Dry Needling: Panacea or Placebo? (Part II)

Well conducted clinical trials are not the only things that can give us insight into the efficacy of a treatment so let’s take a look at a few of the systematic reviews and meta-analyses that have come up regarding dry needling.  We will go in order by year.

• In Cummings et.al. 2001, the authors concluded that for patients with myofascial trigger points, there is no difference between wet needling (needling with the injection of a drug) and dry needling for relieving pain and no study they saw effectively controlled for placebo effects.

“The hypothesis that needling therapies have specific efficacy (ie, efficacy beyond placebo) in the treatment of myofascial trigger point pain is neither supported nor refuted by the research to date. However, the present review suggests that any effect these therapies may have is likely due to the needle or placebo, rather than to the injection, whether it be of liquid in general or a particular substance” (Cummings, 2001).

• In Furlan et.al. 2005, the authors investigated the efficacy of acupuncture and dry needling for non-specific acute or chronic back pain.  The authors found the majority of the relevant studies they were able to include were of poor methodological quality.  They also found there is some evidence to suggest that acupuncture is more effective for pain relief in short term follow ups compared to no treatment or sham treatment.  However, there were no differences later on, and it was no better than any other typical treatment.

“Although the conclusions showed some positive results of acupuncture, the magnitude of the effects were generally small. The average pain reduction (measured by continuous scales such as the VAS) in the group that received acupuncture for chronic low back pain was 32% compared to 23% in those who received sham therapies and 6% in those who received no treatment” (Furlan 2005).

• In Tough et.al. 2009, the authors investigated the treatment effects of needling therapies for myofascial trigger points.  The authors found one study suggested that dry needling can relieve pain better than no intervention (duh), but four studies combined in the meta-analysis showed that dry needling was not better than sham interventions.

“There is limited evidence, deriving from one study that deep needling directly into myofascial trigger points has an overall treatment effect when compared with standardised care. Whilst the result of the meta-analysis of needling compared with placebo controls does not attain statistically significant, the overall direction could be compatible with a treatment effect of dry needling on myofascial trigger point pain” (Tough, 2009).

• In Cotchett et.al. 2010, the authors performed a systematic review of trials testing the efficacy of dry needling for plantar heel pain.  The authors only found three quasi-experimental studies that were of poor methodological quality.  Among many other problems like incomplete reporting of various aspects of the studies, two of the studies did not have a control group and the one that did, did not randomize which people where in which group.  While the authors found that the interventions in each study did decrease pain, the internal validity of these studies was highly suspect.

“This systematic review found limited evidence for the effectiveness of dry needling and/or injections of MTrPs associated with plantar heel pain. However, the quality of the included trials was poor and serious threats to internal validity were evident” (Cotchett, 2010).

• In Kietrys et.al. 2013, the authors investigated the efficacy of dry needling for upper quarter myofascial pain.  The authors found twelve studies and performed four different meta-analyses:
  • immediate effects of dry needling versus sham/control treatments
  • effects after 4 weeks of dry needling versus sham/control treatments
  • immediate effects of dry needling versus other treatments
  • effects after 4 weeks of dry needling versus other treatments.

The authors found that dry needling was better than sham treatments for reducing pain in the immediate short term and at 4 weeks, however there was a large confidence interval for effects at 4 weeks, suggesting the treatments were equivocal.  For dry needling versus other treatments (lidocaine injections, nonlocal acupuncture), the results favored other treatments in the immediate short term, and were equivocal after 4 weeks.  Despite some slightly positive results in favor of dry needling the authors concluded:

“The limited number of studies performed to date, combined with methodological flaws in many of the studies, prompts caution in interpreting the results of the meta-analyses performed here” (Kietrys, 2013).

• In Boyles et.al. 2015, the authors performed a broad systematic review without further statistical analyses to assess the effectiveness of dry needling for multiple body regions.  The authors found that trigger point dry needling can reduce pain for multiple body regions.  However, the authors did not do the real statistical analysis that we want: how does dry needling compare to sham dry needling?  

“It appears that TDN, as performed and measured in each study, does not influence strength, variably improves ROM and function, and frequently decreases pain. These trends must be considered with caution, however, due to methodological issues discussed above and differing methods represented for the collection of some outcome measures” (Boyles, 2015).

“Lack of consistency among the articles in this review in regards to patient recruitment, protocol, methodology and outcome measures precludes the formation of any strong conclusions from the available data” (Boyles, 2015).

• In Cagnie et.al. 2015, the authors investigated the efficacy of dry needling and ischemic compression for the treatment of upper trapezius trigger points.  The authors found that dry needling reduced pain in all studies that looked at it, but they did not specifically look at dry needling against sham dry needling.  

“There is strong evidence that DN has an analgesic effect, whereas the evidence is moderate to weak with respect to its effect on ROM and disability. Only one study showed a longer-lasting effect of DN compared with sham or control” (Cagnie, 2015)

• In Liu et.al. 2015, the authors investigated the efficacy of dry needling for trigger points associated with neck and shoulder pain.  They performed nine separate meta-analyses looking at outcomes in the short, medium, and long term for three comparisons: dry needling versus sham dry needling/control treatments, dry needling versus wet needling, and dry needling versus other treatments.  The authors found no statistical differences between dry needling and control/sham needling in the long term, dry needling versus wet needling in the short term and long term, and dry needling versus other treatments in the short, medium, and long term.  However, the authors did find statistically significant differences in pain reduction when comparing dry needling to sham dry needling/control treatments in the short and medium term.  Disappointingly, the authors did not differentiate between a true sham treatment and a control treatment, which may have influenced the results.  

“On the basis of the available evidence to date, dry needling can be cautiously recommended for relieving MTrP pain in neck and shoulders in the short and medium term than control/sham, but wet needling is found to be more effective than dry needling in relieving MTrP pain in neck and shoulders in the medium term” (Liu, 2015)

• In Rodriguez-Mansilla et.al. 2016, the authors assessed the efficacy of trigger point dry needling for reducing pain and improving ROM for patients with myofascial trigger points.  The authors performed multiple meta-analyses for various subgroups of 19 different studies, and found some mixed results.   There were statistically significant differences in favor of dry needling against control treatments for reducing pain, but no differences between dry needling and placebo treatments.  When comparing dry needling to “other” treatments for pain reduction, they were essentially equivocal.  When considering ROM, there were statistically significant effects in favor of dry needling as compared to placebo treatments.  However, there were also statistically significant effects in favor of “other” treatments when compared to dry needling.  

“Despite DN was more effective in decreasing pain comparing to no treatment, it was not significantly different from placebo in decreasing pain. Other treatments were more effective than DN on decreasing pain after 3-4 weeks. In increasing ROM DN was more effective comparing to placebo, but less than other treatments” (Rodriguez-Mansilla, 2016).

“Therefore, despite clinical practice showing that DN is increasingly used nowadays and that this technique is being applied with positive effects in rehabilitation medicine, especially for the management of MPS, we can observe that the scientific evidence observed in the studies analysed do not have consistent results regarding its effectiveness” (Rodriguez-Mansilla, 2016).

Let’s look at one more piece of evidence; a literature review of systematic reviews and meta-analyses from the Canadian Agency for Drugs and Technologies in Health titled Dry Needling and Injection for Musculoskeletal and Joint Disorders: A Review of the Clinical Effectiveness, Cost-Effectiveness, and Guidelines.  After looking at 15 systematic reviews and meta-analyses, the authors concluded

“Despite the number of systematic reviews on dry needling, evidence to show that it is an effective intervention is still lacking. Most of the systematic reviews, even those with conclusions that favoured dry needling, noted that current evidence is inadequate and better quality trials, with standardized interventions are needed to determine whether there is value in this procedure.”

Interestingly, the authors found that “some systematic reviews overstated their conclusions which can be common in study reports of pain treatments.  Actual results were downplayed, while more positive terms, such as “trending towards” and “potentially significant” were used in the abstracts and conclusions” (Dry Needling and Injection for…, 2016).

In every study that showed some positive outcome in favor of dry needling there was always a catch; it wasn’t better than placebo treatments, it was only slightly better than placebo treatments, internal validity was threatened, they did not use a true placebo, it wasn’t better than other treatments…etc.  The support for dry needling certainly is, at the very least, limited.  In part three, I will give you the most parsimonious explanation of the efficacy of dry needling, what it probably does physiologically, and whether or not it is a treatment we should be utilizing.  

References:

1. Cummings, M.T., et.al. (2001) Needling Therapies in the Management of Myofascial Trigger Point Pain: A Systematic Review. Archives of Physical Medicine and Rehabilitation, Volume 82, Number 8
2. Furlan, A, et.al. (2005) Acupuncture And Dry Needling For Low Back Pain: An Updated Systematic Review Within The Framework of The Cochrane Collaboration. SPINE, Volume 30, Number 8
3. Tough, E.A., et.al. (2009) Acupuncture and dry needling in the management of myofascial trigger point pain: A systematic review and meta-analysis of randomized controlled trials. European Journal of Pain, Volume 13
4. Cotchett, M.P., et.al. (2010) Effectiveness of dry needling and injections of myofascial trigger points associated with plantar heel pain: a systematic review. Journal of Foot and Ankle Research, Volume 3, Number 18.  
5. Kietrys, D.M., et.al. (2013) Effectiveness of Dry Needling for Upper-Quarter Myofascial Pain: A Systematic Review and Meta-analysis. Journal of Orthopaedic and Sports Physical Therapy, Volume 43, Number 9
6. Boyles, R., et.al. (2015) Effectiveness of trigger point dry needling for multiple body regions: a systematic review. Journal of Manual and Manipulative Therapy, Volume 23, Number 5
7. Cagnie, B., et.al. (2015) Evidence for the Use of Ischemic Compression and Dry Needling in the Management of Trigger Points of the Upper Trapezius in Patients with Neck Pain. American journal of physical medicine and rehabilitation
8. Liu, L., et.al. (2015) Effectiveness of Dry Needling for Myofascial Trigger Points Associated with Neck and Shoulder Pain: A Systematic Review and Meta-Analysis. Archives of Physical Medicine and Rehabilitation
9. Rodriguez-Mansilla, J., et.al. (2016) Effectiveness of dry needling on reducing pain intensity in patients with myofascial pain syndrome: a Meta-analysis. Journal Of Traditional Chinese Medicine, Volume 26, Issue 1
10. Dry Needling and Injection for Musculoskeletal and Joint Disorders: A Review of the Clinical Effectiveness, Cost-Effectiveness, and Guidelines (2016).  Canadian Agency for Drugs and Technologies in Health Rapid Response Report: Summary With Critical Appraisal

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