The utilization of dry needling - a survey of contemporary clinical practice within the USA

ABSTRACT

Background

Dry needling (DN) is a skilled intervention commonly used for pain relief and the management of movement disorders in neuromusculoskeletal conditions. Although systematic reviews indicate its effectiveness, variations in treatment parameters exist. This study surveyed U.S. healthcare professionals who utilize DN, examining their clinical techniques, rationale, and use of electrostimulation.

Methods

An electronic survey was created and distributed via Qualtrics™ to healthcare providers performing DN. The survey link was shared through social media and e-mail, and data were analyzed using non-parametric statistical methods (Mann-Whitney U, Spearman’s rho) to identify significant patterns in DN practices.

Results

A total of 1,399 healthcare providers completed the survey, predominantly physical therapists (93.3%) with an average of 13.5 years of clinical experience and 5.2 years in DN. Most worked in outpatient orthopedics (90.3%). Common DN techniques included trigger point needling (95.8%) and deep needling (82.0%), with 44.5% using periosteal pecking. The majority of practitioners used up to 4 needles per session (68.1%), while 63.8% used more than 4. Electro-stimulation (e-stim) was commonly applied, with 62.5% using it after needle insertion and 55.6% combining it with needle manipulation. Differences in techniques were noted between physical and nonphysical therapists, particularly in the practice of leaving needles in place without manipulation.

Conclusion

This study highlights the widespread use and evolving methodologies of DN practices in the U.S. noting the integration of electrostimulation and multimodal approaches. It also highlights inconsistencies in treatment parameters, underscoring the need for standardized protocols to enhance clinical effectiveness and research validity. Future research should focus on the long-term efficacy of various DN techniques and their applications in neurological rehabilitation.

Introduction

The American Physical Therapy Association (APTA) defines Dry Needling (DN) as a ‘skilled intervention that uses a thin filiform needle to penetrate the skin and stimulate underlying myofascial trigger points (MTrPs), muscular, and connective tissues for the management of neuromusculoskeletal pain and movement impairments’ [1]. MTrPs are commonly observed in musculoskeletal and neuromuscular conditions and are often associated with pain, physical impairments, functional limitations, and decreased participation in daily activities [2,3].

Clinical evidence has shown that DN treatment targeting MTrPs can reduce symptoms, improve range of motion, lower pain sensitivity (measured by pressure pain thresholds), and enhance muscle function [4–8]. However, concerns have been raised regarding the APTA’s definition, as it appears to narrowly confine the scope of DN to targeting MTrPs and surrounding connective tissues. This limited interpretation may exclude other valid and effective needling approaches [9,10]. Notably, emerging research supports the therapeutic benefits of DN at non-MTrP sites, demonstrating meaningful reductions in pain and disability among individuals with neuromusculoskeletal conditions [10].

Additionally, growing evidence highlights the limited reliability and validity in the identification and palpation of MTrPs, even among experienced clinicians. Inter-rater reliability has been found to be poor to moderate at best, with studies showing inconsistent agreement on the presence, location, and characteristics of MTrPs [11–13]. These limitations raise questions about the clinical utility of defining DN primarily around the concept of MTrPs and further support the need for a broader, more inclusive conceptualization.

In response to these issues, a task force convened by the Federation of State Boards of Physical Therapy proposed a more comprehensive definition. This revised definition describes DN as a ‘skilled intervention performed by a physical therapist using needles to penetrate the skin and/or underlying tissues to affect functional change in anatomical structures and systems for the evaluation, management, and prevention of neuromusculoskeletal conditions, pain, movement impairments, and disability’ [14].

An umbrella review summarized the clinical effects of DN on musculoskeletal disorders across various body regions, including 36 systematic reviews. It found that DN was more effective than sham or no intervention and comparable to other treatments for short-term pain relief. However, results on physical functioning were inconsistent, highlighting the need for standardized DN protocols to reduce heterogeneity and strengthen evidence [15]. Kearns et al. [16] conducted a scoping review that revealed inconsistencies in reporting DN dosing parameters and adverse events. This has made it challenging to assess the impact of DN dosing on outcomes and determine the optimal dosages. The authors recommended a standardized checklist to improve reporting, enhancing the validity and generalizability of results [16].

Multiple systematic reviews have evaluated the effectiveness of DN performed by various healthcare providers across a range of neuromusculoskeletal conditions [17–21]. A recent systematic review and meta-analysis published in 2021 specifically examined DN administered by physical therapists and its effects on pain in individuals with diverse musculoskeletal disorders [20]. This review analyzed 42 studies and found low to moderate quality evidence supporting the effectiveness of DN for pain reduction in the short term (within 72 hours), medium term (1–12 weeks), and long term (13–24 weeks). The authors concluded that DN was more effective than no treatment, placebo interventions, and, in some cases, other therapeutic approaches for reducing pain up to 24 weeks post-treatment.

Similarly, an earlier systematic review analyzing 13 trials reported comparable findings [22]. It identified low- to moderate-quality evidence that DN reduces pain and improves pressure pain thresholds (PPT) compared to no treatment over a 12-week follow-up period.

Extending beyond typical musculoskeletal conditions, a 2021 systematic review and meta-analysis by Fernández-de-las-Peñas et al. examined the effects of DN in post-stroke populations, specifically its impact on spasticity, pain, and motor function [17]. Analyzing data from 7 randomized controlled trials, the review found that DN significantly reduced spasticity and pain, and in some cases, contributed to improved motor function in stroke survivors. These findings highlight the potential of DN as a neuromodulatory intervention beyond musculoskeletal pain. However, the authors noted that most included studies had small sample sizes and moderate risk of bias, calling for larger, higher-quality trials to strengthen the evidence base.

Similarly, a 2021 systematic review and meta-analysis by Navarro-Santana et al. investigated the influence of treatment dosage by analyzing the effectiveness of DN based on the number of sessions [21]. Their findings suggest that multiple-session protocols yielded superior pain reduction outcomes compared to single-session interventions. These results underscore the importance of treatment frequency in optimizing clinical outcomes and support multi-session DN as part of a comprehensive pain management strategy.

While systematic reviews suggest that DN exhibits evidence of effectiveness, few studies offer specific guidance on treatment parameters and clinical applications of DN. Preliminary evidence suggests that needle placement with greater intramuscular depth may lead to better clinical outcomes than more superficial approaches [23,24]. Other approaches have studied DN applied directly to MTrPs in hopes of obtaining a local twitch response, which is hypothesized to yield superior outcomes than more indirect techniques. The relevance of the latent twitch response (LTR) in response to clinical outcomes remains inconclusive [25,26]. One study compared DN directly into a lower trapezius MTrP versus immediately adjacent to a MTrP and found statistically and clinically better results when directly targeting a MTrP [27]. Finally, a more recent study examined the effects of deep DN with and without needle manipulation on PPT and electromyographic (EMG) amplitude of the lumbosacral multifidus in adults with low back pain. The findings indicated that deep DN combined with needle manipulation significantly reduced mechanical pressure sensitivity compared to DN without manipulation [28]. Relatively few studies have addressed crucial treatment parameters, including needle technique, the number of needles utilized, treatment duration, or the potential benefits of needle retention. Hsieh et al. reported that DN applied to a key MTrP resulted in a reduction of irritability in both the key and satellite MTrPs, as measured by spontaneous electrical activity and PPT [29]. Fernandez-Carnero et al. investigated the effect of different dosages (number of needle insertions) of deep DN on outcomes in patients with cervical myofascial pain and found that higher dosages (more insertions) led to greater reductions in pain intensity and MTrP sensitivity [30]. Finally, Martin-Pintado-Zugasti et al. examined how varying DN dosages influenced post-needling soreness and tenderness, common side effects of the procedure. They found higher dosages were associated with greater and longer-lasting post-needling soreness and tenderness, though these effects were generally mild and self-limiting [31].

The inconsistent reporting of DN dosing parameters in the existing literature and the growing prevalence of healthcare providers employing DN in their clinical practice prompt an examination of how DN is currently utilized for musculoskeletal disorders within the United States. Consequently, this study intended to survey healthcare professionals who incorporate DN into their routine practices to investigate their clinical patterns. The primary objective was to ascertain the methods and rationale behind their use of DN, with particular emphasis on the techniques employed and the quantity of needles utilized in treatment.

Methods

We developed, piloted, and administered an electronic survey designed for healthcare providers throughout the United States. We reported methods and results per the CHERRIES checklist for reporting internet E-surveys [32].

Sample size determination

The sample size of 660 participants was determined utilizing a specific sample size calculation formula [33].

$$\mathit{Ns}\mathit{\hspace{0.17em}}=\mathit{\hspace{0.17em}}\left(\mathit{Np}\right)\left(\mathit{p}\right)\left(1-\mathit{p}\right)/\left(\mathit{Np}-1\right)\left(\mathit{B}/\mathit{C}\right)2+\left(\mathit{p}\right)\left(1-\mathit{p}\right)$$

where: Ns = completed sample size for desired level of precision, Np = size of the population, p = proportion of population expected to choose one of the two response categories, B = acceptable amount of sampling error, C = Z statistic associated with the confidence level [33].

For this study, the population (Np) was drawn from data from the United States Department of Labor, Bureau of Labor Statistics as of September 2022 [34]. Np was calculated at 1,527,400 healthcare providers. The proportion of the population (p) expected to choose one of the two response categories (to participate or not) was designed as a 50/50 split or 0.50. The acceptable sampling error (B) was set to 0.03 (i.e. ±3% of the true population value), while the confidence level (C) was established at 90%, corresponding to a Z-statistic of 1.645. The resulting Ns or completed sample size was 658, rounded to a sample size of 660.

Survey development

In March 2022, a preliminary adaptive survey was distributed using Qualtrics^XM to a panel of 10 licensed physical therapists who were DN experts in practice, education, and research. The feedback from this panel was incorporated into a revised survey, which was then sent to 6 of the panel members in April 2022 for additional comments and feedback. The final survey was adopted once a consensus (with at least 70% agreement) was reached among all six members.

To evaluate the test-retest reliability of the survey, it was distributed to a random sample of 20 licensed healthcare providers. Each provider completed the survey on two separate occasions, two weeks apart. The comparison of results showed the survey to be reliable, with a kappa value of 0.97. Remarkably, 19 of the 20 providers responded identically to all survey questions on both occasions. A list of all questions included in the final version of the survey can be found in Appendix A.

The survey employed an adaptive questioning methodology, with 30 questions systematically organized into distinct blocks. The survey architecture comprised the following sections: Introduction (1 question); Inclusion/Exclusion Criteria (2 questions); Demographics (9 questions); Clinical (5 questions); Stim Use (13 questions); Conclusion of Survey.

This structured approach facilitated an efficient and coherent survey experience for respondents.

The Introduction section outlined the study and its objectives, provided a definition of DN, offered an estimate of the time required to complete the survey, and stated that participants were giving informed consent by continuing the survey. The Inclusion/Exclusion section asked two questions: a) whether the respondent was a healthcare provider (e.g. physician, physical therapist, chiropractor, acupuncturist, occupational therapist, athletic trainer, or other), and b) whether they regularly incorporated DN into their clinical practice. Respondents who answered ‘No’ to either question were directed to the end of the survey. The Demographics section collected information about the respondents, including age, gender, years of experience as a clinician, profession, highest earned degree, board certification, certification in DN, and years of experience using DN. The Clinical section examined the respondents’ healthcare settings, the method of DN used, the number of needles employed in a treatment session, and whether electrical stimulation was utilized. The survey ended if respondents indicated that they never use electrical stimulation during DN. The Stim Use section gathered information regarding the type of electrical stimulation used, the terminology employed for any electrical stimulation in conjunction with DN, frequency parameters, and the rationale behind the various frequencies.

The survey was administered electronically using Qualtrics™ and consisted of a fixed sequence of questions presented uniformly to all respondents. The survey link was distributed through multiple channels to generate a diverse and sufficiently large convenience sample of practicing healthcare providers within the United States. These included targeted outreach via e-mail distribution lists from professional organizations such as the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT) and the Academy of Orthopaedic Physical Therapy (a component of the American Physical Therapy Association), as well as postings on professional social media platforms (e.g. LinkedIn, Facebook groups for clinicians). Efforts were made to reach providers from various geographic regions, practice settings (e.g. outpatient, academic, inpatient, private practice), and experience levels to ensure broad professional representation.

Data processing and statistical analysis

Survey data were downloaded from Qualtrics™ and exported to SPSS (Version 29, SPSS Inc., Chicago, IL). Descriptive statistics were calculated for each variable to determine the demographics of the survey respondents and their utilization patterns for DN. Because the survey data were ordinal, all analyses were conducted using non-parametric statistics. Correlations between demographic variables and survey responses were analyzed using Spearman’s rho (rs) correlational analyses. Differences between physical and nonphysical therapists regarding beliefs about needle insertion, the number of needles used, and the application of electrical stimulation were examined using Mann-Whitney U Tests (the non-parametric alternative for independent-samples t-tests). We gathered frequency counts for the choices in the survey questions and summarized/grouped the similar manually entered responses for the ‘Other (please specify)’ options.

Results

The online survey conducted via Qualtrics from August 2022 to March 2023 recorded 1,776 accesses. After data cleaning, including the removal of non-qualified respondents and incomplete surveys, we finalized a sample size of 1,399, surpassing the initial target of 660. This group includes healthcare providers who regularly administer DN therapy in their practice.

Demographics

Among the 1,399 respondents, 52.7% identified as female, 46.3% as male, and 1% chose not to disclose or identified as non-binary. The average age was 39.7 years, with 13.5 years of clinical experience, including 5.2 years in DN. (Table 2) Most respondents were physical therapists (93.3%), followed by chiropractors (4.1%) and athletic trainers (0.9%). The largest group held a Doctor of Physical Therapy (DPT) degree (73.1%), followed by a Master of Physical Therapy (MPT) degree (8.9%), Doctor of Chiropractic (DC) degree (4.1%), and Bachelor of Physical Therapy (BPT) degree (2.8%). Additionally, 83.8% reported being certified in DN.

Table 2.

Descriptive statistics for the continuous variables of the sample.

Variable	N	Range	Mean	SD
Age (in years)	1399	23–75	39.7	10.1
Years as a clinician	1399	0–50	13.5	10.4
Years of exp. in DN	1399	1–35	5.2	4.4

Most respondents worked in outpatient orthopedics, particularly in the spinal region (1,222 respondents, or 90.3%) and the extremities (1,224 respondents, or 90.5%). Participants could indicate multiple settings, resulting in significant overlap, with 90% of respondents involved in outpatient orthopedics. The next most common setting was outpatient rehabilitation for neurological conditions, reported by 241 respondents (17.8%). For a comprehensive analysis of the demographic data, please refer to Tables 1 and 3.

Table 1.

Demographic data of the 1399 respondents.

Category	Response	Frequency	Percent
Biologic Sex	Male	648	46.3%
	Female	737	52.7%
	Non-binary/third gender	2	0.1%
	Prefer not to say	10	0.7%
Profession	Physical Therapist	1305	93.3%
	Chiropractor	58	4.1%
	Athletic Trainer	13	0.9%
	Physician	7	0.5%
	Occupational Therapist	7	0.5%
	Acupuncturist/East-Asian Medical Practitioner	4	0.3%
	Other – unspecified	2	0.1%
	Other – Military Flight Medic	1	0.1%
Highest Earned Degree	Doctor of Physical Therapy (DPT)	1022	73.1%
	Master of Physical Therapy (MPT)	124	8.9%
	Doctor of Chiropractic (DC)	57	4.1%
	Bachelor of Physical Therapy	39	2.8%
	Doctor of Philosophy (PhD)	20	1.4%
	Masters/Doctorate in Acupuncture	19	1.4%
	Doctor of Science (DSc)	15	1.1%
	Doctor of Medicine (MD)	4	0.3%
	Doctor of Education (EdD)	3	0.2%
	Occupational Therapy Doctorate (OTD)	3	0.2%
	Other	93	6.6%
Certification in DN	Yes No	1172 226	83.8% 16.2%

Table 3.

Reported healthcare settings respondents currently practice in.

Response	Frequency	Percent	Percent of Respondents
Outpatient Orthopedics (Spine)	1222	38.5%	90.3%
Outpatient Orthopedics (Extremities)	1224	38.6%	90.5%
Outpatient Rehab (Neuro)	241	7.6%	17.8%
Athletic training room/team environment	133	4.2%	9.8%
Acute/Inpatient	82	2.6%	6.1%
Pediatrics	42	1.3%	3.1%
Skilled Nursing Facility	30	0.9%	2.2%
Home Health	51	1.6%	3.8%
Other	145	4.6%	10.7%
Total	3170	100.0%	234.3%

1353 participants answered this question. Total Frequency is different from the survey sample size because some participants either did not respond or gave more than one response. Percent is out of the total number of responses given for this question. Percent of Respondents is based on the number of participants who answered this question (i.e. Frequency divided by 1353; the percentages add up to over 100% because some participants chose more than one response).

Respondents indicated the DN methods they commonly use. The most prevalent methods were trigger point DN (1,286 respondents; 95.8%), deep needling (1,100 respondents; 82.0%), and periosteal pecking (597 respondents; 44.5%) (Table 4). For needle insertion and manipulation, 62.5% (831 respondents) typically inserted a needle, left it in place, and applied electrostimulation (E-stim). Meanwhile, 60.6% (805 respondents) manipulated the needle to find a twitch response before leaving it in place. Most did not just insert a needle without further action (39.7%), but 55.6% (739 respondents) often manipulated the needle and then applied E-stim.

Table 4.

Reported method of dry needling by practitioner.

Response	Frequency	% of Responses	% of Respondents
Trigger Point	1286	30.0%	95.8%
Superficial	214	5.0%	15.9%
Myofascial	429	10.0%	32.0%
Deep	1100	25.6%	82.0%
Periosteal Pecking	597	13.9%	44.5%
Perineural	484	11.3%	36.1%
Acupuncture Points	146	3.4%	10.9%
Other	34	0.8%	2.5%
Total	4290	100.0%	319.7%

1342 participants answered this question. Total Frequency is different from the survey sample size because some participants either did not respond or gave more than one response. Percent of Responses is out of the total number of responses given for this question. Percent of Respondents is based on the number of participants who answered this question (i.e. Frequency divided by 1342; the percentages add up to over 100% because some participants chose more than one response).

Respondents were asked to rate their level of agreement with four statements about how they would usually insert a needle. Of the 1333 responses, the greatest agreement (strong and somewhat agree) was to ‘leave it in place (in situ) then apply E-stim to it’ (62.34%); followed by ‘manipulate it “hunting” for a twitch response, then leave it in place’ (60.69%); then ‘manipulate it “hunting” for a twitch response, then apply E-stim to it’ (55.74%). Respondents were less likely to agree that they would insert a needle ‘and leave it in place’ (39.61%). (see Figure 1)

Figure 1.

Respondents’ level of agreement with statements about how they would insert needles during DN.

Respondents were asked to rate their level of agreement with statements about the number of needles they would usually insert in a typical treatment session. The 1325 respondents were more likely to agree that they used ‘up to four needles’ (68.15%), as compared to ‘more than four needles’ (63.62%); ‘two needles’ (31.78%); and ‘just one needle’ (6.49%) (See Figure 2).

Figure 2.

Respondents’ level of agreement with statements about how many needles they would use in a typical treatment.

In terms of their frequency of use of E-stim when DN, the 1318 respondents were more likely to agree that they used it ‘often’ (63.12%), as compared to ‘always’ (41.12%); ‘sometimes’ (35.81%); ‘never’ (15.40%); and ‘rarely’ (14.04%). (see Figure 3)

Figure 3.

Respondents’ level of agreement with statements about how often they would use E-stim with DN.

Responses varied when asked about the terms they use to refer to DN with electrical stimulation. Of the respondents, 352 (31.1%) called it ‘electric dry needling,’ while 248 (21.9%) referred to it as ‘percutaneous electrical nerve stimulation.’ Additionally, 232 respondents (20.9%) labeled it ‘neuromodulation.’ Notably, 478 respondents (42.4%) indicated they used ‘other’ terms and provided varied answers for DN with electrical stimulation. Most of the responses were ‘dry needling with electrical stimulation’ or a similar variant of that answer.

Most respondents provided multiple responses when asked about their reasons for using E-stim in conjunction with DN. The most commonly cited reason was pain relief, with 1,024 participants (92.6%) selecting this option. This was followed by improving the contractile capability of muscles, chosen by 814 respondents (73.6%), enhancing neural transmission and nerve health, indicated by 724 respondents (65.5%), and reducing post-needling soreness, reported by 614 respondents (55.5%).

Spearman’s rho correlational analyses were conducted among various variables. Notably, the results indicated that years of experience in DN were significantly and positively correlated with the use of more than four needles in a typical treatment, r_s(1319) = .174, p < .001. These very weak correlations (Spearman’s ρ = 0.00–0.19) might suggest that individuals with greater experience in DN were more likely to use more than four needles during treatment sessions. Interestingly, the employment of more than four needles was also significantly and positively (although weakly) correlated with three different needle insertion techniques: 1) inserting the needle and leaving it in place, r_s(1319) = .172, p < .001; 2) inserting the needle, leaving it in place, and then applying E-stim, r_s(1319) = .102, p < .001; and 3) inserting the needle, manipulating it for a twitch response, and then applying E-stim, r_s(1319) = .081, p = .003. These weak correlations might suggest that respondents who typically used more than four needles in their treatments were more likely to employ one of these insertion methods rather than the alternative method, which involved inserting the needle, manipulating it for a twitch response, and leaving it in place. There were no other statistically significant correlations among the other variables.

Furthermore, when examining the frequency of E-stim usage in conjunction with DN, the use of more than four needles in a typical treatment showed a significant positive correlation with respondents who often and always used E-stim during DN (r_s(1312) = .114, p < .001 and r_s(1312) = .109, p < .001, respectively).

Mann-Whitney U Tests were conducted to assess the differences between physical therapists and nonphysical therapists regarding the methods of needle application, number of needles used, and use of E-stim. For the method of needle application, nonphysical therapists (M = 3.50, SD = 1.40) significantly utilized the technique of inserting needle(s) and leaving them in place more often than physical therapists (M = 2.74, SD = 1.40), z = −4.674, p < .001. No other methods of needle insertion showed a significant difference in utilization (Table 5).

Table 5.

Results of the Mann-Whitney U test comparing physical therapists and non-physical therapists on needle technique.

Needle application/method	Physical Therapists (N = 1243)			Non-Physical Therapists (N = 84)
	Mean Rank	M	SD	Mean Rank	M	SD	z-value	p
Insert needle and leave in place (in situ)	651.55	2.74	1.40	848.21	3.50	1.40	−4.674	<.001*
Insert needle, leave it in place (in situ) then apply e-stim to it	664.66	3.49	1.46	654.26	3.50	1.35	−0.249	.803
Insert needle and manipulate it ‘hunting’ for a twitch response, then leave it in place	661.41	3.37	1.33	702.33	3.56	1.20	−0.989	.323
Insert a needle, manipulate it ‘hunting’ for a twitch response, then apply e-stim to it	666.12	3.28	1.48	632.68	3.18	1.38	−0.797	.425

Missing or incomplete cases were excluded from the Mann-Whitney U test.

For the number of needles used in a typical treatment, physical therapists used just 2 needles (M = 2.58, SD = 1.34) significantly more often than nonphysical therapists (M = 1.89, SD = 1.22), z = −4.732, p < .001. Physical therapists also used up to 4 needles in a treatment (M = 3.62, SD = 1.21) significantly more often than nonphysical therapists (M = 3.14, SD = 1.45), z = −2.917, p = .004. However, nonphysical therapists used more than 4 needles in a treatment (M = 4.17, SD = 1.20) significantly more often than physical therapists (M = 3.59, 1.33), z = −4.292, p < .001. (Table 6)

Table 6.

Results of the Mann-Whitney U test comparing physical therapists and non-physical therapists on the number of needles used in a typical treatment.

Number of Needles	Physical Therapists (N = 1235)			Non-Physical Therapists (N = 84)
	Mean Rank	M	SD	Mean Rank	M	SD	z-value	p
Use just one (1) needle in a typical treatment	664.10	1.59	0.94	599.68	1.42	0.81	−1.758	.079
Use two (2) needles in a typical treatment	672.54	2.58	1.34	475.59	1.89	1.22	−4.732	<.001*
Use up to four (4) needles in a typical treatment	667.51	3.62	1.21	549.56	3.14	1.45	−2.917	.004*
Use more than four (4) needles in a typical treatment	648.68	3.59	1.33	826.39	4.17	1.20	−4.292	<.001*

Missing or incomplete cases were excluded from the Mann-Whitney U test.

The Mann-Whitney U Test results did not show any significant differences between physical therapists and nonphysical therapists regarding how often they use E-stim when DN (p’s > .05). When looking at clinical reasons for using E-stim with DN, the Mann-Whitney U Test did not show any significant differences between physical therapists and nonphysical therapists (p’s > .05).

Finally, regarding preferred terminology, physical therapists used the term ‘electro-acupuncture’ (M = 4.24, SD = 0.96) significantly more often than nonphysical therapists (M = 3.33, SD = 1.45), z = −5.318, p < .001.

Discussion

The survey results provide an extensive and detailed overview of healthcare providers who regularly administer DN therapy, emphasizing their demographic characteristics, professional qualifications, clinical settings, and specific DN practices. With a final sample size of 1,399 respondents – more than double the initial projection of 660—this study’s results may offer a robust and representative snapshot of current DN practices in the healthcare community.

The demographic profile of respondents aligns with existing research, which shows that the majority of DN practitioners are physical therapists (93.3%) operating in outpatient orthopedic settings. This finding is consistent with studies, such as those reported by Dommerholt and Fernández-de-Las-Peñas et al. [35], which identified physical therapists as the predominant users of DN, especially in managing musculoskeletal conditions. The relatively high level of experience in DN among respondents (mean = 5.20 years) further highlights a skilled cohort, reflecting findings from Tekin et al. [26], who emphasized the importance of practitioner expertise in achieving optimal outcomes.

Techniques and needle usage

The survey reveals that trigger point needling (95.8%) and deep needling (82%) are the most commonly employed techniques, with 44.5% of respondents using periosteal pecking. These results corroborate previous findings highlighting the dominance of trigger point needling in clinical practice [10]. However, the widespread use of periosteal pecking suggests an expansion of DN applications beyond trigger points, a trend not extensively documented in earlier research.

An interesting finding was that nonphysical therapists significantly more often utilized the method of inserting needle(s) and leaving them in place than physical therapists (p < .001). This finding can be examined from several angles, including differences in training and philosophical approach, scope of practice and reimbursement models, patient volume and time management, and professional identity and treatment goals. Nonphysical therapists, like acupuncturists or specially trained medical doctors, typically follow traditional acupuncture principles by keeping needles in place for 10–30 minutes to stimulate energy pathways or modulate nervous system responses. In contrast, physical therapists often focus on Western biomedical models, utilizing trigger point DN, which emphasizes quick needle insertion and removal to achieve local twitch responses and neuromuscular effects [35,36]. Non-PTs may retain needles during treatment to align with billing codes (e.g. acupuncture), while PTs usually focus on movement, integrating needling with rehabilitation or exercise [10,37]. Nonphysical therapists can treat multiple patients at once, using needles while managing various treatment rooms. In contrast, PTs focus on one-on-one care, incorporating manual therapy and education, which allows for shorter needling durations [38]. PTs focus on enhancing functional movement, strength, and mobility, viewing DN as one component of a comprehensive treatment plan. In contrast, non-PTs may use needling as their primary intervention, often involving more extended needle retention techniques [39].

The majority of respondents (68.1%) reported using up to four needles per session, with a significant portion using more than four needles (63.8%). This nuanced approach contrasts with the more limited needle use reported in earlier studies [5,13,37], suggesting that practitioners are tailoring treatment to individual patient needs, potentially informed by growing evidence of the effectiveness of DN for broader musculoskeletal conditions.

E-stim integration and needle manipulation

Most respondents combine DN with electrostimulation (62.5%) or needle manipulation to elicit a local twitch response (60.6%), consistent with Tekin et al. [26], who noted the clinical significance of eliciting a twitch response for pain reduction. Moreover, 55.6% of respondents combine both techniques, reflecting an evolution in practice as clinicians adopt multimodal approaches to optimize outcomes. This aligns with studies that suggest that combining DN with E-stim enhances therapeutic benefits, particularly in chronic pain syndromes [40–42]. In contrast, fewer respondents (39.7%) reported using a ‘leave it in place’ technique without manipulation or E-stim, indicating a shift from passive techniques (inserting the needle, informing the patient of the duration, and then moving on to another patient) toward more active engagement (sitting with the patient providing pain science education or similar education strategies) during DN. This contrasts with earlier studies where static needling approaches were more prevalent, suggesting a paradigm shift driven by new evidence supporting dynamic interventions [43,44]. In the context of DN, dynamic interventions refer to techniques where the needle is used in conjunction with movement or active patient participation, rather than in a static or passive manner.

Gender and professional background

The gender distribution of respondents (52.7% female, 46.3% male) reflects broader trends in the healthcare workforce. Still, it contrasts with some older studies, such as those by Dommerholt et al. [45], where male practitioners dominated DN research samples. This shift may reflect increasing gender diversity in the profession and warrants further exploration to assess its implications for DN practice.

Clinical settings

The predominance of outpatient orthopedic settings (90.3%) in the DN practice survey is well-documented in existing research. A survey of American physical therapists reported that DN is frequently utilized in outpatient orthopedic environments, particularly for musculoskeletal conditions [46]. Additionally, the Academy of Orthopaedic Physical Therapy notes that physical therapists increasingly employ DN to treat musculoskeletal pain and dysfunction, often within outpatient orthopedic settings [47]. However, the reported use of DN in outpatient rehabilitation for neurological conditions (17.8%) highlights its emerging applications, which are less frequently documented in traditional DN literature. Recent studies and clinical applications have begun to explore DN’s efficacy in managing neurological disorders, particularly in reducing spasticity and improving motor function [48–50]. For instance, a descriptive review highlighted DN’s potential benefits in managing post-stroke spasticity, balance issues, and pain, suggesting its emerging role in neurorehabilitation [51].

Implications for practice and future research

The survey provides compelling evidence of DN’s widespread adoption, with practitioners leveraging advanced techniques such as E-stim and needle manipulation to enhance therapeutic outcomes. These findings align with and extend existing research, reflecting a growing consensus on the importance of combining DN with complementary modalities. The data also underscore a nuanced approach to needle use, suggesting that practitioners are increasingly tailoring treatments to individual patient profiles rather than adhering to standardized protocols.

Future research should investigate the clinical outcomes associated with the diverse DN techniques identified in this study, particularly in less-studied areas such as periosteal pecking and DN for neurological rehabilitation. Additionally, longitudinal studies exploring the long-term effectiveness of combined DN and E-stim approaches could provide valuable insights into optimizing DN therapy. Finally, the evolution of DN practices across gender and professional demographics warrants further exploration to ensure inclusivity and the dissemination of best practices across the healthcare community.

By situating these findings within the existing literature, this study highlights the consistency and evolution of DN practices, offering a valuable resource for advancing evidence-based DN applications.

Conclusion

This study provides a comprehensive overview of DN practices among healthcare providers in the United States, highlighting key trends in techniques, needle usage, and the integration of electrostimulation. The findings demonstrate the widespread adoption of DN, particularly among physical therapists in outpatient orthopedic settings, with a growing emphasis on multimodal approaches such as combining DN with E-stim and needle manipulation. The data suggest clinicians are increasingly tailoring treatments to individual patient needs rather than adhering to standardized protocols.

While the results reinforce existing literature on DN’s effectiveness, they also underscore gaps in research, particularly regarding optimal treatment parameters and standardized protocols. Future studies should focus on long-term outcomes, the role of DN in neurological rehabilitation, and the impact of diverse techniques such as periosteal pecking. Importantly, further investigation is needed into specific treatment variables – such as the number and location of needles used, duration of needle retention, and the use and frequency of electrical stimulation (e.g. low vs. high frequency E-stim) – to determine their influence on clinical outcomes. Identifying how these parameters affect spasticity reduction, motor recovery, and neuromuscular reeducation is essential for refining best practices. Additionally, the evolution of DN practices across different professional backgrounds and demographics warrants further exploration to ensure the continued advancement of evidence-based DN applications.

Biographies

Emilio J. Puentedura, PT, DPT, PhD, OCS, FAAOMPT, is a clinical professor at the hybrid-model Doctor of Physical Therapy Program at the Robbins College of Health and Human Sciences, Baylor University in Waco, TX. A manual therapist with over 45 years of experience, he has more than 30 years of teaching experience, has published over 100 papers, and has received multiple research awards.

Keri Maywhort, PT, DPT, is a Senior Lead Instructor and Co-Founder of the Dry Needling Academy. She has been involved in dry needling education since 2008, teaching both post-professional learners and entry-level students. Keri is an adjunct faculty member in the Doctor of Physical Therapy programs at Regis University (residential) and the University of Colorado-Colorado Springs (hybrid model). Additionally, she has contributed as a member of the Federation of State Boards of Physical Therapy Dry Needling Task Force.

Stephanie Pascoe, PT, DPT, DSc, is an assistant professor and the director of post-professional education at the University of Colorado. She is a Board-Certified Orthopaedic Clinical Specialist through the American Physical Therapy Association and a Fellow of the American Academy of Orthopaedic Manual Physical Therapists. She has been teaching musculoskeletal content for over 15 years.

Bradford Tracy, PT, DPT, DSc, OCS, FAAOMPT, is an assistant professor at South College—Knoxville. He is a Board-Certified Orthopaedic Specialist through the American Board of Physical Therapy Specialties and a Fellow of the American Academy of Orthopaedic Manual Physical Therapy.

Adam Weaver, PT, DPT, is a senior physical therapist at Connecticut Children’s and splits his time as a sports physical therapist and research coordinator for Connecticut Children’s Orthopedics, Sports Medicine and Physical Therapy departments. He has over 15 peer reviewed articles specific to quadriceps recovery, blood flow restriction training and outcomes after ACL Reconstruction.

Millicent Weber, BS, MA, PhD(c), serves as the Data Science Librarian at the Baylor Libraries. She is currently finishing up her Ph.D. in Applied Psychology remotely through Southern Illinois University Carbondale (SIUC), where she also served as an Associate and Senior Advisor at Applied Research Consultants.

Dominic Severino, DPT, PhD(c), OCS, FAAOMPT, is an Assistant Professor at Whitworth University in Spokane, WA. He is completing his Ph.D. in Physical Therapy through Nova Southeastern University in Fort Lauderdale, FL.

Shane Koppenhaver, PT, PhD, is a Clinical Professor and Associate Chair for Research at Baylor University’s Department of Physical Therapy. He has received over $6 million in grant funding, published approximately 90 scientific papers in peer-reviewed journals, delivered 80 professional presentations, and received numerous research awards.

Funding Statement

The author(s) reported there is no funding associated with the work featured in this article.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data sharing statement

The data supporting the findings of this study are available upon reasonable request via e-mail from the corresponding author. The data may be reused under the terms of the Creative Commons Attribution 4.0 International License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work.

Statement of institutional review board

The Baylor University Institutional Review Board (IRB) determined that the research project was EXEMPT from review. IRB Reference # 1969299