In 1992 when I was studying a post-graduate manual therapy course at Curtin University, Perth, the educational emphasis was primarily on joints and neural tissue, with an early smattering of pain science. Whilst assessing a patient during one clinical session, no tests related to any of the education provided were positive. All I could find that replicated the patient’s pain was a palpable, tender lump in a muscle. Upon conferring with the course leader/tutor he shrugged and suggested that I press and hold the painful lump.
I don’t recall the outcome, but it triggered an interest in muscles as a source of pain. Subsequently acupressure became an option in my treatment tools. Whereas soft tissue massage was generally looked down upon by the manual therapists of the day, I became a regular user.
In 1994 whilst working in a private practice in Harare, Zimbabwe my employer introduced me to dry needling. There was no formal training to be had at the time, so with rudimentary knowledge of technique I started dry needling. Conscious of my ignorance, later that year when working in the United Kingdom, I purchased Peter Baldry’s 1989 book Acupuncture, Trigger Points and Musculoskeletal Pain, and started practicing on the patients of the National Health Service.
Upon return to Western Australia, the antiquated legislation of the time precluded physiotherapists from piercing the skin. Knowing that I was breaking that law, I felt a relevant qualification might mitigate the severity of any likely prosecution. With the primary objective of learning safety I completed a Traditional Chinese Medicine Acupuncture course designed for and taught by Medical Practitioners in 1995. My primary interest was in pain relief rather than Traditional Chinese Medicine, but the course was all that was available.
As I practiced, I corresponded with Peter Baldry and experimented with combinations of Traditional Chinese Medicine theory and Trigger Point theory. I studied Chan Gunn’s The Gunn Approach to the Treatment of Chronic pain and experimented with his intramuscular stimulation technique but found it to be no more effective and very brutal for the patient. The two volumes of Travell and Simon’s Myofascial Pain and Dysfunction were a significant investment, but they provided excellent anatomical and physiological advice that improved my knowledge of the individual muscles commonly affected. I still refer to them today.
Overall good results with patients triggered interest from colleagues, so upon request I began teaching other physiotherapists in 1997. The timing coincided with a change to the legislation in Western Australia no longer preventing physiotherapists from piercing the skin.
The course was based primarily on the work of Travell and Simons primarily for assessment, and Baldry’s superficial dry needling technique and Hong’s local twitch response for the needling treatment. The course was originally a day and half in length, but international standards for physiotherapists were later developed requiring 16 hours of instruction, so it was necessarily extended as I was, by this stage, teaching on behalf of the Australian Physiotherapy Association.
The practical component of the course covered forty of the most commonly affected muscles in the body. Over the two-day period the needling risk levels increased as the students became more confident and proficient; starting at the gastrocnemius and progressing upward to the thorax, finally culminating in needling the omohyoid muscle in the throat.
From 2000 dry needling became almost a necessary pre-requisite of employment in private practice and over the next twenty plus years I taught more than a thousand physiotherapists in Australia and Brazil. A component of the course included the history of dry needling and this is best summarised by the work of Legge (2014) below:
A History of Dry Needling
Pain arising from palpable nodules in muscles is well recognised in the early scientific literature, although a multitude of terms used in the 18th and 19th centuries reflected a lack of coherent understanding. The credit for getting on the right track is usually given to John Kellgren who was working in University College Hospital, London, under the supervision of Sir Thomas Lewis in the 1930s. Amongst a number of conclusions, two key determinations were that some pain could be relieved by injecting procaine into acutely tender points in muscles, which were often at some distance from the site of the pain, and the relief obtained far outlasted the effects of the anaesthetic.
A poorly acknowledged paper by Brav and Sigmond published in the United States in 1941 made the claim that pain could be relieved by needling without the injection of any substance. Brav and Sigmond did not claim the observation as their own instead referring back to earliest descriptions of acupuncture.
The first mention of the term “dry needling” to describe needling without the injection of any substance was by Paulett in The Lancet in 1947. Paulett established that relief from pain in tender points in the low back could be obtained not only from the injection of procaine but also by injecting saline and “even dry needling”. In the United States, Janet Travell and Seymour Rinzler published a paper in 1952 on myofascial trigger points that included the brief statement that dry needling could be an effective method of treatment.
By the 1960s the concept of trigger points was established in the literature. Although dry needling had been suggested as a treatment, the usual treatment was still the injection of anaesthetic into the tender points.
In the 1970s, China began opening up to the world. There was a subsequent surge of interest in acupuncture, especially for its use for anaesthesia and the treatment of painful conditions.
Chan Gunn, A United States based physician became interested in acupuncture in 1974. He developed an approach to dry needling that combined features of acupuncture (types of needles and needle techniques) with neurological and tender point models.
In 1979 Karel Lewis of Czechoslovakia published a landmark paper called “The Needle Effect in the Relief of Myofascial Pain”. Amongst other findings he reported that acupuncture needles were safer and produced less bleeding and bruising than hypodermic type needles.
In 1989 Gunn published a manual of his system, the first manual of dry needling. In the same year, a UK physician Peter Baldry published ‘Acupuncture, Trigger Points and Musculoskeletal Pain’ in which he attempted to reconcile traditional Chinese acupuncture theory with trigger point theory. His second edition, released in 2001, contained more about the science of pain and myofascial trigger points. This change of emphasis was characteristic of the way dry needling was used by the turn of the century. Even though the use of acupuncture needles had become the norm, the theory and techniques that dry needling relied upon were very different to those used in acupuncture practice. Subsequently, dry needling had become more closely associated with the manual therapy professions rather than the acupuncture profession.
From 2000 there was a surge of interest in dry needling, both clinical and research. The increased interest has been worldwide and involved the medical, physiotherapy, chiropractic and osteopathic professions. The primary reasons for this include:
1. The accessibility of acupuncture needles over the more highly regulated hypodermic needles;
2. The short time required to learn the techniques safely;
3. The publication of excellent guides by Travel and Simons, Gunn, and Baldry;
4. Fairly robust science supporting and explaining dry needling; and
5. Excellent outcomes for patients and practitioners, albeit a bit hit and miss.
References
Legge, D. (2014). A history of dry needling. Journal of Musculoskeletal Pain, 22(3), 301-307.
