What is the efficacy of dry needling (DN) for treating chronic pain in patients who have not responded to other therapies, such as physical therapy, medication management, or acupuncture?

Dry Needling for Chronic Pain: Not Recommended for Most Conditions

Dry needling should NOT be used for chronic low back pain from degenerative disease, and has limited evidence supporting its use for most chronic pain conditions in patients who have failed other therapies. 1, 2

Guideline-Based Recommendations Against Dry Needling

The American College of Neurosurgery provides Level II evidence with a Grade B recommendation explicitly against dry needling for chronic low back pain from degenerative lumbar disease, stating that long-lasting benefit has not been demonstrated. 1, 3, 2 This is the strongest and most direct guideline recommendation available, and it specifically addresses patients who have not responded to other therapies.

Conditions Where Dry Needling Should NOT Be Used:

• Chronic low back pain from degenerative disease: Strong evidence against use (Grade B recommendation) 1, 2
• Osteoarthritis: Multiple clinical practice guidelines recommend against dry needling 3, 2
• Patellofemoral pain: High-quality evidence shows no additional benefit when combined with exercise therapy and demonstrates non-efficacy compared to sham needling 3
• Headache: Insufficient evidence per VA/DoD guidelines to recommend for or against 1, 3, 2

Limited Evidence for Short-Term Use Only

If considering dry needling at all, it should only be for acute/subacute musculoskeletal pain or myofascial trigger points, and only for short-term relief (up to 12 weeks). 1, 4 The evidence shows:

• Moderate-quality evidence suggests potential effectiveness for short-term pain reduction (immediate to 12 weeks) when compared to sham or no treatment 1, 4
• Very low-quality to moderate-quality evidence shows dry needling may decrease pain more than no treatment or sham in the immediate to 12-week period 4
• Evidence of long-term benefit is currently lacking 4
• Studies show no statistically significant difference in pain reduction between dry needling and drug injections (p=0.09) 1, 2

Clinical Decision Algorithm

Step 1: Identify the Pain Condition

• If chronic low back pain from degenerative disease: Do NOT use dry needling; proceed to Step 4 for alternatives 1, 2
• If osteoarthritis, patellofemoral pain, or headache: Do NOT use dry needling 3, 2
• If acute/subacute myofascial trigger points: Proceed to Step 2 1

Step 2: Verify Treatment Failure

• Confirm patient has failed conservative management (physical therapy, medication management) 1, 3
• Do not use dry needling as first-line treatment 2

Step 3: Assess Practitioner Qualifications

• Verify practitioner has >60 hours of formal training in dry needling 1, 3, 2
• Ensure access to ultrasound guidance if needed 3
• Only proceed if these criteria are met 1

Step 4: Preferred Alternative Treatments

For patients who have failed other therapies, consider these evidence-based alternatives instead:

• For acute low back pain: Heat therapy (heating pads or heated blankets) as first-line treatment 2
• For chronic low back pain: Exercise therapy is recommended over dry needling 2
• Acupuncture (distinct from dry needling) shows improved function and pain for chronic conditions 2
• Manual therapy combined with exercise is more effective than dry needling for neck pain 2
• Mind-body interventions have new evidence supporting effectiveness for chronic low back pain 5

Critical Pitfalls to Avoid

Do not confuse dry needling with acupuncture, as acupuncture has stronger evidence for chronic pain conditions and is recommended in guidelines where dry needling is not. 2 The American College of Physicians systematic review supports nonpharmacologic therapies including acupuncture for chronic low back pain, but this does not extend to dry needling. 5

Do not use dry needling for chronic low back pain regardless of patient preference or previous treatment failures, as the American College of Neurosurgery explicitly recommends against it due to lack of long-term benefits. 1, 2

Do not expect functional improvements beyond pain reduction, as low-quality evidence shows no difference in functional outcomes when dry needling is compared to other physical therapy treatments. 4

Treatment Protocol If Proceeding (Acute/Subacute Cases Only)

If all criteria are met and dry needling is deemed appropriate for acute/subacute myofascial pain:

• Use thin monofilament needles (0.25-0.36 gauge, 25-40mm length) 3
• Typical protocol: 2 treatments per week for 8 weeks, then taper to weekly, then biweekly 3
• Patients should attend ≥80% of scheduled sessions (e.g., 19 of 24 treatments) 3
• Limit expectations to short-term relief only (up to 12 weeks maximum) 1, 4

Nuances in the Evidence

While some research studies (particularly from 2020-2022) suggest potential benefits of dry needling for chronic neck pain when combined with manual therapy 6, 7, these findings conflict with the higher-quality guideline evidence that recommends manual therapy combined with exercise over dry needling. 2 The American Society of Anesthesiologists guidelines for chronic pain management do not include dry needling in their recommended interventions, instead focusing on multimodal approaches, nerve blocks, and neuromodulation techniques. 5

The most recent and highest-quality evidence (2025-2026 guidelines from the American College of Neurosurgery) takes precedence and recommends against dry needling for chronic pain conditions. 1, 3, 2