A History of Dry Needling

As a follow-up to my original article on Dry Needling versus Acupuncture: The Ongoing Debate I wanted to share some additional info from the article by Dr. Kehua Zhou that touches on the history of Dry Needling (DN) and acupuncture. Once again, if you were to read any article that speaks to DN and acupuncture living together, please read this info below by Dr. Zhou.

History of Dry Needling

Dry Needling – subtypes of which include related techniques known as intramuscular stimulation or trigger point needling – refers to the use of either solid filiform needles or hollow-core hypodermic needles for the treatment of muscular pain.

Although some PTs claim that DN was first developed in the 1940s by Janet Travell, little evidence exists to support this statement. In Myofascial pain and dysfunction: the trigger point manual, Travell and Simons summarized the key elements of the DN technique as: (1) use of a needle of sufficient length to reach the contraction knots in the trigger points without any preference for needle diameter (range 0.3–3.4 mm); and (2) use of an aseptic technique via careful cleansing with a suitable antiseptic (usually alcohol wipes). Travell and Simons did not mention any specific type of needle used in DN when they proposed that it was as effective as local lidocaine injection in relieving trigger point pain; however, they did mention that ‘DN’ would induce post-injection soreness, which might be more severe and last for a longer period of time than the injection of lidocaine. Thus, the needle they were referring to is more likely to have been a hypodermic needle, rather than an acupuncture needle.

Further evidence that the origin of DN involved the use of hypodermic needles for the treatment of myofascial pain is provided by findings of a review of DN history.

The earliest reference to ‘DN’, as per Legge, was in an article about low back pain in 1947 when Paulett reported that ‘DN’ and injecting saline both relieved pain.

In 1952, Travell and Rinzler explored the origins of myofascial pain, and commented that effective treatment of myofascial pain might include DN. The needles used in these early publications related to DN were likely to have been hypodermic needles, as injection of saline or local anaesthetic was simultaneously mentioned and compared.

Nonetheless, the earliest available study directly identified using the search term ‘dry needling’ in PubMed was authored in 1979 by Lewit, who used acupuncture needles in DN practice. He found that DN produced immediate, complete analgesia of the painful spot without hyperaesthesia for patients with myofascial pain. Based on these results, Lewit reported that the therapeutic effects of needling in myofascial pain originated from the mechanical stimulation of the needling per se and was due to neither the anaesthetic nor the sclerosing solution.

In 1980, Gunn et al recommended the manipulation of acupuncture needles to produce a grabbing sensation in patients with trigger point pain. Gunn et al reported that the techniques were inspired by TA and that DN had powerful therapeutic effects for patients with chronic low back pain. Development of DN was limited in the 1980s and 1990s as indicated by the limited number of publications (<30) in the literature during this period. However, since the 2000s, interest in DN has resurged as healthcare professionals, especially PTs, have begun to recognize the beneficial effects of DN on pain. Currently, DN is practiced by many healthcare professionals in Europe, Australia, more than half of the states across the USA, and in many other countries.

Theory of DN

The use of DN is based on an understanding of human anatomy and physiology regarding myofascial pain and trigger points. Theories regarding DN involve various neurophysiological mechanisms, which are indirectly supported by an expanding volume of clinical research.

Between 1980 and April 2015, almost 200 publications were retrievable by a PubMed search using the term ‘dry needling.’ The majority of this literature reports on the therapeutic effectiveness of DN using solid filiform needles for various types of musculoskeletal pain. Within the available meta-analyses, one study reported that DN treatment of myofascial pain in the lower back appeared to be a useful addition to standard therapies, and another study found that DN was an effective intervention for upper-quarter myofascial pain, which decreased immediately after treatment and at follow-up at four weeks.

Since the most recent meta-analysis, 20 new articles involving DN had been indexed in PubMed by April 2015. Almost all of them have reported that DN is effective for specific types of musculoskeletal pain.

DN procedure

In general, DN techniques can be divided into superficial and deep techniques. In superficial DN, needles are inserted superficially (around 5–10 mm) into tissue above the underlying trigger points. After retention for a short time (30 seconds to 3 min), the needle is removed and the pain is expected to be greatly relieved. If residual pain occurs, the procedure can be repeated two to three times.

Other superficial needling techniques exist too. For example, Fu’s superficial needling involves insertion of needles at an angle of 20–30° without penetrating the muscle. In the newly evolved wrist and ankle needling, the needles are inserted almost horizontally at the wrist and ankle within the connective tissue layer between the muscle and skin. As the needle is inserted and manipulated in the superficial layer of the body, no muscle twitch is expected.

In deep DN, needles are inserted deep into the tissues directly toward the trigger points in order to reach them. ‘Sparrow pecking’ – whereby solid filiform needles are manipulated in and out of each trigger point to elicit a local twitch response – is commonly used with treatment regimens typically consisting of a course of three or more treatments, given once a week. Although Dunning et al states that needles (one or more) are left in situ for between 10 and 30 minutes, DN practice by PTs is typically ‘fast-in and fast-out’, often described as ‘pistoning’, and does not usually involve needle retention. Most studies do not specify the angle of needle insertion, but the conventional needling technique usually involves perpendicular penetration of the skin.

Acupuncture

History of acupuncture

DN has been intertwined with acupuncture since its inception. Meta-analyses of acupuncture or DN for myofascial pain have included studies in both fields in order to decrease bias and strengthen the validity of the results. Results of research into the effects of needling can often be applied to both DN and acupuncture.

The term acupuncture originally referred to the ancient healing technique originating from China 2000 years ago, which has been widely practiced all over the world as a professional practice in the field of complementary and alternative medicine.

Traditional Acupuncture (TA) involves the stimulation of specific points on the body, based upon the theoretical ‘meridian’ concept, via penetration by solid filiform needles. Original acupuncture instruments were made from so-called bian stones. With the introduction and application of iron instruments, bian stone needles were replaced by medical needles made of metal.

Acupuncture theories and techniques have been expanded and optimized by the contribution of acupuncturists of the various time periods throughout history. Since the inception of Chinese culture, acupuncture has been used as one of the major tools for the restoration and maintenance of health in China.

Acupuncture likely emerged in the USA in the late 1800s when large numbers of Chinese workers migrated to the West Coast to build railways. Acupuncture made its official debut, however, in 1971 when journalist J. Reston published an article in the New York Times describing his personal experience with acupuncture, followed by the visit of U.S. President Richard Nixon to China in 1972.

In the UK, physicians were reported to have been needling tender points to relieve musculoskeletal pain in the 1800s. Interest in acupuncture surged in the 1970s. Ever since then, acupuncture has become more and more popular in major western countries. Due to its growing popularity and an accumulation of research evidence, acupuncture, particularly Western Medical Acupuncture (WMA), has been widely integrated into the practice of conventional healthcare in major western countries.

Theories of acupuncture

Classical theories and principles of point selection in TA are based on historical concepts of balancing Yin and Yang and dredging ‘meridians’. Such theories are used to differentiate TA from WMA. Nowadays, both classical theory and modern biomedical sciences are included in the education of acupuncturists in China and around the world.

Besides TA, the contemporary version, WMA – which is based on the understanding of human anatomy, physiology, and pathology – is also widely practiced, especially among physicians and other healthcare professionals. One example of WMA is peripheral neuromodulation, in which practitioners stimulate somatic nerves in order to influence autonomic nerves (via somatovisceral reflexes).

A special category of acupuncture points are the ah shi (translated as ‘ouch’) points, which include acupuncture points that are tender to touch or pressure, with a similar definition to trigger points. Dorsher reported that the distribution of trigger points has a 95% overlap with acupuncture points in the treatment of pain disorders. Thus, in pain conditions, trigger points may represent similar (if not the same) physiological phenomena as acupuncture points.

Acupuncture procedure

Acupuncture involves many different techniques, with various types and lengths of needles depending on the condition and the acupuncture point location. The commonly used procedure for musculoskeletal pain involves ah shi points with treatment protocols similar to DN, but with needle retention. Traditionally, acupuncture point selection and treatment is based on ‘syndrome differentiation,’ which incorporates inspection (including the tongue), palpation (including the pulse), and systematic inquiry. This is the process that many acupuncturists and Traditional Chinese Medicine practitioners use to generate a traditional diagnosis, treatment principle and plan.

Acupuncturists usually emphasize de qi sensations during treatments. De qi refers to a composite of sensations including local muscle twitches and propagation of sensation upon needling. Historically, de qi sensation has been considered to be the foundation for the therapeutic effectiveness of acupuncture for pain, and this is supported by research demonstrating that the stimulation of A-delta afferent nerves that is associated with the de qi sensation is important in mediating the clinical effects of acupuncture.

Most acupuncture procedures last 30–45 min and involve a perpendicular needle insertion. It is worth noting that during the same time period that DN was developing in the western world, Professor Dinghou Lu and colleagues at Beijing Sports University strongly advocated needling at tender (ah shi) points using an oblique angle, as this gave better therapeutic effects in myofascial pain compared with vertical needle insertion.


For more info on the article http://aim.bmj.com/content/33/6/485.long

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