Thursday, May 8, 2014

Topics in Orthopedic Medicine Series: Part 1 - Dry Needling vs. Acupuncture

One of my clinical specializations is integrative orthopedic medicine. I utilize a variety of gentle, supportive therapiees from both Eastern & Western medicine to help patients recover from injury and to alleviate chronic musculo-skeletal pain conditions. Some techniques I use include:
  • acupuncture, 
  • dry-needling, 
  • various massage modalities, including tui na, Swedish and deep tissue,
  • physical therapy-based exercise and stretching techniques, and 
  • various soft-tissue mobilization techniques from orthopedic and osteopathic medicine. 
I'm excited to launch a series of blogposts exploring various topics in orthopedic medicine.

In this article, I introduce the therapeutic modalities of acupuncture and dry needling:

What is acupuncture?
What is dry needling?
What is the difference between the two?
How do they work?

First, a bit of politics:

Acupuncture & dry needling are currently hot topics in orthopedic medicine in the United States. Various state legislatures are discussing & enacting legislation regarding dry needling and the scopes of practice of physical therapists and medical doctors. Professional associations and lobbying groups are bandying about opinions about whether or not dry needling is acupuncture, whether the acupuncture profession has exclusive claims on dry needling therapy, etc. Needless to say, dry needling is becoming more popular as a therapeutic modality, and orthopedic physicians and physical therapists are taking increasing interest in the use of needles -- long the main therapeutic tool of acupuncturists -- to treat of pain and injury.

I'm not going to go any deeper into current political controversies regarding professional scopes of practice and the use of needles. Rather, I hope to simply introduce and compare the modalities of acupuncture & dry needling for the interest of my readers and patients.

So, what are acupuncture & dry needling? Is there a difference between them?

Acupuncture and dry-needling both involve the insertion of fine, filiform needles into points along the body. ("Filiform" means solid, as opposed to the hollow needles used in administering injections.) While the techniques of acupuncture and dry needling overlap, there are significant differences between the two therapies.

Most fundamentally, they are based on different theoretical frameworks:
  • Acupuncture needling is based on theories of Traditional Chinese Medicine (TCM) that have evolved in Asia over the last several thousand years. Acupuncture needles are generally inserted into points along a complex system of meridian pathways.
  • Dry needling, by contrast, is based on the western neuroanatomical conception of the body. Needles are inserted into specific muscle tissues, ligaments, tendons and periosteal regions where tendons and ligaments attach to bones.
Acupuncture is old; dry needling is (relatively) new:
  • In historical context, acupuncture has occupied a center-stage position in the traditional medical practices arising from East Asia, with evidence of the first therapeutic uses of acupuncture needles dating back four or five thousand years.
  • While dry needling therapy is reputed to have been used in western medical traditions dating back to Hippocrates, its place in western medicine has been marginal until recently. Neuro-anatomical concepts underlying dry needling techniques are arguably less than a couple hundred years old and still undergoing intensive clinical research.
Acupuncture generally approaches healing through a wider lens; dry needling uses a narrower focus. This difference accounts for some of the strengths and weaknesses of both therapies:
  • Western orthopedic medicine takes a disease-based approach -- so, dry needling tends to focus on treatment of a specific lesion or tissue injury. This approach typically does not take into account why this "failure" occurred.
  • Holistic medicine systems, by contrast, tend to take a systemic approach, focusing on the background against which the lesion/disease occurred. In TCM-based acupuncture, this background is the system of meridian pathways of the body. Neuromuscular problems, pain & injury, are evaluated as blockages of Qi and Blood of the meridian system. TCM practitioners generally address the background system, in addition to treatment of specific lesions.
This is not to say that dry needling performed by a practitioner trained in systems of medicine originating in the western world never considers the background against which specific lesions or injury occur. Skilled osteopaths, for example, have very nuanced understandings of degenerative processes and injury in the context of the balance of the body in space. Homeopathic medicine also considers illness and injury from a sophisticated holistic perspective. But these are beyond the scope of this article.
From a practitioner's perspective:
  • Dry-needling, by virtue of its specificity, requires an excellent working knowledge of neuroanatomical structures. To effectively treat an injury, a practitioner must have the orthopedic assessment and palpatory skills to hone in on the exact location of a lesion that is causing pain and/or dysfunction. That means determining, for example, exactly which muscle is in spasm or weak, which ligament is lax, or where on a tendon a micro-tear is located.
  • The expertise of the acupuncturist comes in part from his or her ability to make a holistic diagnosis, based in part on palpation of the patient's pulses and tissue qualities along meridian pathways, etc.
The integration of Chinese medicine and biomechanical/biomedical perspectives can increase our understanding of the causes of musculoskeletal pain and the efficacy of treatment. It is because of this that I often integrate Chinese medicine-based acupuncture and dry needling techniques in my work with patients.

For theories on why acupuncture works, please see my article "How It Works: The Science on Acupuncture & Pain Management."

For more on dry needling, please see Topics in Orthopedic Medicine Series: Part 2 -- How Dry Needling Works.

Most of the ideas in this article came from the text book authored by my teacher, Alon Marcus, OMD. Foundations for Integrative Musculoskeletal Medicine: An East-West Approach. Berkeley: North Atlantic Books, 2004.