“How many needles should be used for treating (fill in the blank)?”
One of the most common questions we encounter in our IDN seminars. This is valid question and not easy to answer as there are many factors that need to be considered about clinical dosage of dry needling. The current literature is lacking on a definitive and scientific answer and relies mostly on empirical and historical knowledge. The goal of this paper is to take a practical view of how needle dosage may be determined and applied in a clinical setting.
In general, our definition of needling dosage is based on the number and extent of the therapeutic lesion(s) produced from the needle insertions. Therapeutic lesion is defined as the neurophysiological response of the body to the needle penetrations; the more therapeutic lesion(s) produced, the higher the needle dosage delivered. The extent of a therapeutic lesion(s) is not solely dependent on the number of needles used, but also on the gauge of the needle and how it is manipulated while in situ. Based on that description it is understandable that we do not have a standardized nomenclature to quantify the amount of therapeutic lesion required for optimal clinical effect. This is in contrast to exercise or medication prescription that can have a very specific and easy to follow prescription. For example, the always popular, but highly questionable 3 sets of 10 for exercise or take 2 pills 3 times per day. The lack of a standardized system to measure needle dosage leaves us with vague statements such as continue needling “until it stops twitching”, “until the energy flows”, ‘until the muscle relaxes”, or the intuitive “until the pain goes away?” This highlights one of the major limitations in dry needling research; lack of identification of the needle dosage used to obtain the clinical effect.
When deciding on the treatment dosage for dry needling there are several patient factors to consider. For the purpose of this paper, I would suggest the following short list of considerations related to needle dosage:
- Age and health status of the patient
- State of the condition being treated (acute/chronic)
- Patient experience with dry needling especially within the last 6 months
- Healing potential based on the IDN Quantitative Analysis
When the subjective and physical examinations have been completed, the decision to utilize dry needling has been made, and patient consent obtained, the next step is determining location and dosage of needling. On the first day of treatment it is recommended to “talk more and needle less.” By this we refer to educating the patient about dry needling while also reducing the potential for significant post-needle soreness. Determination of the patient’s tolerance and response to needling is a process so being conservative initially is prudent. With that said, the first treatment should have a therapeutic effect but not at the expense of dogma that states the mission is to “eliminate” knots or points at all costs.
There are several techniques of dry needling that can be integrated into each treatment session, each can be used separately or can be used in combination. The following describes the most common clinical applications utilized:
- Superficial needling: The needle is inserted into the dermal and epidermal layers and not into the muscle tissue. This type of needling is the most conservative and very unlikely to cause pain or post-treatment soreness. A minor therapeutic lesion is still produced allowing the patient to receive the neurological and physiological benefits.
- Deep Needling: The needle is inserted directly into the muscle tissue. There are various levels of needle penetration from inoculating just the outer layer of muscle or needling through the entire thickness of the muscle. Depending on how deep the needle is placed will determine the neurophysiological responses that result because penetrating deeper provides greater stimulation to the additional soft tissue and neurological levels. When the needle is set without needle manipulation it would be considered a basic deep needling technique of low dosage but is a progression of dosage over superficial needling.
- Needle manipulation: The amount of dosage (therapeutic lesion) obtained is also based on the variables of speed, amplitude and intensity of the needle manipulation or movement. This is a progression from basic deep needling and has several manipulation techniques that can be utilized depending on the specific goals you are trying to accomplish. In a subsequent paper I will describe in detail these different techniques and their specific uses:
- Needle rotation- The in situ needle is rotated until a definitive end point is reached signifying the soft tissue has completely “wound” around the needle shaft inducing additional therapeutic lesion.
- Needle tenting- When the soft tissue is wound tightly around the needle it is pulled up causing a traction or stretch of the tissue inducing additional therapeutic lesion.
- Needle pistoning – A high velocity up and down conical movement of the needle. There are various levels of intensity of pistoning that are dependent on the speed, and amplitude of the needling. The higher the speed and amplitude the larger the therapeutic lesion produced. Pistoning is considered the most aggressive needling technique and produces the greatest post-needling soreness.
- Electrical Needle Stimulation (ENS): ENS delivers a mild electrical stimulation to soft tissue via attaching alligator type clips onto the solid monofilament needles. ENS is a progression of dosage of manual needling by inducing rhythmic vibrations (of non-contractile tissue) and repeated muscle contractions. Because the needle is in situ the repeated muscles contractions will induce additional lesion.
- Time in situ: Empirically, the length of time a needle is left in situ (without manipulation) does not have an effect on the dosage, if we define dosage as amount of therapeutic lesion produced.
Research does not currently exist that provides a definitive guideline of needling dosage for specific diagnoses or conditions. Dry needling is a non-specific treatment that relies on the body’s ability to self-heal the needle induced therapeutic lesions via multiple physiological processes. Based on the fact that each patient’s situation, injury and condition are unique, trying to determine the correct dosage is complicated to say the least.
Each clinician has their opinion on proper dosage, based primarily on their clinical experience and empirical evidence. This is important information but it is not easily quantifiable to other patients or for use by other clinicians. We propose a clinical model that quantifies needling dosage into more general categories of low, moderate or high. Each category has an increasing number of needles and progressively more aggressive needling techniques that generate larger therapeutic lesions.
Low Dosage: Applies to the initial treatment session for all patients. Also, patients with compromised physical conditions, low healing potential or are at an advanced age require a cautious start. The following is recommended for this category:
- Superficial needling techniques
- Basic deep needling technique (no needle manipulation)
- Number of needles: 5-10 needles
Moderate Dosage: Applies to patients that have had prior needling treatment (low dosage) with a positive reaction within the last 6 months. They are in relatively good physical condition and have been assessed to have good healing potential.
- Deep needling can now include needle manipulation techniques of moderate intensity, which may include pistoning, rotation and or tenting techniques.
- ENS can be introduced and provided for up to 5 minutes of active muscle contraction.
- Number of needles: Up to 20 needles
High Dosage: Applies to patients that have had significant experience with dry needling treatment and are likely healthy, active individuals with excellent healing potential.
- Deep needling with high intensity needle manipulations, which may include pistoning, rotation and or tenting techniques.
- ENS treatment time can be extended up to 10+ minutes and multiple areas can be treated in one session.
- Number of needles: 21+ needles
In this short paper we provided general categories for the prescription of dry needling dosage focusing only on the induced therapeutic lesion. What needs to be addressed in a subsequent paper is the patient’s perception and response, which are linked to dosage and ultimately the therapeutic outcome. The current guidelines are intended to help all clinicians, but specifically clinicians new to dry needling treatment, with the clinical decision-making related to the original question of “How many needles should be used?” These guidelines were never intended to be the definitive answer as it is not currently possible to specifically quantify the non-specific and systemic modality of dry needling. As research progresses and physiological healing processes are better elucidated we may be better able to quantify the amount of therapeutic lesion required to get the desired treatment effect.