What is the difference between acupuncture and dry needling?

One of the questions I get asked frequently by my students and patients is what is the difference between acupuncture and dry needling, and which is better?

I teach and practice both techniques and if I had to choose between the two, I would say acupuncture has more advantages over dry needling and if used correctly will outperform dry needling. The reason for this choice is that you can treat more conditions such as infertility, irritable bowel syndrome, and insomnia and enhance performance in athletes, etc which you are unable to achieve with dry needling.

Although I have been trained in traditional Chinese medicine, I generally chose my classical acupuncture points based on their evidence-based physiological effect and not from a traditional Chinese medicine perspective. This allows me to target the underlying cause of the condition that I am treating.

Dry needling mainly focuses on pain and deactivation of myofascial trigger points (MTrPs). Therefore, DN is mainly focused on treating the symptom and not in most cases the route cause. For example, if I was treating an acutely inflamed ankle, I could resolve the condition much quicker with classical acupuncture points than dry needling techniques.

 

What are the pros and cons of acupuncture?

Dry needling generally involves local points to the area under investigation, whereas with acupuncture your most effective points have been shown to be located away from the area of investigation mainly in the extremities below the elbow or the knee.

In an acute inflamed ankle sprain if you were to needle too close to the ankle this would cause additional swelling due to the release of vasodilators (histamine, substance P, and calcitonin gene-related peptides) following needling which, in turn, would cause more pain. However, if you are using classical acupuncture points, you can use points away from the injured area (Ki-7, SP-6, SP-9, ST-41, and ST-36) which will reduce swelling around the lateral ankle complex and enhance the healing process.

Furthermore, ST-36 and ST-41 have been shown to enhance muscle strength, nerve conductivity and joint proprioception, soft tissue, and bone repair (1-3), and the migration of macrophage type II (pro-anti-inflammatory) to the site of injury (4-8).

What are the pros and cons of dry needling?

There are times when dry needling into myofascial trigger points and around or into the site of injury is more beneficial than using classical acupuncture. For example, if you have a muscle tear that is slow to heal then dry needling around the site (surround the dragon) can significantly enhance wound closure.

In the management of Achilles tendinopathy, I find dry needling directly into the tendon will accelerate the repair process and improve the laying down of type I collagen fibres. To ease off a muscle spasm needling down to the affected muscle will improve blood circulation to the area and generally release the spasm.

 

 What qualification do I need to train in acupuncture or dry needling?

Although acupuncture and dry needling both use fine needles to penetrate the skin their underpinning and training differ in several ways. Anyone with a standard education and no medical training may enroll in a 3-year degree course in acupuncture. However, you need to have a recognised medical qualification in physiotherapy, sports therapy, nursing, etc to register for a dry needling course.

 

What is involved in acupuncture training?

A 3-year degree in acupuncture will involve learning Western anatomy, physiology, philosophy, and history of Chinese medicine. Non-medical terms such as qi, yin, yang, invigorating blood, and expelling cold are used to make a diagnosis and these terms are used to formulate a treatment.

Students will learn to diagnose disorders by taking the pulse and assessing the tongue. These technique takes several years to master, and I have found them invaluable in the early detection of heart or stress-related disorders that can lead to complications later in life.

Students will take a holistic approach to treatment where they will consider the spiritual and mental being, as well as the physical body, and acknowledge the body’s ability to return to its balanced state of health. This is achieved by giving the body the correct stimulus to do so and recognising that the body is divided by an orderly network of meridians, or channels, through which Qi (Chi) energy flows.

Students are taught to see all illnesses in terms of excesses or deficiencies in various exogenous and endogenous pathogenic factors that will lead to the imbalance of Qi. Traditional acupuncture treatment is aimed at restoring balance. This is a fundamental concept in acupuncture and Chinese Philosophy.

Acupuncture, as a means of treating internal disease with external techniques, evolved over 2000 years as a necessary and important adjunct to these beliefs (9).

 

What is involved in DN training?

Dry needling and medical acupuncture courses are aimed at healthcare professionals such as physiotherapists, osteopaths, sports therapists, nurses, doctors, etc, who already hold a degree in their field of practice. As part of their qualification, they would need to demonstrate that they have a sound knowledge of anatomy and physiology and the management of musculoskeletal and associated disorders.

Dry needling training is much shorter than acupuncture training causes because healthcare professionals already have several years of experience assessing, diagnosing, and treating medical conditions. A Western medical diagnosis is made, and points are selected from a scientific evidence-based perspective.

Dry needling and medical acupuncture courses mainly aim to teach practitioners needling techniques and the underlying physiological effect of needling key points such as myofascial trigger points, motor points, tender points, and needling around an injury to stimulate the healing process. One of the main focuses of dry needling is to reduce pain.

Extensive research over the years has demonstrated the underlying mechanism of dry needling on the pain pathways. This research has been carried over into traditional Chinese medicine to gain a scientific understanding of how acupuncture works.

 

How did dry needling start?

Acupuncturists frequently suggest that dry needling was adopted from acupuncture, and this is what I was led to believe when I first undertook my basic acupuncture training. The precursor to dry needling was started in the 1940s by medical doctors such as Janet Travell, David Simons, and others before them. At the time they would inject various substances (steroids, saline, analgesia, Botox, etc) into myofascial trigger points.

This was known as wet needling until it was discovered that needling into myofascial trigger points without administering any substance had the same effect. Therefore, the term dry needling was coined and instead of using a hypodermic needle without injectable substances, it was more convenient to insert thin monofilament needles, as used in the practice of acupuncture.

 

What is medical acupuncture?

In 2009 White (10) defined dry needling as Western medical acupuncture. Although dry needling started in earlier medical traditions to mainly treat myofascial trigger points over the past decades it has continued to evolve.  Now many healthcare professionals combine dry needling techniques with traditional Chinese methods.

Dry needling is typically used to treat muscles, ligaments, tendons, subcutaneous fascia, scar tissue, peripheral nerves, and neurovascular bundles for the management of a variety of neuromusculoskeletal pain syndromes (11). From a segmental viewpoint, DN can be used to treat disorders of the bladder.

Healthcare professionals are undertaking advanced training programs to learn classical acupuncture points to use alongside dry needling and this type of training is better known as western medical acupuncture. These training programs can take from several months to several years to complete.

The advanced training programs present classical acupuncture points from an evidence-based perspective and use medical terms with regard to their function. Some TCM techniques that are used alongside DN is the surround the dragon technique also known as fencing the dragon.

 

What is the surround the dragon technique and how does it work?

Surround the dragon is an effective technique that has been employed in TCM for several thousand years and consists of local needling using 3 or more needles around the site of a lesion placed about 2cm or more from each other (12). The needles are inserted 45° angled toward the lesion approximately 5mm to 3cm in depth depending on the site and structure which is under treatment.

The distance from the focal site of injury will also vary depending on the location and size of the injury. The aim of the surround the dragon technique is to regulate the inflammatory process and the release of growth factors at the site of the lesion by increasing blood flow to the site of the lesion.

Several studies have found the surround the dragon technique to enhance bone and soft tissue healing by increasing collagen type I fibroblastic cells, reducing the inflammatory response, increasing cell proliferation and angiogenesis, and inducing extracellular matrix remodeling (13-15).

From clinical experience, I have found the surround the dragon technique invaluable in enhancing the healing rate of muscle tears and fractures. This technique can be used to treat sensitive scar tissue, ulcers, burns, muscle tears, tendonitis/osis, and fractures.

 

What courses are available to learn basic and advanced training in medical acupuncture?

I have been teaching healthcare professionals for over 12 years in dry needling and medical acupuncture and our medical acupuncture courses explain the function of classical acupuncture points in a scientific manner.

For example, if a patient presents with an acute ankle sprain, it is important to reduce the swelling as soon as possible to initiate the healing process. The two main points that I would recommend would be ST-36 and SP-6.

The reason I would select these points is that it has been shown that following an injury the inflammatory response is activated through the release of proinflammatory neuropeptides such as substance P, calcitonin gene-related peptide, and histamine which, contribute to the release of proinflammatory cytokines such as tumor necrosis factor-α, interleukin-1β, interleukin -6, and interleukin -10 (12,13).

Acupuncture has been shown to reduce the production of pro-inflammatory neuropeptides (16-22) following injury and have an antihistamine effect in subjects with itchy skin and atopic eczema (23-26). Several studies (7, 4, 5, 27, 28) have shown that SP-6 and ST-26 significantly reduce inflammation. These studies found that daily stimulation of ST-36 and SP-6 induced a reduction of M1 macrophages (pro-inflammatory cells) and increased the numbers of M2 macrophages (anti-inflammatory cells).

Furthermore, M2 macrophages can secrete interleukin-10 (IL-10) to promote healing and repair (28-33). Medically trained practitioners will have a better understanding of the above explanation instead of explaining the function of ST-36 and SP-6 to expel cold and invigorate qi and blood etc.

To express the function of points in terms of expelling heat, cold, damp, or invigorating Qi or blood has very little meaning to many healthcare professionals and their patients. The use of these terms also makes it difficult for healthcare professionals to select appropriate points for the management of musculoskeletal and associated disorders.

 

What are the similarities between dry needling and acupuncture?

Classical acupuncture and DN will:

• Both enhance circulation to the site of injury.
• Both have a local, segmental, and central effect on pain.
• Both stimulate peripheral nerves and blood vessels.
• Both use thin needles that penetrate the skin.

Acupuncture points and MTrPs are seen to correspond to physiological and anatomical features such as.

• Peripheral nerve junctions.
• Blood vessels which are closely associated with autonomic nerve fibres.
• Neurovascular bundle, containing large and small sensory nerves that have terminal nociceptors.

Is there a correlation between acupuncture points and myofascial trigger points?

The locations of classical acupoints are well established however, there are many similarities between MTrPs and acupuncture points including their location and distribution, pain and referred pain patterns, local twitch responses (deqi), and possible spinal cord mechanism (34).

Liu et al (35) found a high correlation between acupuncture points and muscle motor points, whereas Melzack et al (36,37) found a 71% correlation between myofascial trigger points (MTrPs) and acupuncture points. Dorsher (38) and Dorsher and Fleckenstein (39) found a 93% anatomical correlation between the locations of classical acupuncture points and common MTrPs described by the trigger point manual (40,41).

Birch (42) analysed the studies by Melzack and colleagues (36,37) and suggested that trigger points did not correlate to classical acupuncture points and that trigger points could only correlate to Ah Shi points. Birch (42) further announced that no more than 40% of the acupuncture points examined by Melzack and colleagues (36) correlated clinically for the treatment of pain and that correlation was more likely in the region of 18%–19%.

More recently Bailey (12) found a 19.8% correlation between classical acupuncture and MTrPs using Travell and Simons (40,41) trigger point manual, a manual of acupuncture (43), and a practical guide to acupoints (44). Bailey’s (12) findings agree with the estimate of Birch (42).

It is important to note that the methodology used in the studies by Melzack et al (36) and Dorsher and Fleckenstein (39) observed MTrPs in close vicinity to classical acupuncture points and not necessarily precisely in the same location. Melzack et al (36) used a difference of about 3cm between the locations of an MTrP and a classical acupuncture point.

Dorsher and Fleckenstein (39) found that 37% of the 238 corresponding MTrP-acupoint pairs were estimated to be within 1cm of each other. 45% were within 1–2cm of each other, and another 13% were within 2–3cm of each other. Bailey (12) found that 19.8% of acupuncture points were within 0.5cm of MTrPs.

Conclusion

Although there are many differences and similarities between DN and acupuncture to gain optimum results when treating musculoskeletal disorders both techniques should be combined.

 

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