The remarkably unlikely rise of dry needling

Before we get to this month's topic of dry needling, I just want to tell you about a hot new treatment that is poking its head up in my part of the world. This is a new treatment designed primarily for spinal pain. Although it's been around for a while, it seems to be really catching fire. In my city of about 1 million people, there's literally only three clinicians doing the treatment right now. And there's almost no evidence for it other than some very preliminary studies suggesting it has some efficacy for back pain. There are zero studies comparing it to standard treatments for back pain. In fact, unlike manual therapy and exercise, this new treatment actually carries with it some significant risks of adverse events.

It's a risky treatment, and there's no evidence that it works better than standard care. Actually, I can tell you for a fact that in the next 20 years, there will still be very little research suggesting that it is more effective than standard care.

Well, guess what. It happens to be the year 2000 and I just described to you a treatment called intramuscular stimulation.

How did IMS become so popular?

Twenty five years ago almost no physiotherapists performed dry needling. Now, doesn't it seem like every physio does? Why is that? Needling is ubiquitious, it's everywhere but has it actually improved the patient experience? Are we in an era where needling is a mandatory skill that all physios must become certified in? Has it become the basic standard of care?

Getting in trouble over needles

In December 2025 a physiotherapist in Alberta was ordered to pay a fine of up to $8,500 and was issued a reprimand from her college for unprofessional conduct. She also had her practice permit suspended for 30 days and was ordered to write a 1200 word essay on safety in practice. What was her unprofessional conduct?

She put needles in a patient and then left the clinic, asking a non-physio staff member to take them out later. One needle was missed. And when the patient called to let the physio know, she didn't record the conversation or chart it as an adverse event. In fact she even failed to chart the visit completely. She only remembered to do so when she became aware of the event.

When you look at the disciplinary decisions for physio Colleges in Canada you see a trend. Sadly, the most common category of professional discipline is for sexual misconduct - accounting for upwards of 2/3 of all cases. Then along with charting, billing and insurance violations the one other key category that shows up is adverse events to needling. Twelve percent of published disciplinary findings in Alberta, 10% in BC. And interestingly enough there are no recorded disciplinary decisions regarding the provision of manual therapy or of exercise and only one decision against a physiotherapist regarding the inappropriate provision of educational advice.

This begs the question; if needling adverse events make up a sizable portion of College complaints, should clinicians do a better job of applying safer treatment methods first before advancing to dry needling? What if you had a practice that didn't include needling at all? You would cut out a major source of worry about adverse events, disciplinary hearings, fines and 1200 word essays. But some would argue that your practice would be, although less risky, less effective as well.

In order to try to answer that argument I talked to Cory Choma, a clinical specialist in pain science, and a dry needling instructor with 30 years of clinical experience. You can hear his comments on the podcast version of this blog.

One trick ponies and one-tool Toms.

When I worked for a large hosptial system decades ago we weren't allowed to fix any broken equipment because that was the role for the maintenance team. That was their union-protected job and even if a single nut fell off of a bolt, even if just a few twists of the finger could put it back on we were not to be tempted. Instead, we would fill out a requisition for maintenance and wait for One-Tool Tom.

That's what we called him, because at first he would show up with the requisition but no tools, and he would inspect the problem. Even if the request specifically said "please replace the nut on the bike seat", One-Tool Tom would first do an inspection and then head back to his den of equipment and some vague time later he'd arrive with one tool - usually a wrench. And if that wrench wasn't quite the right one, he'd disappear again for hours. It was an awesome display of institutional, union-protected incompetence. One-Tool Tom.

I know some physios a bit like Tom. They seem to bring one tool to the party - their needles. "Let's try some needling." No matter what, they're going to start with needles. The question they ask themselves is not "what's the best treatment in this case," but rather "which muscle will I needle"?

"Let's try some orthotics"

There's a principle in the bioethics healthcare world. It's called "non-maleficence". Essentially it's an imperative for us to weigh the benefits of a therapy against the burdens or harms. It's part of a hierarchy of benificence - where we start by considering safety and we end with considering efficacy. Now I've been following the needling evolution for nearly 25 years and I'm starting to wonder if we are making a collective mistake here.

Here's an example: A patient presents with myofascial neck pain due to sedentary postures for prolonged hours over many years. We all see these folks. If they just took more breaks during the day or did some Japanese Radio Taiso in the morning, or Tai Chi at lunch they'd feel much better, but they come to us hoping we have a cure.

So one physio comes along and says "Let's try some needling." And the patient has heard of needling and their friend had it and without any other information than that, they agree. And they sign the consent form which lists the adverse events than can occur but they trust the physio. And in the end they feel better after a number of sessions and nothing bad happens. Is that a win?

Not according to the bioethicists. Because the research tells us that there is another approach to treating this patient that is rather effective without the same risks. Manual therapy and exercise is well-established as an effective treatment for mechanical neck pain. And mobilizing the neck with your hands and teaching a series of movement-based exercises to be done regularly does not carry the risk of pneumothorax or infection the way needling does.

So in order to say to your patient, hey, "let's try some needling" you have to make a decision for them. You have to decide that the risk of lung puncture is reasonable because, for example, they have already tried manual therapy and exercise and it failed or because needling is quite a bit more effective than manual therapy and exericse. Except there is no research to suggest that it is. We don't actually know if needling is more effective.

Can you imagine telling a patient, "hey, you've got pain in your feet. Let's not bother examining you to find out what's actually going on. Let's just try some orthotics?" That's what a technician or a salesperson would do. And your 6+ years of university education tells the public that you are more than just a technician.

Start with what works

Perhaps your patient has tried manual therapy and exercise already. Maybe they've been to the chiropractor, or kinesiologist, maybe they've already been to another physio and this approach did not work so now you're justified in offering needling. But what if you offer needling as the first line treatment for neck pain and you don't explain that there is a safer treatment? I think that's ethically wrong.

Our Colleges tells us that when we offer to needle a patient and we explain to them the risks of bleeding, infection, lung puncture etc, it's imperative that we also let them know that there are other treatments that may work just as well but carry less risks. Perhaps we need to practice our consent conversation like this: here are some treatment options, some have higher risks than others; do you have a preference?

I'll to you, having been involved in numerous College discinplinary hearings, here's how it going to go. Your patient has a pneumothorax and files a complaint. The College will ask you if you got consent for needling for your patient and you will refer to the standard consent form that they signed, although if the patient signed that consent form at the front desk before they even saw you, the College will consider that non-consent. And the College will ask you, whether, in your consent discussion you advise them of the specific risks and the alternative therapies that they could choose instead. And if you don't have that documented you're going to have to remember, or assert that yes, you did offer them manual therapy and exercise and they declined. And in that case, the college might decide that you did everything right and you did not breach the standards of practice and that in fact the pneumothorax was a risk of treatment that the patient accepted and there's truly little fault involved.

I wonder how many people who provide needling have that discussion with their patient and document it. Because if you don't that's a huge liability in your practice.

Choosing a style of practice that is informed by the literature

Are you starting your career with your graduate degree and feeling that you're already behind in the clinical world because you don't yet needle? You've got 6 or more years of heavy academic indoctrination in your brain; you know how to evaluate the research. Ask yourself, what is the state of evidence on needling? It's a riskier treatment all around. Every time you go below the dermis you introduce a risk of infection and unnecessary bleeding, never mind all the regional risks near the thorax, the spine, the major blood vessels and nerves.

Why are we doing this? Well, because it works, that's why. Needling is effective. It helps many patients. It's remarkably precise. It's unmistakably interactive - no patient walks away without feeling a therapeutic effect, one way or the other. But we have to acknowledge that there are many cases where your assessment will indicate to you that needling is not the appropriate therapy. Just because someone has muscle pain does not automatically indicate needling. You can hear what Cory Choma had to say about this issue on the podcast.

Needling actually shows up on the most recent WHO guidelines for the management of low back pain, published in 2023. That list includes 4 key physical interventions that are recommended - exercise, manual therapy, massage and needling. And interestingly, the list of treatments that are recommended against includes ultrasound, TENS and traction.

We need to approach clinical practice guidelines carefully because they are very broad, wide-reaching and founded on population-based reserach. It's easy for guidelines to miss things that are effective but haven't been proven yet. And in this way the WHO guidelines are actually quite helpful. They highlight the key recommendations as being education of some sort - let's further define that to mean that we are trying to reframe unhelpful thoughts that a patient has about their condition; and then the 3 big physical interventions; exercise, manual therapy / massage, and needling.

I sat in a course with one of the pre-eminent researchers on neuropathic pain and central sensitization in the spine and listened as the physiatrist and researcher Dr. Jay Shah reminded us that we can treat the sensitized portions of the spine with a number of modalities - not just needles.

A physiotherapist does not need to provide dry needling in order to provide highly effective care for musculoskeletal conditions. We do need to have a number of hands-on manual therapy skills that are actually quite easily learned. And we do need to have a real expertise in movement assessment and exercise prescription for the spine - far beyond neck stretching and cat-cow yoga, and certainly way beyond the McGill Three. We need to really understand the stabilizing function of the thorax and how to enhance it with resistance training, and we need to be able to assess the motor control, strength and endurance of the cervical spine and prescribe really boring neck exercises that work really well.

Standard care: are we skipping over the basics?

We definitely need some precise palpation skills and the ability to provide manual trigger point release with our hands, because long before needles we knew how to de-activate a trigger point with finger pressure. In fact, Cory Choma talks about the fundamental textbook called Myofascial Pain & Dysfunction, written by the physicians Janet Travell and David Simons. This is the fundamental text that we relied on to treat myofascial pain before we had needles. It's still relevant today. Cory's comments can be heard on the podcast.

In my practice I've chosen to continue to treat trigger points with manual palpation and massage without adding needling and all it's extra costs, precautions and risks. I'm fortunate to have hands that can handle this - my joints have held up just fine over 30 years. And perhaps that's a reason for some clinicians to adopt needling in their practice. We must get our hands on painful taut bands within muscles and provide treatment to them, and if your hands can't tolerate trigger point massage, then dry needling is an option. But that still doesn't negate the consent discussion you need to have regarding less risky treatments.

So keep in mind that you might be choosing needling because it's easier on you, not necessarily because it's more effective for the patient. And keep in mind also that there are some things you can do with your hands that you just can't with a needle; picking up the scalene muscles off the vertebral bodies and following the bands right down to the base of the posterior triangle; or getting deep into the centre of the deep sternal portion of SCM; and certainly there are no regions of the cervical paraspinals muscles that are off limits or dangerous to palpate with your hands.

Needling or manual therapy. Both come after the basics:

Our key intervention with patients is to interact with their nervous system. And we have to remember to start with the shortest route to their CNS, that there's no quicker route than through the eyes and the ears which are literally centimetres away from the brain. What we say and what we show them on our walls and on their scans; this is the most important thing.

So we then have to know how to motivate patients and communicate with them so that they trust us when we tell them that their headache, or chronic whiplash or postural neck pain symptoms are going to settle or go away completely if they understand the plan and follow it - this takes great connection skills.

We have to really connect with a patient to help them adopt the habits they're going to need to get better under our care. This may take needle-like precision in our listening skills and then our treatment planning, but it does not necessarily take needles.

Needles, if necessary, but not necessarily needles.

Do you know that's a play on a famous quote by Canadian Prime Minister Mackenzie King? He said during the war years "conscription if necessary, but not necessarily conscription."

I wonder if the needling version of this should be the sign on the wall above the door as we leave our staff rooms and head out into the clinic each day.

Needling is ubiquitous in the physiotherapy world. It's a painful treatment that carries with a higher risk than other treatments and yet it's everywhere and patients demand it. Twenty five years ago it would have been hard to predict that we'd end up here. And just because, as a young physio you see it being used by all your mentors, does not mean that you need to adopt needling in your practice. There are multiple ways to interact with our patients' nervous systems. Personally, I've been happily doing this without needles for 30 years.

That's it for today. Consider this all food for thought, and whatever you decide, get back out there each day and do what you can to help hurting humans.

*NOTE: No AI is used in the production of this blog. Just my brain, and my fingers.