Coverage Policy Manual
Policy #: 2016020
Category: Medicine
Initiated: July 2016
Last Review: July 2018
  Dry Needling of Myofascial Trigger Points

Description:
Dry needling refers to a procedure in which a fine needle is inserted into the skin and muscle at a site of myofascial pain. The needle may be moved in an up-and-down motion, rotated, and/or left in place for as long as 30 minutes. The intent is to stimulate underlying myofascial trigger points, muscles, and connective tissues to manage myofascial pain. Dry needling may be performed with acupuncture needles or standard hypodermic needles, but is performed without the injection of medications (eg, anesthetics, corticosteroids). Dry needling is proposed to treat dysfunctions in skeletal muscle, fascia, and connective tissue; diminish persistent peripheral pain; and reduce impairments of body structure and function.
 
The physiological basis for dry needling depends on the targeted tissue and treatment objectives. The most studied targets are trigger points. Trigger points are discrete, focal, hyperirritable spots within a taut band of skeletal muscle fibers that produce local and/or referred pain when stimulated. Trigger points are associated with local ischemia and hypoxia, a significantly lowered pH, local and referred pain, and altered muscle activation patterns. Trigger points can be visualized by magnetic resonance imaging and elastography. Reliability of manual identification of trigger points has not been established. Deep dry needling is believed to inactivate trigger points by eliciting contraction and subsequent relaxation of the taut band via a spinal cord reflex. This local twitch response is defined as a transient visible or palpable contraction or dimpling of the muscle, and has been associated with alleviation of spontaneous electrical activity; reduction of numerous nociceptive, inflammatory, and immune system related chemicals; and relaxation of the taut band. Deep dry needling of trigger points is believed to reduce local and referred pain, improve range of motion, and decrease trigger point irritability. Superficial dry needling is thought to activate mechanoreceptors and have an indirect effect on pain by inhibiting C-fiber pain impulses. The physiological basis for dry needling treatment of excessive muscle tension, scar tissue, fascia, and connective tissues is not as well described in the literature(APTA, 2013). Alternative nonpharmacologic treatment modalities for trigger point pain include manual techniques, massage, acupressure, ultrasonography, application of heat or ice, diathermy, transcutaneous electrical nerve stimulation, and spray cooling with manual stretch (Alvarez, 2002).
 
Regulatory Status
Dry needling is considered a procedure and, as such, is not subject to regulation by the U.S. Food and Drug Administration.
 
Coding
There is currently no specific CPT code for dry needling. The AMA CPT instructs that the unlisted code 20999 should be used for the dry needling procedure. Because dry needling is not acupuncture, CPT codes 97810-97814 are not appropriate.

Policy/
Coverage:
Dry needling of myofascial trigger points does not meet member benefit certificate Primary Coverage Criteria due to the lack of clinical evidence demonstrating its impact on improved health outcomes.  .
 
For members with contracts without primary coverage criteria dry needling of myofascial trigger points is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.      

Rationale:
Randomized controlled trials (RCTs) are particularly important to assess treatment of pain, due to expected placebo effect, the subjective nature of pain outcomes, and the variable natural history of pain that often responds to conservative care. For these reasons, controlled trials are needed to demonstrate the clinical effectiveness of dry needling of trigger points for treating myofascial pain. Evidence assessed for this review focuses on sham-controlled RCTs and RCTs that compare dry needling with manual therapy.
 
Dry Needling of Trigger Points
A number of RCTs and systematic reviews have assessed dry needling for the treatment of trigger points in the neck, heel, and temporomandibular joint.
 
Neck Pain
A 2015 qualitative systematic review by Cagnie and colleagues included 8 studies that met selection criteria for deep dry needling of trigger points of the upper trapezius in patients with neck pain (Cagnie, 2015). Only studies rated as moderate or good quality were included. Outcomes for the short and medium term were assessed for pain, range of motion (ROM), functionality, and quality of life (QOL). Control treatments included lidocaine injection plus self-stretching, non‒trigger point deep needling, mini-scalpel needling, sham acupuncture, and superficial dry needling. All studies showed a decrease in pain with dry needling, but only 1 study found greater improvement in pain with dry needling compared with other treatments. The review found moderate evidence that dry needling, ROM exercises, and lidocaine injections increased ROM. One study found an improvement in QOL comparable to that of nonsteroidal anti-inflammatory medications and, of 3 studies that assessed depression, only 1 found a significant improvement after treatment with deep dry needling.
 
A 2014 report by Llamas-Ramos and colleagues compared trigger point dry needling with trigger point manual therapy in an RCT of 94 patients (Llamas-Ramos, 2015). Strengths of this study included allocation concealment, blinding, intention-to-treat analysis, and adequate power. Patients treated with manual therapy had outcomes similar to dry needling for the primary outcomes of decreased neck pain intensity and disability. For example, pain intensity was 6.2 at baseline for both groups; it decreased to near 2 immediately post-intervention and near 1 at 2-week follow-up. Cervical ROM was also improved to a similar extent in the 2 groups, while pain pressure threshold was significantly better for the dry needling group. Temporary muscle soreness or fatigue was reported by 55% of the dry needling group and 23% of the manual therapy group.
 
Plantar Heel Pain
Cotchett and colleagues reported a systematic review of dry needling and injections of myofascial trigger points associated with plantar heel pain in 2010 (Cotchett, 2010). Three quasi-experimental trials were identified: 2 used dry needling combined with acupuncture and a third examined lidocaine injections combined with physical therapy. The methodologic quality of the trials was rated as poor and meta-analysis was not conducted due to heterogeneity between the trials.
 
In 2014 Cotchett and colleagues reported a double-blinded, sham-controlled RCT of trigger point dry needling for plantar heel pain (Cotchett, 2014). Patients (N=84) with plantar heel pain of at least 1 month in duration were assigned to 6 weekly active or sham treatments. The primary outcomes, first step heel pain and Foot Health Status Questionnaire (FHSQ) scores at 6 weeks, were measured in 81 (96.4%) patients. The group given dry needling had statistically significantly greater improvement in first step pain and foot pain (adjusted mean difference of 14.4 mm on a 100-mm visual analog scale [VAS] and 10.0 points on the FHSQ), but the magnitude of change did not reach the prespecified minimally important difference (MID) for the scales used. Seventy (32% of treatments) minor adverse events were reported in the active dry needling group compared with only 1 (<1%) in the sham group. The number needed to harm was 3. Strengths of this trial included allocation concealment, patient and evaluator blinding, sample size calculations for adequate power, and a high rate of follow-up. Limitations included lack of a clinically significant mean response and the lack of reporting response rates (ie, the percentage of patients who experienced improvement on the primary outcome measures that was equal to or greater than the prespecified MID).
 
Temporomandibular Pain
A double-blind, sham-controlled trial of dry needling for the treatment of temporomandibular myofascial pain was reported by Diracoglu and colleagues (Diracoglu, 2012). Patients (N=52) with symptoms for at least 6 weeks with 2 or more myofascial trigger points in the temporomandibular muscles were included in the trial. Trigger points were stimulated once weekly over 3 weeks. The sham condition involved dry needling in areas away from the trigger points. Both groups showed significant improvements in pressure thresholds and VAS scores at 1 week posttreatment, although the improvement in pressure threshold was greater for the study group. Neither group showed improvement in unassisted jaw opening without pain. Post hoc power analysis found sufficient power to detect improvement in algometric measurements.
 
Adverse Events
A prospective survey of 39 physical therapists, providing 7629 dry needling treatments, reported 1463 (19.18%) mild adverse events (bruising, bleeding, and pain) and no serious adverse events (Brady, 2014).
 
Ongoing and Unpublished Clinical Trials
Some currently unpublished trials that might influence this review are listed below:
 
Ongoing
 
(NCT02312895) Randomized Controlled Trial Comparing the Use of Dry Needling to Manual Therapy for Patients with Mechanical Low Back Pain; planned enrollment 100; completion date December 2016.
 
(NCT02532595) Trigger Point Dry Needling, Manual Therapy and Exercise vs Manual Therapy and Exercise for the Management of Achilles Tendinopathy; planned enrollment 66; completion date December 2016.
 
(NCT02373631) Dry Needling Versus Conventional Physical Therapy in Patients with Knee Osteoarthritis: a Multi-Center Randomized Clinical Trial; planned enrollment 105, completion date February 2017.
 
(NCT02373618) Dry Needling Versus Conventional Physical Therapy in Patients with Plantar Fasciitis: a Multi-Center Randomized Clinical Trial; planned enrollment 108; completion date February 2017.
 
(NCT02373644) Spinal Manipulation and Dry Needling Versus Conventional Physical Therapy in Patients With Sacroiliac Dysfunction: a Multi-center Randomized Clinical Trial; planned enrollment 95; completion date February 2017.
 
(NCT02415660) Short-Term Response of Thoracic Spine Manipulation With or Without Trigger Point Dry Needling for Mechanical Neck Pain: A Randomized Clinical Trial; planned enrollment 58; completion date October 2017.
 
Summary of Evidence
For individuals who have trigger points associated with myofascial pain who receive dry needling of trigger points, the evidence includes a number of randomized controlled trials and systematic reviews. Relevant outcomes are symptoms, functional outcomes, quality of life, and treatment-related morbidity. Overall, dry needling of trigger points has not been shown to be clinically superior to sham treatment or manual therapy. In addition, dry needling is associated with a high incidence of mild adverse events. The evidence is insufficient to determine the effects of the technology on health outcomes.
 
Practice Guidelines and Position Statements
American Physical Therapy Association
The American Physical Therapy Association (APTA) guideline BOD G02-14-18-12 on physical therapist scope of practice lists dry needling as 1 of the interventions provided by physical therapists9: “Physical therapy, which is limited to the care and services provided by or under the direction and supervision of a physical therapist, includes: … (2) alleviating impairment and functional limitation by designing, implementing, and modifying therapeutic interventions that include, but are not limited to: Dry needling.” In 2013, APTA issued an educational resource paper that includes the following indications for dry needling: radiculopathies, joint dysfunction, disc pathology, tendonitis, craniomandibular dysfunction, carpal tunnel syndrome, whiplash-associated disorders, and complex regional pain syndrome (APTA, 2002).
 
American Academy of Orthopaedic Physical Therapists
In 2009, the American Academy of Orthopaedic Physical Therapists (AAOMPT) issued a statement that dry needling is within the scope of physical therapist practice (AAOMPT, 2009). In support of this position, AAOMPT stated that “dry needling is a neurophysiological evidence-based treatment technique that requires effective manual assessment of the neuromuscular system. Physical therapists are well trained to utilize dry needling in conjunction with manual physical therapy interventions. Research supports that dry needling improves pain control, reduces muscle tension, normalizes biochemical and electrical dysfunction of motor endplates, and facilitates an accelerated return to active rehabilitation.”
 
2017 Update
A literature search conducted through June 2017 did not reveal any new information that would prompt a change in the coverage statement. The key identified literature is summarized below.
 
Several RCTs have been published since the Cagnie review (Llamas-Ramos, 2014; De Meulemeester, 2017; Perez-Palomares, 2017; Cerezo-Tellez, 2016(a); Cerezo-Tellez, 2016(b). As noted above, the review focused on trials comparing dry needling with sham or manual therapy. None of the new RCTs was sham-controlled; 2 compared dry needling and manual therapy and are described next.
 
In 2017, De Meulemeester and colleagues published an RCT assessing 42 patients with myofascial neck and/or shoulder pain (De Meulemeester, 2017). Patients were assigned to receive 4 sessions of dry needling (n=20) or manual pressure (n=22). The primary outcome was disability assessed using a 50-point Neck Disability Index (NDI). Baseline NDI score was at least 10 in all patients. Patients were evaluated at the end of the intervention period and again after 3 months. There were no significant differences in NDI scores between the dry needling group and the manual pressure group at either follow-up point (p>0.05). In addition, findings were not significantly better in the dry needling compared with the manual pressure group for secondary outcomes, including the pressure pain threshold and pain intensity (measured on a numeric rating scale).
 
American Physical Therapy Association
A 2012 educational resource paper by the American Physical Therapy Association (APTA) stated: “Dry needling (DN) is a skilled intervention used by physical therapists (where allowed by state law) that uses a thin filiform needle to penetrate the skin and stimulate underlying myofascial trigger points, muscular, and connective tissues for the management of neuromusculoskeletal pain and movement impairments (APTA, 2017)”.
 
2018 Update
A literature search was conducted through June 2018.  There was no new information identified that would prompt a change in the coverage statement.

CPT/HCPCS:
20999Unlisted procedure, musculoskeletal system, general

References: Alvarez DJ, Rockwell PG.(2002) Trigger points: diagnosis and management. Am Fam Physician. Feb 15 2002;65(4):653-660. PMID 11871683

American Academy of Orthopaedic Physical Therapists.(2009) AAOMPT position statement on dry needling. 2009; https://www.aaompt.org/about/statements.cfm. Accessed December 31, 2015.

American Physical Therapy Association (APTA).(2012) Guidelines: Physical therapist scope of practice BOD G02-14-18-12. 2012; https://www.google.com/?gws_rd=ssl#safe=active&q=2009+apta+position+statement+on+dry+needling.

American Physical Therapy Association (APTA).(2012) Physical Therapists and the Performance of Dry Needling. 2012; http://www.apta.org/StateIssues/DryNeedling/ResourcePaper/. Accessed March, 2017.

American Physical Therapy Association (APTA).(2013) Educational resource paper: Description of Dry Needling in Clinical Practice. 2013; http://www.aaompt.org/documents/dryneedlinginptclinicalpracticeeducationalresourcepaper.pdf.

Brady S, McEvoy J, Dommerholt J, et al.(2014) Adverse events following trigger point dry needling: a prospective survey of chartered physiotherapists. J Man Manip Ther. Aug 2014;22(3):134-140. PMID 25125935

Cagnie B, Castelein B, Pollie F, et al.(2015) Evidence for the use of ischemic compression and dry needling in the management of trigger points of the upper trapezius in patients with neck pain: a systematic review. Am J Phys Med Rehabil. Jul 2015;94(7):573-583. PMID 25768071

Cerezo-Tellez E, Lacomba MT, Fuentes-Gallardo I, et al.(2016) Dry needling of the trapezius muscle in office workers with neck pain: a randomized clinical trial. J Man Manip Ther. Sep 2016;24(4):223-232. PMID 27582622

Cerezo-Tellez E, Torres-Lacomba M, Fuentes-Gallardo I, et al.(2016) Effectiveness of dry needling for chronic nonspecific neck pain: a randomized, single-blinded, clinical trial. Pain. Sep 2016;157(9):1905-1917. PMID 27537209

Cotchett MP, Landorf KB, Munteanu SE.(2010) Effectiveness of dry needling and injections of myofascial trigger points associated with plantar heel pain: a systematic review. J Foot Ankle Res. 2010;3:18. PMID 20807448

Cotchett MP, Munteanu SE, Landorf KB.(2014) Effectiveness of trigger point dry needling for plantar heel pain: a randomized controlled trial. Phys Ther. Aug 2014;94(8):1083-1094. PMID 24700136

De Meulemeester KE, Castelein B, Coppieters I, et al.(2017) Comparing trigger point dry needling and manual pressure technique for the management of myofascial neck/shoulder pain: a randomized clinical trial. J Manipulative Physiol Ther. Jan 2017;40(1):11-20. PMID 28017188

Diracoglu D, Vural M, Karan A, et al.(2012) Effectiveness of dry needling for the treatment of temporomandibular myofascial pain: a double-blind, randomized, placebo controlled study. J Back Musculoskelet Rehabil. 2012;25(4):285-290. PMID 23220812

Llamas-Ramos R, Pecos-Martin D, Gallego-Izquierdo T, et al.(2014) Comparison of the short-term outcomes between trigger point dry needling and trigger point manual therapy for the management of chronic mechanical neck pain: a randomized clinical trial. J Orthop Sports Phys Ther. Nov 2014;44(11):852-861. PMID 25269764

Llamas-Ramos R, Pecos-Martin D, Gallego-Izquierdo T, et al.(2014) Comparison of the short-term outcomes between trigger point dry needling and trigger point manual therapy for the management of chronic mechanical neck pain: a randomized clinical trial. J Orthop Sports Phys Ther. Nov 2014;44(11):852-861. PMID 25269764

Perez-Palomares S, Olivan-Blazquez B, Perez-Palomares A, et al.(2017) Contribution of dry needling to individualized physical therapy treatment of shoulder pain: a randomized clinical trial. J Orthop Sports Phys Ther. Jan 2017;47(1):11-20. PMID 27937046


Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
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