Dry needling for physical therapy. Have you heard of it? Many people have at this point, but what exactly is it anyway?
It's a technique performed by physical therapists, chiropractors, acupuncturists, certified athletic trainers, and some physicians or physician assistants, all depending on training and each profession's individual practice act.
I am a licensed physical therapist with many hours of training in this unique skill myself. It's a technique I incorporate into almost every treatment, though the rationale for using it may differ depending on the patients' needs and what I'm trying to change.
In this blog post, I'll lay out just exactly what it is, how it differs from acupuncture, how it works, what it feels like, and why I incorporate it into almost every treatment in the outpatient clinic for musculoskeletal or neuromuscular conditions. I will be speaking of the use of dry needling for physical therapy treatment only.
Dry Needling 101: definition, terms, and practitioners
Dry needling is a technique where a small monofilament needle is inserted into a muscle, or in certain instances near a nerve, in order to provoke change. The sought-after change may be to reduce pain, make changes to muscle tone, improve muscle activation, or alter the neuromuscular function of tissue, joints, or movement patterns. Treatment can improve the quality of a muscle contraction or change how the brain interprets the experience of certain movements. I'll go into the "how" a little further down. It is called dry needling because nothing is being injected; it's a dry, sterile needle. In fact, there is no lumen (hole) in the needle at all.
There are a few different terms that some physical therapists will use to talk about dry needling. The first one is, well, simply Dry Needling (DN). I think of that term as the over-arching umbrella, catch-all term for this technique.
Then there's Trigger Point Dry Needling (TPDN). Typically, clinicians who use this term assume muscles have an abnormally tight and tender band of tissue - called a trigger point - within it when palpated, and utilizing TPDN in this case will break that cycle and restore muscle tissue to its healthy form once more. There are multiple models out there theorizing what causes the initial trigger point. One is where there has either been injury to - or increased demand on - a muscle that ultimately causes shortening of the sarcomeres (the basic contractile unit of muscle fiber), which in turn compromises local circulation and blood supply, creating the trigger point. Another is there is abnormal function at the motor end plate or neuromuscular junction (think where a nerve interacts with muscle to make it contract) causing ongoing tissue dysfunction and ultimately an imbalance of chemicals needed to make a muscle function properly. A third theory is that compression of a nerve at the spinal segment will ultimately lead to shortening of surrounding muscles, which causes more global dysfunction. Regardless of the theory, TPDN is meant to address the involved muscles and provide patients relief by directly addressing the trigger point.
Then there's Functional Dry Needling (FDN), which is the school of thought I've been trained in. Functional Dry Needling clinicians look at how the patient moves and applies the needle technique to the structures contributing to movement dysfunction. They're not solely concerned with pain, but as a result of addressing underlying movement impairments, pain is often eliminated with this treatment as well. For example, if a patient has low back pain and walks with excessive lordosis (too much sway back posture), their hip flexors could be too tight. If the clinician needles the hip flexors to reduce muscle tone, then pelvic position can be addressed, thus back pain will also be reduced or eliminated.
So, who can perform dry needling? As mentioned in the introduction, the practice is performed by licensed professionals whose state practice act states they're allowed to do this. Some licensed professionals allowed to perform DN include physical therapists, chiropractors, acupuncturists, athletic trainers, and some physicians or physician assistants. This varies by profession, by state. For example, physical therapists are prohibited to perform DN in less than a handful of states, such as California, Oregon, and New York. My understanding is those particular states have strong acupuncture interest groups lobbying against physical therapists performing DN. A deeper discussion around this is not suitable for this post, but I will say that the vast majority of states do allow physical therapists to perform DN. I'll explain the difference between DN and acupuncture below. To see if physical therapists can perform DN in your state, click here.
The difference between dry needling and acupuncture
What's the difference between dry needling and acupuncture, you ask? LOTS! A very major difference in my eyes, simply put, is I have not been trained in acupuncture! Acupuncturists complete a rigorous education, with many programs culminating in a doctorate level degree that took at minimal 3 or 4 years to obtain (after an undergraduate degree, of course). They are well versed in the body's energetic pathways (meridians), medicinal herbs, different pulses of the body, and acupuncture/acupressure points for aiding in the function of multiple body systems. Acupuncturists use the needle to unblock stagnant energy in the meridians to help improve overall flow and function in the body.
Conversely, physical therapists' doctorate level education with our depth of understanding in human anatomy and movement assessment sets us apart from other professionals. We view the body through a more allopathic lense, searching for tissue impairment, joint dysfunction, or movement inefficiencies. We use the needle to help facilitate improved tissue quality or better movement patterns, to name just a couple of uses. Simply put, we are two sets of professionals utilizing the same tool for completely different purposes.
So yes, the needle itself is the same. That's about it as far as similarities go. I liken it to a plumber and a carpenter reaching for the same tool in the toolbox but going to work on completely different systems in the house. A tool can be useful for multiple purposes. The person utilizing the tool must know what their intended purpose is for using it, and they must have the training, expertise, and licensure to be able to use it correctly, safely, and effectively.
How dry needling works
So I could dive into what's actually happening at the cellular level, spouting out jargon like it affects the "excess production of acetylcholine from the presynapic membrane...."blah, blah, blah. I'm gonna not. Yes, that's part of the TPDN theory mentioned earlier, but instead, I'll explain this just the way I do to my patients in the clinic.
Based on the TPDN model, the needle essentially interrupts an already dysfunctional cycle in the tissue. Inserting the needle into the muscle creates increased blood flow and healing chemicals locally to the site. The other thing it does is push a "reset" button to the nervous system, and it does so in a two-fold way. First, it can positively impact that neuromuscular junction or nerves more locally, as mentioned up in the TPDN theory. If there's an imbalance, the needling can reset that. The second "reset" occurs on the homunculus, the part of our brain that interprets the experience and sensations of different body parts.
When we needle a body part, that seemingly-noxious stimulus goes to the brain, where it needs to be interpreted. Since the stimulus is new, and likely different than what most people have typically ever felt, it sort of "messes" with the brain, so to speak. For example, let's take somebody who is experiencing knee pain. If the brain is sending "extra loud" signals that something at the knee is painful, we can needle muscles that surround the knee, or muscles near the specific spinal segment where nerve roots that innervate the knee are immediately located, and say, "Hey! Here's a new message to pay attention to!" The result is that the painful message is reduced. It provides a window of opportunity to then have the patient move in specific ways to "reset" their movement patterns and provide new input to the brain that a certain movement that used to be painful no longer is. That can be a very powerful treatment.
What dry needling feels like
Patients ask me all the time, "does it hurt?" My answer is always, no, it doesn't hurt. But it can be uncomfortable. To me, there's a real difference. If something hurts, that means it's truly painful to the point that the body is telling you whatever that's occurring needs to stop. Instead, this is more like a very deep ache in the muscle. My experience with needling, both as a practitioner and as a patient of it, is that the sensation is nothing that cannot be breathed through. And that's when the sensation is strong. Most of the time, it actually feels therapeutic. Patients will tell me, "It hurts so good," like it's targeting exactly the source of their pain. They'll often say, "it feels like I needed that." So, while yes, it may be uncomfortable, just like getting a deep tissue massage may be uncomfortable because those structures are sore and need tending to, I'd argue that it is not a treatment that hurts. And if it does, always tell your provider and they should stop the treatment immediately.
Why dry needling is my go-to tool for treating patients
If you've read up to this point, you'll see that the needle is a multi-faceted tool. If a muscle is too tight, I needle it to calm it down. If the muscle is having a hard time producing a high-quality contraction, I needle it to give it more input to the neuromuscular communication system, which in turn generates a better muscle contraction. If I need to reduce pain in order for a patient to move throughout their full range of motion better, I needle the muscles restricting that motion or causing the pain. It's truly a simple tool with versatile purposes.
Lastly, to be clear, needling is not a stand-alone treatment. It should always be followed up with some sort of movement reinforcement or muscle reloading exercise in order to correct the root cause of why the patient is in the clinic. Otherwise, it may provide somebody relief temporarily, but their issue will almost inevitably return.
The next time you are in need of physical therapy, I encourage you to discuss dry needling as a treatment option with your therapist if you haven't already had the discussion. While it is just one tool in a kit of many often needed to return a patient to their prior level of function, it's a great one to know about and experience.