Journal Article Review April 2018

April, 2018:  Does dry needling work?

1. Hall ML et al: Effects of dry needling trigger point therapy in the shoulder region on patients with upper extremity pain and dysfunction: a systematic review with meta-analysis. Physiotherapy. 2017 Aug 7. pii: S0031-9406(17)30079-2. doi: 10.1016/j.physio.2017.08.001. [Epub ahead of print]

2. Gattie E et al: The Effectiveness of Trigger Point Dry Needling for Musculoskeletal Conditions by Physical Therapists: A Systematic Review and Meta-analysis. J Orthop Sports Phys Ther. 2017; 47(3):133-149. 

 3. Espejo-Antunez L et al: Dry needling in the management of myofascial trigger points: A systematic review of randomized controlled trials. Complement Ther Med 2017; 33:46-57

Within the past year, three groups of investigators from Spain/Portugal, New Zealand, and New Hampshire have published systematic reviews, and in two instances meta-analyses, of the current literature on the effects of dry needling. The investigators restricted their reviews solely to randomized controlled trials. The three reviews complement one another and do not have significant overlap. One investigated trigger point dry needling (TDN) on “upper extremity pain and dysfunction.” 1 One investigated “musculoskeletal conditions.”2 And the other studied “myofascial trigger points.”3 Their analyses included 11, 15, and 13 original studies, respectively.

One original study was included in all three of the reviews, and four original studies were included in two of the reviews. Hence the three reviews analyzed 33 separate studies. Six of the original papers studied neck pain; and one each studied temporomandibular, knee, ankle, low back, and lateral elbow pain. So 22 of the 33 of the papers under analysis looked at shoulder pain in over 900 patients.

The original randomized controlled trials used a wide variety of controls for comparison. These included no treatment, sham needling (only touching the skin with a blunt needle or needling near but not on the trigger point), routine physiotherapy (US, TENS, hot pack, exercise, stretching), acupuncture, electroacupuncture, trigger point compression, botulinum toxin injection, lidocaine injection, oral drugs, and laser.

Outcomes measured by the three reviews all included pain, and one or two included range of motion, disability/functional outcome, depression, quality of life, pressure pain threshold, and strength.

RESULTS The best way to summarize the results is to quote from from the systematic reviews/meta-analyses:

Hall et al: “As a result of the high risk of bias within the included studies and the low strength and quality of the evidence, there is very low evidence to support the use of TDN in the shoulder region for treating patients with upper extremity pain or dysfunction.”

Gattie et al: “Very low-quality to moderate-quality evidence suggests that dry needling performed by physical therapists is more effective than no treatment, sham dry needling and other treatments for reducing pain and improving pressure pain threshold in patients presenting with musculoskeletal pain in the immediate to 12-week follow-up period.” “No difference in functional outcomes exists when compared to other physical therapy treatments. Evidence of long-term benefit of dry needling is currently lacking.”

Espejo-Antunez et al: “The results suggest that dry needling is effective in the short term for pain relief, increased range of motion and improved quality of life when compared to no intervention/sham/placebo. There is insufficient evidence on its effect on disability, analgesic medication intake and sleep quality. Despite some evidence for a positive effect in the short term, further randomized clinical trials of high methodological quality, using standardized procedures for the application of dry needling are needed.”

COMMENT Dry needling is clearly a topic of current interest, testified by 33 randomized controlled trials to show up in the past 10-14 years and for three systematic reviews/meta-analyses from far reaching areas of the world to be published in the past year. Each of the reviews seem to be solidly designed and executed, and as one review noted, the underlying investigations are likely to contain some selection bias. In other words, some studies not showing desired results were likely left incomplete, or if completed, never got published.

Proponents of TDN can pick portions of the three reviews to bolster support for its efficacy:

·         “moderate quality evidence”

·         “effective in the short term”

Skeptics can cite the same reviews and claim:

·         “very low-quality evidence”

·         “very low quality”

·         “no difference … when compared to other … treatments”

As with most things in health care, maybe in life, “Better studies are needed.”