I practice physiotherapy in Vancouver. When I started my career it felt like I couldn’t be a good therapist unless I did dry needling. Chan Gunn, of Gunn IMS, lives and works in Vancouver and has a strong hold on the PT community. I got my dry needling certification and used it for a few years – it seemed to work – but five years on I am glad to have thrown my needles away and begun practicing with a new zeal for healthcare change.
Many would argue that acupuncture and dry needling/IMS/FDN are different therapies. I would argue that although both groups use different terminologies they practice in almost the same way: they use the same needles, they needle “trigger points”, they attempt to get a twitch response, they want to access endogenous opioid channels, and they often needle points away from the site of injury. Please read this article on SBM and this article on painscience.com to understand the fallacy of acupuncture and dry needling differences. For the sake of this blog I will use the term dry needling because physiotherapists have branded their form of acupuncture as such.
My reason for writing this post isn’t to stop everyone needling (I will discuss when dry needling may be appropriate). I want to expose practitioners, who are questioning dry needling validity, to other tools that can get patients better. A common argument for the continued use of dry needling is evidence based medicine is leaving us with less treatment options (no ultrasound, no injections, less manual therapy, etc). I don’t see this as a bad thing, I see this as a good thing. Research is focusing our attention on the treatments that matter most. I have taken needling out of my “tool kit” but have replaced it with what I see as higher value forms of treatment – namely empathy, education, reassurance, load management, and bio-psychosocial care. Can these treatments be used in-conjunction with dry needling? Of course, but why bother wasting people’s time and money.
This challenge may leave you with the following thoughts:
- Therapists swear by it.
- Patients swear by it.
- I have spent money on courses.
- I want to meet a patients expectations for treatment.
- It doesn’t do any harm, why not use it?
These are common arguments for the continued use of dry needling. Lets dissect each argument more closely.
1. Therapists swear by it – anecdotal evidence
Anecdotally the results of dry needling can be profound, and many high powered physiotherapists swear by it. If we are rational, critical physios we should question any treatment that stands only on anecdote (The research for accupuncture and dry needling is simply not there – 1, 2, 3, 4). There are also numerous examples of high powered medical professionals holding onto beliefs for far too long (Great piece in the Atlantic). We need to respect the hard work of therapists before us but we shouldn’t follow them blindly (thank you Adam Meakins).
2. Patients swear by it – anecdotal evidence
Patients got better with ultrasound and TENs but most of us have been comfortable putting aside these treatments. Just because a patient’s symptoms resolve after a treatment does not imply causation between the two. The symptoms may have resolved because of: forced rest, regression to the mean, natural history, placebo or meaning response, and the other treatments offered – including exercise, education, CBT and reassurance that the injury will get better (Great article here). Its a hard pill to swallow but most therapeutic treatments do little over the long term.
Even if we concede that, for a handful of conditions, dry needling could be superior to a placebo, we must ask: is it more effective than the best conventional therapies available today? Is it superior to education? Exercise? Load management? Medication? Lifestyle change? The short answer is no. To date any form of needling has not been shown to be better than less invasive conventional treatments
3. You have spent money on it – sunk cost fallacy
Many of us have spent thousands of dollars to get our needling certifications and to abandon it is a scary venture, especially when many colleagues still swear by it. I am here to say that it can be done and should be considered by more. If your goal is to provide exceptional care that doesn’t rely on fixing, consider leaving the needles at the door.
4. Patients expect it
A common argument for continued use is that patients expect it. Physios commonly argue that we must meet expectations, especially in a pay for fee service. I would have argued this myself a few years ago. As I learn more about our healthcare system I think this practice should stop. If someone expected homeopathy (it cause no direct harm) from a doctor, it doesn’t mean the treatment is justified. Although we are providing a service we are still accountable to the medical system at large. It is our responsibility to provide treatments that are efficacious and evidence based. For those that have abandoned evidence because they do not believe it provides answers I strongly suggest you read the following articles (CFT by O’sullivan, the Lancet series on low back pain, Jeremy Lewis shoulders, Peter Malliaris tendon education, and Tim Gabbett load management.
If someone expects it, how to do you resolve the conflict?
Client – I have had needling in the past and it has done wonders!
Therapist – that is good to know. As we have learnt more about the treatment it turns out that is has very little effect on our physiology. We now know that we can use less invasive treatments that will do the trick as well or better. This happens in medicine – it evolves – treatments we thought once worked are found to work for different reasons than we expected. Ultrasound, TENs, and cupping are other examples.
Client – I don’t mind I just like the feeling.
Therapist – you are right – there isn’t a lot of harm in doing the treatment (although still some risk) but I now believe the less fixing and intervening I do the better off you will be in the long run. My goal is to help you through this episode of pain and hopefully provide you with tools for self management if the pain comes back. I will always be here for support but my goal is to make you self sufficient. Just the same way it is better to teach someone to fish then to give them a fish, I want to give you the tools:) I am going to do my best to help you but if you really want a feel good massage and relaxation session I can help you find a good place.
Client – thats an interesting way of putting it. Thanks for believing in my ability to self heal. Lets give this a go.
You would be surprised how well people respond to honesty and candour. You have to make a decision if you are in this for repeat business (that can be ok in certain cases) or in this to help people live healthier lives without the need of fixing and hand holding.
Client – I have been told that IMS works really well for neck pain.
Therapist – that is good to know. I for a time used IMS. In recent years research has shown, that this mildly invasive treatments is no better than placebo and should not be our first line treatment for neck pain or any musculoskeletal pain. I would rather spend our time on treatments I believe to be of high value. Things like: understanding your pain, what can be done about your pain in the short term, what may lessen the likelihood of re-injury and how we can introduce self-management strategies.
Client – ok – that sounds like a good plan. Lets go for it.
Client – I have never had needling before.
Therapist – perfect, there isn’t a lot of research to support it and there are lots of self management strategies that can help you feel better today and into the future.
If you have become known as a therapist who needles and get referred patients because of it you might be having a few more conversations like this. The beauty is these conversations are freeing. Because you are being honest with the your patients from start to finish you start to feel an unwavering sense of integrity.
5. It does not cause any harm, so why not do it?
Although rare, patients do pay cash for our services. If we are dealing with a medical issue we still have a duty as healthcare providers to offer services that promote self-management and self-care. Our communities need us to be champions for this cause, we do not need more miracle workers offering fixes. Although dry needling is mostly safe you are still piercing an object into a person’s body. There is inherit risk in this no matter how careful you are.
Now I can’t argue that having a needle poked through the skin is a wild experience. It can be pain provoking and at the same time pleasurable. If someone understands dry needling is a sensory experience much like a massage then by all means offer the service. Just as massage has been shown to relax us and provide short term, temporary relief, for those that love the feeling of tiny needles by all means, go for it. It can’t and shouldn’t be used under the guise of fixing diseased tissue, releasing muscles, or balancing energies. If we can move away from dubious claims, needles can be used simply for a relaxing spa treatment. Nothing wrong there. I hope in the years to come, rational physios will refrain from using dry needling or offer it as an experience, not a cure.
It is easy to find blogs and articles to support dry needling but if you look closely at the arguments, they are anecdotal, supported by poor and biased research, and are based off a trigger point theory that is shaky at best.
There are numerous papers on painscience.com, sciencebasedmedicine.org, and bodyinmind.org that provide wonderful insight. A few include:
- Trigger points strike out
- Dry needling for myofascial pain
- An appraisal of an acupuncture meta-analysis
- False claims of Acupuncture
- Is dry needling acupuncture?
Whether it be acupuncture, IMS, or functional dry needling the research is lacking and the potential iatrogenic effects are profound. The use of needles implies the body or tissue needs fixing. Here is my challenge to you – read 10 articles on acupuncture and dry needling, be critical and try needling a few less people. See how it goes.
To finish I would like to take a quote from Paul Ingrahams painscience.com
“Even if it could help in decreasing chronic pain, acupuncture still remains a passive intervention which doesn’t enhance confidence, self-efficacy and self-management of chronic pain” @theocharisy
Thanks for reading
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