The Dry Needling Paradox

Following another research report demonstrating the success of dry needling I am noticing a recent trend in the research methodology that should be critiqued for further success and enhanced outcomes. However, if its fixed it removes validity from the research.  This puts dry needling at a tough paradox; specifically do you study dry needling only and study it with limited parameters (only 1x/wk for ~4wks or even 1-2 sessions only) or do you study as it would be (hopefully) practically used (2-3x/wk for 2wks along with other manual techniques, neuromuscular re-ed, and patient education).    

Unfortunately, there is no good answer for research sake on dry needling due to the fact that as you improve external validity (the success in real world environments) and thus functionality you decrease internal validity (the ability to validate in the lab without other variables or influences) by adding too many independent variables that skew the data.  If you add exercise, etc then it will be argued that the other variable provided the success, not the muscular needling. Consequently, studies try to test the effects of minimal dosage. While still impactful, this may limit its real world use. 

Let me be clear, a VAST majority of my patients rarely get needled more than three sessions.  However, this is also rarely spread out over a course of 3+weeks, rather its completed within a week and a half.  

I suppose the best study will have man & tex vs needling, man, &tex.  Expect good outcomes in both studies but will needling get you there faster? From my clinical experience muscular needling is a wonderful adjunct, but only when the new tone, length, motor control, and pain threshold changes seen in the muscle is reintegrated into movement. 

Dry needling without reintegrating movement and reinforcing with proper home education and even reloading the tissue will limit our success.  Simply, you can't just remove the threat but not changing the environment.  And most dry needling research only dry needles. Trust me, I get it.  If we dry needle and stretch and add a bunch of other stuff every single reader will quickly critique if TDN was the reason for the success. However, like the study above if we only needle once a week for six weeks then we are limiting the importance of loading the new tissue.  This demonstrates that the best research evidence is just as important pillar as our clinical expertise pillar (and the patient's preference for that manner, ie; needle phobia won't fix the worst ATrPs).

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In addition, if Dry needling continues to show success just by itself I think its really showing you how potentially successful it can be in combination with other modalities (yes exercise is a modality).  Dry needling is the Hulk, it can beast through pretty quickly. But needling with movement assessments, exercise, other manual techniques,etc, well that's the full package.  That's the Avengers!