Trigger Point Dry Needling- FAQ

Trigger point dry needling is a relatively new modality, especially in North Carolina where PTs have been able to perform this for just over 5 years. Although its clinical availability has proliferated in the past couple years, many clients/patients are equally unfamiliar with it, athletes and medical practitioners alike. Even some PTs have not had exposure to this relatively new manual therapy.

In parlance with all things PT, education is critical in helping patients understand the role needling will play in their recovery. Every patient I work with gets a great deal of education about what I'm doing, what the goal is, and why I'm doing it: why else would a patient subject themselves to repeated needle sticks. When you operate in a direct pay environment, patients are more invested in every visit and every dollar spent. 

Additionally, many physicians, our primary referral source and advocates, are still unfamiliar with dry needling. I've heard a range of responses from physician colleagues including support for 'holistic care,' claims that dry needling is only a placebo, and doubts as to whether PTs know their anatomy well enough to perform this modality. I've seen referrals from physicians for dry needling that were not appropriate applications of needling. 

As needling grows in popularity, PTs have work to do in educating not just patients, but also medical practitioners. Dry needling is an evidence based modality with power clinical utility that has been a hotly contested issue in courts across the country. Unfortunately, its legitimacy remains sub-par as seen by a refusal by Medicare and some other insurances to reimburse for this service. My name is Allan Buccola and today's post serves to address some of the most frequently asked questions regarding dry needling. Please read on, even if you're 'asking for a friend.' 

Does Dry Needling Hurt? 

The answer is complicated, but often I say no. Reason being, when patient's ask this question, they typically want to know if it will hurt in a concerning and poorly tolerated way. In practice, many patients tell me that it 'hurts so good,' alluding to a soreness that arguably feels productive, similar to a stretch. 

Dry needling is often uncomfortable when done correctly, but extremely similar to an intense deep tissue massage. The acupuncture-style needles used are extremely thin, often not detected by the patient when placed in normal, healthy tissue. When a trigger point is successfully needled, it creates a deep, heavy, achy feeling.

As with any modality, a skilled practitioner takes their clients' comfort into consideration. Technique can be modified to increase comfort for the patient, emotionally and physically. Needles are significantly smaller than those used to inject medications, hence rarely does a patient report it feeling similar in nature. 

Is Dry Needling Acupuncture? 

In no way are acupuncture and dry needling the same thing. This is an important distinction because the goals of these two modalities are very different. The type of needle is essentially the same, but the similarities end there. Acupuncture is rooted in principles of Chinese medicine, with an intent to rectify one's chi. Dry needling is based on principles of Western medicine. 

Why Is Dry Needling 'Dry'? 

In the 1960s when physicians first started acknowledging and treating the phenomenon of trigger points and muscle generated pain, one common approach was a localized injection of analgesic, or pain killer, such as lidocaine. After countless clinical observations and subsequent research, scientists found that just as much pain relief was elicited from the insertion of the needle alone, without any injection at all, hence the term dry.

PTs in the US are not licensed to perform injections of medications, and dry needling does not involve the use of medications. The relief is the result of a mechanical interaction between the needle and the micro structure of the muscle. Some physicians, osteopaths, and physiatrists still perform trigger point injections, but PTs do not. 

What Types of Problems Will Dry Needling Help?

Dry needling addresses muscle dysfunction associated with isolated taught bands of muscle tissue within a relaxed muscle. These isolated, knotted-up areas create localized anoxia, cutting off their own blood supply. Subsequent chemicals released can chemically or neurologically inhibit the adjacent muscle tissue, causing the entire muscle to function poorly, and sometimes can even cause isolated or referred pain.

My high performance athletes often notice a lack of muscle performance first. My less active patients, often recognize pain as the first symptom. It is common to have latent trigger points, knots in the tissue that are below the threshold of causing pain or performance deficits, but these are not typically the target of dry needling, because as they say: 'if it ain't broke[n]- don't fix it!'

Dry needling, by definition targets muscle tissue. To get to the muscles, no doubt the needle will pass through skin, subcutaneous tissue, fat, fascia, and occasionally small vascular tissue, as well as other structures, but these are not the target tissue.

Does Dry Needling Help With Tendonitis?

Dry needling is almost never the sole treatment solution for any problem, however, many clinical cases of tendinitis are closely related to poor loading capacity of the tendon, which would in part is related to poor loading capacity of the muscle. I often find that trigger points related muscle dysfunction precedes a tendon problem.

A wise clinician will address the whole system, not just the tendon. The best recent evidence supports progressive loading as the most appropriate solution to tendinopathy. This cannot be achieved if the muscle is knotted up and under-performing. Dry needling can often be useful in this regard, but very rarely to my knowledge is the tendon a direct target of the needle itself. I am not aware of any of the recent tendon literature that supports this approach. 

What Other Problems Benefit From Dry Needling?

Physical therapists treat a variety of conditions, however nearly any problem that involves aggravation of muscle tissue with a decrease in muscle performance and/or resultant pain will likely benefit. Often the patient's response to the first needling session can be the best indicator. 

Best case scenarios that come to mind are acute low back pain that involves muscle spasm generated pain, shoulder pain from prolonged immobilization in a sling, muscle overuse injury in endurance sports, and postural muscle pain in head, face, and neck. Dry needling is also a powerful tool in muscles too deep to effectively palpate with fingers, typically thick or deep muscles such as the gluteals, hamstrings, calves, and spine stabilizers. 

How Does Dry Needling Fit Into a Treatment Plan? 

This will vary with each patient, but there are some consistencies. The time needed to address the problem is often driven by the chronicity of the problem, as a muscle that has been in knots for 3 years, hasn't functioned in a normal way in three years. Often the entire system has been moving differently and will need to be retrained.

Dry needling is often used to address the contractile components of the muscle, the ones that shorten when activated. Other forms of manual therapy make a great adjunct after needling to address the surrounding soft tissue. 

Early on, I typically emphasize frequent low tension stretching and low load muscle activation to begin reconditioning the muscle to function better as a singular unit. Once symptoms are stable and the tissue is more tolerant to activity, a loading program is almost always the next step to improve the functional capacity of the muscle.

For athletes, the last step is a gradual transition to progressive plyometric loading. I find that patients that don't follow through with these last two steps are likely to sustain reinjury. 

Does Dry Needling Address Fascial Restrictions? 

For the average person, understanding the difference between fascia and muscle is difficult. As I vegan, I still like to use animal-based food references to explain anatomy from time to time. Many can relate to the experience of eating a drum stick or turkey leg and appreciate that the meat comes off the bone in layers, not just a singular piece of tissue from skin to bone. These layers are separated by fascia. If you think of individual muscles as sausage links, the fascia would be the casing. 

Fascial restrictions are different from trigger points, although they can occur together.  I like to characterize a trigger point as a run in your stocking, wherein a single band of tissue is notably tighter than surrounding tissue and causes a disruptions to the continuity of the entire unit. You can try to stretch your stocking out, but ultimately that run remains. This is akin to stretching a muscle with a trigger point: there may be some relief, but often the trigger point goes nowhere. 

Generalized fascial restrictions are more akin to when you first take your blue jeans out of the dryer. There is some generalized tightness in all of the tissue, that when stretched out eventually comes back to the soft, comfy fit you might be used to. Unfortunately, until your jeans are stretched back out, it will restrict your normal movement, and when fascia is tight, it has the same effect on the muscle tissue.

 Dry needling and myofascial release often go hand-in-hand

Dry needling and myofascial release often go hand-in-hand

There are a number a conditions that might lead to fascial restrictions that are beyond the scope of this article, however I most commonly see it in patients who are immobilized after a sprain or surgery. I also tend to see it in patients who have had trigger points for months-years, where the trigger point never resolved and overtime, the fascial tissue surrounding is has adaptively shortened. In these, patients, dry needling to release the trigger points will be minimally effective if the fascia is not also addressed through some other means of manual therapy. 

Is Dry Needling For Everyone?

Not at all. Some patients will not be medically appropriate for this type of manual therapy, and others will not be good candidates due to fears or anxieties over needles. Only in special circumstances is dry needling used on children or the frail. A small minority of patients have abnormal responses that would indicate an alternative modality in its place.

There are also a number of patients who will present with myofascial pain related to an underlying neurological condition like spinal stenosis, cerebral palsy, multiple sclerosis, stroke, or brain injury. There is minimal evidence and less clinical anecdote that dry needling will provide long-term benefit to patients. This is taken into account, even after recognizing that regular stretching can be very helpful approach to pain management in some of these patients. 

For those who are appropriate, dry needling is not the only way to go about addressing trigger points. I like to personally use it as it seems to provide a faster result than other modalities I use. It's ideal for muscles too deep to palpate, such are the multifidus, tibialis posterior, quadratus plantae, and pterygoids. Regardless, I have plenty of patients who are not interested, and fare just as well with other approaches even if they might take a bit longer. 

If you have comments or questions about dry needling from a patient or clinician perspective, please feel free to contact me. The goal of this post is to educate, but also to generate some conversation about a relatively new modality. 

Until next time, don't stop moving! 

-Allan