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EVIDENCE-TO-PRACTICE REVIEW  

 

21 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 4 – Issue 2 – September 2021 

 
 

Dry Needling and Management of Trigger Points with Low Back Pain: 
An Evidence to Practice Review  
Matthew J. Drescher, DAT, LAT, ATC; Matthew J. Rivera, DAT, LAT, ATC; Lindsey E. Eberman, PhD, LAT, ATC 
Indiana State University, Terre Haute, IN 

  

 
ABSTRACT 
Low back pain is a common health concern. The 
development of myofascial trigger points due to low back 
pain can cause debilitating pain and loss of functional 
movement in patients. Dry needling is a minimally invasive 
procedure that has shown to be useful in the treatment of 
myofascial trigger points when used with other forms of 
treatment. However, the literature surrounding dry 
needling and myofascial trigger points in patients with low 
back pain is lacking. The guiding systematic review and 
meta-analysis sought to analyze the effectiveness of dry 
needling for patients with low back pain. The review 
utilized eight databases for randomized controlled trials 
and selected 11 of 784 articles for analysis based on 
inclusion and exclusion criteria. A 6-subgroup meta-analysis 
was conducted on these studies, and 6 of the 11 studies 
were found to have high risk of bias. The included studies 
used both pain measurements and functional measurements 
including the visual analogue scale (VAS), Oswestry 
Disability Index (ODI), and the Roland-Morris Disability 
Questionnaire (RDQ). The studies did not include objective 
functional measurements. Overall researchers found a 
clinically meaningful decrease in outcome scores in the 
short-term, but there were no significant differences in pain 
or functional outcomes through long-term follow-up. This 
seems to correlate with the current literature on dry 
needling and its inflammatory effects on the body, 
suggesting that dry needling alone does not provide any 
long-term effect on myofascial trigger points in patients 
with low back pain. Dry needling should be combined with 
other treatments and high-quality rehabilitation to provide 
longer-lasting results and better treatment outcomes for 
patients with low back pain. 
  
 
Key Phrases 
Functional testing, manual therapies, patient-
reported outocmes 

 
Correspondence 
Dr. Matthew Drescher, 567 Nth 5th St, Terre Haute, IN 
47809. 
E-mail: mdrescher@sycamores.indstate.edu  
Twitter: @Matt_Drescher  
 
Full Citation 
Drescher MJ, Rivera MJ, Eberman LE. Dry Needling 
and Management of Trigger Points with Low Back 
Pain: An Evidence to Practice Review. Clin Pract Athl 
Train. 2021;4(2): 21-25. 
https://doi.org/10.31622/2021/0004.2.3.     
 
Submitted: October 16, 2020 Accepted: March 11, 2021. 

 

ORIGINAL REFERENCE 
Liu L, Huang QM, Liu QG, Thitham N, Li LH, 
Ma YT, Zhao JM. Evidence for dry needling in 
the management of myofascial trigger points 
associated with low back pain: a systematic 
review and meta-analysis. Arch. Phys. Med. 
Rehabil. 2018, 1;99(1):144-52. 
 
SUMMARY 
 
CLINICAL PROBLEM AND QUESTION 
 

Low back pain (LBP) is a common healthcare 

concern worldwide for both the patient and the 
healthcare system itself. This has subsequent 
burden, both socially and economically, to the 
patient and the healthcare system.1 In many cases, 
the development of myofascial trigger points 
(MTrPs) due to chronic LBP can cause debilitating 
pain and loss of function in patients. MTrPs are 
defined by Simons et al. as a hyperirritable 
nodule within a taut band of muscular fibers, and 
these are typically painful to palpation.2 Dry 
needling (DN) is a minimally invasive therapy that 
uses small monofilament needles to produce 
physiological changes in the patient, most often 
targeted at muscle tissue.3 It is widely accepted 
that the needle causes microtrauma in the tissue, 
resulting in a cascade of physiologic events that 
produce changes in the body. These changes 
include pain modulation (via gate-control and 
descending pain control theories), increased blood 
flow, and reduction in taut band activity in the 
muscle.4, 5 Current physiological theory states that 
taut bands of muscle and MTrPs cause ischemic 
conditions within the muscle leading to the increase 
in acetylcholine left in the interstitial tissue. This 
causes sensitization of peripheral pain receptors, 

mailto:mdrescher@sycamores.indstate.edu
https://doi.org/10.31622/2021/0004.2.3


Dry Needling and Management of Trigger Points with Low Back Pain: An Evidence to Practice Review 
 

 

22 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 4 – Issue 2 – September 2021 
 

and it is hypothesized that long-term peripheral 
sensitization can cause central nervous system 
sensitization in the spinal cord leading to chronic 
pain.6, 7 

Previous literature suggests that DN treatment 
improves the outcomes in patients with MTrPs when 
combined with other treatments.8 However, 
current literature on utilizing DN treatments on 
MTrPs in patients with LBP is lacking. Further, the 
quality of evidence is low due to low sample sizes. 
The guiding systematic review and meta-analysis 
sought to provide a quantitative analysis on the 
effectiveness of DN for patients with MTrPs when 
compared to other treatments individually and in 
combination with other treatments. 

SUMMARY OF LITERATURE 

The guiding review used eight databases and 
searched for randomized controlled trials that 
included patients with diagnosed LBP and MTrPs, 
DN used as a treatment alone, and pain and or 
functional movement used as an outcome measure. 
While this review evaluated studies that 
compared DN to other treatments, these studies 
must have studied DN alone as well. This review 
did not include studies that compared different 
types of dry needling to each other, randomized 
control trials had no data, full text could not be 
obtained, or did not define MTrPs by the criteria 
set by Simons et al.2 Two blind reviewers 
evaluated the validity of studies based on the 
methodologic quality criteria list. Of the original 
784 articles identified by the original search, 11 
randomized control trials were selected for 
analysis. A 6-subgroup meta-analysis was 
conducted on the selected randomized control 
trials that evaluated pain outcomes and functional 
disability outcomes at post-intervention and 
follow-up. Of the 11 studies included, 6 presented 
with high risk of bias due to lack of blinding of 
practitioners and patients, low trial numbers, or 
low patient recruitment. There is also limited 
information on objective measurement of 

functional scores or pain due to lack of integration 
in the studies reviewed. 

SUMMARY OF OUTCOMES 

The outcomes used within the included studies 
were pain intensity scores either by visual 
analogue scale (VAS) or an alternate Likert scale, 
and functional disability with either the Oswestry 
Disability Index (ODI) or the Roland-Morris 
Disability Questionnaire (RDQ). One study utilized 
a custom Likert scale model for pain intensity and 
functional disability. Both ranged from 0-3, with 0 
being no pain or restriction, respectively, and 3 
being severe pain or restriction, respectively.9 
Overall, 10 studies utilized the VAS,10-19 3 studies 
utilized the ODI,16, 17, 19 and 7 studies utilized the 
RDQ.10-15, 19 In the original studies, researchers 
identified clinically meaningful improvements in 
the outcome scores in all recorded outcome 
measures after the use of DN intervention. 
However, the differences ranged between 
studies, where some studies only found moderate 
changes and others showed large improvements. 
One study did not assess functional disability, 
focusing only on VAS scores.18  

FINDINGS AND CLINICAL IMPLICATIONS 

At post-intervention, DN alone saw significant 
improvements in pain and functional disability 
outcomes compared to other treatments.20 
However, at follow-up evaluation there were no 
significant differences in pain and functional 
disability outcomes between the two groups. Only 
two of the studies compared DN alone with DN 
used in combination with other treatments. These 
studies found significant improvements in pain 
scale scores in the short term for DN used in 
combination with other treatments when compared 
to using DN alone. This evidence illustrates the 
usefulness in DN as a treatment in the short-term 
improvement of pain and functional disability, 
which could provide an opportunity for patients to 
see greater improvements during therapeutic 
exercise sessions.  



Dry Needling and Management of Trigger Points with Low Back Pain: An Evidence to Practice Review 
 

 

23 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 4 – Issue 2 – September 2021 
 

The results from treatment are mostly local 
physiological responses, similar to an acute 
laceration in the tissue. While there is no current 
literature on the healing response to dry needling 
specifically, it seems to reason that because DN 
has an acute inflammatory mechanism in the body, 
in terms of direct tissue disruption, the effects 
would only last for a short time. Thus, without 
further treatment such as therapeutic exercise to 
solidify tissue changes due to this disruption during 
the subsequent healing phases, the relief gained 
from dry needling would only be short lived, and 
this is reflected by the results in both clinical trials 
and meta-analytical research both 
physiologically and functionally.5, 21  

Interestingly, current literature also shows that DN 
has been effective in eliciting higher passive peak 
torque, muscle compliance, and stretch tolerance 
in target tissues at immediate follow-up and at 15 
minutes post-intervention compared to static 
stretching, and this may account for the 
improvement in functional disability scales 
immediately after treatment but not during long-
term follow-up.22 This seems to be a distinct effect 
of DN separate from the local tissue disruption 
and inflammatory response, however other 
research suggests that DN has the same moderate 
to long-term effects on peak torque, muscle 
compliance, and stretch tolerance as static 
stretching.23 Therefore, it seems that the DN 
response would not continue past the short-term 
without further stimulation such as follow-up 
therapeutic exercise. These factors shed light onto 
the short-term effects seen by studies investigating 
DN alone. Furthermore, low back pain is often a 
multifactorial pathology. The multiple mechanisms 
of treatment that occur from DN may explain why 
there are beneficial effects for patients with LBP 
within the short-term window as shown by the 
guiding review.20  

A majority of studies in this review had a high risk 
of bias due to lack of blinding of patients or 
practitioners. However, it is nearly impossible in 

clinical outcomes research, specifically with 
manual therapy, to blind study participants to the 
treatment. In addition, the clinicians must know 
what treatment they are performing to actually 
perform the treatment. While single-blind 
randomized controlled trials could be performed, 
there is still a necessary unblinding required for 
this type of research. 

CLINICAL BOTTOM LINE 

Dry needling, while useful alone in the short-term 
to decrease pain and dysfunction, should be 
combined with other treatments and rehabilitation 
to provide longer-lasting results and better 
treatment outcomes in both the short-term and 
long-term treatment of LBP. While the risk of bias 
within manual therapy research is high, future 
research should endeavor to continue with highly 
rigorous research with focus on the physiological 
effects of dry needling. 

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Dry Needling and Management of Trigger Points with Low Back Pain: An Evidence to Practice Review 
 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 4 – Issue 2 – September 2021 
 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 4 – Issue 2 – September 2021 
 

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	ABSTRACT

