Dry needling versus acupuncture:the ongoing debate

Kehua Zhou,1,2 Yan Ma,3,4 Michael S Brogan5

1Department of Health CareStudies, Daemen College,Amherst, New York, USA2Daemen College PhysicalTherapy Wound Care Clinic,Daemen College, Amherst,New York, USA3Division of InterdisciplinaryMedicine and Biotechnology,Beth Israel Deaconess MedicalCenter, Harvard Medical School,Boston, Massachusetts, USA4Internal Medicine and SleepCenter, Eye Hospital, ChinaAcademy of Chinese MedicalScience, Beijing, China5Department of Physical Therapy,Daemen College, Amherst,New York, USA

Correspondence toDr Kehua Zhou, Department ofHealth Care Studies, DaemenCollege, 4380 Main Street,Amherst, NY 14226, USA;kzhou@daemen.edu

Accepted 18 September 2015Published Online First6 November 2015

▸ http://dx.doi.org/10.1136/acupmed-2015-010977

To cite: Zhou K, Ma Y,Brogan MS. Acupunct Med2015;33:485–490.

ABSTRACTAlthough Western medical acupuncture (WMA)is commonly practised in the UK, a particularapproach called dry needling (DN) is becomingincreasingly popular in other countries. Thelegitimacy of the use of DN by conventional non-physician healthcare professionals is questionedby acupuncturists. This article describes theongoing debate over the practice of DN betweenphysical therapists and acupuncturists, with aparticular emphasis on the USA. DN andacupuncture share many similarities but maydiffer in certain aspects. Currently, littleinformation is available from the literatureregarding the relationship between the twoneedling techniques. Through reviewing theirorigins, theory, and practice, we found that DNand acupuncture overlap in terms of needlingtechnique with solid filiform needles as well assome fundamental theories. Both WMA and DNare based on modern biomedical understandingsof the human body, although DN arguablyrepresents only one subcategory of WMA. Theincreasing volume of research into needlingtherapy explains its growing popularity in themusculoskeletal field including sports medicine.To resolve the debate over DN practice, we callfor the establishment of a regulatory body toaccredit DN courses and a formal, comprehensiveeducational component and training forhealthcare professionals who are not physiciansor acupuncturists. Because of the closerelationship between DN and acupuncture,collaboration rather than dispute betweenacupuncturists and other healthcare professionalsshould be encouraged with respect to education,research, and practice for the benefit of patientswith musculoskeletal conditions who requireneedling therapy.

INTRODUCTIONWestern medical acupuncture (WMA) is atherapeutic modality involving the inser-tion of solid filiform needles. It is amodern adaptation of traditional acu-puncture (TA) using current biomedicalunderstanding and research evidence.1

WMA is widely practised by convention-ally trained healthcare providers includ-ing physicians, chiropractors, andphysical therapists (PTs).1 AlthoughWMA is relatively commonplace in theUK and Sweden,1 a particular approachcalled dry needling (DN), which ismainly practised by PTs, is becomingincreasingly popular in other majorwestern countries.2–4 WMA, DN and TAare all needling procedures that involvepenetration of the skin with solid filiformneedles with therapeutic intent. DN is atechnique that PTs and other healthcareprofessionals use to treat various painfulconditions of the musculoskeletal system,usually myofascial pain syndrome,4

whereas TA is a technique used by profes-sional acupuncturists. Compared withDN, both TA and WMA have a broaderrange of indications including musculo-skeletal pain, and gastrointestinal andneurological disorders.1 5 Patients andhealthcare professionals may be confusedabout the relationship between DN andacupuncture as they seem to share simi-larities and yet may differ in certainaspects. Currently, little information isavailable from the literature regarding thesimilarities and differences between thesetwo needling techniques. In this article,we aim to: (1) explore the professionalcontroversies surrounding the practice ofDN; (2) review the origins, theory, andpractice of DN and acupuncture; and (3)seek potential solutions in response tothe ongoing debate.

THE ONGOING DEBATEThe dispute about the legitimacy of DNpractice by healthcare professionals whoare not physicians or acupuncturists hasbeen ongoing now for more than adecade, particularly in the USA. Here, wefocus on the debate between acupunctur-ists and PTs regarding DN practice.Acupuncturists oppose the practice of

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DN by PTs because they perceive DN to be a form ofacupuncture, which they feel should not fall into thescope of practice of PTs and other practitioners, suchas chiropractors. They also argue that, with minimaltraining, PTs are unlikely to be able to master thetechnique and thus may endanger patient safety andwellbeing.6 In response, PTs claim that DN is not acu-puncture3 because, although both acupuncture andDN are needling techniques, DN is based on modernbiomedical science rather than TA theories orterminology.3

However, DN and acupuncture clearly overlap tosome extent in view of their most common indication(musculoskeletal pain) and their use of solid filiformneedles.3 4 Additionally, with the single exception ofcases of pneumothorax due to inappropriate and/orunlawful practice, which is also reported in acupunc-ture practice,7–9 no significant patient safety eventshave been reported in relation to the practice of DN.Thanks to accumulating evidence for its applicability,utility, and lack of side effects (which are minimal tonone), the practice of DN is becoming increasinglypopular among conventionally trained healthcare pro-viders around the world, especially among PTs in theUSA.2–4 DN is the de facto practice of PTs in manycountries and states across the USA, yet it is unavail-able in others, which further convolutes the debate ofwho can and should practise DN.3

The other argument lies in the training of PTs inDN.6 The practice of acupuncture by trained clini-cians requires enhanced experience. In most states andcountries, the practice of acupuncture requires hun-dreds and often thousands of hours of acupunctureeducation in specialised educational programmes. Inthe USA, the practice of acupuncture requires statelicensure, which is based on passing national levelexaminations and maintaining good professionalrecords. The practice of acupuncture is governed bythe acupuncture or medical board of the state educa-tion department in most states across the USA.By contrast, current training of DN for PTs in the

USA is done only through continuing education orcertificate programmes, which are not strictly regu-lated and have few (if any) standards that need to becomplied with.3 6 With these non-formal training pro-grammes in DN, acupuncturists argue that PTs’ expos-ure, experience and skills in needling therapy arelikely to be limited.6 Additionally, evaluation systemsfor the practice of DN by PTs are currently unavail-able, and standards for healthcare governing adminis-trations and policymakers are not yet established.

DRY NEEDLINGHistory of DNDN, subtypes of which include related techniquesknown as intramuscular stimulation or trigger pointneedling, refers to the use of either solid filiformneedles or hollow-core hypodermic needles for the

treatment of muscular pain. Although some PTs claimthat DN was first developed in the 1940s by JanetTravell, little evidence exists to support this state-ment.4 10 In Myofascial pain and dysfunction: thetrigger point manual, Travell and Simons11 sum-marised the key elements of the DN technique as: (1)use of a needle of sufficient length to reach the con-traction knots in the trigger points without any prefer-ence for needle diameter (range 0.3–3.4 mm); and (2)use of an aseptic technique via careful cleansing witha suitable antiseptic (usually alcohol wipes). Travelland Simons11 did not mention any specific type ofneedle used in DN when they proposed that it was aseffective as local lidocaine injection in relievingtrigger point pain; however, they did mention that‘DN’ would induce post-injection soreness, whichmight be more severe and last for a longer period oftime than the injection of lidocaine. Thus, the needlethat they were referring to is more likely to have beena hypodermic needle, rather than an acupunctureneedle.Further evidence that the origin of DN involved the

use of hypodermic needles for the treatment of myo-fascial pain is provided by findings of a review of DNhistory. The earliest reference to ‘DN’, as per Legge,10

was in an article about low back pain in 1947 whenPaulett12 reported that ‘DN’ and injecting saline bothrelieved pain. In 1952, Travell and Rinzler13 exploredthe origins of myofascial pain, and commented thateffective treatment of myofascial pain might includeDN. The needles used in these early publicationsrelated to DN were likely to have been hypodermicneedles, as injection of saline or local anaesthetic wassimultaneously mentioned and compared.11–13

Nonetheless, the earliest available study directly iden-tified using the search term ‘dry needling’ in PubMedwas authored in 1979 by Lewit,14 who used acupunc-ture needles in DN practice. He found that DN pro-duced immediate, complete analgesia of the painfulspot without hyperaesthesia for patients with myofas-cial pain. Based on these results, Lewit14 reported thatthe therapeutic effects of needling in myofascial painoriginated from the mechanical stimulation of theneedling per se and was due to neither the anaestheticnor the sclerosing solution. In 1980, Gunn et al15

recommended the manipulation of acupunctureneedles to produce a grabbing sensation in patientswith trigger point pain. Gunn et al15 reported that thetechniques were inspired by TA and that DN hadpowerful therapeutic effects for patients with chroniclow back pain. Development of DN was limited in the1980s and 1990s as indicated by the limited numberof publications (<30) in the literature during thisperiod.10 However, since the 2000s, interest in DNhas resurged as healthcare professionals, especiallyPTs, have begun to recognise the beneficial effects ofDN on pain.2–4 10 Currently, DN is practised by manyhealthcare professionals in Europe, Australia, more

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than half of the states across the USA, and in manyother countries.2–4 10

Theory of DNThe use of DN is based on an understanding ofhuman anatomy and physiology regarding myofascialpain and trigger points.4 Theories regarding DNinvolve various neurophysiological mechanisms,1 4

which are indirectly supported by an expandingvolume of clinical research. Between 1980 and April2015, almost 200 publications were retrievable by aPubMed search using the term ‘dry needling’. Themajority of this literature reports on the therapeuticeffectiveness of DN using solid filiform needles forvarious types of musculoskeletal pain.16–18 Within theavailable meta-analyses, one study reported that DNtreatment of myofascial pain in the lower backappeared to be a useful addition to standard therap-ies,17 and another study found that DN was an effect-ive intervention for upper-quarter myofascial pain,which decreased immediately after treatment and atfollow-up at 4 weeks.18 Since the most recentmeta-analysis,18 20 new articles involving DN hadbeen indexed in PubMed by April 2015. Almost all ofthem have reported that DN is effective for specifictypes of musculoskeletal pain.

DN procedureIn general, DN techniques can be divided into superfi-cial and deep techniques.3 4 In superficial DN,needles are inserted superficially (around 5–10 mm)into tissue above the underlying trigger points.4 Afterretention for a short time (30 s to 3 min), the needleis removed and the pain is expected to be greatlyrelieved. If residual pain occurs, the procedure can berepeated another two to three times. Other superficialneedling techniques exist too. For example, Fu’ssuperficial needling involves insertion of needles at anangle of 20–30° without penetrating the muscle.4 Inthe newly evolved wrist and ankle needling, theneedles are inserted almost horizontally at the wristand ankle within the connective tissue layer betweenthe muscle and skin.4 As the needle is inserted andmanipulated in the superficial layer of the body, nomuscle twitch is expected.4 In deep DN, needles areinserted deep into the tissues directly toward thetrigger points in order to reach them.4 ‘Sparrowpecking’, whereby solid filiform needles are manipu-lated in and out of each trigger point to elicit a localtwitch response, is commonly used with treatmentregimens typically consisting of a course of three ormore treatments, given once a week.17 AlthoughDunning et al4 states that needles (one or more) areleft in situ for between 10 and 30 min, DN practiceby PTs is typically ‘fast-in and fast-out’, oftendescribed as ‘pistoning’, and does not usually involveneedle retention.2 Most studies do not specify theangle of needle insertion, but the conventional

needling technique usually involves perpendicularpenetration of the skin.17

ACUPUNCTUREHistory of acupunctureDN has been intertwined with acupuncture since itsinception. Meta-analyses of acupuncture or DN formyofascial pain have included studies in both fields inorder to decrease bias and strengthen the validity ofthe results.16–18 Results of research into the effects ofneedling can often be applied to both DN and acu-puncture. The term acupuncture originally referred tothe ancient healing technique originating from China2000 years ago, which has been widely practised allover the world as a professional practice in the fieldof complementary and alternative medicine. TAinvolves the stimulation of specific points on the body,based upon the theoretical ‘meridian’ concept, viapenetration by solid filiform needles.5 Original acu-puncture instruments were made from so-called bianstones. With the introduction and application of ironinstruments, bian stone needles were replaced bymedical needles made of metal. Acupuncture theoriesand techniques have been expanded and optimised bythe contribution of acupuncturists of the various timeperiods throughout history. Since the inception ofChinese culture, acupuncture has been used as one ofthe major tools for the restoration and maintenanceof health in China.5

Acupuncture likely emerged in the USA in the late1800s when large numbers of Chinese workersmigrated to the west coast to build railways; however, itmade its official debut in 1971 when journalist JReston19 published an article in the New York Timesdescribing his personal experience with acupuncture,followed by the visit of US President Nixon to China in1972. In the UK, physicians were reported to have beenneedling tender points to relieve musculoskeletal pain inthe 1800s, and interest in acupuncture surged in the1970s.1 Ever since then, acupuncture has become moreand more popular in major western countries.1 20 Dueto its growing popularity and an accumulation ofresearch evidence, acupuncture, particularly WMA, hasbeen widely integrated into the practice of conventionalhealthcare in major western countries.20

Theories of acupunctureClassical theories and principles of point selection inTA are based on historical concepts of balancing Yinand Yang and dredging ‘meridians’. Such theories areused to differentiate TA from WMA. Nowadays, bothclassical theory and modern biomedical sciences areincluded in the education of acupuncturists in Chinaand around the world. Besides TA, the contemporaryversion, WMA, which is based on the understandingof human anatomy, physiology, and pathology, is alsowidely practised, especially among physicians andother healthcare professionals.1 15 One example of

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WMA is peripheral neuromodulation, in which practi-tioners stimulate somatic nerves in order to influenceautonomic nerves (via somatovisceral reflexes).21 22

A special category of acupuncture points are the ahshi (translated as ‘ouch’) points, which include acu-puncture points that are tender to touch or pressure,with a similar definition to trigger points. Dorsher23

reported that the distribution of trigger points has a95% overlap with acupuncture points in the treatmentof pain disorders. Thus, in pain conditions, triggerpoints may represent similar (if not the same) physio-logical phenomena as acupuncture points.23

Acupuncture procedureAcupuncture involves many different techniques withvarious types and lengths of needles depending on thecondition and the acupuncture point location. Thecommonly used procedure for musculoskeletal paininvolves ah shi points with treatment protocols similarto DN but with needle retention. Traditionally, acu-puncture point selection and treatment is based on‘syndrome differentiation’, which incorporates inspec-tion (including the tongue), palpation (including thepulse), and systematic inquiry. This is the process thatmany acupuncturists and Traditional ChineseMedicine practitioners use to generate a traditionaldiagnosis, treatment principle and plan.24

Acupuncturists usually emphasise de qi sensationsduring treatments.25 De qi refers to a composite ofsensations including local muscle twitches and propa-gation of sensation upon needling.25 Historically, de qisensation has been considered to be the foundationfor the therapeutic effectiveness of acupuncture forpain,25 and this is supported by research demonstrat-ing that the stimulation of A-delta afferent nerves thatis associated with the de qi sensation26 is important inmediating the clinical effects of acupuncture.27

Most acupuncture procedures last 30–45 min andinvolve a perpendicular needle insertion. It is worthnoting that during the same time period that DN wasdeveloping in the western world, Professor DinghouLu and colleagues at Beijing Sports University stronglyadvocated needling at tender (ah shi) points using anoblique angle, as this gave better therapeutic effects inmyofascial pain compared with vertical needleinsertion.28

NEEDLING EFFECTS IN THE MUSCULOSKELETALSYSTEM: THERAPEUTIC MECHANISMSDuring the past two decades, tremendous progress hasbeen made investigating the mechanisms of actionunderlying the effects of needling on the musculoskel-etal and nervous systems. Besides the widely recog-nised gate control theory and regulation of theendogenous opioid system,1 two other major findingsworth noting are the regulation of the purinergic sig-nalling system and stretch-like needling effects in themusculoskeletal system.29–31 Researchers in China and

the USA have demonstrated that acupuncture inducesan immediate local increase in adenosine (part of thepurinergic signalling pathway) in both humans andanimals.29 30 Adenosine has not only been found tobe involved in pain modulation, but is also a vitalsource for energy for muscles.32 Interestingly, besidespain relief, needling of muscle has been found toincrease muscle strength and improve the range ofmovement at joints.33–35 These effects of needling aresuggested to be similar to those of stretch in physicalexercise. Langevin et al31 reported that acupuncturefunctions like physical stretch, activating fibroblaststhat trigger signal transduction pathways at themolecular level. Fibroblasts not only produce proteinsthat make up the extracellular matrix, but also trans-form into myofibroblasts to repair injury via produc-tion of collagen and α smooth muscle actin protein.36

Findings from research studies on the mechanismsof action underlying the effects of needling not onlyexplain why needling per se is effective for musculo-skeletal pain treatment,29–35 but also account for thegrowing use of DN in the musculoskeletal fieldincluding sports medicine. Needling may thusimprove muscle performance, although large, highquality research studies are needed to determine theoptimal parameters of needling, including locationand direction of needle insertion, duration of needleretention, the requirement for a local twitch responseor de qi sensation, the frequency of treatments, and itspotential role as a preventive measure. As convention-ally trained healthcare professionals are usually wellequipped with profound knowledge about the muscu-loskeletal system, and acupuncturists are usually welltrained in needling procedures, collaborationsbetween these professionals may help optimise the useof needling therapy in musculoskeletal conditions.

DN VERSUS ACUPUNCTURE: A POTENTIALSOLUTIONQuestions surrounding the practice of DN and its rela-tionship with acupuncture exist among patients andclinicians. Acupuncture overlaps with DN withrespect to needling instruments, technique, and itswidespread use in disorders of the musculoskeletalsystem. Additionally, both WMA and DN are basedon modern biomedical understandings of the humanbody. Acupuncture points (including ah shi points)and trigger points overlap significantly in the treat-ment of pain; localised muscle twitches in DN and deqi sensations in acupuncture, respectively, are used asprognostic criteria to predict the effectiveness of need-ling. As stated by White and colleagues in the defin-ition of WMA,1 variations include subcutaneousneedling over tender muscle trigger points. Thus, DNshould be recognised as a subcategory of WMA.As physicians are well trained in needling proce-

dures, pathophysiology and the management ofcommon disorders, their practice of WMA (including

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DN) can generally be considered safe. However, adispute exists regarding the practice of DN by health-care professionals who are not physicians or acupunc-turists and may lack the necessary training. For theinterests of patients, greater effort should be paid toidentifying solutions to the dispute rather than ques-tioning the legitimacy of DN practice by other health-care professions.Although needling therapy has been proven to be

safe in general, healthcare professionals who are notphysicians or acupuncturists need to develop theircompetence in order to provide skilled and proficienttreatment and to prevent possible adverse eventsrelated to needling. Besides the establishment of aregulatory body to accredit DN courses, so that stan-dards are set to guarantee patient safety and optimaloutcomes, needling practice per se and the use of DNto treat patients should require formal and compre-hensive education and training, which should includethe essential biomedical education and training inneedling skills needed to practise DN safely. This willadd credence and strengthen the capability of thesehealthcare professionals in the practice of DN for thetreatment of musculoskeletal disorders.

CONCLUSIONDN and acupuncture overlap with respect to needlingtechniques using solid filiform needles as well as somefundamental theories. DN should be recognised asone subcategory of WMA. The establishment of aregulatory body to accredit DN courses and a formaland comprehensive education and training pro-gramme are needed to support its practise by health-care professionals who are not physicians oracupuncturists. Because of the close relationshipbetween DN and acupuncture, collaboration ratherthan dispute between acupuncturists and other health-care professionals should be encouraged with respectto education, research, and the practice of needlingfor the benefit of patients with musculoskeletal painwho require needling therapy.

Contributors KZ conceived the idea and drafted the article.MSB provided constructive guidance and feedback. YMco-authored a portion of the article.

Competing interests None declared.

Provenance and peer review Not commissioned; externallypeer reviewed.

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ongoing debateDry needling versus acupuncture: the

Kehua Zhou, Yan Ma and Michael S Brogan

doi: 10.1136/acupmed-2015-0109112015

2015 33: 485-490 originally published online November 6,Acupunct Med 

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