IMPORTANCE: Dry needling (DN) is widely used in musculoskeletal practice. However, the incidence and severity of adverse events (AEs) associated to DN remain unclear.
OBJECTIVE: The objective was to report the frequency and severity of AEs related to DN.
DESIGN: This was a systematic review with meta-analysis.
SETTING: Following the PRISMA checklist, PubMed, Web of Science, and Scopus databases were systematically searched from September 2024 to April 2025.
STUDIES AND INTERVENTION: Case reports, case series, surveys, observational studies, and randomized clinical trials conducted on humans, applying DN and assessing associated AEs, were collected.
MAIN OUTCOMES AND MEASURES: Methodological quality and risk of bias were assessed using the Joanna Briggs Institute tool, the AXIS tool, the PEDro scale and the Newcastle-Ottawa scale. Data were screened and extracted by 2 independent investigators, consulting a third researcher in case of doubts. The information was analyzed and classified in separate tables detailing the characteristics of the sample, the interventions, the AEs, and the methodological quality from the different types of studies.
RESULTS: A total of 59 articles were included, comprising 25 patients in case reports and case series, 1947 patients in randomized clinical trials and prospective observational studies and 2380 professionals in surveys. DN was found to commonly produce minor AEs, ranging from 0% to 48.15% per treatment and from 2.56% to 72.73% throughout a clinician's career. Major AEs per treatment are uncommon (0%-0.43%) but are reported by 0.98% to 39.14% of professionals when assessing their complete clinical practice.
CONCLUSIONS AND RELEVANCE: While DN is widely used and generally associated with minor AEs, this review highlights the potential for rare although serious complications.
| Discipline Area | Score |
|---|---|
| Rehab Clinician (OT/PT) |  |
| Physician | |
Physician rater
In musculoskeletal pain practice, dry needling appears safe, with minor AEs, while serious AEs remain rare. This supports pre-procedural history-taking, anatomical prudence, and informed consent. Study limitations are inconsistent AE definitions and reporting, reliance on case reports (selection/publication bias) and career-recall surveys (recall bias), high statistical heterogeneity (I²), wide confidence intervals, and language restrictions.
Physician rater
Dry needling typically causes minor, temporary side effects. However, needling in the thoracic/cervical periscapular and paraspinal areas carries the greatest risk of serious injury. Patients with implants or recent surgery are at risk of deep infection. Ultrasound guidance and anthropometry-based techniques can reduce the risk of pneumothorax and nerve damage. Shorter thoracic needles are recommended. Standardized adverse event reporting, informed consent procedures, and comprehensive training are essential.
Rehab Clinician (OT/PT) rater
This systematic review addresses an important and clinically relevant topic. Dry needling is widely used, but adverse events remain insufficiently understood. The review could support safer clinical practice, practitioner training, patient screening, and informed consent. Studies using active adverse event monitoring should be distinguished from those relying on spontaneous or retrospective reporting. Failure to report an adverse event does not necessarily mean that none occurred. The classification of syncope as a major adverse event may require further justification because brief vasovagal syncope may resolve without lasting harm.
Rehab Clinician (OT/PT) rater
As a clinician working in the field of orthopedic physical therapy, I expected dry needling to be associated primarily with mild adverse events. However, this article systematically presents the incidence of serious complications and highlights the risks that require particular attention, especially when performing dry needling in the cervical and thoracic regions, thereby providing strong evidence to support my clinical decision-making. It is also a valuable resource by providing evidence-based information that I can use to educate patients and facilitate the informed consent process.
, McMaster University