The Debate on Dry Needling

It is said that science and medicine advances in disagreement. This is certainly evident among various medical professionals debating on the efficacy of dry needling. (1-3) One debate is between practicing dry needling clinicians and those who do not practice dry needling.   The other is among dry needling clinicians debating on which dry needling technique is the most effective.

We will first focus on the debate between the proponents of dry needling and those opposed to it. Both the proponents and opponents in the debate claim they are scientifically and evidence-based. What neither of them fully realizes is they are partially right and partially wrong. All proponents and opponents use these partial truths of dry needling therapy to either promote or oppose dry needling in its entirety. Truth may be revealed through debate. Scientifically and philosophically, what is the truth? In simple terms, truth is the precise information. Can we, as medical scientists or clinicians, claim that we have all the precise information about what we are doing to our patients?  As is the case with most medical techniques, no reasonable clinician would claim that he or she possesses all the precise information about the medical techniques or procedures that he or she is performing on patients. But during the debate, some individuals may lose this objective position and criticize the other party, not realizing he or she possesses those same biases. We analyze both parties in the following paragraph.

The opponents of dry needling therapy usually are well-trained medical professionals. Usually they hold authoritative positions in their medical fields. They see medicine as a science and advocate that medicine should be practiced based on scientific evidence. We absolutely agree, but we would like to indicate here that medicine, so far as we practice, is still an imperfect science. Though they could be very successful clinicians in their own field, but they may lack first-hand clinical experience with dry needling therapy. Because they are successful in certain medical fields, they are very confident about what they are doing. Thus, from their understanding of modern medicine, they judge and criticize dry needling according to the theory, not according to the fact or reality of the techniques. Many of their opinions are scientifically and clinically correct, but they have made common mistakes, just as early medical professionals in history, they did not differentiate theory from reality. They may ignore how science and medicine have advanced historically. Ironically they criticize proponents of dry needling for not differentiating theory from fact or reality though they make the same mistakes. They often believe that these incorrect theories of dry needling lead to fake practice. Simply put, they state dry needling is a sham procedure that cheats patients or at best dry needling is a placebo procedure because dry needling is based on false theory.

The proponents of dry needling include some medical scientists, but most are clinicians. Many of them are also successful medical workers in their own medical fields with first-hand experience with dry needling therapy. They see the positive clinical effects of dry needling from empirical data (seeing is believing) and they conduct research to justify the clinical efficacy and practice. Some of their research is better designed than others. Some research is well described in their techniques but really problematic in their interpretation. The proponents truly and honestly believe that dry needling is a valuable clinical technique that offers satisfactory or even amazing results. They believe in dry needling not based on their faith, but based on their empirical data. Just like their opponents, their clinical successes make them confident that what they are doing is clinically effective and scientifically correct. With this confidence, some clinicians, due to lack of adequate scientific training, hold the extreme attitude that only their dry needling techniques are correct and all other techniques of dry needling are wrong.  For these extremists, their perception and clinical use of dry needling will be limited by their narrow experience, knowledge and thinking.

The other debate is among the dry needling practitioners themselves. Some believe that only the myofascial trigger point approach is correct and that precise identification and deactivation of a myofascial trigger point is necessary. Having this bias, their practice is limited by a misleading guidance, thus they are reducing the clinical efficacy of dry needling.

The classic theory of myofascial trigger points was founded by Dr. Janet Travell (4) at least 6 decades ago and later further developed by her colleague Dr. David G. Simon. The term myofascial trigger point has worldwide recognition and is utilized by both medical workers and patients when they describe muscle pain. This classic theory describes the histology and physiology of trigger points and advocates the use of wet or dry needling to deactivate trigger points.

There have been review papers, clinical manuals and research studies, of varying methodological quality, that were published to support the deactivation process of trigger points. This research reinforces the clinical believers of trigger points that both their theories and practice are correct because of the clinical effect achieved. However, more and more high quality clinical research was conducted since the 1990’s that show the classic myofascial trigger point theory is questionable.

One example is the widely cited paper published by Dr. Shah (5) and his colleagues. With careful analysis, it shows that Dr. Shah’s papers were not actually proof of the presence of latent or active trigger points. His paper better describes neurogenic inflammation and that dry needling had a positive effect in reducing inflammation.  This is similar to Dr. Janet Travell’s (1) description of the histology of myofascial trigger points in that she was more likely describing neurogenic inflammation of soft tissue. The mystery of myofascial trigger point medicine is that the classic theory is questionable, or at least the original theory is more empirical than scientific, yet positive clinical outcomes are still achieved. Some opponents of trigger point dry needling are not able to see the fact that theory in many cases may not precisely represent the reality (clinical effect).  It is factual that trigger point dry needling works, but the original theory of myofascial trigger points is empirically based,. A scientific approach is superior to an empirical approach in that a scientific approach reduces human errors and better controls human bias. It must be acknowledged that a scientific approach cannot guarantee that we can obtain the truth (the precise information) from it since all research has flaws. Also in science, we do not worship science, we question even falsify current science trying to advance medical practice.

Philosophically when we examine a theory, it is important to examine the association between theory and fact. A good theory explains the fact more precisely, and a wrong theory may misrepresent the fact. Most theories in science only partially explain the reality and they are tentative. No theory is everlasting correct or precise. The original myofascial trigger point concept is such an example. The original theory requires identification and local needling of the trigger point, but it cannot explain why we still achieve good clinical results even though the needle never touches the actual trigger point. This example demonstrates that the original myofascial trigger point concept represents low association with the fact of the reality. However, we are seeing new understanding of the trigger point concept emerging that will advance our knowledge of trigger points and muscle pain.

The purpose of debate is to explore the truth so to advance our medicine. Each side of the debate has partial truth and some bias. We need to have an open mind to the truth of the other party and our own bias. In debate we defend ourselves not for protecting ourselves, but for advancing medicine and our profession. The lessons from the debate on myofascial trigger points are the following:

  1. Any debate on clinical techniques, firstly should examine whether the procedure (dry needling) is effective or superior to placebo or not.
  2. The degree of association of the theory with the reality should be examined.
  3. A technique should be judged by its fact, not the theory.

Medical science is different from other theoretical sciences in that it is more complicated so we should be more careful when we draw conclusions. Finally, we hope that the debate will lead to a better understanding of muscle pain, trigger points, and dry needling application with the goal of improving patient care.

 

  1. Quintner J, Bove G, Cohen M. A critical evaluation of the trigger point phenomenon. Rheumatology. 2015; 54(December): 392-9.
  2. Dommerholt J, Gerwin R. A critical evaluation of Quintner et al: Missing the point. Jour Bodywork & Movement Therapies. 2015; 19:193-204.
  3. Quintner JL, et al. Response to Dommerholt and Gerwin: Did we miss the point? Jour Bodywork & Movement Therapies. 2015; http://dx.doi.org/10.1016/j.jbmt.2015.02.008.
  4. Travell J, Simons D. The Trigger Point Manual. Baltimore: Williams and
    Wilkins; 1983.
  5. Shah J, Danoff J, Desai M, et al. Biochemicals associated with pain and inflammation are elevated in sites near to and remote from active myofascial trigger points. Arch Phys Med Rehabil. 2008; 89(Ja