When You Can't Handle the Pain

You're sore. Stiff. Your back and neck are a stepped terrace of knots, and you've had to skip your last few morning workouts because you were looking in the mirror with your hands pressed against your lower back and wondering if age hadn't decided it was time for your body to start working against you rather than with you. The muscle pain is excruciating.

The ibuprofen just isn't cutting it anymore, and the relief from the massage only lasts as long as it takes to get from the chiropractor's door to the parking lot. As soon as you slide into the driver's seat, you can feel those ever-present knots in your back and neck swelling with pride at having eluded yet another attempt to destroy them. You need to do something, and you'd prefer it not to be purchasing some tennis balls to cut in half and stick to the bottom of your walker.

person walking on the road with a guide walker

Image: by cocoparisienne, via Pixabay

A co-worker sees you lumbering into the office with the gait of an inebriated gorilla and cheerfully tells you how all your ailments can be instantly cured if you'd only visit his new best friend, a physical therapist who specializes in dry needling: sticking needles straight into the knots that ail you.

physical therapist massaging the head of the patient

Image: by rawpixel.com, via Pexels

No way, you're thinking. You're already sore, and you hate needles. You get to work, storing your pain and stiffness into the part of your brain you keep readily available for hiding unpleasant truths like the upcoming tax deadline and how you shouldn't eat onions after 8 pm. Next thing you know, it's lunch break – and you find your muscles are so taut and sore that you spend 28 of your 30-minute lunch break simply lifting yourself out of your chair.

Dry needling? Why not? Maybe it's time to consider giving Bert a call.

process of dry needling application on a person's nape

Maj. Melissa Durham, 6th Medical Operations Squadron physical therapist, performs dry needling on a patient and uses an electrical stimulation unit at MacDill Air Force base, Fla. (U.S. Air Force photo by Airman 1st Class Mariette M. Adams/Released), Image: Image: Public Domain, via MacDill AFB

What Is Dry Needling?

Dry needling is a relatively new method of treating myofascial pain syndrome, which is how people who work in the field describe muscle pain. Myo- simply means muscle, and -fascial is the word for the connective tissue that covers and connects muscles. Needles are pushed into what doctors call myofascial trigger points, and the rest of us call “knots.”

therapist applying dry needling on trigger points of the body

U.S. Air Force Maj. Jon Wilson, 93d Air Ground Operations Wing director of human performance, performs trigger-point dry needling, Image: Public Domain, U.S. Air Force photo by Staff Sgt. Jamal D. Sutter/Released, via Moody AFB

The reason the professionals call it myofascial trigger points instead of knots is because there are no actual knots. Our muscles don't suddenly contort into a bowline or a clove hitch - though it certainly feels like it at times.

Instead, think of a myofascial trigger point as a tiny spot in your muscle prone to cramping; sort of a miniaturized “Charlie horse.”

Now, we've all had a Charlie horse before, and though we may have felt like an entire army of demonic mites had attacked our calf with serrated knives cooked in the flames of hell, the moment was brief, and we didn't suffer any permanent damage.

Myofascial trigger points aren't that nice.

They're devious. And complicated. Not only do they cause pain in and of themselves, but they complicate other problems that cause pain, and they sometimes disguise themselves as an entirely different problem. This is referred pain, whereby a myofascial trigger point mails its pain sensations through your nerves to a distant location. Think of how the classic warning sign of a heart attack is a dull pain in the left arm. The heart isn't there, but the nerves are.

Why Dry and Why Needling?

It's called “dry” simply to differentiate it from other procedures which involve using needles to inject a medicine directly into the muscle. Think corticosteroid shots to relieve the tennis elbow that's turned your once-vicious backhand into the feeble wave of an arthritic sloth.

information about back pain infographic

Image: CC BY 2.0, by Pain Pix, via Flickr, altered

Instead of medicine, dry needling does exactly what it sounds like: a dry needle, with nothing up its sleeve, is inserted into a myofascial trigger point, with the end goal being pain relief. Where the needle is inserted depends on where the pain and/or stiffness is occurring. Needle depth and the amount of time the needle stays in depends on who's doing the needling, who's receiving the needling, where the needling is occurring, and the problem the needling is attempting to solve.

How it works, and even if it works, isn't entirely clear. Some people and practitioners swear by it, and others swear against it.

The one objectively honest description of dry needling that sums up the entire process without bias is the term “intramuscular stimulation” – a synonym for dry needling that some practitioners use for billing purposes. It's not particularly fancy or memorable, but it is a quick way of saying “making muscles do something by doing something to them first in their own house.”

Why Not Call It Acupuncture?

We know what you're thinking - this all sounds like acupuncture trying to disguise itself so it can finally get into the doctor's lounge at the hospital with all the free donuts. But it isn't- – not entirely.

dry needling vs acupuncture information

Chart by author, all rights reserved

Acupuncturists and acupuncture devotees claim that dry needling is simply an acupuncture technique that's been repackaged and relabeled to make it palatable to Western audiences skeptical of acupuncture.

Practitioners and defenders of dry needling don't deny that its' origins lie in acupuncture, but claim its' current incarnation is pure Western medicine, rooted solidly in the scientific method, and should be viewed as a separate medical process rather than acupuncture's latchkey kid.

There are certainly similarities between dry needling and acupuncture, the most obvious being someone you don't really know very well sticking needles into your flesh. But there are some very significant differences as well.

Acupuncture is Very, Very Old

Acupuncture is a staple of traditional Chinese medicine, and has been around for a very long time. The first written records are from no later than 100 B.C., and there's some pretty convincing evidence it's been around much, much longer.

Otzi the Iceman is the name given to an amazingly well-preserved body found encased in ice by some German hikers wandering the Alps in 1991. The body was chipped out of the ice and sent to wherever it is that scientists who specialize in antique corpses congregate, where it was determined that Otzi lived somewhere between 3400 and 3100 B.C.

Most interesting was Otzi's tattoos located at traditional acupuncture trigger points - the exact same trigger points used in acupuncture today.

Dry Needling is Very, Very New

a neurologist Prof. Karel Lewit

Prof. Karel Lewit, Image: CC BY-SA 3.0, by Jarmila Podrazska, via Wikimedia

In the historical timeline of medicine, dry needling just pulled up to the front door; its U-haul still unpacked. Inserting needles into myofascial trigger points without medication was first explored by the Czech doctor Karel Lewit in the 1970s, who found a large majority of his patients experienced significant pain relief when needles were inserted directly into the most painful location.

The term dry needling itself was first used in 1983 in a 2-volume book co-authored by Dr. Janet Travell: Myofascial Pain and Dysfunction: Trigger Point Manual. She wasn't outlining the procedure of dry needling as we know it today, and she was rather vague on the whole process, but she was the first physician of renown to differentiate between using “wet” and “dry” needles for treatment of myofascial trigger points.

Just to clarify, Drs. Lewit and Travell weren't just academics spending their time writing massive tomes entirely indecipherable to the average person. Dr. Lewit literally wrote the book on treating musculoskeletal pain still used today in Czechoslovakia, had a minor planet named after him, and lived to 98. Dr. Travell was President Kennedy's personal physician - a man known to suffer from significant back and muscle pain throughout his life - and she lived to 95.

janet travell's speech on dry needling

Image: Public Domain, JFK Library Archives, via Wikipedia

We'll take this as proof the two were at least competent in their chosen professions.

Acupuncture is a Lifestyle; Dry Needling is a Weekend

Dry needling was, historically, a technique; a maneuver aimed at providing relief from chronic pain and/or stiffness, and but one of a multitude of pain relief tools found in modern Western medicine.

In contrast, acupuncture wasn't just aimed at pain relief – it was, and still is, considered a systemic cure-all for what ails you. By placing needles at specific trigger points across the body, the body's “chi” or energy is realigned and redirected onto proper pathways, which can result in everything from pain relief to proper organ function to an end to depression.

Wait — Acupuncture and Dry Needling Both Use Needles to Stop Pain?

You're right – they do. And not only that, but both procedures largely use the exact same spots. Several studies compared the trigger points used in dry needling to those used in acupuncture, and the similarity ranges from a low of 70% to over 90%.

So Otzi the Iceman may have been practicing dry needling rather than acupuncture.

What Does Dry Needling Treat and How Does It Work?

Here are a few of the problems that dry needling treats.

  • Relief from chronic pain
  • Tension headaches
  • Muscle tension
  • Jaw pain
  • Back pain
  • Neck pain
  • Shoulder pain
  • Arm and leg pain

How is it done?

There isn't a single uniform method for dry needling. Different practitioners have different techniques, though they can be generally ordered into three different parts:

dry needling process on how it's done

Chart by author, all rights reserved

And Those Needles?

Here's another similarity between acupuncture and dry needling: they use the same needles. As acupuncture has been around for quite a while, dry needle practitioners found it was much cheaper to buy existing acupuncture needles rather than open their own needle factory.

dry needling needles

Image: CC BY-SA 1.0, by Xhienne, via Wikimedia, Altered by author, all rights reserved

And you should be thankful that Dr. Travell's initial choice of needle never became the industry standard. She wasn't against acupuncture per se, but she wasn't a fan of acupuncture needles, which mostly range between 30 to 40 gauge. She saw them as too thin and too flimsy and likely to simply bounce off any knot worth worrying about, and instead preferred 22 gauge needles.

Gauge is how the outside circumference of needles are measured, and the higher the gauge, the thinner the needle. (We don't know why it works this way - we just know the British invented the current system because the only reasonable alternative was invented in France).

A 22 gauge needle is roughly 0.02 inches in thickness, a 30 gauge 0.01 inches, and a 40 gauge 0.006 inches. This may not seem like much of a difference until you consider that the needle is being inserted directly into your muscle. In that light, every hundredth of an inch in diameter counts.

acupuncture dry needling needle sizes

Screengrab via embedded video

Does It Work?

Like almost all therapies labeled as alternative medicine, the answer is - we don't know. Not academically, anyways. Not a lot of studies have been done, and when they are, the sample size is usually too small to come to a firm conclusion. It's not the easiest procedure to mimic with a placebo - you either have a needle in you, or you don't. There are a lot of clever researchers out there, but none have yet conclusively created a placebo needle.

There is, however, plenty of anecdotal evidence that it provides relief to persons suffering from any number of muscle pain issues. People who've received it love it, and more and more practitioners are adding it to their standard therapies.

Why Does It Work?

The simple answer is: we don't know. Not really. There are certainly a lot of ideas, some more valid than others. Pretty much all practitioners agree that a positive sign is when the inserted needle causes a “local twitch response” or “LTR,” where the muscles suddenly contract around the insertion point. The LTR is an involuntary spinal cord reflex, and doctors have suggested relief comes from one of two (or both) outcomes of the LTR:

1. The LTR convinces the body to release natural pain-killers targeting the activated trigger site.

2. The LTR resets the muscle's memory, essentially giving your problematic muscle a concussion so that it no longer remembers it was being a complete jerk to you.

Does It Hurt?

Yes - sometimes, for some people, it hurts. Practitioners note achieving LTR can cause a cramp-like sensation, or a dull ache. And there is the fact that a needle is being pressed through your flesh and into muscle. This can cause discomfort, and some minor pain, though many people have claimed this was minimal, if at all.

What About All the Blood?

Think of what you know about acupuncture. Have you ever heard of anyone experiencing significant blood loss? Neither have we.

See? He's been doing it since the late ‘80s with no problem.

Since the same needles are used, you can expect any bleeding to be minimal, typically 30 seconds at the most and easily controlled by holding a cotton swab over the site.

How Many Times Do I Need to Get Stuck by a Needle?

Once again, this depends on who's doing and who's receiving the sticking. Most practitioners claim relief can be found after three to four sessions, though more difficult and chronic muscular pain issues can require as many as six sessions before relief is achieved. Generally, practitioners don't recommend more than two sessions in a single week, though there's no firm rule for the amount of time to be had between sessions.

Standard risks include:

  1. Infection
  2. Bleeding
  3. Soreness
  4. Fainting
  5. Fatigue
  6. Bruising

More serious rare risks:

  • Damage to underlying cartilage or tissue
  • Punctured organs

The Wielders of the Needles

Dry needling, once a fringe rarity, is becoming increasingly common. You'll find it used in physical therapy, sports medicine, and even by some physicians. The biggest advocates by far are physical therapists.

What training is required?

Typically, training is minimal, especially compared to the multi-year process acupuncturists are required to go through. Agencies that do offer dry needling certification generally have classes that range anywhere from a weekend to several weeks.

Your average used car salesman can't just walk into a weekend class and then set up a dry needling clinic in his guest bedroom, however. You do need to have pre-existing licensure or certification, such as that of a physical therapist before you can take the class.

For a more expansive explanation of the difference in training between acupuncturists and dry needlers, see the YouTube video here.

Does Insurance Cover it?

That depends on your insurance. Nationwide, dry needling is considered an “alternative therapy,” the same categorization as acupuncture. If your insurance has a blanket statement refusing payment for alternative therapies, then no. On the other hand, when dry needling is conducted by a physician with an ultrasound, it will probably be categorized as an actual medical procedure, because physicians like to get paid just like the rest of us.

The onus is on you to contact your insurance agency and determine what they will pay for.

Is It Legal Where I Live?

Dry needling is legal in all 50 states. The only contention is who can do it. Some states have passed judgments preventing physical therapists from using dry needling, though the argument isn't based on the actual practice but rather how lawyers define “scope of practice,” which is legalese for who's allowed to do what in the world of medicine.

In the states that have had a problem with physical therapists and dry needling, the point of contentions lies in the little word “invasive,” which refers to any procedure which has to go through to the skin to get at what lies beneath. Some states see only physicians as being allowed to conduct “invasive” procedures, whereas others take a more liberal view of the term and allow physical therapists to have their needle on so long as they stay away from the organs.

A Final Warning

Most practitioners of dry needling are quite specific that the procedure isn't a one-stop cure-all, but rather one of many tools to be used in providing relief to persons suffering from muscle pain and stiffness. Do your homework. Talk with people who have had it done. Talk to people who do it. Make sure the people you're talking to know exactly what it is you're looking for, and your full medical history. Go to clinics and specialists who have solid reputations and are well respected in their field and communities.

And if you decide to go ahead and make an appointment with the twitchy guy gesturing to you from the back-lit doorway of a dead-end alley with the words "Dry Needling - Cheap!" scrawled onto a piece of cardboard, that's on you.

Featured image: Public Domain, Lt. Cmdr. Charles Rainey, physical therapist at Naval Health Clinic Hawaii, performs trigger point dry needling to alleviate musculoskeletal pain and dysfunction. U.S. Navy photo by Susan Schultz, Naval Health Clinic Hawaii Public Affairs

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