Our Needles Have Always Been Dry

For a very long time, only acupuncturists used acupuncture needles. Acupuncture needles are different from other needles used in medicine. They are technically “filiform” — like wires, they are solid and thin without a cutting surface. Western biomedical needles typically were either hollow (to allow injections or to draw blood) or were to carry thread for sutures. 

In the past decade, however, there has been an explosion in the medical field, particularly in Physical Therapy, of something called “dry needling.” Dry needling got its name because, prior to the legalization of acupuncture in the United States beginning in the 1970s, hypodermic syringes were used in the technique but nothing was injected — hence the “dry” part. The origin of the term is attributed to Dr. Janet Travell. In her 1983 book, Myofascial Pain and Dysfunction: The Trigger Point Manual, she uses the term dry needling to disambiguate it from performing injections of procaine anaesthetic when performing trigger point therapy. Hypodermic needles, as any child at a doctor’s office will tell you, don’t feel that great. Hence, dry needling didn’t really take off until practitioners began moving away from hypodermics and switched to relatively painless acupuncture needles. 

Once dry needling practitioners began using the same tools as acupuncture, the debate of what distinguished dry needling from acupuncture began to be more acute (from the Latin acus ‘needle’), so to speak. 

The origins of “dry needling”

According the Second Edition of Travell’s book, “The distinction between TrPs and acupuncture points for the relief of pain is blurred for a number of good reasons. First, the mechanisms responsible for the pain relief associated with the two concepts have until very recently been enigmatic or controversial. Second, as reported by Melzack, et al., there is a high degree of correspondence (71% based on their analysis) between published locations of TrPs and classical acupuncture points for the relief of pain. Third, a number of studies report similar results when needling TrPs using acupuncture needles as when using hypodermic needles with injected solution.” A 2009 paper concluded that “a strong (up to 91%) consistency of the distributions of trigger point regions’ referred pain patterns to acupuncture meridians provides…evidence that trigger points most likely represent the same physiological phenomenon as acupuncture points in the treatment of pain disorders.” 

Physical therapists (PTs) will often argue that unlike acupuncture, dry needling is based on biomedical concepts. But since acupuncture for musculoskeletal pain and trigger point dry needling overlap so extensively, it seems to be, for all practical purposes, “you say tomato, I say tomahto.” No matter what justification is used for choosing the points, they are the same points, and the needling technique can be identical, depending on the style of acupuncture. So why choose one over the other? 

Why choose acupuncture over dry needling?

Acupuncturists have been exploring the use of our “dry needles” for over two millennia of recorded history. Hence, the theories and techniques have had a much longer time to develop. Acupuncture, through its theories of precisely stimulating and moving the qi or energy of the body (often now considered to be the neurological mechanism of acupuncture), encompasses much more than treating trigger points, or treating pain for that matter. Acupuncture has shown clinical results in everything from infertility to improving cardiac health. It’s well known for inducing deep relaxation and strongly affecting the autonomic nervous system. Acupuncture has even been used successfully in lieu of anaesthesia. 

Dry needling, on the other hand, is concerned with just needling trigger points, not how these relate to the entire body or health of the patient. It’s therefore a subset of acupuncture. The training of dry needlers reflects this. Typical education in dry needling is over the course of a few weekends, and practitioners can begin practicing immediately without any lengthly supervised internships. Acupuncturists spend three years or more practicing their technique and learning how to needle safely and effectively, including 1-2 years of supervised clinical internship. These are big differences! 

Why dry needling is everywhere

So why is dry needling so popular now? The main reason is that 1) it’s provided by practitioners that patients are already familiar with — usually PTs — from whom they may already be receiving care. It’s one-stop shopping for many patients. 2) It’s cheaper oftentimes — either because more insurance covers it, or because it’s a small add-on charge to other therapies. Because it’s limited and takes little training, it’s reimbursed by insurance for half or less of what acupuncture is paid for, acknowledging its relative scope. 

The low price of dry needling comes at a cost

This is not to say that dry needling is not good or worthwhile — as a simple form of acupuncture adapted to PT, it’s useful when it’s useful. But it also has some disadvantages. 1) Due to its skimpy training, the skill of the needler may be untested. No one would get surgery from someone who studied it over a few weekends, and yet here are needles (larger and thicker usually then what an acupuncturist would use for the same result) being weilded in your direction by weekend warriors. 2) Because PTs consider this a mechanical thing, i.e. just manually stimulating muscles, there is a tendency to want to use more force and a bigger needle because the practitioner isn’t looking to see if the whole system is engaged. Thinking about the intelligence of the whole system, and how to get the body to do more of the change on its own, leads acupuncturists to usually take a softer approach. We want the nervous system to be reeducated, the whole of the body to be repatterned, not just take control of one little part and hammer away until it changes. Sometimes you have to really bother a muscle, but often you can gently suggest a change and get the same or better result. 

Acupuncture can also change the function of parts of the body, including the musculoskeletal system, using distal points, points that may be on on opposite limb, or on the scalp or ear (distal points form the basis of Backupuncture). MRI and clinical studies have confirmed this effect. One recent Massachusetts General Hospital study in particular which looked at local, distal and sham (fake) acupuncture found the distal points had nearly the same efficacy as local needles for carpal tunnel syndrome, and both were superior to sham needling. This opens up the possibility of choosing points that can be more gently needled to create the needed effect, or are safer to needle, or are in areas that are less likely to get irritated. 

Reductive therapy versus whole health

In other words, acupuncture needles are acupuncture needles! And for pain they are used in remarkably similar places and in quite similar ways, no matter what kind of practitioner is using them. In other words, all acupuncture needles are dry! The main difference is the training, skill, and medical philosophy of the practitioner. Physical therapists are not “more medical” when they needle just because they describe it a certain way, and acupuncturists are not “more woo-woo” when they do the exact same thing and get same or better results on a myofascial trigger point because they call it an ah-shi point (pronounced "ahh-shure,” meaning “that’s the spot”) and call the needling technique “lifting and thrusting to disperse stagnant qi.” The language used by each is inscribed in a greater philosophy. PTs are specialists — they work on the musculoskeletal system only. So they don’t have the intent or training to contextualize their technique within its effects or appropriateness of, say, the patient’s issues with stress, anxiety, depression, or autonomic dysfunction, described in poetic language by Chinese physicians of yore as patterns of “Liver Qi Stagnation” or “Spleen Qi Deficiency” or “Liver and KIdney Yin Deficiency” or “Heart Fire.” These names do not bely wishful thinking, but are a way of organizing information within a system of interlocking patterns of disharmony crossing multiple organ systems and ruled over by an intelligent, always self-calibrating system of feedback loops whose goal is homeostasis — the self-maintenance of the status quo of health, however the body’s intelligence can understand it at a particular moment. Acupuncturists work to remind the body that its current state is not its only possible state of health. Often, we get pushed into a new normal of poorer health and neither consciously or unconsciously know how to get ourselves out of the hole. The body needs reminding, retraining, therapy. PTs do this too, but via the reductive and highly specialized medical landscape of modern biomedicine, especially in the United States. They are looking at the body as a collection of joints and muscles, with no intent to tie them together with the psychology, neurology, or immune system of the patient, because that’s not their training (typically, to be fair — there can be very holistic PTs on the fringes, and there can be very reductive acupuncturists, especially on the sports medicine end of the field).

This difference, between holism and reductionism, can be very pragmatic. When someone comes in with knee pain, I am not just sticking a bunch of needles into the knee. I examine the lower spine and pelvis, to make sure there is no asymmetry causing uneven weight distribution and altered gait, uneven stresses on the knees causing stresses in the knee joint. I’m looking at the ankles for the same reason. And I might not use a single needle in the knee! I might get the structure straight, then use needles in the opposite elbow while the patient moves their knee or walks around, using a map of the knee on the elbow (distal points) to find restrictions in the knee that reveal themselves in motion. You can’t walk with needles in your knee! Moreover, is there an internalized pattern of emotional stress or overactive autonomic nervous system reactivity contributing to these structural imbalances? Is the immune system overactive and causing too much inflammation? Is the structure compromised because of burnout or fatigue due to work or lifestyle or emotional exhaustion? All of these get examined in an acupuncture course of treatment.

This shows how this maybe flowery-sounding language of qi is not silly medieval Chinese superstition, but a system based on thousands of years of observation and painstaking progress unencumbered by our false, historically derived and arbitrary Western divisions between mind and body, and between organ systems, and between the intelligence of the nervous system and the body it is constantly maintaining. Our scientific community and medical systems have an intense bias against any knowledge not derived in the West, and especially the United States, and any ideas older than the 20th century, just on principle. Nevermind that agriculture and astronomy developed absent clinical trials or modern biology or physics and their instruments — we often simply can’t conceive that the ancient mind paid attention to anything or observed anything true that we haven’t figured out yet on our own. Now that our planet is in peril because we abandoned such ideas as “living in harmony with nature” as primitive superstition, perhaps these biases need a proper reexamination.

Perhaps we need to, maybe, balance our qi a little more. :-)