Last year, the American Physical Therapy Association (APTA) produced a resource paper that highlights the practice of dry needling, which involves the therapist to use a thin, acupuncture-like needle to puncture the skin and stimulate underlying trigger points in connective and muscle tissue to reduce muscle pain and movement problems. Although dry needling is getting more popular among physical therapists, some scientists are giving it a skeptical eye about its efficacy due to a lack of strong scientific evidence and research.
Neuroscientist Lorimer Moseley, Ph.D., from the Samson Institute for Health Research at the University of South Australia, and his colleagues, Neil O’Connell, Ph.D., and physiotherapist Daniel Harvie, criticized a systematic review about the current evidence of the effectiveness of dry needling that was published in the Journal of Orthopaedic & Sports Physical Therapy in 2013. They stated that the study’s conclusion contradicts its results. The full article suggests that the “available data are flimsy” and systematic reviewed showed that dry needling is “probably no better than sham” and may be worse than similar treatments.
However, the study’s researchers favored dry needling as a clinical recommendation for pain treatment, calling it “grade A evidence.” Clearly, there is a polar conflict of statements in their conclusion and results. Moseley and colleagues wrote that this systematic review falls under the garbage-in-garbage-out phenomenon: If the original research and articles are “crap,” then even the best review simply “collate crap.” The recommendations do not fairly reflect on what the data presented. Thus, dry needling gets a skeptical eye due to inconsistent evidence, data, and interpretation.
Physiotherapist Barbara Cagnie, Ph.D., from Ghent University in Belgium and physiotherapist Frank Timmermans from Uplands Physio Clinic in British Columbia, Canada, told Guardian Liberty Voice in an online interview that double-blinded studies are not easy to do for dry needling. However, they claimed that dry needling works in a clinical setting. “We [physiotherapists] see and can measure that dry needling helps. We can call this ‘practice-based evidence’. It’s quite comparable to spinal manipulation. There’s a lot of debate about the safety of this procedure. We see it works in clinic, but is very difficult to provide evidence by scientific studies. However, scientists, of course, prefer ‘evidence-based practice,’ and here we get to the current dilemma: we need properly conducted research to prove that (and how) dry needling works.”
Cagnie and Timmersman cited from their article that was published in Current Pain and Headache Reports: “Rigorous evidence about its physiological mechanisms of actions and effects is needed now in order to start supporting it as evidence based practice. The difficult methodological characteristics related to experimental studies and the complex network in pathological conditions may certainly account for this lack of research so far.”
When asked if the evidence is lacking and weak, why is drying needling applied to patients? Cagnie and Timmersman replied:
“Because it works, but we need better research to support dry needling. It is just a matter of time that this better conducted research will ‘prove’ what we see every day in the clinic. It really helps, but we are still waiting to be (more) supported by evidence-based research. However, we see that studies evaluating myofascial approach, and in specific dry needling, are currently gaining more and more importance in scientific research.”
Dry needling uses the myofascial trigger point theory that focuses on releasing taut bands of muscle and connective tissues that could cause pain and movement dysfunction. This theory stems from the teachings of Dr. Janet Travell, M.D., and Dr. David Simons, M.D., who authored a book called Myofascial Pain and Dysfunction: The Trigger Point Manual. For many physiotherapists, manual therapists, and massage therapists, it was the “bible” of trigger point therapy since the 1990s.
“Ultrasound feedback and special MRI techniques verify the taut band and the ‘energy crises’ idea presented in the model,” stated Cagnie and Timmersman. “In our opinion, the trigger point model (at a local level) is quite suitable to use in a research setting. Also, there are also other ideas to try to explain myofascial pain, e.g. Dr Gunn’s hypothesis from Canada. He and other researchers see myofascial pain as a result of discrete problems in the spinal root nerves. This is a more ‘centralized idea’ to explain local pains compared to the more local trigger-point model.”
They also mentioned that other scientists, like Dr. Moseley, see pain stems from the brain. “We think in the average ‘real’ patient there is a mix of peripheral and central components and explanations. Pending on the patient, it is crucial to identify the dominant pain mechanisms. If nociceptive pain is the dominant mechanism, we are convinced that DN does help. In patients with a dominant central pain mechanism, characterized by central sensitization, we may have to look for other (central/cognition based) therapies.”
However, not all physical rehab and related professionals buy into such logic behind the “it works” mentality. Science journalist Paul Ingraham stated that asking science to prove a certain modality works is a common fallacy in medicine, especially in alternative medicine. “That is bass-ackwards. It’s a terrible inspiration for doing science, guaranteed to dial confirmation bias up to 11,” he wrote on his website Save Yourself.
He mentioned that clinical experience does not prove anything and cannot be trusted, even if the treatment “works.” “Treatment efficacy must be actually tested and proven rigorously first. We need find out if an idea actually produces measurable medical results and then — if it works, if it actually helps people enough to be measurable — then and only then do we proceed to try to illuminate the mechanism. Stated even more briefly: we cannot study how a treatment works if we haven’t figured out if it works.”
Physiotherapist Diane Jacobs, who practices in Weyburn, Saskatchewan in Canada, said in an online interview that the “practice-based evidence” model is a “doubly flawed” idea. First, “evidence-based medicine concerns itself only with outcomes, and never considers whether or not a primary premise has legitimacy in the first place.” Jacobs cited Dr. Harriet Hall, M.D., who is one of the co-founders of Science-Based Medicine, who refers practice-based medicine as “tooth fairy science.”
“Although you can leave the tooth wrapped in a tissue or in a sandwich baggie, leave it on a windowsill or under a pillow, measure each strategy in terms of outcomes that have to do with amount of money left behind, the whole effort has nothing to do with or nothing to say about whether the tooth fairy actually exists,” Jacobs explains. “In this manner, a lot of dubious concepts have papers written up now, and have achieved some sort of pseudo-respectability as a result. People can point at them and say, “There is evidence, which proves the concept is valid” when in fact it does no such thing. Therefore, secondly, to assert that something is valid (when no evidence or, more importantly, prior plausibility exists), and call it “practice-based evidence” is to be completely anti-scientific, not even just regular tooth fairy science with no prior plausibility.”
The reasoning behind the efficacy of dry needling and most interventions gets a skeptical eye from most scientists. In 2005, Robert Herbert, Ph.D., who is the senior lecturer at the School of Physiotherapy at the University of Sydney, and his colleagues wrote in an editorial in the Australian Journal of Physiotherapy that warned researchers and physiotherapists that “clinical outcomes are influenced by many factors other than intervention,” such as the natural course of the condition, placebo effects, and statistical regression. Outcome measures measure outcomes, and they do not measure the effects of intervention. “Outcomes of interventions and effects of interventions are very different things. The implication is that a good outcome does not necessarily indicate that intervention was effective; the good outcome may have occurred even without intervention. A poor outcome does not necessarily indicate that intervention was ineffective; the outcome may have been worse still without intervention. This is why proponents of evidence-based physiotherapy, including ourselves, argue it is necessary to look to randomized trials to determine, with any degree of certainty, the effects of intervention.” Thus, it is illogical to look for evidence at randomized controlled trials while searching for “evidence” to justify an intervention’s effectiveness in clinical practice — as in this case, dry needling.
By Nick Ng
Body In Mind
Journal of Orthopaedic & Sports Physical Therapy
The American Academy of Orthopaedic Manual Physical Therapists
Current Pain and Headache Reports
Interview with Barbara Cagnie, PT, Ph.D.
Interview with Diane Jacobs, PT
Australian Journal of Physiotherpy