If someone changes their views, do you applaud or condemn them? Are they someone who challenged their bias and viewpoint or are they a flip-flopper who lacks conviction?
I am of the former opinion. I ascribe to the Paul Saffo (link) mantra of ‘strong opinions, weakly held.’ I will stand by my beliefs until objective evidence points me in a different direction, at which point I will happily make the switch. Although, if significant time or money was invested in the previous viewpoint, happiness may not be involved.
Here’s the kicker. Once you make that radical shift in a viewpoint, a second shift is far more challenging. When you confront your bias, listen and adhere to disconfirming evidence, and change your mind, you are more convicted that the new way of thinking must be right.
This frequently happens in healthcare and it is a big problem.
It happened to me with dry needling.
I stopped dry needling patients
“You cannot overestimate the unimportance of practically everything.” — John Maxwell
The day was finally here. After treating for a little over a year, I completed residency, took on a clinic director role, and published my first paper — a case series in the Journal of Orthopedic and Sports Physical Therapy — but the real prize was just now arriving.
It was finally time to become dry needling certified.
Dry needling is the use of solid filiform needles to stimulate muscle tissue and surrounding fascia with the goal of reducing pain and improving neuromuscular recruitment. The clinician penetrates the skin and inserts the needle into the desired tissue. The needle can either be left in situ (often 10–20 minutes) or rapidly moved up and down until a local muscle twitch response is achieved (“pistoning”). The latter is more common and is referred to as trigger point dry needling. The number of needles varies depending on the style, location, and desired effect.
Dry needling would be the game-changer. It was the advanced technique that would take my clinical practice to new heights and solve all my patients’ problems. Or so I thought in 2015.
During the training, several of us were not only sponges for information, we were sponges for needles. We would volunteer to be the practitioner and patient for every technique possible — the ones on and off of the course agenda. Some 400 needles and 34 hours later, I crashed on my couch exhausted but excited to continue practicing.
Over the next few months, I blew past my ’50 cases with supervision’ requirement and prepared for the second weekend of training. Another 30+ hours and 400+ needles later, I was finally certified and ready to needle away all pain and trigger points (fancy term for muscle knots).
There are several theories behind the effect of dry needling. It may reduce pain by affecting the biochemical environment and local blood flow surrounding a trigger point and the nervous system. It may also cause hormonal and peptide changes for a short-term pain-reducing effect. While I understood the current theories of the mechanism, once certified, my primary focus was on the results.
Many of my patients were equally excited for the day I was certified. I had recently opened a new clinic. As a solo clinician, no one in the building was available to needle patients. Before I was certified, those seeking dry needling had to settle for my non-twitch response-inducing hands. But once the certification was hung on my wall, there was no holding me back.
I would talk up the beneficial effects of dry needling, use it as a primary intervention, and listen to patients sing my praises. I even had some patients acting as salespeople for others, telling anyone who would listen that dry needling should be added to their plan of care.
All of this continued for about two years and then I was asked to help teach the certification course. I had helped in the lab portion before but had never lectured on the content. To prepare, I conducted a deep dive into the literature, far more robust than the review I conducted as a participant. That is when the glass-shattering moment hit.
It turns out, the research in support of the effectiveness of dry needling is weak.
Yes, the outcomes I achieved were real. Yes, there are studies that demonstrate patients experience a reduction in pain following dry needling. But many studies show the effect is no greater than a control group or sham dry needling. If there is a difference, the effect sizes are small, not any better than other treatment options.
What is going on? Why is the research different from the experiences of my patients?
The improvements are driven by one of the most powerful treatments in healthcare: placebo.
Once I understood the primary influence of placebo, I stepped away from dry needling, refusing to use it in clinical practice or teach it. But here’s the problem with my line of thinking: placebo is part of every treatment we do.
You can’t completely remove the placebo effect
A placebo is an inert treatment. The most common is a sugar pill, used to tease out the effects of a medication with active ingredients. The placebo effect is when a treatment effect is noted after receiving a placebo. For example, if you give someone a sugar pill but tell them it is pain medication, they will likely experience a reduction in pain.
Placebo is influenced by expectations. Our mind expects an effect to occur and our bodies make it happen. Placebo is found in all aspects of health care. Even surgery often includes placebo, with previous research showing patients derive the same benefit from receiving a sham surgery as a real one for knee pain.
How would you respond to an exercise if primed with one of the following messages by a physical therapist?
“I just finished designing a personalized exercise program for you. I think you will find these initial exercises particularly helpful. Many of my patients report their pain improves after completing them.”
“A have a handful of exercises for you. I’m not gonna lie, they aren’t fun. It’s likely they will increase your pain but they are necessary for your condition.”
I guarantee if you run a trial, the second group will report far more pain after completing the prescribed exercises than the first group. Expectations matter. Placebo modulates every interaction we experience. Placebo is not an all or none phenomenon.
How does this apply to dry needling?
When I first needled my patients, they experienced a real reduction in pain and improvement in function, but they also all expected a good response. I talked up the treatment — as did surrounding patients. If the patient felt better later, they assumed needling was the cause, even if natural history, regression to the mean, or many other potential factors may have been responsible. Granted, if they didn’t feel better, other factors would be blamed (e.g. a poor night of sleep).
The reliance on placebo and expectations is what drove me away from the procedure. Why puncture skin and add the cost of needles when they aren’t needed? Dry needling is never necessary to help someone recover.
I missed the big picture.
I will now needle patients but rarely
I have taken a big picture approach with exercise and been critical of trials that knock it down. For example, some studies show exercise doesn’t help with pain, therefore it isn’t useful in rehabilitation. However, exercise has many more health benefits — improved strength, endurance, cardiovascular health, mental health, resilience, metabolic health — that to narrow your view to pain is a disservice to the patient.
Yet that is exactly what I did with dry needling.
I have not given dry needling — or manual therapy — the same assessment. Instead, because of my previous mind shift, I dismissed the potential value of a treatment that falls in line with patient expectations. I did not look at the secondary benefits — patient buy-in to therapy, short-term pain reduction, avoiding harmful treatments (e.g. opioids) — and instead only looked at the therapeutic effect relative to sham.
Now, I will note that patients need to be informed. Also, effect size matters. Just because a treatment “works” does not mean it is appropriate. When I treat patients, I have a finite amount of time to work with them. My treatments must use that time efficiently and effectively. I provide treatments that fall in line with patient goals and I use shared-decision making.
Going forward, some of those treatments will include dry needling.
If a patient expects dry needling — either because of previous experience or recommendations they received — I will consider using it. First, I will explain the potential benefits — acknowledging placebo likely plays a large role — and risks of dry needling. I will then stress that dry needling is not a stand-alone treatment. It does not heal anyone. Dry needling can be implemented within a plan of care provided the high-value, long-term treatments are prioritized (exercise, pain education, lifestyle habits such as diet and sleep).
If all of those boxes are checked, then dry needling can be a great resource for my patients. It can be the treatment that gets them through a rough patch of treatment. It can be the difference between seeking an opioid solution and not.
This experience has reminded me to avoid thinking in absolutes. Every time I make a dramatic shift in my thinking, the sunk-cost fallacy tugs at me. I reflect, even if I don’t want to, on the “wasted” time, money, and effort. Yet, they weren’t a waste.
It’s ironic as sunk-cost often causes people to cling to dry needling as they don’t want to acknowledge current research doesn’t support the technique they spent time, money, and effort learning. But again, this isn’t an all-or-none situation.
I refused to teach the dry needling class for three years because of my changed mindset.
I am scheduled to teach part of our next weekend course.
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