Wet needling uses hollow-bore needles to deliver corticosteroids, anesthetics, sclerosants, botulinum toxins, or other agents. In contrast, dry needling requires the insertion of thin monofilament needles, as used in the practice of acupuncture, without the use of injectate into muscles, ligaments, tendons, subcutaneous fascia, and scar tissue. Dry needles may also be inserted in the vicinity of peripheral nerves and/or neurovascular bundles in order to manage a variety of neuromusculoskeletal pain syndromes. Nevertheless, some position statements by several US State Boards of Physical Therapy have narrowly defined dry needling as an ‘intramuscular’ procedure involving the isolated treatment of ‘myofascial trigger points’ (MTrPs). To operationalize an appropriate definition for dry needling based on the existing literature and to further investigate the optimal frequency, duration, and intensity of dry needling for both spinal and extremity neuromusculoskeletal conditions. According to recent findings in the literature, the needle tip touches, taps, or pricks tiny nerve endings or neural tissue (i.e. ‘sensitive loci’ or ‘nociceptors’) when it is inserted into a MTrP. To date, there is a paucity of high-quality evidence to underpin the use of direct dry needling into MTrPs for the purpose of short and long-term pain and disability reduction in patients with musculoskeletal pain syndromes. Furthermore, there is a lack of robust evidence validating the clinical diagnostic criteria for trigger point identification or diagnosis. High-quality studies have also demonstrated that manual examination for the identification and localization of a trigger point is neither valid nor reliable between-examiners. Several studies have demonstrated immediate or short-term improvements in pain and/or disability by targeting trigger points (TrPs) using in-and-out techniques such as ‘pistoning’ or ‘sparrow pecking’; however, to date, no high-quality, long-term trials supporting in-and-out needling techniques at exclusively muscular TrPs exist, and the practice should therefore be questioned. The insertion of dry needles into asymptomatic body areas proximal and/or distal to the primary source of pain is supported by the myofascial pain syndrome literature. Physical therapists should not ignore the findings of the Western or biomedical ‘acupuncture’ literature that have used the very same ‘dry needles’ to treat patients with a variety of neuromusculoskeletal conditions in numerous, large scale randomized controlled trials. Although the optimal frequency, duration, and intensity of dry needling has yet to be determined for many neuromusculoskeletal conditions, the vast majority of dry needling randomized controlled trials have manually stimulated the needles and left them in situ for between 10 and 30 minute durations. Position statements and clinical practice guidelines for dry needling should be based on the best available literature, not a single paradigm or school of thought; therefore, physical therapy associations and state boards of physical therapy should consider broadening the definition of dry needling to encompass the stimulation of neural, muscular, and connective tissues, not just ‘TrPs’.

Objective: The purpose of this study was to examine the psychometric properties of the neck disability index (NDI) and numeric pain rating scale (NPRS) in patients with neck pain (NP) without concomitant upper extremity (UE) symptoms. Design: A secondary psychometric analysis of 107 patients with NP without UE symptoms. Test-retest reliability, construct validity, area under the curve (AUC), minimum detectable change (MDC), and minimum clinically important difference (MCID) were calculated.Results: The NDI exhibited excellent reliability (ICC = 0.88; [0.63 to 0.95]), while the NPRS exhibited moderate reliability (ICC = 0.67; [0.27 to 0.84]). The AUC for both the NDI (0.86; [0.79 to 0.93]) and NPRS (0.81 [0.73 to 0.90]) was acceptable. The MDC for the NDI was 6.9, and the MCID for the NDI was 5.5(Sn = 0.83; Sp = 0.79). For the NPRS, the MDC was 2.6, and the MCID was 1.5(Sn = 0.93; Sp = 0.64). Conclusion: The threshold for MCID for the NDI and NPRS in patients without UE symptoms is lower (NDI = 5.5; NPRS = 1.5) than that of patients with UE/radicular symptoms (NDI = 8.5 points; NPRS = 2.2). Knowledge of these cut-scores in each presentation of NP is needed for successful research and clinical treatment. Additional outcomes may be warranted for patients with UE symptoms.

Although commonly utilized interventions, no studies have directly compared the effectiveness of cervical and thoracic manipulation to mobilization and exercise in individuals with cervicogenic headache (CH). The purpose of this study was to compare the effects of manipulation to mobilization and exercise in individuals with CH. One hundred and ten participants (n = 110) with CH were randomized to receive both cervical and thoracic manipulation (n = 58) or mobilization and exercise (n = 52). The primary outcome was headache intensity as measured by the Numeric Pain Rating Scale (NPRS). Secondary outcomes included headache frequency, headache duration, disability as measured by the Neck Disability Index (NDI), medication intake, and the Global Rating of Change (GRC). The treatment period was 4 weeks with follow-up assessment at 1 week, 4 weeks, and 3 months after initial treatment session. The primary aim was examined with a 2-way mixed-model analysis of variance (ANOVA), with treatment group (manipulation versus mobilization and exercise) as the between subjects variable and time (baseline, 1 week, 4 weeks and 3 months) as the within subjects variable. The 2X4 ANOVA demonstrated that individuals with CH who received both cervical and thoracic manipulation experienced significantly greater reductions in headache intensity (p < 0.001) and disability (p < 0.001) than those who received mobilization and exercise at a 3-month follow-up. Individuals in the upper cervical and upper thoracic manipulation group also experienced less frequent headaches and shorter duration of headaches at each follow-up period (p < 0.001 for all). Additionally, patient perceived improvement was significantly greater at 1 and 4-week follow-up periods in favor of the manipulation group (p < 0.001). Six to eight sessions of upper cervical and upper thoracic manipulation were shown to be more effective than mobilization and exercise in patients with CH, and the effects were maintained at 3 months. NCT01580280 April 16, 2012.

Objectives: To compare the effects of adding electrical dry needling into a manual therapy (MT) and exercise program on pain, stiffness, function, and disability in individuals with painful knee osteoarthritis (OA). Materials and Methods: In total, 242 participants (n=242) with painful knee OA were randomized to receive 6 weeks of electrical dry needling, MT, and exercise (n=121) or MT and exercise (n=121). The primary outcome was related-disability as assessed by the Western Ontario and McMaster Universities (WOMAC) Osteoarthritis Index at 3 months. Results: Individuals receiving the combination of electrical dry needling, MT, and exercise experienced significantly greater improvements in related-disability (WOMAC: F=35.504; P<0.001) than those receiving MT and exercise alone at 6 weeks and 3 months. Patients receiving electrical dry needling were 1.7 times more likely to have completely stopped taking medication for their pain at 3 months than individuals receiving MT and exercise (OR, 1.6; 95% confidence interval, 1.24-2.01; P=0.001). On the basis of the cutoff score of ≥5 on the global rating of change, significantly (χ²=14.887; P0.82) for all outcome measures in favor of the electrical dry needling group at 3 months. Discussion: The inclusion of electrical dry needling into a MT and exercise program was more effective for improving pain, function, and related-disability than the application of MT and exercise alone in individuals with painful knee OA. Level of Evidence: Level 1b—therapy. Prospectively registered February 10, 2015 on www.clinicaltrials.gov (NCT02373631).

Randomized, single-blinded, multi-center, parallel-group trial. To compare the effects of adding electrical dry needling into a program of manual therapy, exercise and ultrasound on pain, function and related-disability in individuals with plantar fasciitis (PF). The isolated application of electrical dry needling, manual therapy, exercise, and ultrasound has been found to be effective for PF. However, no previous study has investigated the combined effect of these interventions in this population. One hundred and eleven participants (n = 111) with plantar fasciitis were randomized to receive electrical dry needling, manual therapy, exercise and ultrasound (n = 58) or manual therapy, exercise and ultrasound (n = 53). The primary outcome was first-step pain in the morning as measured by the Numeric Pain Rating Scale (NPRS). Secondary outcomes included resting foot pain (NPRS), pain during activity (NPRS), the Lower Extremity Functional Scale (LEFS), the Foot Functional Index (FFI), medication intake, and the Global Rating of Change (GROC). The treatment period was 4 weeks with follow-up assessments at 1 week, 4 weeks, and 3 months after the first treatment session. Both groups received 6 sessions of impairment-based manual therapy directed to the lower limb, self-stretching of the plantar fascia and the Achilles tendon, strengthening exercises for the intrinsic muscles of the foot, and therapeutic ultrasound. In addition, the dry needling group also received 6 sessions of electrical dry needling using a standardized 8-point protocol for 20 minutes. The primary aim was examined with a 2-way mixed-model analysis of covariance (ANCOVA) with treatment group as the between-subjects variable and time as the within-subjects variable after adjusting for baseline outcomes. The 2X4 ANCOVA revealed that individuals with PF who received electrical dry needling, manual therapy, exercise and ultrasound experienced significantly greater improvements in first-step morning pain (F = 22.021; P<0.001), resting foot pain (F = 23.931; P<0.001), pain during activity (F = 7.629; P = 0.007), LEFS (F = 13.081; P<0.001), FFI Pain Subscale (F = 13.547; P<0.001), FFI Disability Subscale (F = 8.746; P = 0.004), and FFI Total Score (F = 10.65; P<0.001) than those who received manual therapy, exercise and ultrasound at 3 months. No differences in FFI Activity Limitation Subscale (F = 2.687; P = 0.104) were observed. Significantly (X² = 9.512; P = 0.023) more patients in the electrical dry needling group completely stopped taking medication for their pain compared to the manual therapy, exercise and ultrasound group at 3 months. Based on the cutoff score of ≥+5 on the GROC, significantly (X² = 45.582; P<0.001) more patients within the electrical dry needling group (n = 45, 78%) achieved a successful outcome compared to the manual therapy, exercise and ultrasound group (n = 11, 21%). Effect sizes ranged from medium to large (0.53<SMD<0.85) at 3 months in favor of the electrical dry needling group. The inclusion of electrical dry needling into a program of manual therapy, exercise and ultrasound was more effective for improving pain, function and related-disability than the application of manual therapy, exercise and ultrasound alone in individuals with PF at mid-term (3 months). Therapy, Level 1b.