Dry Needling in Patient Care

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.

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).

Image 1: Dry Needling

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.

Image 2: Auricular Acupuncture

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.

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.

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.

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.

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.

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