Sign Up
You are not currently logged in. Please log in to CEUfast to enable the course progress and auto resume features.

Course Library

Dry Needling in Patient Care

1.5 Contact Hours
Listen to Audio
CEUfast OwlGet one year unlimited nursing CEUs $39Sign up now
This peer reviewed course is applicable for the following professions:
Advanced Practice Registered Nurse (APRN), Certified Nurse Practitioner, Certified Registered Nurse Practitioner, Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Nursing Student, Occupational Therapist (OT), Occupational Therapist Assistant (OTA), Physical Therapist (PT), Physical Therapist Assistant (PTA), Registered Nurse (RN), Registered Nurse Practitioner
This course will be updated or discontinued on or before Thursday, September 24, 2026

Nationally Accredited

CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.


Outcomes

≥ 92% of participants will know what dry needling is, how it is used to treat myofascial pain, indications for utilization, basic dry needling techniques, and safety considerations when using dry needling.

Objectives

After completing this course, the participant will be able to meet the following objectives:

  1. Define dry needling.
  2. Differentiate the philosophical differences between dry needling and acupuncture.
  3. Examine the role of trigger points in myofascial pain and how dry needling is utilized in treating trigger points.
  4. Compare dry needling techniques.
  5. Evaluate the indications for including dry needling in a treatment plan and its efficacy for various musculoskeletal pain disorders.
  6. Summarize the safety considerations related to dry needling.
  7. Examine the legal considerations related to dry needling in healthcare practice.
** Please note that this course is for foundational knowledge only and is not meant to teach the participant how to perform dry needling. If the participant wants to become qualified to perform dry needling, please consult your state regulations and the Professional Practice Act and seek a comprehensive, hands-on course to provide the proper education required to become a certified practitioner to utilize this intervention.
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

Last Updated:
  • $39 Unlimited Access for 1 Year
    (Includes all state required Nursing CEs)
  • No Tests Required
    (Accepted by most states & professions)
  • Instant Reporting to CE Broker
  • Instant Access to certificates of completion
Logo Audio
Now includes
Audio Courses!
Learn More
Restart
Restart
  • 0% complete
Hide Outline
Playback Speed

Narrator Preference

(Automatically scroll to related sections.)
Done
Dry Needling in Patient Care
0:00
0:15
 
To earn a certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Attest that you have read and learned all the course materials.
    (NOTE: Some approval agencies and organizations require you to take a test and "No Test" is NOT an option.)
Author:    Cindy Endicott (PT, DPT, FAAOMPT, ATC, Cert Dn)

History Of Dry Needling

The history of dry needling traces back to Dr. Janet Travell, who was trained as a cardiologist, started to investigate musculoskeletal pain in the chest, and then moved into the field of orthopedic medicine (Wilson, 2003).  Through this investigation, myofascial trigger points were identified and defined. In 1942, Dr Travell began to suffer from shoulder and arm pain, during which she treated herself by performing injections into the muscles to relieve her pain (Wilson, 2003), a topic on which she published her first landmark paper.  She later teamed up with David Simons to study the science behind referred pain. Together, they identified and mapped out the most common trigger points and their typical referral patterns in "Tavell & Simons' Myofascial Pain and Dysfunction: The Trigger Point Manual" (Simons et al., 1999). This manual still serves as the essential road map for identifying trigger points and their referral pain patterns today. In this manual, the original term "dry needling" was used to differentiate between the two hypodermic needle techniques of injection of local anesthetic and the use of a hypodermic needle without injecting solution.

In 1942, a Czechoslovakian scientist, Karel Lewit, published an article entitled "The Needle Effect in the Relief of Myofascial Pain" (Lewit, 1979). In this publication, Lewit demonstrated that a therapeutic local reduction in pain spots could be a factor of the puncture of the needle itself and not a result of the anesthetic injected. This was the start of using needles "dry" vs. as a vessel to inject anesthetic. His study examined the short- and long-term effects of dry needling in treating chronic myofascial pain. He noted that the effectiveness of treatment was related to the intensity of the pain produced by the trigger point and the precision with which the point of maximal tenderness was located by the needle. The immediate analgesia produced by needling the most painful spot has been termed the "needle effect" (Lewit, 1979).  Since then, systemic dry needling concepts have been developed, becoming an accepted and popular treatment intervention.

What is Dry Needling?

Dry needling is an increasingly popular and widely used treatment for many orthopedic pain conditions. Dry needling is an interventional technique many healthcare professionals use to treat pain, muscle tightness, and movement impairments. Dry needling is also known as intramuscular needling and intramuscular manual therapy (Unverzagt et al., 2015)During the treatment, a thin, filiform needle (a needle that is not hollow and does not inject fluid into the body) is used to penetrate the skin and stimulate underlying myofascial trigger points, muscular tightness, and connective tissues to help manage pain in neuromuscular pain and promote an improved range of motion, mobility and movement patterns (McAphee et al., 2022).

photo of dry needling

Image 1: Dry Needling

Dry Needling: Isn't it Just Acupuncture?

Both dry needling and acupuncture involve the insertion of thin needles into body parts, but just because they use the same tool does not mean they are the same.

While both techniques use needles, the main difference between dry needling and acupuncture is the philosophy of use. Dry needling is part of a Western medicine philosophy of treating locally and is primarily used to treat musculoskeletal conditions. Acupuncture is based on Traditional Chinese Medicine (TMC) and has been a treatment within TCM for more than 2500 years (Maurer et al., 2019). During an acupuncture evaluation, an acupuncturist performs a series of examinations using questioning, listening to cues within the patient's vocal qualities, visual inspection, often of the shape, color, and coating of the tongue, auditory and olfactory data, and palpation of pulses (Mayo Clinic, n.d.; NCCAOM, n.d.; Price, n.d.). The goal of this evaluation process is to detect imbalances in energy pathways before they become pathological according to Traditional Chinese Medicine beliefs and to balance the flow of energy, known as Qi (chee), that is believed to flow through defined pathways (meridians) in the body (Price, n.d.; Mayo Clinic, 2024). This differs greatly from Western medical philosophy. In acupuncture, if the acupuncturist finds "weakness in your Kidneys or your Spleen, it does not mean there is something wrong that will show up in your blood test or a CT-Scan (Price, n.d.)." Acupuncture treats many conditions, including various diseases and dysfunctions. Twelve principle meridians connect acupuncture points, each connecting to an organ system and extending to an extremity and eight collaterals (Maurer et al., 2019). Treatment is conducted through the use of very thin monofilament acupuncture needles, pressure, laser stimulation, or moxibustion (burning small portions of dried mugwort/moxa) at acupoints along the appropriate line of meridian identified during the evaluation process (Maurer et al., 2019). Acupuncture points treated may be far away from the patient's location of pain or problem, known as distal points. They may even be located along specific ear points believed to correspond with specific organs. Distal points are considered outside the scope of dry needling. Wet needling and warm needling are also techniques associated with acupuncture that are not within the scope of dry needling.

photo of auricular acupuncture

Image 2: Auricular Acupuncture

Foundational Knowledge

Identification of Trigger Points

Myofascial pain is a prominent problem that can affect any skeletal muscle. Dry needling is an increasingly popular non-opioid treatment used to treat musculoskeletal movement dysfunctions and pain. It also improves mobility, myofascial tightness, and pain within musculoskeletal tissue. Following an in-depth evaluation of mobility, movement quality, muscle strength, and pain patterns, the clinician will often assess for the presence of trigger points. A trigger point (TrP) is a hyper-irritable spot, often palpable as a nodule within a muscle belly or taut bands in the muscle fascia. Trigger points can cause referred pain in characteristic patterns for specific muscles. Trigger points can disrupt muscle function, restrict the range of motion, reduce strength within a muscle, and cause pain and tenderness.

It is interesting to note, however, that a 2022 publication was released comparing the 255 "most common trigger points illustrated in the 1st edition of the Trigger Point Manual to classical acupoints or "Ah-shi" points in acupuncture (Dorsher, 2022). This investigation examined anatomic locations, clinical indications (pain and non-pain), and their referred pain distribution. This study found that there was an anatomically corresponding classical acupoint for each of the 255 "most common" trigger points that are often targeted by dry needling (Dorsher, 2022). The challenges faced when comparing these two practices revolve around language, differing terminology, treatment goals, and treatment parameters.

graphic showing referral pain pattern from trigger points

Image 3: Pain Pattern from Trigger Points

Etiology of Trigger Points

The exact cause of TrP is unknown; however, they tend to develop due to injury or muscle overuse, often with poor form, poor posture, lack of exercise, and chronic stress, among other possible causes. People who often feel stressed or anxious may be more likely to get trigger points, possibly from clenching their muscles and causing repeated strain to a particular muscle (physiopedia, n.d.).

The specific physiologic mechanisms by which trigger points form remain unknown; however, new literature is evolving to unify TrP formation theories. Gerwin (2023) proposes that the "initiating event is either an acute muscle overload or repetitive muscle action to fatigue resulting in either an excess of acetylcholine (ACh) molecules at the motor endplate or high concentration levels of serum Calcium (Ca2+) or both." This can result in a failure of the presynaptic and postsynaptic feedback mechanisms, leading to the perpetuance of the trigger point (Gerwin, 2023).

The acidity level of the extracellular substance inside trigger points has been found to be quite acidic, with a pH of 4-5. The acidic pH suggests that the trigger point is hypoxic and ischemic (Gerwin, 2023) and has decreased motility and contractility (Bubnov, 2020).

Sustained muscle contraction and continuous release of the previously mentioned molecules can cause nocioception and pain. Trigger points can then repetitively and consistently pull on tendons and ligaments within the muscle, leading to reduced strength and elasticity of the associated muscle (Tsai et al., 2024).

The Technique of Dry Needling

When a trigger point is identified as part of the overall problem that needs to be addressed, dry needling might be considered in the treatment plan. Following a patient screening for appropriateness for dry needling and the patient's consent, the patient is placed in a comfortable position where the muscle to be treated can be relaxed and not in tension. It is suggested that the patient be in a laying position in case of a vasovagal response to the treatment. The patient should be properly draped to allow for adequate exposure to the area to be treated, but appropriate modesty should be allowed during the treatment session. It is important that the practitioner performing the dry needling follow proper safety guidelines, including hygienic conditions, utilizing gloves and sterile, single-use, disposable needles. After identifying applicable bony landmarks, muscle tissue is palpated to determine tightness, tenderness, and if a nodule or trigger point is identified. The trigger point is palpated with flat palpation or with a pincer technique between the provider's fingertips to determine where the most tender point is located. Once located, the provider will tap the needle gently through the skin, utilizing a guide tube for direction. The provider performing dry needling must have proper training and exceptional anatomical and palpatory skills to ensure the proper depth and direction of penetration. Anatomical knowledge is also important in attempting to avoid blood vessels and nerves.  Proper depth and direction of penetration are imperative to avoid accidentally penetrating nearby structures that should be avoided (apex of the lung if dry needling the upper trapezius, for example). The needle can be left in place for several seconds or up to 20-30 minutes.  One or more needles may be utilized, and needles may be placed into multiple trigger points during a treatment session; in fact, inserting multiple needles for 10-30 minutes is common practice in both dry needling and acupuncture (Butts et al., 2021). The treatment time will depend on the treatment location, the number of needles used, and the treatment goals (Jensen, 2023). There is some evidence that indicates that the insertion of multiple needles for 20-30 minutes may produce larger treatment effects and a longer-lasting outcome than brief single-needle techniques (Butts et al., 2021).

There is, however, no standardized method or protocol for dry needling, leading to variety and inconsistency between practitioners who utilize dry needling.

Needle Manipulation Techniques

During a dry needling treatment session, the provider may choose to apply various application techniques, depending on the muscle's response, the goal of the treatment, the patient's level of comfort with dry needling, and the provider's preference.

Needle Pistoning

Needle pistoning is when the needle is inserted into a trigger point, pulled part of the way out, and inserted again rapidly and repeatedly (similar to a sewing machine)The main goal of the pistoning technique is to elicit a local twitch response (LTR) within the muscle.The LTR is an involuntary contraction reaction of the muscle/trigger point to the stimulus of the puncture with the dry needle(Rodriguez-Huguet et al., 2022). The pistoning may continue until the TrP no longer twitches, indicating the muscle has "released." It is believed that once the acetylcholine trapped in the endplate is depleted, the twitching will stop (McAphee et al., 2022). This  LTR causes the sarcomeres within the muscle to disband from each other, creating muscle relaxation and causing the trigger point to dissolve. Stimulation of an LTR can be painful but is often described as a beneficial pain, as the patient can feel that this exact point is contributing to their overall pain. Trigger point pistoning and resulting LTR can be intimidating and frightening to patients new to dry needling and is often not a great choice of technique for newer patients.

Intricate Art Spine & Body Solutions proposes that pistoning-style dry needling should not be utilized (Intricate Art Spine & Body Solutions, n.d.). They purport that "pistoning techniques produce too much sympathetic autonomic nervous system hyperactivity, producing poor physiologic responses and not guiding the system toward homeostasis (Intricate Art Spine & Body Solutions, n.d.)."

Needle Rotation

Needle rotation involves inserting the needle into the trigger point and slowly rotating it in one direction until it is taut and no longer easily rotates. The needle rotation causes the connective tissue to wind around the needle, deforming the collagen fibers. As the needle is left in situ for several minutes, these fibers release, allowing the needle to be rotated again before ending the treatment. This technique is analogous to putting a fork into spaghetti noodles and winding the noodles around the fork.

Electrical Stimulation while Dry Needling (electrical dry needling)

Electrical dry needling, or dry needling with electrical stimulation, involves the addition of electrical current through the needles while the needles are still in situ. Electric dry needling can be accomplished by touching a handheld electrical stimulation machine to the end of the needle or, more commonly, by attaching small alligator clips to the ends of the needles. The electrical stimulation parameters can be altered to include a higher frequency, similar to tens, and a lower frequency that produces a slight muscle twitch. Electrical dry needling reduces pain, decreases muscle tone, and improves circulation. Dry needling with electrical stimulation also stimulates nociceptive fibers that drive opioidergic, reducing pain. This activates the anterior middle cingulate cortex, which modulates chronic pain (Young et al., 2024). It is important to note that electrical stimulation should not be used with dry needling in patients with cardiac pacemakers (Bachmann et al., 2022) or electrical stimulation units implanted for pain control.

photo of electrical stimulation with needling

Image 4: Electrical Stimulation with Needling

How does Dry Needling Work?

Although the mechanism through which dry needling works remains unclear, the leading mechanisms involve biochemical reactions on the sarcomeres of the muscle tissue and impact on the neural pathways and the sodium-potassium pump, leading to alterations in muscle polarization (Barber et al., 2023). The influx of calcium ions releases adenosine triphosphate (ATP) in the peripheral nerve endings. ATP release and eventual metabolization lead to pain relief and tissue remodeling.

A neurological component to needling has also been introduced, connecting the LTR as a spinal cord reflex that can reduce the number of neurotransmitters and inflammatory substances in the tissue (Barber et al, 2023). Excess neurotransmitters can lead to more sustained contractions, and reducing their presence reduces the tetany and tone of the surrounding tissue.

Additionally, dry needling has been shown to promote local vasodilation within the trigger point. The minor amount of local trauma to the muscle creates a temporary release of neuropeptides leading to relaxation (Butts et al., 2021). Vasodilation will also increase oxygenation within the trigger point, decreasing the hypoxic environment. Studies have shown a 72% increase in blood flow following dry needling of the upper trapezius with a single needle (Butts et al., 2021). More recently, dry needling has been described as adjusting the overall tone of connective tissue and changing its biochemical matrix (Barber et al., 2023).

However, another theory revolves around impacting the remodeling of the tissue collagen fibers and restoring healthy healing. Chronic tendinopathies have been shown to have disorganized collagen formation, poor vascularization, and decreased tensile strength, leading to poor tendon integrity (Grimaldi et al., 2024). The locally controlled trauma created by dry needling is thought to bring this chronic degenerative tissue back to an acute state of healing that can then be allowed to heal in a healthy, stronger form of collagen. Especially combined with proper therapeutic exercise, it can be utilized in the appropriate healing stages to prevent overload stress, which likely leads to tendinopathy in the first place.

Indications and Utilization

Who would benefit from Dry Needling

Dry needling may benefit patient populations with musculoskeletal pain, including mechanical neck pain, fibromyalgia, and those recovering from orthopedic injuries(Padanilam et al., 2021). There is strong evidence that dry needling causes pain reduction across all body regions at short-term evaluation. The current evidence shows that dry needling is superior to no intervention/sham/placebo for improvements in pain intensity (Gattie et al., 2017), but it may be of additional value to other interventions used to date in clinical practice. Several studies have shown an additional effect when combining dry needling with therapeutic interventions compared to these interventions in isolation (Chys et al., 2023)Studies regarding the efficacy of dry needling are abundant for many body parts and ailments, including neck pain, headaches, low back pain, tendinopathies, osteoarthritis, and foot pain/plantar fascitis, to name a few.

Neck pain/ headaches

Chronic neck pain is a substantial cause of disability worldwide, with a prevalence of over 30% (Rodrigues-Huguet et al., 2022), contributing to significant socioeconomic costs and the use of pain medications. Dry needling has become a popular intervention in treating chronic neck pain and headaches. Rodriguez-Huguet, Vinolo-Gil & Gongora-Rodriguez (2022) performed a systematic review investigating the efficacy of dry needling for chronic neck pain (CNP). All studies included in the systematic review were randomized clinical trials (RTCs); ultimately, eight were included (Rodrigues-Huguet et al., 2022). What they found as a result of their search is that dry needling is an effective treatment option for persons with CNP, with positive outcomes in both the short-term and follow-ups performed between 3 and 6 months. Additionally, dry needling proved to produce better outcomes than a placebo intervention simulating the application of dry needling. In addition to having improvement in the intensity of the neck pain experienced, improvements were noted in the range of motion, the neck disability index outcomes measure, and the pain pressure threshold (Rodrigues-Huguet et al., 2022), which measures how much pressure is needed to change a nonpainful stimulus into a painful sensation (APTA, n.d.b).

Pourahmadi et al. conducted a systematic review and meta-analysis on dry needling to treat tension-type, cervicogenic, and migraine headaches (2021). Their review concluded that dry needling could significantly improve headache frequency, health-related quality of life, trigger point tenderness, and cervical range of motion in patients with tension-type headaches and cervicogenic headaches. They concluded that dry needling produces similar effects to other interventions for short-term headache pain relief but better improvement in related disability than other therapies (Pourahmadi et al., 2021)

Similarly, Vazquez-Justes et al. (2022) concluded that dry needling should be considered for treating headaches and was associated with significant improvements in function and sensory outcomes.

When dry needling for CNP or headache, the upper trap, the cervical paraspinal muscles, and the nuchal ridge along the suboccipital muscles are commonly involved.

Low back pain

In a systematic review and meta-analysis investigating the efficacy of dry needling for treating low back pain (LBP), sixteen RCTs were included, and it determined that dry needling was superior to sham needling for decreasing pain intensity at post-intervention and follow-up and functional disability at post-intervention (Hu et al., 2018). Some challenges when looking at the data and studies are related to mixed interventions, non-standardized treatment applications, and methods.

Additionally, the gluteus medius and minimus trigger points tend to have referral pain patterns to the lower back, medial buttock, and sacral and lateral hip, radiating into the upper thigh (Asher, 2019). Alvarez et al. (2022) concluded that dry needling of the most hyperalgesic trigger points of the gluteus medius in subjects with non-specific low back pain improved pain intensity, pain pressure threshold, and quality of life more than other interventions investigated but did not statistically improve range of motion.

Tendinopathies

The use of dry needling for tendinopathies has been extensively researched, and current research supports the efficacy of dry needling for tendinopathy. The insertion of dry needles is thought to disrupt the degenerative process by encouraging local bleeding and fibroblast proliferation (Stoychev et al., 2020). In a manner, the technique is essentially bringing the injury from a chronically degenerative process to a mild acute injury that can now have appropriate healing pathways through a controlled trauma process. Three systematic reviews, seven randomized controlled trials, and 6 cohort studies evaluating the efficacy of dry needling for tendinopathy were reviewed by Stoychev (2020), and there was a statistically significant improvement in patient-reported symptoms in most studies (Stoychev et al., 2020). The following sites were studied: wrist common extensor origin (tennis elbow), patellar tendon, rotator cuff, and tendons around the greater trochanter and iliotibial band.

Osteoarthritis

Recently, studies have emerged investigating the efficacy of needling as a treatment for pain and symptoms associated with knee and hip osteoarthritis (Dunning et al., 2018; Amani et al, 2022; Jimenez-Del-Barrio et al., 2022). While individual studies show short to medium-term improvement in the patient's pain and functional ability following dry needling (Amani et al., 2022; Dunning et al., 2018), a systematic review and meta-analysis conducted by Jimenez-Del-Barrio et al. in 2022 showed little statistical evidence of the intervention when compared to sham, exercise or control interventions. Jiminez-Del-Barrio et al. indicated that the technique and muscles treated varied greatly between studies, indicating a need for more specific protocols.

Clinically, a provider may utilize dry needling to provide short-term relief of pain. Dry needling may improve the patient's ability to withstand exercise and improve their physical function, or it may be used between exercise sessions to reduce muscle pain (Ughreja & Prem, 2021).

Foot/ Plantarfascitis

Two studies found that dry needling for plantar heel pain or plantar fascitis effectively improves pain intensity and related disability in the long term with moderate quality of evidence. It also seemed as if three sessions may not be enough to improve pain in individuals with plantar fascitis (Chys et el., 2023).

Safety Considerations

Contraindications

There are some conditions where dry needling should not be utilized or only with special precaution. These include (Bachmann et al., 2022):

  • Acute Infection
  • Acute emergencies
  • Anticoagulant dysfunction or anticoagulant medications: Dry needling may be utilized if the patient takes NSAIDs such as Aspirin, ibuprofen, diclofenac, etc. Dry needling must not be used when the patient is taking anticoagulants such as Plavix, Heparins, coumarins, Eliquis, and Xarelto (this is not exhaustive of all of the anticoagulants)
  • In areas of significant paresthesia
  • Patients with lymphedema
  • Patients at increased risk for infection, immunocompromised or immunodeficient
  • In the area of a tumor
  • In the area of a hematoma

Caution/Special Considerations

In some circumstances, dry needling may be utilized, but special care must be taken, or there may be local contraindications. These include (Bachmann et al., 2022):

  • Pregnancy: Pregnant patients must be treated with great caution, especially in the first trimester. There is disagreement among healthcare professionals and in the literature regarding the safety of dry needling during pregnancy. Still, most companies providing dry-needling certification courses advocate not performing dry-needling within the first semester of pregnancy (Dunning, 2016). Additionally, certain points are considered best to avoid entirely during pregnancy. Some of these points are based on TCM acupuncture and are thought to induce uterine contraction potentially.
  • Children: Minors may only be treated with their and a parent's consent.
  • Psychiatric patients: A patient with a psychiatric disorder must be able to understand the procedure and risks, provide consent, and interpret the stimulus correctly.
  • Nickel allergy: Most acupuncture needles are made with nickel, so it is important to utilize special needles when the patient has a known nickel allergy. Special gold-plated needles are made for use with patients with nickel allergies.
  • Epilepsy: Caution should be utilized.
  • Severe pulmonary diseases: The thorax should not be treated through dry needling in a patient with severe pulmonary disease.
  • Dry needling to mucous membranes, eyes, or genitals.

Screening

It is vital that a practitioner thoroughly screen a patient before the use of dry needling as an intervention. In addition to a physical exam to determine musculoskeletal involvement, a thorough screening of the patient's medical history, medications, metabolic and endocrine disorders, and skin integrity is important to determine if the patient is appropriate for dry needling. Additionally, does the patient have any prior experience, and what was their tolerance to the treatment? Solely relying on the palpation of trigger points as a rationale for the use of the intervention is highly discouraged.

General Safety and Needle Handling

A therapist must implement many safety considerations when considering dry needling as an intervention in any patient care program. First and foremost, the therapist should only apply dry needling in the areas of the body for which they have been trained (Bachmann et al., 2022). A comprehensive patient history must be obtained before treatment to determine contraindicated conditions. The healthcare provider must keep detailed records of the patient's consent, application, and reactions to all needling treatments. It is also suggested that the healthcare provider be vaccinated against hepatitis A/B (Bachmann et al., 2022).

Hygenic arrangements should be utilized, including a clean work area and surfaces, the use of non-latex gloves, proper disinfection of the skin of the muscle to be treated, and sterile, single-use monofilament acupuncture needles.  It is important not to reuse needles to reduce the risk of infection. The healthcare provider should use proper needle handling techniques and dispose of the used needles in proper sharps receptacles to avoid needle stick injuries.

A patient must be fully advised on dry needling, what to expect during treatment, the rationale and goal of the intervention, and the risks associated with treatment. In compliance with regulatory requirements, this often is documented through a written consent form that outlines the specific local educational requirements for healthcare providers to perform dry needling, an explanation of the intervention, and an outline of the risks.

Minor Adverse Reactions

Minor adverse reactions during dry needling include local bleeding, bruising, and soreness during or for a short time following the intervention(Boyce et al., 2020; Valdez, 2021a). While rare, vasovagal responses may be experienced during or following dry needling and may include (Boyce et al., 2020; Valdes, 2021a):

  • Dizziness
  • Nausea
  • Sweating
  • Syncopy

Serious Adverse Reactions

While dry needling has been shown to be an effective and safe intervention in the hands of a trained and competent provider, the risks of severe adverse reactions must be divulged to the patient. Serious or major adverse reactions are considered medium—to long-term, moderate—to severe events that may require further treatment (Boyce et al., 2020). It is important to note that serious adverse events are commonly associated with practitioner negligence and poor adherence to practice standards(Valdes, 2021b).

Serious Adverse Reactions may include (Boyce et al., 2020; Valdez, 2021b):

  • Pneumothorax or Hemothorax: This adverse event receives the most attention. The incidence of pneumothorax from this mechanism is less than 0.01/10,000 interventions, and most patients who sustain a pneumothorax fully recover, and mortality is rare (Valdes, 2021b). It is a risk that must be discussed with the patient if dry needling is to be done in the thorax region or the upper trapezius, informing the patient of symptoms to watch for and appropriate follow-up if symptoms do occur. It is critical that proper patient positioning, palpation, and proper depth and direction of needle insertion be utilized when needling the upper trapezius region.
  • Infection: Infections related to dry needling are rare but can be complicated by infections caused by organisms on the patient's skin. The most commonly used skin disinfectant before needling is 60% or 70% isopropyl alcohol, yet some mycobacterium is resistant (Valdes, 2021b).
  • Forgotten or broken needles: Practitioners must be vigilant about counting the number of needles inserted and taken out to ensure that no needles are forgotten and accidentally left in place when the patient leaves. Needle breakage is rare, especially given that single-use needles are the standard, so the concern for needle fatigue decreases. If a needle does break, it must be removed immediately. The location must be marked carefully if the needle disappears into the skin.
  • Nerve injury: Needling of nerves or near the nerve is generally considered out of the scope of practice for dry needling, although some advocate for including perineural needling into the definition and practice acts for dry needling. If dry needling is applied too close or directly to a nerve, injury to the myelin sheath may occur, resulting in neuropraxia or axonotmesis (Bachmann et al., 2022).

"Dry needling education must emphasize anatomical knowledge with advanced training when needling the trunk, thorax, head, and cervical regions. It is essential that practitioners screen for individual risk factors associated with each patient, practice strict adherence to sterile needle practices, and be able to recognize acute adverse event complications (Valdes, 2021b)."

Legal Considerations

Many educational companies provide comprehensive educational courses resulting in certification to perform dry needling; however, the most common companies include The Dry Needling Institute through the American Academy of Manipulative Therapy  (AAMT, 2001); Evidence in Motion (EIM, 2022) and Integrative Dry Needling (Integrative Dry Needling, 2024). Each company offers multiple-day courses that must include hands-on laboratory components to ensure the participant learns the proper technique. Different companies structure their courses differently, with some requiring multiple courses before full certification is accomplished, so it is important to research structure, cost, and contact hours at completion to ensure that it meets your professional requirements. All the above companies indicate that licensed physical therapists (PTs), athletic trainers (ATs), occupational therapists (OTs), and doctors of chiropractic (DCs) are eligible to take the dry needling courses ( AAMT, 2001; EIM, 2022; Integrative Dry Needling, 2024), while some include medical doctors (MDs), doctors of osteopathy (DOs), nurse practitioners (NPs), and physician assistants (PAs) (AAMT, 2001.; EIM, 2022). It is important to realize that although these professionals can take the courses and complete the dry needling certification process, state regulations vary greatly regarding including dry needling into the scope of practice for different professions. It is up to the participant to know their practice act to understand if they can legally perform dry needling within their practice.

Medical Doctors, Doctors of Osteopathy

The American Medical Association (AMA) "recognizes dry needling as an invasive procedure and maintains that dry needling should only be performed by practitioners with standard training and familiarity with routine use of needles in their practice, such as licensed medical physicians and licensed acupuncturists (AMA, 2016)." They adopted a policy that states "therapists and other non-physicians practicing dry needling should — at a minimum — have standards that are similar to the ones for training, certification and continuing education that exist for acupuncture."

Physical Therapists (PTs)

The laws pertaining to dry needling differ from state to state. According to the American Physical Therapy Association (APTA), "Dry needling in physical therapy is increasing, but the regulatory landscape is uneven, with the intervention being included in the PT scope of practice in some states and not others. APTA supports the inclusion of dry needling in regulatory frameworks, accompanied by appropriate educational qualifications for the PTs to engage in the intervention (APTA, n.d.a)." As of June 2023, 39 states and Washington, DC, permit physical therapists to perform dry needling, four states prohibit PTs from performing dry needling, and seven states are silent on the matter (APTA, n.d.a).

In most states, physical therapy assistants (PTAs) cannot perform dry needling, except for Texas, Illinois, Kentucky, and Alabama (AAMT, n.d.).

Athletic Trainers (ATs)

The National Athletic Trainers Association (NATA) has created a fact sheet endorsing the use of dry needling as a therapeutic technique that athletic trainers should be able to use with the "requisite knowledge and skills" attainder through a board-approved course (NATA, n.d.)

Similar to OTs, many state practice acts are silent on the utilization of dry needling by ATs. Since this does not specifically rule in or out the utilization by ATs, it is often regarded as not disallowed. For this reason, many athletic trainers perform dry needling. Others do not want to take the risk. As of April 2022, Arizona, Maryland, Illinois, Nevada, and North Carolina have passed legislation allowing ATs to perform dry needling with appropriate education and training (BOC, 2022). Dry needling is a topic of significant interest within athletic training, and many states are actively working to clarify a stance related to dry needling and athletic trainers. It is interesting to note that athletic trainers in California may be able to use dry needling since they are not regulated by any California state board. In contrast, it is considered outside the scope of practice for PTs.

Occupational Therapists (OTs)

In a poll of state practice acts conducted by Integrative Dry Needling in March 2022, only five states specifically included dry needling within the scope of practice for OTs; nine states were specific in their stance that dry needling is not within the scope of practice for OTs, and the remainder of the states were silent on the intervention (Integrative Dry Needling, 2023). State statute silence on the techniques neither specifically allows nor disallows utilization.

In April 2023, however, the American Occupational Therapy Association (AOTA) released a revision of policy E.18: Interventions to support Occupations. In this document, the AOTA stated that "Use of interventions to support occupations may include the application of PAMs, mechanical modalities, instrument-assisted (manual) modalities (e.g., dry needling), and other new and emerging techniques. It is important to differentiate that little or no published evidence for new and emerging techniques does not equate to a lack of effectiveness. It is an indicator that further research is needed (AOTA, 2023)." They further clarified that interventions "may not be entry-level skills and may require advanced training and certification (AOTA, 2023)." 

Given the inclusion of dry needling in the above policy, it is likely that there will be significant discussion and possible regulatory changes within individual state governing boards regarding specific language around the practice of dry needling.

Doctors of Chiropractic (DCs)

Similar to the other professions discussed, chiropractic regulations vary greatly between states. According to the American Chiropractic Association in 2019, "the majority of states approve the use of dry needling by chiropractors and physical therapists (Hamm, 2019)."

Nurse Practitioners (NPs) and Physicians Assistants (PAs)

While NPs and PAs are allowed to take most of the advertised dry-needling courses, very little information was found regarding the support of NPs, PAs, or nurses to utilize dry needling.

Billing Considerations

Official CPT codes for dry needling were established in 2020 (Wallace et al., 2024). The two codes are listed with the muscle injection codes, which describe services as "insertion without injection." Each code is differentiated by the number of muscles treated in the session.

  • Code 20560:Needle insertion(s) without injection; 1-2 muscle(s)
  • Code 20561: Needle insertion(s) without injection; 3 or more muscle(s)

Both codes are untimed codes. They include the cost of the needles and other supplies required but do not include the application of electrical stimulation through the needles.

Frustration about billing for dry needling started when the Center for Medicare Services (CMS) ruled that it would not cover dry needling billing codes, as it does not cover acupuncture (Wallace et al., 2024). As a result, many commercial payers followed suit and decided not to cover or reimburse for dry needling codes. There is an obvious source of frustration as dry needling, as discussed earlier in the course, is a Western medicine intervention approach to treat musculoskeletal dysfunctions. It does not try to balance chi and clear energy pathways and uses very different diagnostic criteria. This decision to not reimburse for dry needling billing codes led many clinicians to include dry needling as part of manual therapy (intramuscular manual therapy) or neuromuscular education CPT codes. Since dry needling has a specific and separate billing code associated with the treatment, billing under different codes would be considered a form of billing fraud. There are also many considerations a clinician must account for when trying to bill the patient for a non-covered service.

Case Study #1: Dry Needling for Chronic Headaches

Patient Background:

Mr. A is a 45-year-old male who presented to physical therapy with complaints of chronic headaches that had persisted for over five years. He described his headaches as dull and persistent, primarily located in the frontal region with occasional radiation to the temples. These headaches interfere significantly with his daily activities and quality of life. He had previously tried various medications and chiropractic treatments with limited success.

Assessment:

Upon assessment, Mr. A demonstrated a limited range of motion in his cervical spine, particularly in rotation and extension. He had bilateral tenderness in the upper trapezius, suboccipital, and upper cervical paraspinal muscles. Trigger point palpation reproduced his headache symptoms, confirming myofascial involvement in his pain presentation. No neurological deficits were noted during the examination, and Mr.A did not present with any contraindications to dry needling.

Treatment Plan:

Given the findings, a treatment plan incorporating dry needling was discussed and initiated. A consent form was signed and dated. The goals of dry needling for Mr. A included:

  1. Pain Reduction: Targeting trigger points in the cervical and upper thoracic muscles to alleviate pain and improve function, specifically his upper trapezius, cervical paraspinal, and suboccipital muscles bilaterally.
  2. Improved Range of Motion: Addressing muscular restrictions contributing to cervical spine mobility impairments.
  3. Functional Improvement: Enhancing Mr. A's ability to perform daily activities with reduced headache frequency and intensity.

Intervention:

Over six weeks, Mr. A received eight sessions of dry needling, administered twice weekly. Each session targeted specific trigger points identified during the initial assessment. The needles were typically left in place for 10-15 minutes to achieve maximal therapeutic effect with needle rotation at 5 minutes, except for in the upper trapezius. While treating this muscle, an inferior to anterior/superior direction of insertion was utilized into the center of the trigger point until an LTR was achieved. Needle pistoning was performed until LTRs stopped occurring,  at which point the needle was removed and disposed of. Mr. A reported minimal discomfort during the procedure and significant relief immediately following each session.

Outcome:

By the fourth session, Mr. A reported a noticeable reduction in headache frequency, intensity, and duration. His range of motion in the cervical spine improved, with decreased tenderness in palpable trigger points. By the conclusion of the treatment period, Mr. A reported being headache-free on most days. He was able to resume activities such as work and exercise without the fear of triggering severe headaches.

Follow-up:

At a one-month follow-up appointment, Mr. A reported continued improvement in headache symptoms. He was advised to perform home exercises to maintain cervical spine mobility and prevent the recurrence of trigger points. A maintenance plan with occasional dry needling sessions was discussed to manage future exacerbations.

Case Study #2: Dry Needling with Electrical Stimulation for Ilitibial Band Syndrome

Patient Background:

Mr. S., a 35-year-old avid runner, complained of sharp pain on the outer side of his left knee during and after running. He had been experiencing symptoms for the past three months, which progressively worsened despite rest and stretching exercises. Physical examination revealed tenderness over the lateral aspect of the knee joint, tightness in the iliotibial band (IT band), and multiple trigger points in his vastus lateralis. Ligamentous and meniscal clinical tests were all normal, and no instability was noted.

Diagnosis:

Based on clinical assessment and history, Mr. S. was diagnosed with iliotibial band syndrome (ITBS), a common overuse injury among runners characterized by inflammation and irritation of the IT band as it rubs against the lateral femoral epicondyle.

Treatment Plan:

Given the chronic nature of Mr. S.'s symptoms and his unresponsiveness to conventional treatment (rest, stretching), it was recommended to incorporate dry needling into his rehabilitation plan.

Procedure:

During the initial session, the dry needling rationale, goal, and procedure were explained to Mr. S, and informed consent was obtained. Trigger points along the IT band and surrounding muscles were identified through palpation. Sterile single-use needles were then inserted directly into these trigger points to elicit a local twitch response. The needles were left in the musculature, and electrical stimulation was incorporated into the treatment via alligator clips attached to the needles. The electrical stimulation was allowed to run for 10 minutes, after which the needles were removed and disposed of in a sharps container.

Outcome and Follow-Up:

After the first dry needling session, Mr. S. reported a noticeable reduction in pain during daily activities and running. He underwent six sessions of dry needling over a period of three weeks, each combined with stretching exercises and therapeutic ultrasound to enhance the effectiveness of treatment. By the third week, Mr. S. reported a complete resolution of his symptoms and could resume his regular running routine without experiencing pain or discomfort.

Conclusion

In conclusion, dry needling represents a promising therapeutic intervention that blends modern understanding of anatomy and neurophysiology with ancient principles of acupuncture. As evidenced by its growing utilization across various healthcare disciplines, including physical therapy and sports medicine, dry needling offers a non-pharmacological approach to managing musculoskeletal pain and dysfunction. While further research is needed to elucidate its mechanisms and optimize its application, current evidence supports its efficacy in alleviating trigger points, improving range of motion, and enhancing overall patient functional outcomes. Embracing dry needling as part of integrative care strategies underscores its potential to positively impact patient care and quality of life, marking it as a valuable tool in contemporary healthcare.

Select one of the following methods to complete this course.

Take TestPass an exam testing your knowledge of the course material.
OR
No TestAttest that you have read and learned all the course materials.

Implicit Bias Statement

CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.

References

  • Álvarez, S. D., Saornil, J. V., Milá, Z. S., Crespo, G. J., Chekroun, A. C., Casas, J. M. B., Llanes, R. F., & Sanz, D. R. (2022). Effectiveness of dry needling and ischemic trigger point compression in the gluteus medius in patients with non-specific low back pain: A randomized short-term clinical trial. International Journal of Environmental Research and Public Health/International Journal of Environmental Research and Public Health, 19(19), 12468. Visit Source.
  • Amani, M., Shafizadegan, Z., & Taheri, N. (2022). Effects of dry needling on pain in patients with knee osteoarthritis: A preliminary study. Advanced Biomedical Research, 11(1), 47. Visit Source.
  • American Academy of Manipulative Therapy (AAMT) Spinal Manipulation & Dry Needling Institutes. (n.d.). Dry Needling Certification® for PTS, ATS and DCS | Dry Needling Institute. American Academy of Manipulative Therapy Spinal Manipulation & Dry Needling Institutes. Visit Source.
  • American Medical Association. (2016, June 15). AMA adopts new policies on final day of Annual Meeting. Visit Source.
  • American Occupational Therapy Association (AOTA). (2023). Policy E.18: Interventions to support occupations. American Occupational Therapy Association. Visit Source.
  • American Physical Therapy Association (APTA). (n.d.a).  Dry needling. American Physical Therapy Association. Visit Source.
  • American Physical Therapy Association (APTA). (n.d.b). Pain pressure threshold (PPT). American Physical Therapy Association. Visit Source.
  • Asher, S. (2019). Trigger point of the week – Gluteus Medius. Trigger Points 3D. Visit Source.
  • Bachmann, S., Colla, F., Gröbli, C., Mungo, G., Gröbli, L., Reilich, P., Dry Needling Association Switzerland, & Weissmann, R. (2022). Swiss Guidelines for safe Dry Needling. In Dry Needling Association Switzerland. Visit Source.
  • Barber, J., Lodo, F., Nugent-Head, A., & Zeng, X. (2023). Comparative techniques of acupuncture and dry needling intersecting with trigger point physiology and diagnostics: A cross-discipline narrative review. Medical Acupuncture, 35(5), 220–229. Visit Source.
  • Board of Certification for the Athletic Trainer (BOC). (2022). Trends in legislation: Dry needling and insurance - Board of certification for the athletic trainer. Board of Certification for the Athletic Trainer. Visit Source.
  • Boyce, D., Wempe, H., Campbell, C., Fuehne, S., Zylstra, E., Smith, G., Wingard, C., & Jones, R. (2020). Adverse events associated with therapeutic dry needling. International Journal of Sports Physical Therapy, 15(1), 103–113. Visit Source.
  • Bubnov, R., Kalika, L. (2020). ABO961 Myofascial Trigger Points are the undervalued hypoxic nisches altering posture and phenotype. Annals of the Rheumatic Diseases, 79(1), 1777. Visit Source.
  • Butts, R., Dunning, J., & Serafino, C. (2021). Dry needling strategies for musculoskeletal conditions: Do the number of needles and needle retention time matter? A narrative literature review. Journal of Bodywork and Movement Therapies, 26, 353–363. Visit Source.
  • Chys, M., De Meulemeester, K., De Greef, I., Murillo, C., Kindt, W., Kouzouz, Y., Lescroart, B., & Cagnie, B. (2023). Clinical effectiveness of dry needling in patients with musculoskeletal pain—An umbrella review. Journal of Clinical Medicine, 12(3), 1205. Visit Source.
  • Dorsher, P. T. (2022). The anatomic, clinical, and physiologic correspondences of myofascial trigger points and classical acupuncture points. Longhua Chinese Medicine, 5, 7. Visit Source.
  • Dunning, J. (2016). Dry needling during pregnancy: The risks and benefits. Spinal Manipulation Institute. Visit Source.
  • Dunning, J., Butts, R., Young, I., Mourad, F., Galante, V., Bliton, P., Tanner, M., & Fernández-De-Las-Peñas, C. (2018). Periosteal electrical dry needling as an adjunct to exercise and manual therapy for knee osteoarthritis. The Clinical Journal of Pain: The Clinical Journal of Pain, 34(12), 1149–1158. Visit Source.
  • Evidence in Motion (EIM). (2022). Dry needling courses and certification. EIM. Visit Source.
  • Gattie, E., Cleland, J. A., & Snodgrass, S. (2017). The effectiveness of trigger point dry needling for musculoskeletal conditions by physical therapists: a systematic review and meta-analysis. Journal of Orthopaedic and Sports Physical Therapy, 47(3), 133–149. Visit Source.
  • Gerwin, R. D. (2023). A new unified theory of trigger point formation: Failure of Pre- and Post-Synaptic Feedback control mechanisms. International Journal of Molecular Sciences, 24(9), 8142. Visit Source.
  • Grimaldi, A., Mellor, R., Nasser, A., Vicenzino, B., & Hunter, D. J. (2024). Current and future advances in practice: tendinopathies of the hip, Rheumatology Advances in Practice, 8(2), rkae022. Visit Source.
  • Hamm, A. (2019). Billing for dry needling services (Needle insertion without injection). American Chiropractic Association. Visit Source.
  • Hu, H., Gao, H., Ma, R., Zhao, X., Tian, H., & Li, L. (2018). Is dry needling effective for low back pain? Medicine, 97(26), e11225. Visit Source.
  • Integrative Dry Needling. (2023). Does your scope of practice allow dry needling?. Integrative Dry Needling. Visit Source.
  • Integrative Dry Needling. (2024). Training courses. Integrative Dry Needling. Visit Source.
  • Intricate Art Spine & Body Solutions (n.d.). Dry needling: to piston or not to piston. Intricate Art Spine & Body Solutions. Visit Source.
  • Jenson, B. (2023). On pins and needles: Just what is dry needling? Mayo Clinic Health System. Visit Source.
  • Jiménez-Del-Barrio, S., Medrano-De-La-Fuente, R., Hernando-Garijo, I., Mingo-Gómez, M. T., Estébanez-De-Miguel, E., & Ceballos-Laita, L. (2022). The effectiveness of dry needling in patients with hip or knee osteoarthritis: A systematic review and meta-analysis. Life, 12(10), 1575. Visit Source.
  • Lewit, K. (1979). The needle effect in the relief of myofascial pain. Pain, 6(1), 83–90. Visit Source.
  • Maurer, N., Nissel, H., Egerbacher, M., Gornik, E., Schuller, P., & Traxler, H. (2019). Anatomical evidence of acupuncture meridians in the human extracellular matrix: Results from a macroscopic and microscopic interdisciplinary multicentre study on human corpses. Evidence-Based Complementary and Alternative Medicine, 2019, 1–8. Visit Source.
  • Mayo Clinic. (n.d.). Acupuncture. Mayo Clinic. Visit Source.
  • McAphee, D., Bagwell, M., & Falsone, S. (2022). Dry needling: A clinical commentary. International Journal of Sports Physical Therapy, 17(4). Visit Source.
  • National Athletic Trainers’ Association (NATA). (n.d.). Intramuscular Manual Therapy Technique: Dry Needling and Athletic Trainers. National Athletic Trainers’ Association. Visit Source.
  • National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM). (n.d.). About Acupuncture. Visit Source.
  • Padanilam, S. J., Dayton, S. R., Jarema, R., Boctor, M. J., & Tjong, V. K. (2021). Dry needling for the treatment of musculoskeletal ailments with trigger points. Video Journal of Sports Medicine, 1(5), 263502542110237. Visit Source.
  • Pourahmadi, M., Dommerholt, J., Fernández-De-Las-Peñas, C., Koes, B. W., Mohseni-Bandpei, M. A., Mansournia, M. A., Delavari, S., Keshtkar, A., & Bahramian, M. (2021). Dry needling for the treatment of tension-type, cervicogenic, or migraine headaches: A systematic review and meta-analysis. Physical Therapy & Rehabilitation Journal, 101(5). Visit Source.
  • Price, L. M. (n.d.). Acupuncture diagnosis. Healthpointe Acupuncture and Wellness. Visit Source.
  • Rodríguez-Huguet, M., Vinolo-Gil, M. J., & Góngora-Rodríguez, J. (2022). Dry needling in physical therapy treatment of chronic neck pain: Systematic review. Journal of Clinical Medicine, 11(9), 2370. Visit Source.
  • Simons D. G., Travell J. G., & Simons L. S. (1999). Travell & Simons’ myofascial pain and dysfunction : the trigger point manual. CiNii Books. Visit Source.
  • Stoychev, V., Finestone, A. S., & Kalichman, L. (2020). Dry needling as a treatment modality for tendinopathy: A narrative review. Current Reviews in Musculoskeletal Medicine, 13(1), 133–140. Visit Source.
  • Tsai, P., Edison, J., Wang, C., Sefton, J., Manning, K. Q., & Gramlich, M. W. (2024). Myofascial trigger point (MTrP) size and elasticity properties can be used to differentiate characteristics of MTrPs in lower back skeletal muscle. Scientific Reports, 14(1). Visit Source.
  • Ughreja, R. A., & Prem, V. (2021). Effectiveness of dry needling techniques in patients with knee osteoarthritis: A systematic review and meta-analysis. Journal of Bodywork and Movement Therapies, 27, 328–338. Visit Source.
  • Unverzagt, C., Berglund, K., & Thomas, J. J. (2015). Dry needling for myofascial trigger point pain: A clinical commentary. International Journal of Sports Physical Therapy, 10(3), 402–418. Visit Source.
  • Valdes, V. R. (2021a). Dry needling in physical therapy practice: Adverse events Part 1: Types and frequency of adverse events. Orthopaedic Practice, 33(1), 34-39. Visit Source.
  • Valdes, V. R. (2021b). Dry needling in physical therapy practice: Adverse events Part 2: Serious adverse events. Orthopaedic Practice, 33(2), 96–100. Visit Source.
  • Vázquez-Justes, D., Yarzábal-Rodríguez, R., Doménech-García, V., Herrero, P., & Bellosta-López, P. (2022). Effectiveness of dry needling for headache: A systematic review. Neurología, 37(9), 806–815. Visit Source.
  • Wallace, J., McDermott, E., & Giebel, R. (2024). Get to the point: Billing for dry needling and payer coverage issues. WebPT. Visit Source.
  • Wilson, V. P. (2003). Janet G. Travell, MD: A daughter’s recollection. Texas Heart Institute Journal, 30(1), 8–12. Visit Source.
  • Young, I., Dunning, J., Butts, R., Bliton, P., Zacharko, N., Garcia, J., Mourad, F., Charlebois, C., Gorby, P., & Fernández-De-Las-Peñas, C. (2024). Spinal manipulation and electrical dry needling as an adjunct to conventional physical therapy in patients with lumbar spinal stenosis: a multi-center randomized clinical trial. The Spine Journal 24(4), 590–600. Visit Source.