Treatment Guidelines and Decision Tree for Dry Needling Musculoskeletal Conditions: A Consensus Statement

Background: Dry needling (DN) is commonly used to address pain and movement-related impairments, with the goal of improving range of motion, muscle performance, and functional movement. Despite its growing use, techniques and procedural parameters vary widely and lack standardization in both research and clinical practice. Purpose: The purpose of this modified Delphi study was to develop consensus statements to guide clinicians and researchers in the application of DN for use in individuals with musculoskeletal dysfunction. Study Design: A modified Delphi technique was employed with nine physical therapists identified as experts in DN. The panelists participated in four rounds of questions and related discussions to reach consensus on guidelines for implementing DN as a therapeutic intervention. Additionally, the authors developed a decision tree outlining key clinical decision-making parameters, including patient candidacy, treatment dosage, target tissue selection, and post-intervention strategies. Results: The panel reached consensus on all statements guiding DN interventions. Individuals experiencing musculoskeletal pain, mobility limitations, muscle performance deficits, or movement dysfunction may be appropriate candidates for DN, provided they are first evaluated for absolute contraindications, precautions, or reasons to modify or defer treatment. DN dosage including the number of needles used, anatomical regions treated, and overall treatment volume, as well as intensity and aggressiveness should be based on the patient's level of irritability and estimated tolerance for treatment. A comprehensive functional movement examination should be conducted before and after DN intervention. When neurological assessments reveal deficits, DN targeting spinal segmental structures-such as the multifidus at the corresponding nerve root levels-should be considered; peripheral structures may be targeted when impairments are identified through manual muscle testing, range of motion assessments, flexibility evaluations, pain provocation testing, or diagnosis-specific special tests. Immediately following DN treatment and reassessment, patients should perform appropriate therapeutic exercises to load the treated tissues and address movement impairments identified during reassessment. If no meaningful change is observed, clinicians should re-evaluate the working hypothesis, including movement, neurological, or regional assessment findings, and adjust treatment accordingly to better align with the primary driver of dysfunction. Clinicians should also provide education on post-treatment expectations to support post-needling response and recovery (e.g., expected soreness, activity modification) and optimize outcomes. Conclusion: This consensus provides clinical guidance on the utilization of DN, including recommendations for patient selection, determining appropriate treatment scope and intensity, and identifying when DN should be directed toward spinal segments versus extremities. It also emphasizes key post-treatment considerations, such as reassessment and patient education, to enhance therapeutic outcomes. Level of Evidence: Level V (Expert Opinion / Consensus Statement).