Dry Needling and Acupuncture

Ray Ford -Dr of Chinese Medicine

In this short article I will outline Dry Needling, -its history, how it works and compare it to acupuncture therapy. There has been some fierce debate taking place in the last decade regarding the similarities and differences between the two modalities regarding scope of practice. Some states in the US such as California, New York, Hawaii and Oregon havebanned dry needling unless performed by a licenced acupuncturist.

Dr. Janet Travell- the pioneer of dry needling

Dr. Janet Travell (1901-1997) was an esteemed American physician and researcher recognised for her contributions to myofascial pain management. The technique that she refined involves the precise insertion of hypodermic needles into reactive points within muscles.Initially, Dr. Travell used a hypodermic needle to inject pain-killing medication into these points, although she later transitioned to using hypodermic needles alone, without any medication, coining the term “dry needling’ to describe her approach.  Dr. Travell’s mastery of this technique, coupled with her profound understanding of anatomy, revolutionised treatment strategies for myofascial pain by leveraging the body’s innate healing potential instead of relying solely on medication.

Throughout her illustrious career, Dr. Travell authored over 100 scientific papers and co-authored two popular manuals with David Simons which detailed her innovative approach to diagnosing and treating muscular pain and their referral patterns. As a result of her pioneering research, the terms “dry needling” and “trigger points” have become well-known terms and widely adopted in the field of myofascial pain therapy.

Janet Travell was born in New York in 1901, the daughter of respected MD Willard Travell and her highly creative Mother -Janet Davidson who fostered a creative and artistic home environment. In her autobiography “Office Hours Day and Night’ Janet Travell described her early years as blessed and happy, describing how she experienced a wonderful and interesting life. She emphasized the love, safety, and inspiration she felt in her home growing up and how these factors were important in her future development. Willard Travell-her father, was well- known for his experimentation with alternative methods of pain relief often utilizing physical medicine and X-ray therapy. His profound curiosity and experimentation with these methods for the treatment of myofascial pain had a significant influence on both of his daughters who followed in his footsteps. They both became MD’s. Janet stated that she learnt the value of time and the importance of focused concentration from the influence of her father.

Janet Travell attended Cornell University Medical College in New York City and graduated at the top of her class in 1926. Alongside her academic success, she also excelled in collegiate tennis, winning many trophies in singles and doubles with her sister Ginny.Later, she interned at the Cornell Medical Division of the New York Hospital from January 1927 to December 1928, being the only female doctor on staff. Dr. Travell exhibited genuine care for her patients, leaving no stone unturned in helping them regain their health. Her curiosity and determination were evident from an early age.

Initially specializing in cardiology, Dr. Travell became involved in a collaborative research project studying the effectiveness of the drug digitalis in treating lobar pneumonia. Her interests in pharmacology, cardiology, and patient care converged during this study. In recognition of her contributions to the study, she was awarded an instructorship at the Cornell University Medical College, where she remained for 30 years, achieving the rank of associate professor of pharmacology in 1952.

Dr. Travell eventually transitioned from cardiology to orthopaedic medicine, where she focused on relieving musculoskeletal pain- that she often observed in her patients with cardiac and pulmonary conditions. Eventually, this led her to develop treatment protocols using hypodermic needles to inject anaesthetic into acutely sensitive areas in muscles which were known as trigger points. Dr. Travell found that most people have trigger points- she thought that the more sporting a person is -the more likely they will experience active trigger points at some point in their lives. Trigger points can be differentiated into latent and active points, when they are latent- they do not cause tight bands nor very hot sensitive spots. Active trigger points however create muscular pain and dysfunction that were often relieved by Dr. Travell’s techniques.

In an interview with Dr. Larry White (the interview can be found on-line), Dr Travell discussed a personal experience that made her think deeply about muscular pain. Whilst she was in medical school and later interning at the New York Hospital, she experienced a very painful shoulder. Upon examination, nothing significant was revealed, however she couldn’t lie comfortably on her right side at all. Upon pressing around in the shoulder area, she found a spot she could just reach. It was very sore and when the point was pressed it reproduced the pain down her arm. It was a trigger point in the infraspinatus muscle, out of curiosity she began studying it. It didn’t match any known pain pattern of nerve root, segmental distribution or that of any peripheral nerve; she concluded that it was an independent pattern.

When she later examined patients with shoulder pain it was found that this was the most common source of their pain. Dr. Travell found that relieving these painful trigger points often alleviated her patients’ symptoms. Her treatments involved injecting local anaesthetics into painful points within muscles, followed by the application of cooling spray, stretching, and manual therapy. Eventually, she began experimenting with using hypodermic needles without injecting any substances at all, which is how the term Dry Needling came into being.

At that time the common understanding of muscular pain was that it had to follow a segmental pattern. Constant observation and research revealed that these trigger point and referral patterns do not follow the previously predicted segmental patterns. It is interesting to note that when these findings were presented by Dr.Travell to a major Conference for Neurologists- her data was widely accepted -to her surprise! The therapeutic treatment and research that she pioneered became her life’s work.

Interestingly, Dr. Travell was just one of three clinicians, alongside Michael Gutstein in Germany and Michael Kelly in Australia, independently publishing papers about myofascial pain and its treatment in English. They all identified myofascial trigger points and highlighted their importance as a root cause in pain syndromes. However, they were not aware of each other’s work at the time, and their shared observations went unnoticed for decades. Among the three pioneers, Dr. Travell’s influence endured and stood the test of time possibly due to her international fame.

Dr. Travell’s success in alleviating muscular pain- led many people who were suffering intractable pain, to beat a path to the door of her practice in New York. Her most famous patient being then Senator-John F. Kennedy, who she assisted significantly with his excruciating back pain. Later, she gained national and international attention in 1961 when JF Kennedy who became President, appointed Dr. Travell to the position of White House Physician, making her the first female Physician in the White House. After leaving the White House Dr. Travell spent the next 30 years researching, writing and teaching her methods of myofascial pain management. Her contribution to the field of myofascial pain over 60 years, culminated in the publishing of two important myofascial pain and dysfunction manuals, co-authored with David Simons.

The current practice of Dry Needling

The application of Dry Needling has evolved from the early days with Dr Travell- when hypodermic needles were used- to today where filiform acupuncture needles are the most common type of needle used. These thinner needles, with a guide tube for painless insertion, are now the preferred choice for Dry-needling practitioners, because hypodermic needles are much thicker and can be extremely painful.
Janet Travell’s research demonstrated that Dry needling is based on Western anatomical and neurophysiological principles. The primary objective of dry needling is to deactivate trigger points, which are often associated with the development of muscular pain and dysfunction.

The procedure involves the insertion of a needle into the targeted muscle or tissue, aiming to elicit a local twitch response (LTR). The LTR is a brief involuntary muscle contraction that occurs in response to a needle stimulus. This response helps release tension and promote healing by increasing blood flow and oxygenation to the affected area. Dry needling is generally considered safe when performed by a trained healthcare professional. However, like any medical procedure, there may be potential side effects, including temporary soreness, slight bleeding, bruising, or infection at the needle insertion site. Dry needling is now practised worldwide by massage therapists, chiropractors, osteopaths, physiotherapists, and podiatrists due to its low-tech, cost-effective treatment of muscular pain and dysfunction.

Acupuncture-History

Acupuncture, a cornerstone of Chinese Medicine has a legacy spanning over two thousand years. It is deeply intertwined with the historical, philosophical, and cultural fabric of China. The longevity of acupuncture stands as a testament to the enduring wisdom of ancient healing traditions. In the 21st Century, acupuncture offers a low cost, simple, effective, holistic approach to health and wellness. It resonates with people worldwide who seek alternative and complementary therapies to help with pain and dysfunction.

The origins of Acupuncture can be traced back to the Shang Dynasty (circa 1600–1046 BCE), where Shamanistic healing practices, including the use of divination, stone needles and bone tools, laid the groundwork for what would later evolve into acupuncture.
The deeper philosophical underpinnings of acupuncture began to take shape during the subsequent Zhou Dynasty (1046–256 BCE), where systematic correspondence, Five Phase and Yin /Yang theory were developed as a framework for understanding the body’s interconnectedness with the universe.

Chinese Medical knowledge reached a high point, a Renaissance- in the Han Dynasty (206 BC- 220 AD). In this period a major medical work emerged known as the Nei Jing, which incorporated a text called the Ling Shu-a treatise on acupuncture. The work is still revered today, studied widely by Scholars and utilized by practitioners of Chinese Medicine and known collectively as “the Classics.”

They provide guidance for practitioners to follow and dive deeply into a world view held by the Han Chinese practitioners 2000 years ago-a world view still relevant today. The Nei Jing gives lifestyle advice as well as knowledge of how to treat illness and live in harmony with environmental, emotional and cosmological influences. Simple examples that are explained are; the five flavours and the influence they have to harmonise internal organs that are imbalanced. There are explanations of why long- held emotional states can damage particular organs and how acupuncture points on channel pathways can regulate blood and qi flow thereby regulating the whole system.

Acupuncture theory views the body as a dynamic system of veins, arteries, fluid, connective tissue and muscles, known collectively as vessels  through which blood and a vapour -essence, known as Qi-flows (in the west the word Meridian is often used instead or Vessel or Channel). According to Chinese Medical theory, health is achieved when Qi and Blood flow freely and harmoniously throughout the body.

Acupuncture is not solely based on the acupuncture points and the channels of Chinese medicine. The training (Batchelor level University degree) encompasses the surface and underlying anatomy of acupuncture points and covers the importance of anatomical knowledge for safe, effective treatment. Acupuncture is a legitimate therapy for the diagnosis and treatment of pain, -it excels in the treatment of general pain and myofascial pain in particular.

Scientific investigation has shown that acupuncture stimulates the release of endorphins, neurotransmitters, and neuropeptides, which play crucial roles in pain modulation, stress reduction, and immune function. Additionally, acupuncture influences the autonomic nervous system, promoting relaxation and healing. Thus acupuncture has gained recognition, acceptance and increasing popularity worldwide, due to its efficacy and affordability for the treatment of a wide range of conditions.

The debate between dry needling and acupuncture practitioners 

As I have previously mentioned -dry needling, rooted in Western medical principles, involves the insertion of fine needles into trigger points within muscles, aiming to alleviate pain, improve range of motion, and enhance musculoskeletal function. Advocates argue for its efficacy in targeting specific muscle knots and tension areas, particularly in conditions like myofascial pain syndrome and sports injuries.

On the other hand, acupuncture finds its roots in Chinese Medicine which views health as the harmonious flow of qi and blood along meridians/channels in the body. Proponents of acupuncture highlight its holistic approach and potential benefits beyond musculoskeletal issues, for example- stress reduction and immune system enhancement.

Critics of dry needling often raise concerns about its scientific foundation and potential risks, including puncturing organs or nerves if performed improperly. One of the main complaints regarding Dry Needling is the lack of uniform training or regulating bodies. Dry needling training courses can be completed over only two days. Critics believe this is simply not enough training whereas physiotherapists for example state that since they know the muscular anatomy of the body extensively-they do not need to take long drawn-out courses.

Similarly, sceptics of acupuncture point to the lack of robust empirical evidence supporting its mechanisms and efficacy, attributing its perceived benefits to placebo effects. The ongoing debate underscores the clash between Western biomedical perspectives and holistic Eastern healing traditions, reflecting broader discussions that are needed within the healthcare community.
Acupuncturists argue that dry needling is a form of acupuncture since acupuncture needles are used as a replacement for the original hypodermic needles. Exponents of Dry Needling claim it is a technique rooted in biomedical sciences and therefore has nothing to do with acupuncture nor its theories.

There is ongoing discussion and disagreement about whether trigger points align with acupuncture points or channels, nevertheless, research has shown significant consistency between the two systems, suggesting a physiological connection.
Finally, both styles of treatment are pointers to the fact that myofascial pain and dysfunction can be significantly helped or relieved with the use of skilfully applied needles.

Many people have been helped by both systems of treatment and ultimately it will be the public themselves who decide on the type of treatment they want to receive.