Dry Needling. What is it and what are the issues?
Opinion piece by Melanie Gibson.

Recently a COCA short course on dry needling was offered to chiropractors and osteopaths in Perth. This was the second in our 2008 seminar series and was offered in line with our aim to provide the professions with a variety high quality vocational education. This comprehensive introduction to dry needling offers practitioners a therapy which may add an extra dimension to their treatment possibilities.

The incorporation of this therapy into chiropractic and osteopathic practice raises some interesting dilemmas and discussion points. This article aims to set out these issues, providing comment on each of them from members of the COCA Board.

The popularity of the dry needling seminar held at Murdoch University could herald a future direction in chiropractic and osteopathic clinical practice. This popular seminar offered practitioners an increased stake in the musculoskeletal field by allowing for a greater scope of practice and adding to their expertise. Over the last 30 years chiropractors and osteopaths have witnessed significant changes, particularly in the addition of physical therapies and low force techniques into the professions. Is the popularity of dry needling indicative of a directional change or just a niche technique? Whatever the outcome, it can be said that practitioners have a limited array of interventions available to them and a willingness to expand their treatment options. Dry needling is a therapeutic intervention that at present is underutilised by musculoskeletal practitioners. The procedure is simple, safe & effective. It can be easily incorporated into practice as either an adjunct or indeed the main stay of treatment.

Seminar speaker chiropractor Dr Steven Wood believes that “This is a worthwhile addition to our “brand”. Dry needling by itself can replace manipulation in some circumstances, as anecdotally I have demonstrated for the last thirty years, or it can be used to enhance it. The procedures are not mutually exclusive.”

There is some baseline evidence for the use of dry needling for trigger points and tender points. Much of the research is based on that which has been done for acupuncture but there is also baseline research for dry needling itself. However, it is important to distinguish between dry needling and acupuncture.

Dry needling is the insertion of fine needles (acupuncture needles) into trigger and tender points for the purpose of relieving pain and spasm. It is not acupuncture in the Traditional Chinese sense as it uses western theories and evidence to guide its administration. Dr. Wood said that “The current scientific view is that manipulation may act as an analgesic procedure perhaps by stimulating neurotransmitter release within the central nervous system. It could be postulated that needling does to a muscular mechanoreceptor what manipulation does to those in the joint capsule”. He went on to say that “Acupuncture literally means a “needle puncture” but the term is usually applied when the needling is performed at prescribed points. Dry needling is performed at a palpated trigger point or tender point. Current research supports the procedure as deactivating these neurologically active points. Internationally dry needling is being performed by advanced myotherapists, musculoskeletal physicians, physiotherapists, chiropractors and acupuncturists. Locally a handful of chiropractors perform dry needling subject to the provisions of local skin penetration regulations which prescribe safety and hygiene requirements.”

More specifically it refers to the insertion of a needle without any drugs going through it into the muscle or soft tissue. It is a more recent development and it tends to be much more mechanical in its approach thank Traditional Chinese acupuncture, where needles are inser ted determined by where the pain is in soft tissue.

It is used for muscular and soft tissue pain; and is effective in treating tendinopathy type conditions, deep trigger points and, patients intolerant to deep soft tissue therapy, and is also successful in relaxing muscles. It not a cure all in itself but it offers an extra dimension to therapy possibilities.

All treatments have got potential adverse affects. “Probably the one we stressed on the weekend at the Perth seminar was the avoidance of collapsed lung known as pneumothorax. Because deep needle insertion can penetrate the chest wall and actually pierce a lung causing collapsed lung.”

“That’s the major problem. There’s obviously minor side affects where you can actually drive the needle through a very small blood vessel and cause some localised bruising. There has been reports of needles that have actually broken off inside the body. That’s a very, very rare thing in the fifty-five years of the combined practice time of the two speakers on the weekend they hadn’t experienced it. Though they did go through a list of other possibilities. But generally speaking so long as short needles are used around the trunk and inserted to a specific depth there’s no problem”, Dr Bruce Walker, Academic, Murdoch University.

Before COCA offered this course it was confronted with a number of legal issues. Was it legal to teach dry needling in WA? Were chiropractors or osteopaths legally able to use the method once they successfully completed the course? What legal obligations are there for those who use it?

To answer these questions COCA instructed lawyers in Perth to advise. In summary the advise was positive about conducting a course and practising the modality. However, it was clear that practitioners needed to abide by the Skin Penetration regulations. It is likely that these Regulations and the Code of Practice that accompanies it are much the same in each state of the Commonwealth. They set out correct hygiene practices for needle use. The Regulations became an integral part of the Dry needling course. It was also clear that individual practitioners be aware of other local state regulations that may govern the use of dry needling.

Another significant question that arose was "could chiropractors and osteopaths obtain professional indemnity insurance for dry needling?" COCA inquired of its insurer AON who agreed that dry needling would be regarded as part of the policy as long as policy holders abided by some simple rules set out in their Policy. Another question that insurers ask that qualifies the modality for coverage is "is the modality a part of chiropractic services?" At a meeting of the COCA Executive in May this was decided in the affirmative.

The introduction of dry needling follows its popularity among Chiropractors in South Africa. It is likely that this modality will receive high uptake by COCA members. The evidence base for the modality is reasonable but much more research needs to be done.

“Certainly chiropractic and acupuncture together is not that uncommon and even in Australia quite a few chiropractors are practicing Traditional Chinese Medicine acupuncture. There is a reasonable amount of evidence for the efficacy of acupuncture for treating certain conditions. However, there seems to be an equal amount against its efficacy. So, at the moment the jury is out and more research needs to be undertaken” Dr Walker

COCA would advise practitioners interested in incorporating dry needling into their practice to look at the evidence and be cognisant of the current best practice available for that particular intervention. Chiropractors have already received University training in anatomy, and biochemistry, physiology, pain and diagnosis. So they have a solid education base. Therefore the introduction of any technique should specifically be about the technique itself and any therapeutic effects and any practical considerations and the adverse affects that are possible.

“It should touch on legal issues and that is what we’ve done. My advice to anyone considering dry needling is to not start it without specific advice and preferably to undertake a course of instruction”, Dr Walker. “Course providers should address the theoretical scientific underpinning’s of the technique. They need to address the practical considerations of needle insertion including how to do it and where not to do it.”

“Practitioners also need to consider very carefully the legal implications and the codes of practice that are determined by state government and local government. It is also important to carefully study your own insurance policy about whether you are actually covered to use dry needling. Fortunately those that are insured with AON and the under writer QBE are covered for dry needling in their policy but there are certain simple requirements and regulations that AON and QBE stipulate.”

“I don’t have any firsthand knowledge relating to Guild insurance or Osteopathic insurers about whether they’ll cover it within the existing Chiropractic or Osteopathic policies. So I suggest that individuals follow this up and seek advice about it.”

We trust that patients are going to receive the best possible care from the practitioner who practices many different modalities. The increased skill obtained through continuing education may be invaluable to both patients and practitioners. “For somebody who practices a ridged core of only one thing there will be people who arrive at their offices who don’t fit into the box that they are treating. All practitioners deal with patients that don’t improve. And when they don’t improve the astute practitioner would be look for other reasons for why they’re not improving. Whether that’s based on their diagnosis or whether that based on the interventions their using. Any practitioner should be giving the best available treatment for the individual patient. Traditionally Chiropractors give manipulation, however that’s not necessarily the best modality to use for every individual. So there should be an assessment of the evidence and the patient preference and the skill of the practitioner to determine what is the most appropriate intervention in a particular situation”, Dr Simon French, Chiropractor, Academic and COCA Board Member.