Needling; Research, Safety and Clinical Benefits
Acupuncture and dry needling have received much examination on the dual fronts of safety and lack of evidence. The former has largely been answered in the past two decades, with reports noting that in the hands of an adequately trained and competent practitioner, the incident of a severe adverse event (requiring hospitalisation) is very low and that minor adverse events range between 7-10% (Haake et al., 2007; Macpherson, Scullion, Thomas, & Walters, 2004; White, 2006). Training, including a high degree of anatomical knowledge remain critical.
The quality of acupuncture and dry needling research has continued to improve over the past 20 years. Initially reportings were dominated with case studies and anecdotal discussions. Research is now including more exacting methods like systematic reviews and randomised controlled studies. However, this is not without significant challenge. In drug research it is easy to supply a patient population with a same coloured pill to achieve a randomisation effect, annulling, selection and a range of other bias. In acupuncture research, participants are hard to fool when it comes to knowing whether they have or have not received the insertion of a needle.
So, in needling research, in addition to a normal control group (receiving standard care), there also needs to be a sham acupuncture group, in which a needle like substitute is used replicate the needling experience. Methods used include a Streitberger or Park sham needles (needle retracts into the shaft), tooth pick pressure, needling of 'non-related' sites and using naïve needle participants. Practically, this means recruiting three groups of adequate size to enable useful statistical findings. Recruitment is the hardest aspect of research and big pharma is not interested, so funding is non-existent. These challenges increase the level of difficult when it comes to generating high quality acupuncture research.
A criticism of acupuncture research is the lack of significant difference between the sham and verum groups, take cLBP for example. Three papers found that sham and verum acupuncture provided significant relief compared to participants in the control group (Brinkhaus et al., 2006; Haake et al., 2003; Mendelson et al., 1983) but no significant difference between sham and verum acupuncture, for short and intermediate term pain relief and functional improvement (n = 298, n = 1162 & n=190, respectively). The first two groups of researchers used superficial needle insertion at non-acupuncture points and the latter group used superficial needle insertion with lignocaine 2% at non-acupuncture points as the sham acupuncture.
This lack of a difference between sham and verum acupuncture, raises a research debate about how appropriate controls can be chosen and also a clinical debate, does it matter where needles are placed? Researchers will have to continue to examine the effect of sham alternatives, but the clinician in me thinks so what. My goal is to achieve greater health and functional outcomes in my clients. If I can harness client placebo effects through demonstration of knowledge, appropriate Q & A and activating beneficial chemical pathways, then I am in. A recent animal study confirmed that the endogenous opioid system is one such pathway triggered by distal needling (Hsieh, Hong, Liu, Chou, & Yang, 2016) confirming that needling away from painful areas still stimulates non-specific pain modulating pathways. I will continue to use clinical reason and be as accurate in my needling for safety reasons as possible. If I am not 100% accurate on the trigger point (ashi point) or I am stimulating distal areas, dry needling is still a useful tool and has been shown to have positive clinical outcomes (Chou et al., 2011).
Brinkhaus, B., Witt, C., Jena, S., Linde, K., Streng, A., Wagenpfeil, S., . . . Willich, S. (2006). Acupuncture in patients with chronic low back pain: a randomized controlled trial. Archives of Internal Medicine, 166(4), 450-457.
Chou, L., Hsieh, Y., Chen, H., Hong, C., Kao, M., & Han, T. (2011). Remote therapeutic effectiveness of acupuncture in treating myofascial trigger point of the upper trapezius muscle. American Journal of Physical Medicine & Rehabilitation, 90(12), 1036-1049.
Haake, M., Muller, H.-H., Schade-Brittinger, C., Prinz, H., Basler, H.-D., Streitberger, K., . . . Molsberger, A. (2003). The German Multicenter, Randomized, Partially Blinded, Chronic Low-Back Pain: A Preliminary Report on the Prospective Trial of Acupuncture for Rationale and Design of the Trial. The Journal of Alternative and Complementary Medicine, 9(5), 763-770. doi:10.1089/107555303322524616
Haake, M., Müller, H., Schade-Brittinger, C., Basler, H., Schäfer, H., Maier, C., . . . Molsberger, A. (2007). German Acupuncture Trials (GERAC) for chronic low back pain: randomized, multicenter, blinded, parallel-group trial with 3 groups. Archives of Internal Medicine, 167(17), 1892-1898.
Hsieh, Y., Hong, C., Liu, S., Chou, L., & Yang, C. (2016). Acupuncture at distant myofascial trigger spots enhances endogenous opioids in rabbits: A possible mechanism for managing myofascial pain. Acupuncture in Medicine, 34(4), 302-309.
Macpherson, H., Scullion, A., Thomas, K. J., & Walters, S. (2004). Patient reports of adverse events associated with acupuncture treatment: a prospective national survey. Qual Saf Health Care, 13(5), 349-355. doi:13/5/349 [pii]
Mendelson, G., Selwood, T., Kranz, H., Loh, T., Kidson, M., & Scott, D. (1983). Acupuncture treatment of chronic back pain: A double-blind placebo-controlled trial. The American Journal of Medicine, 74(1), 49-55.
White, A. (2006). The safety of acupuncture -- evidence from the UK. Acupuncture in Medicine, 24, 53-57.