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considerations
Jan Dommerholt1,2
Bethesda Physiocare, Bethesda, MD, USA, 2Myopain Seminars, Bethesda, MD, USA
Dry needling is a common treatment technique in orthopedic manual physical therapy. Although various
dry needling approaches exist, the more common and best supported approach targets myofascial trigger
points. This article aims to place trigger point dry needling within the context of pain sciences. From a pain
science perspective, trigger points are constant sources of peripheral nociceptive input leading to
peripheral and central sensitization. Dry needling cannot only reverse some aspects of central sensitization, it reduces local and referred pain, improves range of motion and muscle activation pattern, and
alters the chemical environment of trigger points. Trigger point dry needling should be based on a thorough
understanding of the scientific background of trigger points, the differences and similarities between active
and latent trigger points, motor adaptation, and central sensitize application. Several outcome studies are
included, as well as comments on dry needling and acupuncture.
Keywords: Myofascial pain, Trigger points, Sensitization, Pain, Dry needling
Introduction
Over the years, dry needling has become a popular
treatment technique in manual physical therapy.1
Physical therapists and other healthcare providers
in many countries employ dry needling in the
clinical management of patients with myofascial
pain and trigger points. In the USA, approximately
20 states and the District of Columbia have approved dry needling by physical therapists, which is a
dramatic increase since 2004, when only four states
approved dry needling.2 In 2009, the American
Academy of Orthopaedic Manual Physical Therapists adopted a position statement that dry needling is within the scope of manual physical therapy.
The advantages of dry needling are increasingly
documented3 and include an immediate reduction
in local, referred, and widespread pain,47 restoration of range of motion and muscle activation
patterns,5,8,9 and a normalization of the immediate
chemical environment of active myofascial trigger
points.10,11 Dry needling can reduce peripheral and
central sensitization.4
Popular explanations of myofascial pain tend to be
relatively simplistic and do not always offer a wellevidenced theoretical foundation to direct clinical
treatment strategies.1 Historically many researchers
and clinicians have considered a vicious cycle
Correspondence to: Jan Dommerholt, Bethesda Physiocare/Myopain
Seminars, 7830 Old Georgetown Road, Suite C-15, Bethesda, MD
20817, USA. Email: dommerholt@myopainseminars.com
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muscles,24 while others found that the activity of motor neurons is not necessarily uniformly decreased.2529
A new motor adaptation model has been proposed.22
Although various needling approaches are commonly referred to as dry needling, it is important to
realize that there are significant differences between
schools of dry needling, their specific needling techniques, underlying philosophy or rationale, and duration
of training programs. Each approach appears to
address particular aspects of the total picture.
Different dry needling techniques have been promoted
to treat various forms of soft tissue dysfunction.3032
Contemporary schools approach dry needling from
a broad pain sciences perspective.30,32,33 For example,
Ma has developed a dry needling approach based on
clinical applications of pain sciences and he maintains
that his integrative systemic dry needling is required
to restore and maintain normal physiology of soft
tissues and to reduce systemic stress to improve
homeostasis.32,33 To date, there are no research studies
of Mas needling approach. The intramuscular
stimulation dry needling approach developed by
Gunn is one of the first medical dry needling approaches. Gunn considers myofascial pain to be secondary to neuropathy.31 A few studies demonstrated the
efficacy of intramuscular stimulation, but there are
no studies that validate the underlying theoretical
assumptions.1,34,35 Dommerholt and Huijbregts focused on dry needling of trigger points, which
occasionally has been interpreted erroneously as a
more local approach.30 Trigger point dry needling
has local and widespread effects5,7 and influences
remote parts of the body.6,36,37 A superficial and a
deep technique have been developed, whereby proponents of superficial needling suggest that the intervention targets primarily peripheral sensory afferents,
while deep trigger point dry needling targets mostly
dysfunctional motor units.38,39
To better appreciate the potential therapeutic role
of dry needling, a review of the current research on
myofascial trigger points follows within the context
of pain sciences. The therapeutic effects of dry
needling can only be understood against a pain
management background. Therefore, review will
focus on sensory and motor mechanisms relevant to
dry needling, and indirectly on the application of dry
needling. Unless indicated otherwise, references to
dry needling in this article should be interpreted as
trigger point dry needling based on the work of
Travell, Simons and Lewit.7,40,41
Dry needling is relatively easy to learn for qualified
healthcare providers, which may include manual
physical therapists, physicians, dentists, chiropractors, and acupuncturists. A solid background and
education in anatomy, physiology, and pain sciences
are prerequisites. To use dry needling as an effective
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kinds of ASICs play different roles in the development of hyperalgesia,154 i.e. ASIC3 is important for
inflammatory pain and ASIC1a is involved in central
sensitization and in processing noxious stimuli.153
Repeated intramuscular injections of acid saline in
rats activated N-methyl-D-aspartate (NMDA) receptors in the brainstem and other parts of the central
nervous system.155 A low pH downregulates acetylcholine esterase and triggers the release of several
nociceptive substances, such as calcitonin generelated peptide (CGRP), adenosine triphosphate
(ATP), bradykinin (BK), serotonin (5-HT), prostaglandins (PGs), potassium, and protons.156 ATP is
one if the most important activating substances of
muscle nociceptors by binding to P2X3 receptors.
There are many interactions between these substances. For example, the combination of ATP and
acid increases the pH sensitivity of the ASIC3
receptor.157 Combinations of BK and 5-HT produce
more muscle hyperalgesia than each chemical
alone.158,159 BK, PG, and 5-HT are not only very
effective at sensitizing or activating muscle nociceptors, but they can also cause local vasodilation, which
can lead to mechanoreceptor activation by distorting
the normal tissue relationships. A sensitized muscle
nociceptor has a lowered stimulation threshold into
the innocuous range and will respond to harmless
stimuli like light pressure (allodynia) and muscle
movement (mechanical hyperalgesia). Most data are
derived from animal studies as there are only few
human research on muscle nociceptor activation.160,161
processing.188 As Lim et al. summarized, the nociceptive flexion reflex is a physiological measure that is
commonly made from the biceps femoris muscle
following electrical stimulation of the sural nerve. It
involves the lowest noxious stimulation intensity
required to trigger a reflex without stimulating
peripheral nociceptors.188
Patients had significantly worse outcomes when
they presented with relatively high levels of central
sensitization, including hyperalgesia and referred
pain, before subacromial decompression surgery.169
Dry needling and trigger point injections commonly
elicit and eliminate local and referred pain patterns or
areas of secondary hyperalgesia.178,189191 As a side
note, the effects of injections are comparable to dry
needling.192 The outcomes of subacromial decompression would conceivably have been much
improved after central sensitization would have been
addressed with trigger point therapy including dry
needling, injections, or manual inactivation.169,193196
The same applies to the other listed diagnoses, i.e.
trigger point needling decreased the overall sensitivity
in patients with fibromyalgia and decreased pain and
increased range of motion in whiplash, post-mastectomy, and temporomandibular patients.4,5,172,197
Patients with a hypersensitive trigger point in the
upper trapezius muscle exhibited significantly enhanced somatosensory and limbic activity and decreased activity in the dorsal hippocampus compared
with control subjects.198 Using functional magnetic
resonance imaging, Niddam et al. showed that pain
following the insertion of a needle into a trigger point
combined with electrical stimulation is mediated
through the periaqueductal gray in the brainstem.199
Central sensitization is the mechanism of referred
pain from trigger points, which Travell and Simons
described for most musculoskeletal muscles.40,200 The
mechanisms of muscle referred pain have been
described in detail by Hoheisel, Mense, ArendtNielsen, and Graven-Nielsen, among others, and
involve sensitization and an expansion of receptive
fields.56,201207
The immediate environment of active trigger points
is characterized by significantly increased levels of
substance P (SP), CGRP, BK, 5-HT, norepinephrine,
tumor necrosing factor-alpha, and interleukin-1beta
compared to latent trigger points and normal muscle
tissue.11,147,208 These chemicals sensitize and activate
not only muscle nociceptors, but can also activate
glia cells. Whether trigger points stimulate glia cells
is not clear, as different studies show conflicting results. Chacur and colleagues demonstrated that chronic muscle lesions can activate microglial cells,209
but others suggested different mechanisms.210213
Irrespective of the mechanism, myofascial trigger
points become sources of ongoing nociceptive input
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Summary
Dry needling or trigger point inactivation rarely is a
stand-alone kind of intervention and is just one
aspect of a comprehensive manual physical therapy
approach. Dry needling is usually combined with
other manual therapies116,278280 and should be
considered an instrument-assisted manual therapy
technique, similarly to other instrument-assisted
manual therapy techniques such as the Graston
Technique.281,282 Dry needling is not solely in the
scope of any one particular discipline. Overlap in
scope of practice is not only inevitable; it may even be
desirable to best meet the needs of patients. Dry
needling is an easy to learn technique in the hands of
qualified health care providers.
In this review, we have postulated that dry needling
is a potent therapeutic measure to remove a constant
source of peripheral nociceptive input originating
from myofascial trigger points. As such, dry needling
does not replace other manual physical therapy
technique, but may be useful in facilitating a rapid
reduction of pain and a return to function. A
thorough understanding of the role of trigger points
in peripheral and central sensitization is important in
manual physical therapy practice. Trigger points can
be inactivated with manual techniques and joint
manipulations,119,283 but dry needling may be a more
efficient and quicker method.1
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