Dry needling is most appropriately carried out by the discipline of Physical Therapy: Scientifically sound and evidence-based, the inclusion of this tool by physical therapists yields the best results at the greatest cost efficiency.

I have been reviewing medical records for attorneys in the greater Richmond area since 1980. I first
noticed the term “trigger points” and the use of “dry needling” in 2005-06. Out of all the patient records
being reviewed at that time, only two local physical therapists carried out dry needling of trigger points.
This number increased dramatically after 2013, and over the past year more than 75% of the physical therapy records mentioned trigger points and/or treatment with dry needling.

This increased focus on trigger points has also been seen in the physician treatment records. Prior to 2012, trigger points were rarely mentioned. Out of all the records I reviewed, only one general practitioner and two local rheumatologists occasionally administered a trigger point injection. Over the past the past three years, however, the number of patients receiving trigger point injections has increased from rarely to “very frequently,” and within the past two years a new procedure, that of trigger point injection using ultrasound guidance, has been noted. In the records that I have reviewed, trigger point injections using ultrasound guidance have been carried out most often by orthopedic physician assistants and PM&R specialists; they are typically carried out during separate additional office visits that have been scheduled specifically for the trigger point injection using ultrasound for trigger point localization and needle placement.

This change in the treatment of trigger points has not been seen in the records of chiropractic treatment that I reviewed, and I have not seen any chiropractic records that included dry needling or the injection of trigger points by a chiropractor.

Out of all the records I’ve reviewed since the 1980s, very few have included treatment by acupuncturists. The terminology and treatment methods documented in those records are distinctly different from those of all the other medical disciplines and they do not resemble their medical records in any way. Although there appears to be an overlap between dry needling and acupuncture, the procedures are quite different in intent and practice. Trigger points can be seen with ultrasound imaging, the twitch response can be seen on EMG recordings, and the goal of dry needling is the stimulation of the trigger point in order to elicit twitch responses. Acupuncture uses needles to influence “force energy flowing through meridians.” Even the relatively new type of acupuncture known as Acupuncture Physical Medicine combines classics-based French-meridian acupuncture with Western physical medicine techniques including “trigger point needling” for the release of myofascial constrictions known as “holding patterns.” (Tri-State College of Acupuncture).

Of all the treatment rendered by the previously noted specialists, only treatment sessions that included dry needling of trigger points were associated with patient comments that the dry needling had resulted in the most benefit of all treatment received to date. Treatment utilizing dry needling was typically just one part of the treatment rendered during a PT session, however when seen by a physician or physician assistant for a trigger point injection, no additional rehab measures were employed and the injection itself was the only treatment for the trigger point. Office visits for trigger point injections were also separated by longer periods of time (three weeks or more) whereas physical therapy sessions were carried out much more frequently. Trigger point injections by physicians were sometimes carried out while a patient was also enrolled in physical therapy, however the injections were still rendered during separate office visits that were usually not on the same day.

A review of the scientific studies reveals that:

• Trigger points can be visualized with ultrasound (Ballyns 2011, Niraj 2011);
• They are associated with EMG changes of increased activity at rest known as “endplate noise”  at the motor endplate zones of a muscle and changes in appearance and EMG activity are seen following a “twitch” response (Chu 2002, Kuan 2007, Chou 2009 and 2014);
• There are changes in the chemical environment around the motor endplate zones of active trigger points and this chemical environment changes following a twitch response (Shah 2008);
• The twitch response is essential for the chemical changes and the resultant improvement (Hong 1994);
• There is no significant difference in trigger point resolution with the injection of a medicinal sub-stance although the medication can decrease post-injection soreness (Lewit 1979, Hong 1994, Venancio 2008)

Both dry needling and trigger point injection have the needle stimulation of the trigger point in order to elicit a twitch response as a common denominator. The insertion of the medication is an additional, and not necessarily required, step in the deactivation of the trigger point. The correct placement of the needle within the trigger point is essential and experienced examiners can, with reliability, locate relevant trigger points by palpation without the aid of equipment (Mora-Relucio 2016).  

In the medical records I have reviewed, I have noted an improvement of patient symptoms, a decrease in the need for treatment, and only minimal complaints of soreness following trigger point injections. The frequency of use of dry needling during physical therapy sessions and ultrasound-guided trigger point injections in orthopedic and PM&R offices has increased significantly. Physical therapists who have received additional training in dry needling are able to locate trigger points by palpation as opposed to needing ultrasound guidance, and their treatment following the deactivation of trigger points would maximize the benefit of this modality as a treatment method. The inclusion of dry needling in the PT program would provide better monitoring of patient improvement following dry needling while being more cost effective at the same time. Based on the literature, treatment with dry needling of trigger points should be an additional modality available to those trained in its use, and the regulatory language should be modified to reflect and endorse this capability.         

Christine Ruch, BSN, RN
RN Reviews, LLC

REFERENCES
Ballyns, JJ, Shah JP, et al. Objective Sonographic Measures for Characterizing Myofascial Trigger Points Associated with Cervical Pain. J Ultrasound Med. 2011 October; 30(10): 1331-1340.
Chou LW, Hsieh YL, et al. Remote Influences of Acupuncture on the Pain Intensity and the Amplitude Changes of Endplate Noise in the Myofascial Trigger Point of the Upper Trapezius Muscle. Arch Phys Med Rehabil 2009 June; vol 90: 905-912.
Chou LW, Hsieh YL, et al. Needling therapy for myofascial pain: recommended technique with multiple rapid needle insertion. BioMedicine 2014 June; vol 4(2): 39-46.
Chu J. The muscle twitch in myofascial pain relief: effects of acupuncture an other needling methods. Electromyogr Clin Neurophysiol. 2002 Jul-Aug; 42(5):307-311.
Hong, C. Z. Lidocaine injection versus dry needling to myofascial trigger point. The importance of the local twitch response. Am J Phys Med Rehabil. 1994 Jul-Aug; 73(4):256-263.
Kuan T-S, Hsieh Y-L, et al. Myofascial Pain Syndrome: Correlation between the Irritability of Trigger Points and the Prevalence of Local Twitch Responses during Trigger Point Injection. Am J Phys Med Rehabil 2007 March; 86(5): 397-403.
Lewit K.  The needle effect in the relief of myofascial pain. Pain 1979 (6): 83-90.
Mora-Relucio R, Nunez-Nagy S, et al. Experienced versus Inexperienced Interexaminer Reliability on Location and Classification of Myofascial Trigger Point Palpation to Diagnose Lateral Epicondylalgia: An Observational Cross-Sectional Study. Evidence-Based Complementary Alternative Medicine. 2016 vol 2016.
Niraj G, Collett BJ, Bone M. Ultrasound-guided trigger point injection: first description of changes visible on ultrasound scanning in the muscle containing the trigger point. Br J Anaesth 2011 September; 107(3): 474-475.
Shah JP, Danoff JV, Desai MJ, 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 Jan;89:16–23.
Venancio R, Alencar F, Zamperini C, Different Substances and Dry-Needling Injection in Patients with Myofascial Pain and Headaches. The Journal of Craniomandibular Practice 2008 April; 26(2):1-8.