
DN. The needles used in these early publications
related to DN were likely to have been hypodermic
needles, as injection of saline or local anaesthetic was
simultaneously mentioned and compared.
Nonetheless, the earliest available study directly iden-
tified using the search term dry needling in PubMed
was authored in 1979 by Lewit,
who used acupunc-
ture needles in DN practice. He found that DN pro-
duced immediate, complete analgesia of the painful
spot without hyperaesthesia for patients with myofas-
cial pain. Based on these results, Lewit
reported that
the therapeutic effects of needling in myofascial pain
originated from the mechanical stimulation of the
needling per se and was due to neither the anaesthetic
nor the sclerosing solution. In 1980, Gunn et al
recommended the manipulation of acupuncture
needles to produce a grabbing sensation in patients
with trigger point pain. Gunn et al
reported that the
techniques were inspired by TA and that DN had
powerful therapeutic effects for patients with chronic
low back pain. Development of DN was limited in the
1980s and 1990s as indicated by the limited number
of publications (<30) in the literature during this
However, since the 2000s, interest in DN
has resurged as healthcare professionals, especially
PTs, have begun to recognise the beneficial effects of
DN on pain.
Currently, DN is practised by many
healthcare professionals in Europe, Australia, more
Education and practice
486 Zhou K, et al. Acupunct Med 2015;33:485490. doi:10.1136/acupmed-2015-010911 on December 12, 2015 - Published by from
than half of the states across the USA, and in many
other countries.
Theory of DN
The use of DN is based on an understanding of
human anatomy and physiology regarding myofascial
pain and trigger points.
Theories regarding DN
involve various neurophysiological mechanisms,
which are indirectly supported by an expanding
volume of clinical research. Between 1980 and April
2015, almost 200 publications were retrievable by a
PubMed search using the term dry needling. The
majority of this literature reports on the therapeutic
effectiveness of DN using solid filiform needles for
various types of musculoskeletal pain.
Within the
available meta-analyses, one study reported that DN
treatment of myofascial pain in the lower back
appeared to be a useful addition to standard therap-
and another study found that DN was an effect-
ive intervention for upper-quarter myofascial pain,
which decreased immediately after treatment and at
follow-up at 4 weeks.
Since the most recent
20 new articles involving DN had
been indexed in PubMed by April 2015. Almo st all of
them have reported that DN is effective for specific
types of musculoskeletal pain.
DN procedure
In general, DN techniques can be divided into superfi-
cial and deep techniques.
In superficial DN,
needles are inserted superficially (around 510 mm)
into tissue above the underlying trigger points.
retention for a short time (30 s to 3 min), the needle
is removed and the pain is expected to be greatly
relieved. If residual pain occurs, the procedure can be
repeated another two to three times. Other superficial
needling techniques exist too. For example, Fus
superficial needling involves insertion of needles at an
angle of 2030° without penetrating the muscle.
the newly evolved wrist and ankle needling, the
needles are inserted almost horizontally at the wrist
and ankle within the connective tissue layer between
the muscle and skin.
As the needle is inserted and
manipulated in the superficial layer of the body, no
muscle twitch is expected.
In deep DN, needles are
inserted deep into the tissues directly toward the
trigger points in order to reach them.
pecking, whereby solid filiform needles are manipu-
lated in and out of each trigger point to elicit a local
twitch response, is commonly used with treatment
regimens typically consisting of a course of three or
more treatments, given once a week.
Dunning et al
states that needles (one or more) are
left in situ for between 10 and 30 min, DN practice
by PTs is typically fast-in and fast-out, often
described as pistoning, and does not usually involve
needle retention.
Most studies do not specify the
angle of needle insertion, but the conventional
needling technique usually involves perpendicular
penetration of the skin.
History of acupuncture
DN has been intertwined with acupuncture since its
inception. Meta-analyses of acupuncture or DN for
myofascial pain have included studies in both fields in
order to decrease bias and strengthen the validity of
the results.
Results of research into the effects of
needling can often be applied to both DN and acu-
puncture. The term acupuncture originally referred to
the ancient healing technique originating from China
2000 years ago, which has been widely practised all
over the world as a professional practice in the field
of complementary and alternative medicine. TA
involves the stimulation of specific points on the body,
based upon the theoretical meridian concept, via
penetration by solid filiform needles.
Original acu-
puncture instruments were made from so-called bian
stones. With the introduction and application of iron
instruments, bian stone needles were replaced by
medical needles made of metal. Acupuncture theories
and techniques have been expanded and optimised by
the contribution of acupuncturists of the various time
periods throughout history. Since the inception of
Chinese culture, acupuncture has been used as one of
the major tools for the restoration and maintenance
of health in China.
Acupuncture likely emerged in the USA in the late
1800s when large numbers of Chinese workers
migrated to the west coast to build railways; however, it
made its official debut in 1971 when journalist J
published an article in the New York Times
describing his personal experience with acupuncture,
followed by the visit of US President Nixon to China in
1972. In the UK, physicians were reported to have been
needling tender points to relieve musculoskeletal pain in
the 1800s, and interest in acupuncture surged in the
Ever since then, acupuncture has become more
and more popular in major western countries.
to its growing popularity and an accumulation of
research evidence, acupuncture, particularly WMA, has
been widely integrated into the practice of conventional
healthcare in major western countries.
Theories of acupuncture
Classical theories and principles of point selection in
TA are based on historical concepts of balancing Yin
and Yang and dredging meridians . Such theories are
used to differentiate TA from WMA. Nowadays, both
classical theory and modern biomedical sciences are
included in the education of acupuncturists in China
and around the world. Besides TA, the contemporary
version, WMA, which is based on the understanding
of human anatomy, physiology, and pathology, is also
widely practised, especially among physicians and
other healthcare professionals.
One example of
Education and practice
Zhou K, et al. Acupunct Med 2015;33:485490. doi:10.1136/acupmed-2015-010911 487 on December 12, 2015 - Published by from
WMA is peripheral neuromodulation, in which practi-
tioners stimulate somatic nerves in order to influence
autonomic nerves (via somatovisceral reflexes).
21 22
A special category of acupuncture points are the ah
shi (translated as ouch) points, which include acu-
puncture points that are tender to touch or pressure,
with a similar definition to trigger points. Dorsher
reported that the distribution of trigger points has a
95% overlap with acupuncture points in the treatment
of pain disorders. Thus, in pain conditions, trigger
points may represent similar (if not the same) physio-
logical phenomena as acupuncture points.
Acupuncture procedure
Acupuncture involves many different techniques with
various types and lengths of needles depending on the
condition and the acupuncture point location. The
commonly used procedure for musculoskeletal pain
involves ah shi points with treatment protocols similar
to DN but with needle retention. Traditionally, acu-
puncture point selection and treatment is based on
syndrome differentiation, which incorporates inspec-
tion (including the tongue), palpation (including the
pulse), and systematic inquiry. This is the process that
many acupuncturists and Traditional Chinese
Medicine practitioners use to generate a traditional
diagnosis, treatment principle and plan.
Acupuncturists usually emphasise de qi sensations
during treatments.
De qi refers to a composite of
sensations including local muscle twitches and propa-
gation of sensation upon needling.
Historically, de qi
sensation has been considered to be the foundation
for the therapeutic effectiveness of acupuncture for
and this is supported by research demonstrat-
ing that the stimulation of A-delta afferent nerves that
is associated with the de qi sensation
is important in
mediating the clinical effects of acupuncture.
Most acupuncture procedures last 3045 min and
involve a perpendicular needle insertion. It is worth
noting that during the same time period that DN was
developing in the western world, Professor Dinghou
Lu and colleagues at Beijing Sports University strongly
advocated needling at tender (ah shi) points using an
oblique angle, as this gave better therapeutic effects in
myofascial pain compared with vertical needle
During the past two decades, tremendous progress has
been made investigating the mechanisms of action
underlying the effects of needling on the musculo skel-
etal and nervous systems. Besides the widely recog-
nised gate control theory and regulation of the
endogenous opioid system,
two other major findings
worth noting are the regulation of the purinergic sig-
nalling system and stretch-like needling effects in the
musculoskeletal system.
Researchers in China and
the USA have demonstrated that acupuncture induces
an immediate local increase in adenosine (part of the
purinergic signalling pathway) in both humans and
29 30
Adenosine has not only been found to
be involved in pain modulation, but is also a vital
source for energy for muscles.
Interestingly, besides
pain relief, needling of muscle has been found to
increase muscle strength and improve the range of
movement at joints.
These effects of needling are
suggested to be similar to those of stretch in physical
exercise. Langevin et al
reported that acupuncture
functions like physical stretch, activating fibroblasts
that trigger signal transduction pathways at the
molecular level. Fibroblasts not only produce proteins
that make up the extracellular matrix, but also trans-
form into myofibroblasts to repair injury via produc-
tion of collagen and α smooth muscle actin protein.
Findings from research studies on the mechanisms
of action underlying the effects of needling not only
explain why needling per se is effective for musculo-
skeletal pain treatment,
but also account for the
growing use of DN in the musculoskeletal field
including sports medicine. Needling may thus
improve muscle performance, although large, high
quality research studies are needed to determine the
optimal parameters of needling, including location
and direction of needle insertion, duration of needle
retention, the requirement for a local twitch response
or de qi sensation, the frequency of treatments, and its
potential role as a preventive measure. As convention-
ally trained healthcare professionals are usually well
equipped with profound knowledge about the muscu-
loskeletal system, and acupuncturists are usually well
trained in needling procedures, collaborations
between these professionals may help optimise the use
of needling therapy in musculoskeletal conditions.
Questions surrounding the practice of DN and its rela-
tionship with acupuncture exist among patients and
clinicians. Acupuncture overlaps with DN with
respect to needling instruments, technique, and its
widespread use in disorders of the musculoskeletal
system. Additionally, both WMA and DN are based
on modern biomedical understandings of the human
body. Acupuncture points (including ah shi points)
and trigger points overlap significantly in the treat-
ment of pain; localised muscle twitches in DN and de
qi sensations in acupuncture, respectively, are used as
prognostic criteria to predict the effectiveness of need-
ling. As stated by White and colleagues in the defin-
ition of WMA,
variations include subcutaneous
needling over tender muscle trigger poin ts. Thus, DN
should be recognised as a subcategory of WMA.
As physicians are well trained in needling proce-
dures, pathophysiology and the management of
common disorders, their practice of WMA (including
Education and practice
488 Zhou K, et al. Acupunct Med 2015;33:485490. doi:10.1136/acupmed-2015-010911 on December 12, 2015 - Published by from
DN) can generally be considered safe. However, a
dispute exists regarding the practice of DN by health-
care professionals who are not physicians or acupunc-
turists and may lack the necessary training. For the
interests of patients, greater effort should be paid to
identifying solutions to the dispute rather than ques-
tioning the legitimacy of DN practice by other health-
care professions.
Although needling therapy has been proven to be
safe in general, healthcare professionals who are not
physicians or acupuncturists need to develop their
competence in order to provide skilled and proficient
treatment and to prevent possible adverse events
related to needling. Besid es the establishment of a
regulatory body to accredit DN courses, so that stan-
dards are set to guarantee patient safety and optimal
outcomes, needling practice per se and the use of DN
to treat patients should require formal and compre-
hensive education and training, which should include
the essential biomedical education and training in
needling skills needed to practise DN safely. This will
add credence and strengthen the capability of these
healthcare professionals in the practice of DN for the
treatment of musculoskeletal disorders.
DN and acupuncture overlap with respect to needling
techniques using solid filiform needles as well as some
fundamental theories. DN should be recognised as
one subcategory of WMA. The establishment of a
regulatory body to accredit DN courses and a formal
and comprehensive education and training pro-
gramme are needed to support its practise by health-
care professionals who are not physicians or
acupuncturists. Because of the close relationship
between DN and acupuncture, collaboration rather
than dispute between acupuncturists and other health-
care professionals should be encouraged with respect
to education, research, and the practice of needling
for the benefit of patients with musculoskeletal pain
who require needling therapy.
Contributors KZ conceived the idea and drafted the article.
MSB provided constructive guidance and feedback. YM
co-authored a portion of the article.
Competing interests None declared.
Provenance and peer review Not commissioned; externally
peer reviewed.
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ongoing debate
Dry needling versus acupuncture: the
Kehua Zhou, Yan Ma and Michael S Brogan
doi: 10.1136/acupmed-2015-010911
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... However, they have differences regarding the needling procedure (procedure duration, orientation of needle, etc) and the target structure (acupuncture points vs myofascial trigger points). 15 The Hoffmann reflex (H reflex) evoked by electrical pulses applied on peripheral nerves and recorded in corresponding muscles is a tool to quantitatively evaluate spinal processing in normal and pathological conditions. 16 When the H reflex is produced by consecutive pulses at stimulation frequencies ≥1 Hz, a Rate-Dependent Depression (RDD) of the H reflex occurs. ...
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Background: Spasticity is a common symptom of multiple sclerosis (MS) which affects mobility. Dry Needling (DN) has shown a reduction in spasticity in neuromuscular conditions such as stroke and spinal cord injury although the mechanism of action is still unclear. In spastic individuals, the Rate-Dependent Depression (RDD) of the H reflex is decreased as compared to controls and analyzing the effects of DN in the RDD may help to understand its mechanism of action. Objective: To evaluate the effect of Dry Needling on spasticity measured by the Rate-dependent Depression (RDD) of the H reflex in an MS patient. Methods: Three time points were evaluated: Pre-intervention (T1), Post-intervention assessments were carried out in the seventh week at two-time points: Before DN (T2) and After DN (T3). Main outcomes included the RDD and latency of the H reflex in the lower limbs at stimulation frequencies of 0.1, 1, 2, and 5 Hz in a five consecutive pulses protocol. Results: An impairment of the RDD of the H reflex at frequencies ≥1 Hz was found. Statistically significant differences were found when comparing the mean RDD of the H reflex in Pre-intervention compared to Post-intervention at 1, 2, and 5 Hz stimulation frequencies. Mean latencies were statistically lower when comparing Pre- vs Post-intervention. Conclusion: Results suggest a partial reduction in spasticity represented by decrease of the excitability of the neural elements involved in the RDD of the H reflex following DN. The RDD of the H reflex could be implemented as an objective tool to monitor changes in spasticity in larger DN trials.
... 880.5580 Acupuncture needle, an acupuncture needle is a device intended to pierce the skin in the practice of acupuncture" 19 . In myofascial trigger point therapy, the neural processes of acupuncture and dry needling treatments and the localization of trigger points and classical acupuncture points are highly compatible. ...
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Complementary and alternative therapies (CAM) are methods for the prevention, diagnosis and treatment of diseases based on various cultural beliefs and experiences that are not currently considered part of modern medicine. In recent years, the integration of CAM applications into healthcare systems all over the world has led to an increase in their use and frequency, and it has also increased the necessity and expectation of evidence-based practices. In this review, it was aimed to examine the alternative treatment methods that are frequently used in different conditions, their mechanisms of action, and their application within the framework of scientific evidence. For this purpose, popularly used complementary and alternative therapies for musculoskeletal conditions (dry needling, instrument-assisted soft tissue mobilization, dry cupping), neurological conditions (acupuncture, reflexology), and other conditions such as cancer and metabolic diseases (yoga) were examined.
... O dry needling, também conhecido como agulhamento a seco, é uma técnica que envolve a penetração de agulhas de acupuntura em regiões com formação de trigger points (nódulos) e permite tratar várias condições dolorosas do sistema musculoesquelético, uma vez que, é baseado na ciência biomédica moderna, e realiza a inserção de agulhas no músculo e não em pontos de acupuntura, diferenciando-se, desse modo, da acupuntura sistêmica (Zhou, Ma & Brogan, 2015;Fernández-De-Las-Peñas & Cuadrado, 2016). ...
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Objetivo: Analisar a aplicação do dry needling no controle do quadro álgico e funcionalidade de participantes com dor crônica cervical. Metodologia: Foi realizado um estudo clínico não randomizado de antes e depois, com 15 participantes de ambos os gêneros, entre 20 e 60 anos com dor crônica cervical. Após os participantes assinarem o termo de consentimento livre e esclarecido, foram submetidos a uma avaliação geral com anamnese e exame físico, aplicação da Escala Visual Analógica de Dor, Escala Funcional de Incapacidade do Pescoço de Copenhagen e o Índice de Incapacidade Relacionada ao Pescoço. A técnica foi realizada durante um mês, uma vez por semana, totalizando quatro sessões de vinte minutos cada. Resultados: Os resultados sugerem que a aplicação do dry needling nos pontos previamente estabelecidos proporcionou melhora significativa (p£0.05.) no quadro de dor, incapacidade e funcionalidade após o tratamento. Conclusão: Com base nos resultados do presente estudo, foi evidenciado que a técnica dry needling apresentou desfechos positivos no controle do quadro álgico e funcionalidade.
... Exclusion criteria were: 1) trials evaluating the effect of acupuncture/electroacupuncture combined with other treatments that were not used in control groups; 2) trials evaluating the efficacy of dry needling at myofascial trigger points (because the relationship between dry needling and acupuncture is still a subject of debate) [18]; 3) trials with healthy volunteers; and 4) trials using other sham methods as placebo control (transcutaneous laser or transcutaneous electrical stimulation). ...
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Background Along with increasing research on acupuncture for chronic pain, the validity of sham acupuncture (SA) has also been argued. Methods Nine databases were searched for randomized controlled trials (RCTs) from the inception date to July 5, 2022. Using Markov Chain Monte Carlo methods, a Bayesian multiple treatment network meta-analysis (NMA) with random-effects model was conducted. Results A total of 62 RCTs with 6806 patients and four kinds of treatments (real acupuncture (RA), non-acupuncture (NA), penetrative SA (PSA) and non-penetrative SA (NPSA)) were included. The results indicated that both NPSA and PSA were not superior to NA in improving chronic pain (NPSA: MD -4.77 [95% CI, -11.09 to 1.52]; PSA: MD, -4.96 [95% CI, -10.38 to 0.48]). After combining NPSA and PSA into the SA group, the weak trend of pain relief from SA was still not statistically significant (MD, -4.91 [95% CI, -9.93 to 0.05]). NPSA and PSA had similar effects (MD, 0.18 [95% CI, -5.45 to 5.81]). RA was significantly associated with pain relief, compared with NPSA and PSA (NPSA: MD, -12.03 [95% CI, -16.62 to -7.41]; PSA: MD, -11.85 [95% CI, -15.48 to -8.23]). The results were generally consistent regardless of pain phenotype, frequency, duration, acupuncture methods, analgesic intake, or detection bias. Conclusion These results suggested that acupuncture was significantly associated with reduced chronic pain. The two kinds of placebo acupuncture, NPSA and PSA, have similar effects. Both NPSA and PSA, with a weak but not significant effect, are appropriate to be inert placebo controls in RCTs for chronic pain.
... 12,13 The main difference between acupuncture and DN is that the former uses standardised points as a reference, whereas the latter targets painful areas and MTPs. 14 DN has become increasingly widespread in clinical practice, particularly among physiotherapists specialising in pain management, 15,16 and has proven to be effective for the management of myofascial pain in such areas as the trunk and the upper and lower limbs. 17,18 However, few studies have evaluated its effectiveness for the management of craniofacial pain. ...
Introduction Non-pharmacological treatment of patients with headache, such as dry needling (DN), is associated with less morbidity and mortality and lower costs than pharmacological treatment. Some of these techniques are useful in clinical practice. The aim of this study was to review the level of evidence for DN in patients with headache. Methods We performed a systematic review of randomised clinical trials on headache and DN on the PubMed, Web of Science, Scopus, and PEDro databases. Methodological quality was evaluated with the Spanish version of the PEDro scale by 2 independent reviewers. Results Of a total of 136 studies, we selected 8 randomised clinical trials published between 1994 and 2019, including a total of 577 patients. Two studies evaluated patients with cervicogenic headache, 2 evaluated patients with tension-type headache, one study assessed patients with migraine, and the remaining 3 evaluated patients with mixed-type headache (tension-type headache/migraine). Quality ratings ranged from low (3/10) to high (7/10). The effectiveness of DN was similar to that of the other interventions. DN was associated with significant improvements in functional and sensory outcomes. Conclusions Dry needling should be considered for the treatment of headache, and may be applied either alone or in combination with pharmacological treatments.
Background: There is a relationship between low back pain (LBP) and central nervous system dysfunction. Needling therapies (e.g. acupuncture, dry needling) are proposed to impact the nervous system, however their specific influence is unclear. Purpose: Determine how needling therapies alter functional connectivity and LBP as measured by functional magnetic resonance imaging (fMRI). Methods: Databases were searched following PRISMA guidelines. Studies using fMRI on individuals with LBP receiving dry needling or acupuncture compared to control or sham treatments were included. Results: Eight studies were included, all of which used acupuncture. The quality of studies ranged from good (n = 6) to excellent (n = 2). After acupuncture, individuals with LBP demonstrated significant functional connectivity changes across several networks, notably the salience, somatomotor, default mode network (DMN) and limbic networks. A meta-analysis demonstrated evidence of no effect to potential small effect of acupuncture in reducing LBP (SMD -0.28; 95% CI: -0.70, 0.13). Conclusion: Needling therapies, like acupuncture, may have a central effect on patients beyond the local tissue effects, reducing patients' pain and disability due to alterations in neural processing, including the DMN, and potentially other central nervous system effects. The meta-analysis should be interpreted with caution due to the narrow focus and confined sample used.
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Fibromyalgia (FM) is a syndrome that involves chronic pain, fatigue, sleep disturbance and impaired quality of life and daily functioning. In addition to medical and psychological therapies, other therapies including acupuncture and dry needling aim to reduce pain and disability in patients with FM. The aim of this study was to investigate the efficacy of dry needling and acupuncture in patients with FM regarding pain, function and disability in both the short and the long term. MEDLINE, PubMed, SCOPUS and Web of Science databases were systematically searched for randomized controlled trial studies evaluating efficacy data of dry needling or/and acupuncture treatments to improve pain, fatigue, sleep disturbance and impaired quality of life and/or daily function. A qualitative analysis including the methodological quality and a systematic data synthesis was performed. A total of 25 studies addressed the selection criteria. Most studies had an acceptable methodological quality. Four studies assessed the effect of dry needling, and twenty-one studies assessed the effect of acupuncture. In general, both interventions improved pain, anxiety, depression, fatigue, stiffness, quality of sleep and quality of life. However, both techniques were not compared in any study. Acupuncture and dry needling therapies seems to be effective in patients with FM, since both reduced pain pressure thresholds, anxiety, depression, fatigue, sleep disturbances and disability in the short term. It is still required to compare both techniques and their application in the long term.
Background: Dry needling (DN) is commonly used to treat myofascial trigger points (MTrPs). Objective: To compare the effect between DN with and without needle retention in the treatment of MTrPs in the upper trapezius muscle. Methods: Fifty-four patients who had active MTrPs in the upper trapezius muscle were randomly allocated into the DN group or the DN with retention group. The DN group received DN only, while the DN with retention group received DN with needle retention for 30 minutes. The visual analogue scale (VAS) and pressure pain threshold (PPT) were recorded both before and after 7 and 14 days of the treatment sessions. Results: Both groups showed a significant decrease of the VAS at 7 and 14 days (mean difference DN group -53.0, DN with retention group -57.0, p< 0.001). The PPT was also significantly improved in both groups (mean difference DN group 109.8 kPa, DN with retention group 132.3 kPa, p< 0.001). However, there were no significant differences in the VAS or PPT between the groups. Conclusions: Both DN and DN with retention had significant improvement of pain intensity in the treatment of MTrPs in the upper trapezius muscle at 14 days. However, pain reduction was not significantly different between the interventions.
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Background: Wet needling uses hollow-bore needles to deliver corticosteroids, anesthetics, sclerosants, botulinum toxins, or other agents. In contrast, dry needling requires the insertion of thin monofilament needles, as used in the practice of acupuncture, without the use of injectate into muscles, ligaments, tendons, subcutaneous fascia, and scar tissue. Dry needles may also be inserted in the vicinity of peripheral nerves and/or neurovascular bundles in order to manage a variety of neuromusculoskeletal pain syndromes. Nevertheless, some position statements by several US State Boards of Physical Therapy have narrowly defined dry needling as an ‘intramuscular’ procedure involving the isolated treatment of ‘myofascial trigger points’ (MTrPs). Objectives: To operationalize an appropriate definition for dry needling based on the existing literature and to further investigate the optimal frequency, duration, and intensity of dry needling for both spinal and extremity neuromusculoskeletal conditions. Major findings: According to recent findings in the literature, the needle tip touches, taps, or pricks tiny nerve endings or neural tissue (i.e. ‘sensitive loci’ or ‘nociceptors’) when it is inserted into a MTrP. To date, there is a paucity of high-quality evidence to underpin the use of direct dry needling into MTrPs for the purpose of short and long-term pain and disability reduction in patients with musculoskeletal pain syndromes. Furthermore, there is a lack of robust evidence validating the clinical diagnostic criteria for trigger point identification or diagnosis. High-quality studies have also demonstrated that manual examination for the identification and localization of a trigger point is neither valid nor reliable between-examiners. Conclusions: Several studies have demonstrated immediate or short-term improvements in pain and/or disability by targeting trigger points (TrPs) using in-and-out techniques such as ‘pistoning’ or ‘sparrow pecking’; however, to date, no high-quality, long-term trials supporting in-and-out needling techniques at exclusively muscular TrPs exist, and the practice should therefore be questioned. The insertion of dry needles into asymptomatic body areas proximal and/or distal to the primary source of pain is supported by the myofascial pain syndrome literature. Physical therapists should not ignore the findings of the Western or biomedical ‘acupuncture’ literature that have used the very same ‘dry needles’ to treat patients with a variety of neuromusculoskeletal conditions in numerous, large scale randomized controlled trials. Although the optimal frequency, duration, and intensity of dry needling has yet to be determined for many neuromusculoskeletal conditions, the vast majority of dry needling randomized controlled trials have manually stimulated the needles and left them in situ for between 10 and 30 minute durations. Position statements and clinical practice guidelines for dry needling should be based on the best available literature, not a single paradigm or school of thought; therefore, physical therapy associations and state boards of physical therapy should consider broadening the definition of dry needling to encompass the stimulation of neural, muscular, and connective tissues, not just ‘TrPs’.
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Objectives: To trace the development of the practice and theoretical basis of dry needling by means of an examination of the literature. Findings: The term dry needling arose from the need to provide a contrast to the injection of a fluid through a hypodermic syringe [now sometimes referred to as wet needling]. Dry needling does not involve the injection of any substance, merely the insertion of a needle. The history of dry needling is inextricably bound up with the search for effective treatment of painful musculoskeletal disorders. In particular, it was the research into the use of injections, to both cause and relieve pain in muscular tissue, that led to the development of trigger point theory and then to the use of dry needling as a treatment. Conclusions: A search of the literature reveals that the important clinical finding that simple dry needling of tender points could produce profound and long-lasting relief of musculoskeletal pain had been published in 1941 and again in 1947. This provoked little interest in the wider academic or clinical community until the focus on acupuncture in the 1970s and the publication of a scientific explanation of the nature of myofascial trigger points in the 1970s and 1980s. Since 2000, there has been a surge in academic interest in dry needling and its use has expanded into the allied health professions of physiotherapy, osteopathy, and chiropractic.
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Study design: Systematic review and meta-analysis. Background: Myofascial pain syndrome (MPS) is associated with hyperalgesic zones in muscle called myofascial trigger points. When palpated, 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 effectiveness 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 effect favoring dry needling. The findings of 2 studies 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 effect limits the impact of the effect. 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 effective 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 decreasing 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-.
Western medical acupuncture is a therapeutic modality involving the insertion of fine needles; it is an adaptation of Chinese acupuncture using current knowledge of anatomy, physiology and pathology, and the principles of evidence based medicine. While Western medical acupuncture has evolved from Chinese acupuncture, its practitioners no longer adhere to concepts such as Yin/Yang and circulation of qi, and regard acupuncture as part of conventional medicine rather than a complete "alternative medical system". It acts mainly by stimulating the nervous system, and its known modes of action include local antidromic axon reflexes, segmental and extrasegmental neuromodulation, and other central nervous system effects. Western medical acupuncture is principally used by conventional healthcare practitioners, most commonly in primary care. It is mainly used to treat musculoskeletal pain, including myofascial trigger point pain. It is also effective for postoperative pain and nausea. Practitioners of Western medical acupuncture tend to pay less attention than classical acupuncturists to choosing one point over another, though they generally choose classical points as the best places to stimulate the nervous system. The design and interpretation of clinical studies is constrained by lack of knowledge of the appropriate dosage of acupuncture, and the likelihood that any form of needling used as a usual control procedure in "placebo controlled" studies may be active. Western medical acupuncture justifies an unbiased evaluation of its role in a modern health service.
Pneumothorax is a well-recognised but rare adverse event related to acupuncture or deep dry needling (DDN) over the thorax.1 ,2 This report of a pneumothorax resulting from DDN is unusual for a number of reasons: both the practitioner and the subject were doctors and both have contributed to this report; the practitioner was very experienced in DDN and had not knowingly caused such an event in the previous 45 years of practice and teaching DDN; the incident was captured on video and is presented online with this report (see online supplementary video). We hope that by reporting this event and review of the video recording we can suggest ways to reduce the risk of reoccurrence of such adverse events of DDN. The setting was a hands-on workshop teaching the technique of DDN for the treatment of myofascial pain syndromes. The workshop used the format of lecture, demonstration on a volunteer, and then practice by the group in groups of two or three individuals at an examination couch. Safety procedures were emphasised for each muscle considered. The safety precautions included identification of landmarks each time one prepared to needle the subject and an awareness of the local anatomy and of possible complications. During the introduction to the demonstrations the complication of pneumothorax was discussed. Symptoms were described and the advice to go to the emergency department for a chest X-ray was given. The muscle to be demonstrated was the iliocostalis muscle, one of the erector spinae muscles. RR-M volunteered to be the subject. The lecturer emphasised the danger of pneumothorax and spoke of the technique of ‘blocking’ the rib by placing a finger …
Acupuncture is a safe procedure when performed by a trained health professional,1 and sound anatomical knowledge is pivotal in the training process. Pneumothorax is the most common serious traumatic complication of acupuncture.2 I believe your readers will be interested in the diagnosis and management of a pneumothorax sustained by a student at the 2nd Post-Graduation Course on Medical Acupuncture of the University of Minho. Surface and functional anatomy and needling safety have been mainstays at the Medical Acupuncture Post-Graduation Courses held in both the Medical Sciences Faculty at the New University of Lisbon and at the Health Sciences School of the University of Minho. In a total of six programmes, over 120 medical doctors have been trained. This is the first serious adverse event sustained during training. A 30-year-old male medical doctor attended the training programme. His weight was 62.5 kg, height 169 cm, body mass index of 21.9 and no prior smoking habits. He reported mild chest pain and respiratory crepitus the day after an acupuncture training session. The symptoms started about 1 h after having been needled on the right anterior scalene by one of the instructors (with more than 10 years of experience in needling). Earlier the same day, needling of the thoracic and lumbar erector spinae and upper trapezius muscles by other students had been performed under supervision. Needling of the anterior scalene was performed after location of anatomical landmarks (clavicle, posterior border of the clavicular head of the sternocleidomastoid and external jugular vein) and identification of the anterior scalene by …
We report on a patient with a rare case of bilateral tension pneumothorax that occurred after acupuncture. A 69-year-old large-bodied man, who otherwise had no risk factors for spontaneous pneumothorax, presented with chest pressure, cold sweats and shortness of breath. Immediately after bilateral pneumothorax had been identified on a chest radiograph in the emergency room, his blood pressure and percutaneous oxygen saturation suddenly decreased to 78 mm Hg and 86%, respectively. We confirmed deterioration in his cardiopulmonary status and diagnosed bilateral tension pneumothorax. We punctured his chest bilaterally and inserted chest tubes for drainage. His vital signs promptly recovered. After the bilateral puncture and drainage, we learnt that he had been treated with acupuncture on his upper back. We finally diagnosed a bilateral tension pneumothorax based on the symptoms that appeared 8 h after the acupuncture. Because the patient had no risk factors for spontaneous pneumothorax, no alternative diagnosis was proposed. We recommend that patients receiving acupuncture around the chest wall must be adequately informed of the possibility of complications and expected symptoms, as a definitive diagnosis can be difficult without complete information.