Most Systematic Reviews of Dry Needling for Musculoskeletal Pain Have High Risk of Bias: A Systematic Review of Systematic Reviews

OBJECTIVE: The primary aim was to evaluate the risk of bias (ROB) of systematic reviews on the effectiveness of dry needling in patients with musculoskeletal conditions. The secondary aim was to summarize findings related to harms.

DESIGN: Systematic review of systematic reviews

LITERATURE SEARCH: Five databases were searched until December 2024.

STUDY SELECTION CRITERIA: Systematic reviews that compared dry needling to any intervention

DATA SYNTHESIS: ROB was assessed using the ROB in Systematic reviews (ROBIS) tool. The type and frequency of harms reported in primary trials was extracted. A descriptive analysis was performed.

RESULTS: A total of 5190 studies were identified with 38 reviews included. Reviews were published between 2009–2024. One review (3%) had low ROB and 31 reviews (82%) had high ROB. Five (13%) reviews were low risk for ‘Eligibility Criteria’, four (11%) for ‘Identification and Selection of Studies’, twelve (32%) for ‘Data collection and Appraisal’ and two (5%) were low risk for ‘Synthesis and Findings’. Twenty-one (55%) reviews reported on harms related to dry needling. When reported, harms were mostly minor and transitory (e.g., post-needling soreness). Moderate harms included syncope (4 patients), presentation to hospital with fever, chills and a systemic upset (1 patient), chest pain (1 patient) and severe pain (1 patient).

CONCLUSION: Due to the high ROB in most systematic reviews, clear clinical recommendations for dry needling in the management of musculoskeletal pain cannot be confidently made. The inconsistent reporting of harms may result in their underestimation or overestimation.