Needling and Spasticity: What's the Score?

As many of you will know, my specialisation and clinical background are focused on MSK and sleep. Along these lines, I have taught dry needling (DN), functional foot, anatomy and clinical reasoning courses for the past 30 years. During the DN courses, one of the most 'off-topic' questions I receive relates to the effectiveness of DN for spasticity. Even though I have a rural and remote practice and treat a wide range of conditions, neuro/post-stroke is just not one of them. My answer in the past has been that I don't have any clinical experience and have directed people to Val Hopwood's book Acupuncture in Neurological Conditions, 2010.

A confluence of inquiries and emails following my last course in Perth breathed life into the topic again, so I thought I would look at the recent literature, write a summary and see what level of interest this provoked from those interested and or more knowledgeable in this area. Here goes.

Spasticity is the most common complication after stroke and a main obstacle in the recovery of motor function. The presence of spasticity seriously affects the patient's quality of life and brings a heavy burden to families and society. Several therapeutic strategies (e.g., physiotherapy, oral spasmolytic, botulinum toxin injections) are used to treat post-stroke spasticity. There are reported downsides;

  • Physiotherapy, the limited effect and long-term treatment course may lead to poor compliance
  • Oral spasmolytic, not long-lasting, and prolonged use of these drugs may cause multiple side effects (e.g., hepatotoxicity and muscle weakness)
  • Botulinum toxin repeated injections may result in the formation of neutralising antibodies and attenuate the treatment efficacy.

Hence, there is a need for an effective and safe therapy for post-stroke spasticity.

Included are a selection of articles examining needling and spasticity; two clinical articles using randomised control trial (RCT) designs and three systematic reviews (SR) to guide clinicians in their treatment deliberations. 

The articles

Article 1. Fernández-de-Las-Peñas C, et al, 2021. Conducted an SR examining if DN is effective for the management of spasticity, pain, and motor function in stroke patients. An on-point question for sure!

They aimed to evaluate the effects of muscle DN alone or combined with other interventions on post-stroke spasticity (muscle tone), related pain, motor function, and pressure sensitivity.

They included seven studies (three within the lower extremity, four in the upper extremity) and found significantly large effect sizes of dry needling for reducing spasticity (-1.01, 95%CI-1.68 to -0.34), post-stroke pain (-1.01, 95%CI -1.73 to -0.30), and pressure pain sensitivity (1.21, 95% CI: 0.62 to 1.80) as compared with a comparative group at short-term follow-up.

The authors concluded there was moderate evidence to suggest a positive effect of DN on spasticity in the lower extremity in post-stroke patients in the short term, but none at four weeks.


Article 2. Nakhostin Ansari N, et al 2023 wanted to examine the effects of DN session frequency on wrist flexor spasticity and motor recovery after stroke. This single-blinded RCT is a practical example of considering a clinical situation and how many treatments are necessary for an effect.

Twenty-four patients were randomly and equally divided into two groups. One group received one session of DN, while the other group received three sessions of DN in one week. Both groups received one minute of DN of the flexor carpi radialis and flexor carpi ulnaris. The outcome measures were the modified Modified Ashworth Scale (MAS), passive resistance torque (PRT), wrist active and passive extension range of motion, and the Brunnstrom Stages of Stroke Recovery measured before, immediately after, and one week after the last DN session.

The authors concluded that "Administering three sessions of DN can effectively improve spasticity and motor function after stroke." What I can't understand is why they emphasised three sessions, when in the results they stated "both groups demonstrated a significant improvement in all outcomes (p < .05)". Why use three treatment sessions, when one was as effective?


Article 3. Sánchez-Mila Z, et al 2018 examined the effects of DN on post-stroke spasticity, motor function and stability limits. This RCT focused on the comparison between providing a Bobath guided treatment (e.g., strengthening, stretching and reconditioning exercises) or the same treatment in combination with a DN session of ultrasound-guided dry needle into tibialis posterior. A greater number of individuals receiving Bobath plus DN exhibited a decrease in spasticity after treatment (p<0.001). Patients receiving Bobath plus dry needling also exhibited greater improvements in their balance (0.8, 95% CI 0.2 to 1.4), sensory (1.7, 95% CI 0.7 to 2.7) and range of motion (3.2, 95% CI 2.0 to 4.4).

With access only to the abstract, I couldn't confirm the sequence of DN and Bobath in the session nor how or why the tibialis posterior was selected for DN. If anyone can provide the full article I would be most grateful.

The authors concluded, "The inclusion of deep DN into a treatment session following the Bobath concept was effective at decreasing spasticity and improving balance, range of motion and the accuracy of maintaining stability in patients who had experienced a stroke."


Article 4. Xue C, et al, 2022 also carried out an SR, examining the effectiveness and safety of acupuncture for post-stroke spasticity.

The authors deemed 88 studies eligible (i.e., 6,431 individuals) and pooled the data, finding that acupuncture combined with conventional rehabilitation (CR) was superior to CR alone in reducing the MAS. Acupuncture combined with CR on a daily or twice daily frequency significantly reduced MAS, but alternate-day sessions were not significant, and a total number of sessions 10 - 30, 30 - 60 and > 60 were all significant. These sessions were acupuncture-based treatment, not DN and authors noted the majority of included studies had a high risk of bias and results should be treated with caution.

The authors concluded that acupuncture could be recommended as adjuvant therapy for spasticity after stroke. However, due to the high risk of bias and heterogeneity of the included studies, the effectiveness of acupuncture for post-stroke spasticity remains to be confirmed.


Article 5. Yi Let al, 2024 examined the quality of evidence included in SRs around the topic of acupuncture for post-stroke spasticity. Ten SRs were included based on selection criteria. Of these eight were found to have critically low methodological qualities.

The authors concluded "Based on the evidence, acupuncture may be a promising complementary treatment to improve post-stroke spasticity and quality of life. Further high-quality RCTs are needed in future studies to support the broader application of acupuncture for the treatment of PSS."


My summary

As for most clinically based topics, "more research with better quality designs is required". No surprises there. However, there is enough evidence to recommend the trial use of one to three sessions of DN focused on specific muscles involved in spasticity. When combined with conventional Physiotherapy treatments such as Bobath, additional functional outcomes like balance and range of motion are improved. Likewise, the use of acupuncture for treating spasticity is promising, and again requires more, and higher quality studies to enable the pooling of data.