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What is Dry Needling?

Updated: May 6, 2021

Let's learn a bit about dry needling.

It is slightly more in-depth than my previous posts due to the amount of research validating this technique. There is also the politics of acupuncture vs dry needling to discuss plus the different types of dry needling available. The term dry needle means “no liquid” it’s like a hollow bore needle during a corticosteroid injection. The needle is a solid filament needle also known as an acupuncture-type needle. They have different lengths and diameters depending on the treatment area. Small 0.5in needles are used in the hands or feet, a 5 to 6 in. needle will be used in the gluteals (yes, they are that large in athletes, sometimes larger). The good news about dry needling is the type of needle does not cause scar tissue like a hollow bore needle and it does not damage structure. If the needle touches a nerve it will push the nerve out of the way and continue moving, sometimes causing a radiation sensation from the mechanical stimulation of the nerve. This is the medical version of hitting the funny bone. Within the dry needling spectrum you have 6 different types of needling: superficial, deep, triggerpoint, periosteal pecking, electric stimulation and peripheral neuromodulation. Superficial is exactly like it sounds, only going a few millimeters into the skin and does not go into muscle. This style has been shown to change the sensory of the area and reduce pain. Deep dry needling is designed to target muscle, which can change scar tissue, rescue tissue tightness and reduce pain. An example would be piriformis syndrome (which is when the muscle becomes tight and irritates the sciatic nerve), which decreases the tension and it reduces the symptoms. Periosteal pecking is when the needle touches bone, mainly at an insertion site, to cause inflammation in an attempt to heal tissue. This is very common with tendinosis or tendonitis. Golfers or tennis elbow respond well to this technique. Electrical stimulation can be added to the needles. Yes, let that sink in. I first heard of this when Charles Barkley was interviewed about knee pain and was using acupuncture with electric stim to control his knee pain. This therapy works for chronic pain and osteoarthritis pain. Peripheral neuromodulation is only performed by people with acupuncture or western medical education with eastern training. The premise behind this is organ pain. Organs can refer pain in a specific area of the body and the needling will affect the organ which is why untrained people will leave not perform this technique. There are different ways to stimulate the needles. The last training I attended had a 4-step approach to manually stimulating the needles, unlike the first training I took that didn’t teach this approach. (I might still be bitter!) The first is the insertion of the needle, the second is winding the needle like a radio dial. The third is winding in one direction until you feel tissue resistance then the final is called tenting. Tenting is the 4th step which is winding in one direction until tissue resistance then gently lifting. The additional step is adding electric stimulation after all these steps. Dosage is another factor to consider. The length, diameter, and amount of needles used will affect the patient. Generally, you start with one or two needles then build in numbers and depth. People respond differently to treatment and the best way to modulate the potential reaction is to start small. The next question is what conditions will dry needling treat? The better question is what musculoskeletal condition does it not treat? Headaches, migraines, neck pain, chronic pain, tendonitis, tendinosis, piriformis syndrome, radiating pain from discogenic pain, plantar fasciitis, carpal tunnel, and patellar tendonitis can all be treated with dry needling. Scar tissue is another condition that can be treated with dry needling. It can be a new or old scar and deep scar tissue after surgeries can be accessed with the deep needling technique. When it comes to muscle recovery and athletic performance, it can be used to help recover after training sessions. The final fact is dry needling can be used to manage injuries through a season or keep a person training until the event is over. Dry needling is a very versatile therapy that people don’t know. Now circling back to the beginning of the article about the politics within the healthcare system. This country's healthcare system is lacking and I have seen many different things from my rotations at the Veterans Affairs, private practice, and the emergency medicine side of things. I can go on a long rant and still not cover everything. Acupuncture is now being covered by insurance companies for low back pain. Most of the research is coming from the UK because acupuncture is taught to physiotherapists. Yes, that is correct, acupuncture is taught within the physical therapy curriculum. The current argument is only acupuncturists understand how the body is affected with needling and dry needling violates the body's meridians. Meridians are points on the body that correlate to an organ. There are some areas on the body where many different points are close together and it could stimulate different organs simultaneously. This can over or under stimulate different organ systems and lead to disease. When treating structures, and not meridians, the potential to affect different organs is inevitable. If you are curious, acupuncture is becoming more accepted in the USA. For example, the Maryland EMS system has a protocol with an acupuncture point called L14 on the hand between the thumb and index to help reduce nausea. There is another point above the ankle to avoid when performing soft tissue during pregnancy as it can cause uterus contractions. There is an argument to be made with research showing needling helps and acupuncture points are being taught to medical professionals. The never-ending insurance saga.

Last year, Blue Cross Blue Shield covered dry needling but now considers the procedure experimental, even though multiple quality research articles validate the therapy. Welcome to the world of insurance, where the goal is to collect premiums and deny benefits. I have experienced many shocking things when dealing with insurance companies. I once had a peer-to-peer interview with a doctor who represented an insurance company that denied my MRI order because the patient didn’t meet the criteria. This patient began having weakness in the legs, severe low back pain in all positions, changes in reflex and muscle strength. These are by definition worsening neurological symptoms that qualify as “red flags” and warrant immediate imaging. I didn’t have the chance to explain, as the doctor quoted the stated criteria of why the patient didn’t need the scan. I explained my reasoning and was still denied. I asked for the reference number of the call, the doctor's name and explained what happened during the call to the patient. Luckily, the patient's boss was the owner of the company and threatened to cancel the multi-million dollar policy. The order for the imaging was approved and it turned out a surgical consult was necessary. I will eventually have a blog in the future titled the wild west of insurance. In summary, this is a moderate review of the good, bad, and ugly of dry needling. I hope it was an interesting read.

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