Bridging the Dose Gap: Standardization in Dry Needling Research vs. Clinical Practice
Introduction
Dry needling has grown rapidly across physical therapy, chiropractic, athletic training, and occupational therapy. Yet one persistent challenge continues to divide the conversation: dose standardization.
In research, standardization is essential. Without consistent reporting of how many needles, how deep, how long, or whether electrical stimulation was applied, it’s impossible to compare results or build meta-analyses.
In practice, however, rigid protocols don’t make sense. Clinicians must adapt their approach to the patient in front of them, guided by factors such as SINSS (Severity, Irritability, Nature, Stage, Stability). For example, a highly irritable acute case may tolerate only minimal needling, while a stable, chronic case may benefit from higher “doses.”
This blog explores:
What recent research says about reporting gaps in dry needling
Why research and practice differ in their need for standardization
How clinicians can balance evidence with individualized care
What parameters would be most useful for future studies to report consistently
What the Evidence Tells Us
Reporting Gaps in Clinical Trials
Thomas et al. (2025) conducted a scoping review of randomized controlled trials (RCTs) and found that most failed to fully report dose parameters. Insertion depth, duration, pistoning technique, or whether e-stim was used were often omitted. Without those details, replicating or comparing studies is almost impossible【Thomas 2025】.
Wide Variability in Clinical Practice
Valera-Calero et al. (2024) surveyed clinicians and confirmed wide variability in how dry needling is applied. Some use a single insertion, others multiple. Some leave needles in for minutes, others seconds. Electrical stimulation parameters varied from one clinic to the next【Valera-Calero 2024】.
Similarly, Puentedura et al. (2025) showed that even among clinicians with similar training backgrounds, practices differ dramatically—suggesting that dosing decisions are strongly influenced by clinician preference and patient presentation【Puentedura 2025】.
Why Research Needs Standardization
Kearns et al. (2022) argued that this lack of consistency makes systematic reviews less meaningful, dilutes effect sizes, and clouds our understanding of safety. To build true dose–response data, researchers must report intervention details with much greater precision【Kearns 2022】.
Why Clinical Practice is Different
In clinical practice, strict standardization can be counterproductive. Unlike in research, where homogeneity is needed to compare groups, real-world patients present with unique constellations of pain, irritability, and functional limitation.
This is where SINSS becomes essential:
Severity – How intense are the symptoms?
Irritability – How easily are symptoms aggravated and how long do they last?
Nature – What is the underlying pathology or clinical reasoning?
Stage – Is the presentation acute, subacute, or chronic?
Stability – Are the symptoms stable or changing quickly?
For example:
A patient with severe, irritable acute neck pain may only tolerate a single, static insertion for 20 seconds.
A chronic low back pain patient with stable symptoms may benefit from multiple deeper insertions combined with e-stim for several minutes.
Trying to force both cases into the same “standardized protocol” would not only be unhelpful but could risk harm.
Take-home: In practice, we don’t want cookie-cutter protocols. We want to tailor dose to the person in front of us.
The Research–Practice Divide
So where does that leave us?
In research: we need consistency to compare interventions and to advance the evidence base. This means trials should clearly report:
Pistoning: yes/no, and if yes, how many repetitions
Needle retention: how long needles remain in situ
Electrical stimulation: whether it was used, with what frequency, intensity, and duration. Was it used as a circuit to address specific goals.
Placement: specific targets (muscles, ligaments, tendons, nerves)
In practice: we need flexibility to adapt to SINSS and treat patients as individuals. Rather than memorizing rigid protocols, clinicians should learn principles for adjusting dosage based on clinical reasoning.
The tension between these two worlds is not a contradiction—it’s a natural difference in priorities.
Practical Guidance for Clinicians
What can, and SHOULD be standardized is safety and that every needle should have a purpose. A thoughtful clinical assessment - and post treatment reassessment - should be part of each dry needling session. However, clinicians can improve consistency and safety by:
Documenting Your Parameters Clearly
Record the specific targets addressed, and e-stim parameters if applied.
Adapting to SINSS
Use symptom irritability and severity to guide how “aggressive” or “conservative” your needling should be.
Tracking Objective measures and Post-Treatment Outcomes
Pair patient outcomes (subjective pain ratings, function, ROM) with detailed documentation of your interventions.
Learning from Adverse Events
Note any bruising, soreness, or more serious reactions and connect them to dose decisions.
Avoiding Rigid Protocol Thinking
Use research findings as a guide, not a recipe. Always adapt to patient tolerance and presentation.
Future Directions
To truly advance the field, research should:
Include dose–response studies (low vs. high dose, short vs. long retention, pistoning vs. static, with vs. without e-stim).
Use consensus reporting frameworks so that every study lists parameters in the same structured way.
Explore how SINSS could be incorporated into research designs—for example, stratifying participants by irritability or severity before applying a protocol.
Encourage clinicians to publish detailed case reports or case series that include dosing details, helping bridge the gap between controlled trials and real-world practice.
Conclusion
Dry needling dose is a moving target. In research, we need more consistency and detail to make sense of outcomes across trials. In practice, however, rigid standardization doesn’t fit the reality of patient care and doesn’t match up with best practice.
By embracing both perspectives, clinicians can deliver individualized treatment tailored to SINSS, while still contributing to a broader evidence base that requires clear reporting.
Key takeaway: In research, standardization improves comparability. In practice, flexibility ensures safety and efficacy. The art of dry needling lies in balancing both.
References
Thomas E, et al. Completeness of Dry Needling Intervention Reporting in Randomized Clinical Trials. J Orthop Sports Phys Ther Methods. 2025. Link
Valera-Calero JA, et al. Current State of Dry Needling Practices: A Comprehensive Overview. 2024. PMC
Kearns C, et al. Lack of Standardization in Dry Needling Dosage and Its Implications. 2022. PMC
Puentedura EJ, et al. The Utilization of Dry Needling – a Survey of Contemporary Use. J Man Manip Ther. 2025. Link
