Definition of dry needling. According to the American Physical Therapy Association, or APTA, dry needling is a skilled intervention that uses a thin filiform needle to penetrate the skin and stimulate underlying myofascial trigger points, muscular, and connective tissues for the management of neuromusculoskeletal and movement impairments.
Dry needling is a technique used to treat dysfunctions in skeletal muscle, fascia and connective tissue, and diminish persistent peripheral nociceptive input, and reduce or restore impairments of body structure and function, leading to improved activity and participation.
Fast in-out. Pistoning, or dynamic, deep, or rotational dry needling, they’re all meaning the same thing.
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Travell never used an acupuncture needle to map the referral patterns of each muscle and record them in the myofascial pain and dysfunction volumes.
She used a syringe. Many since Travell have used myofascial trigger point injection techniques as the treatment intervention in experimental studies. In this next video clip, we’ll demonstrate fast in-out or local twitch response type needling to the biceps brachii.
One notable researcher, Dr Chang Zern Hong, has developed this syringe based technique, making it less painful for the patient and reducing the potential for needle bend on the in-stroke and potential excessive tissue damage.
The eponym, Hong fast in-out, is now used to describe not only the injection technique which often carries an injectate of 0.5% lidocaine, and the needling technique using acupuncture needles.
Pistoning, fast in-out, dynamic deep with rotation are all synonyms for essentially the same technique aimed at eliciting a local twitch response.
Although the LTR is the goal of deep dry needling, this is the desired concomitant of this type of needling, not the objective effect.
The benefit for the patient is reduced pain and return to function. Hong et. al. describes the technique as being fast-in fast-out, meaning the acupuncture needle is inserted quickly into the location depth and direction. Hong suggests that if an LTR and referred pain is elicited prior to the deep dry needling technique being applied, then this should be the signs and symptoms that are elicited during the procedure.
There may be a number of myofascial trigger points in one given area. Release of all the myofascial trigger points in the area is recommended using a funnel-like approach. Watch as the needle goes into the tissue, comes out, changes direction, and then goes back in again, like clearing a minefield.
It is important to emphasise that the needle must be withdrawn to the level of the subcutaneous tissue at every insertion. Its angle of insertion altered in order to find new myofascial trigger points rather than repetitively irritate the same tissues.
Chou et. al. developed a new technique based on the fast in-out method in which simultaneous rotation is applying to the needle, acupuncture needle or a syringe, as it advances towards and away from the target tissue.
The needle is quickly screwed in as it advances towards the trigger point and is quickly screwed out as the needle is withdrawn from the trigger point. The rotation is applied to avoid needle bend, especially when using a finer needle and reduces pain from contact with sensitive local nociceptors.
In a paper by Dr. Peter Baldry which compares superficial and deep dry needling, he states that he only uses deep dry needling in presentations of myofascial pain with a suspected aetiology of nerve root compression or when the myofascial trigger point has led to muscle shortening.In a paper by Dr. Peter Baldry which compares superficial and deep dry needling, he states that he only uses deep dry needling in presentations of myofascial pain with a suspected aetiology of nerve root compression or when the myofascial trigger point has led to muscle shortening.
Travell and Simons recommended the following list of guidelines for deep dry needling:
Palpate and identify anatomical landmarks, palpate the taut band with cross-fibre flat or pincer palpation, identify the trigger point and fix with either a pincer grip or flat palpation.
Needle with straight in and out motions, elicit a local twitch response or referred pain.
Draw the needle back to the subcutaneous tissue and redirect the needle to treat other myofascial trigger points in the same or nearby areas.
Provide haemostasis immediately upon withdrawal of the needle, 30 seconds or longer. Apply a post-needling intervention for reducing post needling soreness.
Post needling soreness protocol includes haemostasis using digital compression, 30 seconds, move and stretch the needled muscle post-treatment. Activate the needled muscles.
Actively encourage the full range of motion of the affected joints. Inform the patient about post needling soreness.
Static or in situ needling are synonyms used to describe a type of needling only involving an acupuncture needle, not a syringe.
Sun Simiao, a child prodigy who had mastered the Chinese classics by age 20 and was a physician in the sixth century CE, described what we call myofascial trigger points or Ah Shi points. This literally translates to “Ah Yes” points, the type of response a patient might give confirming that the right tender spot is being palpated.
This reaction was described by Peter Baldry in 2002. He stated that dry needling needed to be of sufficient strength to abolish both signs, jump and shout, and that superficial needling technique was adequate in 90% of patients. The remaining 10% of patients, in addition to having no susceptive myofascial trigger point pain also suffered some form of nerve root compression pain and responded to deep dry needling.
patients who received superficial dry needling showed considerable improvements with respect to pain. The study was very small, however. Rather than deep dry needling in this study, patients who did not respond to superficial dry needling were given electroacupuncture in addition to superficial dry needling.
Dry needling aimed at eliciting a local Twitch response using a pistoning action may disrupt contraction knots, stretch contracted sarcomere assemblies and reduce the overlap between actin and myosin filaments. It may destroy motor endplates and cause distal axon denervation and changes in the endplate cholinesterase and acetylcholine receptors similarly to the normal muscle regeneration process.
DN may also change the excitability of spinal motor neurones and improve muscle tone separate from its analgesic effect.
Dry needling’s primarily focused on reducing pain and restoring function through the release of myofascial trigger points in the muscle.
What is a Myofascial Trigger Point?
A myofascial trigger point, also known as a knot in the muscle, is a group of muscle fibres that have shortened when activated but have not lengthened back to a relaxed state after use. A myofascial trigger point develops a sensitive nodule in the muscle (Simons, Travell & Simons, 1999). In addition to this nodule, the remainder of the muscle also tightens to compensate (Simons et al., 1999; Simons, 2002). This hypersensitivity occurs as the muscle fibres become so tight that they compress the capillaries and nerves that supply them (McPartland, 2004; Simons et al., 1999). As a result, the muscle cannot frequently move, obtain a fresh blood supply containing oxygen and nutrients, or flush out additional acidic chemicals (McPartland, 2004; Simons et al., 1999). The presence of a myofascial trigger point in a muscle can lead to discomfort with touch, movement and stretching, decreased joint motion, and even a temporary loss of coordination (Simons et al., 1999).
How Does Dry Needling Work?
Dry needling assists with decreasing local muscular pain and improve function by restoring a muscle’s natural ability to lengthen and shorten by releasing myofascial trigger points.
What Does Dry Needling Do?
When the delicate filament needle inserts into the centre of a myofascial trigger point, blood pools around the needle, triggering the contracted muscle fibres to relax. This reaction, in turn, leads to the decompression of the local blood and nerve supply. It also helps to provide those fibres with fresh oxygen and nutrients and flushing away any additional acidic chemicals.
What Causes a Myofascial Trigger Point?
A myofascial trigger point develops as part of the body’s protective response following:
- injury – the muscle will tighten in an attempt to reduce the severity of an injury;
- unexpected movements, e.g. descending a step that is lower than initially anticipated;
- quick movements, e.g. looking over your shoulder while driving;
- change in regular activity or muscle loading, e.g. an increase in the number or intensity of training sessions for sport;
- sustained postures e.g. prolonged sitting for work or study;
- nerve impingement – the muscle will tighten to protect the nerve;
- stress;
- illness (bacterial or viral);
- nutritional deficiencies, or;
- metabolic and endocrine conditions.
(Simons, et al., 1999)
When Is Dry Needling Treatment Recommended?
Dry needling can assist in treatment:
- to help release myofascial trigger points (muscle knots);
- to assist with pain management, and;
- to restore movement at a joint if inhibited by myofascial trigger points.
What Will You Feel During Dry Needling Treatment?
During a dry needling treatment, you may feel a mild sensation as the needle inserts and withdraws. Patients don’t report any discomfort during needle manipulation.
A brief muscle twitch may occur during a dry needling treatment. This twitch may happen when the needle directly stimulates a myofascial trigger point.
Where Does Dry Needling Fit Within Your Rehabilitation Program?
Dry needling is one of many techniques that your physiotherapist can utilise to assist with your rehabilitation. We combine dry needling with other physiotherapy techniques, including massage, manual therapy, and exercise prescription.
What are the Side Effects of Dry Needling?
Every form of treatment can carry an associated risk. Your physiotherapist can explain the risks and determine whether dry needling is suitable for you based on your injury and general health.
When dry needling occurs, single-use, sterile needles are always used and disposed of immediately after using a certified sharps container.
Is Dry Needling Safe?
Everybody is different and can respond differently to various treatment techniques, including dry needling. In addition to the benefits that dry needling can provide, some side effects may occur, including spotting or bruising, fainting, nausea, residual discomfort or even altered energy levels. However, these symptoms should last no longer than 24 to 48 hours after treatment.
Can You Exercise After Dry Needling?
We recommend avoiding strenuous or high impact activities immediately after dry needling to allow the body time to recover and maximise the treatment benefits.