Dry Needling versus Manual Therapy

This week's blog was co-written by Joe LaVacca and Taylor Huang, SPT.  Taylor is a student of physical therapy, and has certifications in SFG Level I kettlebell, pilates, TRX and yoga. She has been involved in weight training, powerlifting, and have taken various courses in PNF, FMT, FR and FMS. Currently, she is training for SFG Level II kettlebell and Crossfit Level 1 trainer. On any given day, you can find her training her clients in the park, being creative in the kitchen or taking a run across town.

In recent months/years the conversation of the benefits of dry needling have continued to gain momentum and favor in the rehab world.  A growing number of  professional organizations, such as the NYPTA, continue to lobby for legislation to allow physical therapists to include such intervention in our practice acts.  Currently, there is nothing stating that physical therapists "can" perform dry needling, but there is nothing saying we "cannot" in New York State.  There are many issues at hand as to why there is debate, but perhaps a better question is simply, "Does it work better then manual therapy?"  As a physical therapist we emphasize hands on skills and care when treating patients - this can be taxing when performed repeatedly and it is often difficult to distinguish what tissues we are actually treating/manipulating unless trained correctly.  The theory of dry needling involves the treatment of myofascial pain by direct treatment of muscular trigger points.  

Trigger points are described as tender, sensitive spots within skeletal muscle fibers that correlate to a patients specific symptoms or referral pattern.  These taut bands are likely more neurological in nature than they are muscular.  One of my favorite quotes was from Erson Religioso who said, "Cadavers do not have trigger points."  So while patients may report "knots" in their tissue this is likely more increased electrical impulses then truly restricted tissue.  An important concept to remember is that some things simply "hurt" when they are pressed on - just like that "knot" in your upper trap/neck, or the "spot" outside of your elbow.  Just because something hurts when it is touched does not mean it needs to be released, taped, or needled unless it corresponds to your primary complaint or dysfunction.  With that being said, a true trigger point is capable of producing both local and referred pain, can restrict movement, and are actually considered a major source of pain in ~30% of individuals with musculoskeletal dysfunction.  

Pictured here is an example of how a trigger point of the scalene musculature of the neck can have an impact through the entire upper quarter and arm of patients in pain.  

Pictured here is an example of how a trigger point of the scalene musculature of the neck can have an impact through the entire upper quarter and arm of patients in pain.  

The mechanism as to how trigger point dry needling affects trigger points is not fully understood, however, several  theories have been suggested.  The taut bands felt in trigger points restrict capillary circulation causing the muscle to rely on anaerobic energy, thereby resulting in subsequent accumulation of increasing levels of lactic acid and pain.  In theory the proposed effects of dry needling include disturbance of motor end plates, stretch of contracted cytoskeletal structures, and relaxation of the locked actin-myosin bands which in turn results in restoration of the muscle fiber to an appropriate length and simultaneously increases circulation and decreases lactic acid levels.  

The "Actin-Myosin Cross Bridge" is one theory on how muscle fiber is recruited or contracted.  When a muscle is activated these fibers theoretically slide over one another forming a bond in order to release energy/potential within a motor unit.  

The "Actin-Myosin Cross Bridge" is one theory on how muscle fiber is recruited or contracted.  When a muscle is activated these fibers theoretically slide over one another forming a bond in order to release energy/potential within a motor unit.  

To date, only one study has been conducted comparing the effectiveness of dry needling to manual therapy in the management of chronic neck pain.  There have not been any additional published studies comparing the effectiveness of dry needling and manual therapy in the management of upper quarter or lower quarter myofascial pain.  Upon being studied independently, both dry needling and manual therapy appear to be effective interventions in the management of upper quarter myofascial pain associated with trigger points. However, in the only study to directly compare the two interventions it seems that one method is not superior to the other in providing improved outcomes in disability, pain, or cervical range of motion.  At least not yet.

As dry needling is a newly emerging skill in the field, it is difficult to use evidence-based practice to guide treatment with the limited number of studies analyzing the technique.  Moreover, as of March 2014, only 33 states in the United States allow the legal usage of dry needling as a physical therapy intervention.  Thus, the results of studies comparing dry needling to placebo or controls may be appealing to therapists nationwide and serve as the basis for promoting it into clinical practice, however it is likely going to be years before it is made accessible to the rest of the 17 states.  

Dry needling has received considerable attention in literature, but it appears future research needs to be conducted before it will be considered a long-standing physical therapy intervention or more importantly deemed more beneficial then traditional manual therapy.

Until next time, Happy Rehabbing!

Do you practice in a state that allows Dry Needling?  If so share your experiences and patient outcomes and how it has improved (or not improved) your practice.

 

REFERENCES

Bron C, Dommerholt JD. Etiology of Myofascial Trigger Points. Current Pain and Headache Reports. 2012;16(5):439-444. doi:10.1007/s11916-012-0289-4.

Abbaszadeh-Amirdehi M, Ansari NN, Naghdi S, et al. The neurophysiological effects of dry needling in patients with upper trapezius myofasical trigger points: study protocol of a controlled clinical trial. BMJ Open. 2013; 3:e002825. Doi:10.1136/bmjopen-2013-002825

Myofascial pain syndrome. Mayo Clinic website http://www.mayoclinic.org/diseases-conditions/myofascial-pain-syndrome/basics/preparing-for-your-appointment/con-20033195. Updated Dec. 09, 2014. Accessed March 2, 2015.

Kietrys DM, Palombaro KM, Azzaretto E, et al. Effectiveness of Dry Needling for Upper-Quarter Myofascial Pain: A Systematic Review and Meta-analysis. J Orthop Sports Phys Ther. 2014; 43(9): 620-634.

Lucy W Ferguson, Robert Gerwin. Clinical Mastery in the Treatment of Myofascial Pain. Lippincott Williams & Wilkins; 2004. Tennis Elbow; p. 132.

Llamas-Ramos R, Pecos-Martin D, Gallego-Izquierdo T, et al. Short-Term Outcomes Between Trigger Point Dry Needling and Trigger Point Manual Therapy for the Management of Chronic Mechanical Neck Pain: A Randomized Clinical Trial. J Orthop Sports Phys Ther. 2014; 44(11): 852-861.

Mejuto-Vazquez MJ, Salom-Moreno J, Ortega-Santiago R, et al. Short-term changes in neck pain, widespread pressure pain sensitivity, and cervical range of motion after the application of trigger point dry needling in patients with acute mechanical neck pain: a randomized clinical trial. J Orthop Sports Phys Ther. 2014; 44(4): 252-261.

Pecos-martín D, Montañez-aguilera FJ, Gallego-izquierdo T, et al. Effectiveness of dry needling on the lower trapezius in patients with mechanical neck pain: a randomized controlled trial. Arch Phys Med Rehabil. 2015. doi:10.1016/j.apmr.2014.12.016.