Background
Prior to participating in my clinical rotations, I had very little knowledge or experience related to dry needling. On my second clinical rotation, my clinical instructor introduced me to dry needling, allowed me to observe many patient needling sessions, and performed dry needling on me. While my clinical instructor and his patients agreed that dry needling was an effective tool to resolve musculoskeletal pain complaints, I wanted to further examine the research to determine if using dry needling can be considered evidence-based practice. I began this literature review and critical analysis while developing an inservice for my third clinical rotation, and while completing my Critically Appraised Topic in the summer and fall of 2021. My findings during these experiences inspired me to continue deepening my knowledge in this subject area, and ultimately to share my findings with my classmates through my capstone project.
Statement of Need
Individuals with myofascial trigger points present to physical therapy with several indications for treatment, including pain, reduced range of motion, and reduced function in affected areas. Trigger points affect numerous patients; epidemiological studies estimate that trigger points may be primary pain sources in 30-85% of patients that seek treatment for musculoskeletal pain.1 Physical therapists must treat trigger points and related impairments according to the principles of evidence-based practice, including considering best available evidence, clinician expertise, and patient preferences to guide interventions.2 It is essential that entry level clinicians are familiar with all available treatment options for trigger points to enable them to select appropriate interventions based on these tenets.
While trigger point dry needling is not considered an entry level skill, it is within the scope of practice of physical therapists in North Carolina, and is a commonly practiced treatment technique for trigger points that many students will be exposed to during clinical rotations.3,4 Furthermore, recent evidence suggests that dry needling performed by physical therapists is more effective than other therapies for reducing musculoskeletal pain, and equally effective for improving functional outcomes, in the short and long terms.5,6 Therefore, entry level students should at a minimum possess introductory knowledge of this treatment technique. Other DPT programs locally and across the nation provide such education to their entry level students. Students should additionally receive this education early in the DPT curriculum to best prepare them for clinical experiences.
Purpose
The purpose of this capstone project is to introduce students within the DPT first year class PHYT722: Selected PT Modalities Theory and Applications to the theory, evidence, and application of trigger point dry needling. This project will additionally provide DPT students excellent foundational knowledge should they choose to pursue continuing education and perform dry needling as beyond entry level clinicians. This project is not intended to instruct or certify students in dry needling. The development of this capstone project addresses the UNC DPT program mission of promoting exemplary physical therapist clinical practice, as it promotes comprehensive understanding of evidence-based practice in the treatment of trigger points.7
Products
Products for this capstone project include a Critically Appraised Topic examining the efficacy of dry needling in treating musculoskeletal conditions, as well as evidence tables and an evidence quick reference guide summarizing an updated literature review on the same topic. Other products, which were included as course materials in PHYT722 to supplement an existing lecture on myofascial trigger points, include a PowerPoint slide presentation with VoiceThread narration and an infographic handout. The PowerPoint slide presentation and VoiceThread narration provide students with background information on trigger points and dry needling, theories of the physiological effects of dry needling, research examining the efficacy of dry needling, and practical information related to application of dry needling in clinical practice including considerations for safety, scope of practice, and reimbursement concerns. All products are linked below.
Background and Application Evidence Table
Head, Neck, and Upper Extremity Evidence Table
Low Back and Lower Extremity Evidence Table
Multiple and Other Systems Evidence Table
Evidence Quick Reference Guide
Evaluation
I created and distributed a Qualtrics survey to students in PHYT722 to evaluate the quality and value of the PowerPoint slide presentation, VoiceThread narration, and infographic handout materials, as well as to provide suggestions for improvement and project refinement. 18 out of 30 (60%) students completed the survey. Key results are discussed, and complete results are available via the Qualtrics Survey Responses Link below.
Regarding the PowerPoint slide presentation, 100% of students indicated that included information complemented information already presented in PHYT722. This data suggests that PHYT722 is an appropriate course to include these materials. 100% of students also reported that the presentation was well organized, easy to read, and visually appealing, indicating that it acceptably addressed health literacy concerns.
Regarding the VoiceThread narration, 94.4% of students indicated that it enhanced the PowerPoint slide presentation. Students also overwhelmingly reported that the narration was provided in a clear manner (100%) and sustained their attention (94.4%), indicating that it acceptably addressed health literacy concerns and was valuable to the project as a whole.
Regarding the infographic handout, 94.4% of students indicated that they would use it in future clinical practice as a personal reference or for patient education. This data supports the clinical utility of the project materials. 100% of students also reported that the handout was easy to read and visually appealing, indicating that it acceptably addressed health literacy concerns.
After viewing all project materials:
- 94.4% of students agreed or strongly agreed that they could define trigger point dry needling in a manner consistent with definitions provided by physical therapy regulatory bodies.
- 88.9% of students agreed or strongly agreed that they could describe theories of the physiologic effects of trigger point dry needling using language appropriate for patient education.
- 94.4% of students agreed or strongly agreed that they could evaluate the effectiveness of trigger point dry needling in treating body structure and function impairments, activity limitations, and participation restrictions for specific health conditions based on presented research.
- 100% of students agreed or strongly agreed that they could accurately describe personal, professional, and legal scope of practice issues related to the implementation of trigger point dry needling, including safety concerns and certification requirements.
This data suggests that the project effectively increased student knowledge of dry needling. However, it may be appropriate to revise content related to the physiologic effects of dry needling in future iterations of this project to enhance student comprehension of this material, and improve student outcomes related to this objective.
Overall, 94.4% of students reported that introductory information about dry needling should be provided to entry level DPT students. Additionally, 100% of students indicated that this project appropriately provided such information. 94.4% of students rated this project as excellent. This data supports that this project has great value for entry level DPT students, and should be included in the program curriculum.
Self-Assessment
My personal learning objectives for this capstone project included learning more about the effectiveness of dry needling through timely completion of new literature reviews, developing my time management and communication skills by meeting self-directed project deadlines and facilitating dialogue with committee members, and developing my ability to instruct peers using appropriate, relevant, and engaging methods and materials. I believe I successfully met all of these objectives.
I completed comprehensive, new literature reviews over the course of one month. I reviewed 45, high-quality, recent articles for my capstone project, thereby evaluating the best evidence to reach my personal and professional conclusions about the effectiveness of dry needling.
In order to present my capstone materials concurrently with an existing lecture about trigger points in PHYT722 this semester, I had to work on an accelerated timeline. I demonstrated exceptional time management skills throughout project development to achieve this outcome. I consistently completed work ahead of schedule, and sought feedback from all committee members at multiple points during project development. I also accepted and incorporated constructive feedback from all parties.
The most challenging aspect of developing this project was ensuring that all products for students in PHYT722 were appropriate and engaging. With the exception of hosting one inservice, I had very limited experience in professional and peer education prior to completing this project. Based on student feedback, I believe I ended up creating high-quality and valuable products that will serve many future UNC DPT classes well.
Overall, I am very pleased with my efforts and outcomes related to this capstone project. I believe that completing this project not only helped me develop as an academic, but also as a professional.
Acknowledgements
To Jeff O’Laughlin, PT, DPT, thank you for sharing your time and expertise as my capstone advisor. Your attentiveness and feedback regarding my project were instrumental in providing me a good experience and developing the best materials possible.
To Michael Gross, PT, PhD, FAPTA, thank you for coordinating the capstone class this year and serving as my interim capstone advisor and committee member. Your willingness to help me develop this project and feedback along the way were much appreciated.
To Bria Dunn, PT, DPT, thank you for serving as my committee member and allowing me to share my capstone project with your class. Your openness and excitement about including this project in your class gave my project a sense of purpose.
To Patrick Schultze, PT, DPT, thank you for introducing me to dry needling in clinical practice. Your encouragement to seek out new knowledge and experiences sparked my interest in this topic, which has carried me through my final year in this program.
To the UNC DPT Class of 2024, thank you for viewing and being so responsive to my capstone project. Your feedback was critical to evaluate this project, and provided me a sense of accomplishment.
Sources
- Tough EA, White AR, Cummings TM, Richards SH, Campbell JL. Acupuncture and dry needling in the management of myofascial trigger point pain: a systematic review and meta-analysis of randomised controlled trials. Eur J Pain. 2009;13(1):3-10. doi:10.1016/j.ejpain.2008.02.006
- Components of Evidence-Based Practice | APTA. https://www.apta.org/patient-care/evidence-based-practice-resources/components-of-evidence-based-practice. Accessed January 12, 2022.
- Dry Needling State Laws | APTA. https://www.apta.org/patient-care/interventions/dry-needling/laws-by-state. Accessed September 16, 2021.
- Scope of Practice. https://www.ncptboard.org/app/LandingPages/ScopeOfPracticeHome.php. Accessed April 6, 2022.
- Sánchez-Infante J, Navarro-Santana MJ, Bravo-Sánchez A, Jiménez-Diaz F, Abián-Vicén J. Is Dry Needling Applied by Physical Therapists Effective for Pain in Musculoskeletal Conditions? A Systematic Review and Meta-Analysis. Phys Ther. 2021;101(3). doi:10.1093/ptj/pzab070
- Gattie E, Cleland JA, Snodgrass S. The Effectiveness of Trigger Point Dry Needling for Musculoskeletal Conditions by Physical Therapists: A Systematic Review and Meta-analysis. J Orthop Sports Phys Ther. 2017;47(3):133-149. doi:10.2519/jospt.2017.7096
- Mission and Vision | Physical Therapy. https://www.med.unc.edu/ahs/physical/about-us/mission-and-vision/. Accessed April 6, 2022.
6 Responses to “Introduction to Dry Needling: Theories, Evidence, and Application for Students”
mjkress
Cheyenne,
This was a great project to go through! This is a topic that many have interest in including myself. Your materials were all very well developed and informative at the same time. Much like LA and Lindsay’s materials, I will use your information as a quick reference in my own clinical practice. I agree that it would be nice to including information about dry needling in our modalities class and hopefully dry needling “sticks” around long enough, no pun intended, to be taught in class as well as commonly used in clinic. As much as I have read on dry needling including other’s posts during our 3rd year, I was still able to gain significant knowledge from your materials that I will carry with me. I will admit, I am surprised you didn’t make a kahoot for old time’s sake! Great work!
admutch
Cheyenne,
This project was really interesting to me because I too am interested in becoming DN certified after graduation and like Robbey have read many different statements on dry needling that can be conflicting about its efficacy. Like Lindsay, I had chronic, non-traumatic low back pain throughout undergrad (and still do to this day) and have been dry needled many times. I personally found it helpful for pain relief and function, so also like Lindsay, it was helpful for me to see that it has been at least researched enough for pain control, maybe not for function. All of your resources are extremely helpful and I can see how much time and effort you put into them. All of your documents look very professional and are so clean and neat. I especially like your Infographic because that is something that you can hand out to patients who have questions about Dry Needling, or even fellow providers who may not know as much about it. I appreciate all of the work you did to include reimbursement because (especially lately) it seems as though insurance companies change their mind about whether they will cover DN or not. I wish that this material would have been in the Modalities course while we were first years because it would have been more helpful going into our first clinical rotations. Still- I can use this information for our next clinical experience and let it guide me to the decision to take a DN course or not in the future! Great work, I look forward to sharing this knowledge with my future patients!
Michael Gross
Cheyenne- Fantastic work on this project. You were super organized and completed a ton of work in record time. All of your outcome products are so polished and professional. Thanks for having on the committee. Mike
robbey
Cheyenne, when I saw the title of your capstone, I became extremely excited to see what the research has stated. I have contemplated getting dry needling certified, so learning what the research has verified is necessary to know. Over the course of the DPT program, I have read conflicting research so reading your synthesis of data has been enlightening. Your quick reference of research for different regions of the body was well organized and visually easy to understand. I thought it was interesting that DN has support for the use of it alone for a few of the topics because I always thought of this modality in conjunction with other therapies. The research does seem to support the two main topics that I had preconceived notions that DN impacted, pain and disability, which is reassuring. When reviewing your PowerPoint slides, I think you did an amazing job presenting the material. You kept the slide content to a minimum, emphasized pertinent information, had transitional slides, and the information was presented in fluid nature. Also, when looking at your infographic, you developed an image that can be given to patients to educate them on dry needling without overloading them with scientific research. Your body chart with circles around areas that research has supported was a clever way to allow patients to visually see what is a “go/green” for dry needling and relate to; by thinking about where the pain is on their body.
When reflecting about my experience compared to the students of PHYT 722, I could report similar feelings to their opinions. I think the PowerPoint was easy to read like I stated above and visually appealing. The narrative definitely improved the engagement and understanding of the material. When reading about your reflection and how you had to have an accelerated timeline to have everything finished in time to present to the class of 2024, I applaud you for that. That takes organizational skills, dedication, and professional drive to accomplish everything you did. Well done Cheyenne, I am very impressed by your product materials and research performed. I think this will be a great addition to the material presented in the Modalities class and continue to push the UNC DPT program to be a frontier in education and implementation of evidence based treatments.
Lindsay Morrow
Cheyenne,
I loved your project and really appreciated all the wonderful information that you found regarding dry needling. When I was still swimming and had chronic overuse shoulder injuries, dry needling was one tool that seemed to be particularly efficacious for me. Therefore, I have been particularly interested in this topic and plan to seek out getting the certification as soon as I can. After listening to your VoiceThread, I learned that dry needling is effective at reducing non-traumatic shoulder pain, which is what I had. So, this proved to me that it was not just a placebo affect that I experienced.
Your infographic was incredibly clear and I loved the color-coding scheme to aid in health literacy and understanding. Furthermore, the quick reference guide and evidence tables provide a great overview of the literature, and I can see myself using them in the future when patient prepping and to aid in selection of research articles to dive further into. Your PowerPoint was incredibly professional, concise, and adequately informative. I appreciated the vast amount of information that you provided that encompassed many of the details regarding the use of this modality such as the associated CPT codes. The narrative that you provided complimented it greatly and you were very articulate. You answered so many of my questions and covered all pertinent information just short of getting certified. The theories of physiologic effects were particularly interesting as I was previously not quite sure how dry needling actually worked.
I wish that I had the chance to experience the full lesson that you made for the first-year students, and I have heard great feedback from them about it. The data gathered from the evaluation tools you created definitely support the clinical utility and effectiveness of your project, so you should be very proud! I would not be surprised if dry needling becomes more integrated in DPT school curriculum in the near future, while some of the other less evidence-based modalities are de-emphasized.
Great work!
Maureen Marquie
Cheyenne,
I am extremely impressed with your capstone. I too was exposed to dry needling during my clinical rotation and wondered about the evidence related to it and even looked up dry needling compared to acupuncture back in EBP 1 our first year. I was truly impressed with your organization, detail, presentation, vast array of products, and purpose of your capstone. I really enjoyed your quick reference guide, powerpoint, and handout as those tools I can go back to during my future career and use to educate patients and myself. I think your dry needling handout was especially patient-friendly with the red/yellow/green coloring as people automatically know what those colors mean due to stop lights when driving. I also thought it was smart to have a QR code for your references as that is a simple and quick way for people to access your references. Your reference table was amazing and I loved how you separated it by the body area with an easy key to understand the research based on those areas. Lastly, your powerpoint and voice thread was digestible, understandable, and educational. I really liked how you included not only the evidence, theories, and application of the material but also brought in PT scope of practice, reimbursement, etc. because dry needling is a topic brought up in multiple courses as well as those topics being important for students to know if they plan to get certified. Overall great job and I’m truly amazed and impressed by your work!