Expert consensus on the application of dry needling in stroke patients: A modified delphi method

Abstract

Objective

This study aimed to establish an expert consensus on the use of dry needling for treating spasticity in stroke patients via the Delphi method.

Design

A modified Delphi technique was conducted over four rounds.

Setting

The study was guided by the NEUMUSK Group Research, Department of Physiotherapy, Faculty of Health Sciences. Ávila Catholic University, following the Checklist for Reporting of Survey Studies (CROSS).

Participants

A total of 102 international experts in stroke rehabilitation and dry needling collaborated on this consensus study.

Intervention

Panellists rated 35 key questions across rounds via a 6-point Likert scale. Questions that failed to reach 70% consensus were eliminated.

Main measurements

Validated Likert scale responses to carry out the expert consensus.

Results

There was a high level of consensus regarding the use of dry needling in the early spasticity and hypertonia phases of stroke rehabilitation (early spasticity defined as the first few weeks after stroke when increased muscle tone begins to appear), with 87% and 91% agreement, respectively. However, less consensus has been reached for its application in hypotonia. Local twitch responses have been identified as critical indicators of treatment success, and ultrasound-guided dry needling has been widely endorsed for its precision. The effects of dry needling were reported to last between 48 and 72 h.

Conclusion

This study provides clear recommendations for the use of dry needling in stroke patients, particularly during the early stages of spasticity. While the short-term benefits are evident, further research is needed to optimize the treatment frequency and explore its role in different stages of recovery, such as hypotonia. This consensus will aid healthcare professionals in integrating dry needling into comprehensive stroke rehabilitation programmes.

Keywords

Dry needling stroke neurological rehabilitation consensus

Introduction

Stroke is one of the leading causes of illness and mortality due to the interruption of blood flow to the brain, either by ischaemia or haemorrhage.¹ Damage to blood vessels, such as cerebral haemorrhage or infarction, causes severe and localized injury to the central nervous system. Disruption of brain function for more than 24 h following a stroke can trigger various diffuse and focal clinical symptoms.²

Stroke survivors often face a wide range of disabilities, including coordination and balance issues, difficulty speaking or understanding language (aphasia), memory and cognitive problems, emotional disorders such as depression, and weakness or paralysis on one side of the body (hemiparesis or hemiplegia).^3,4 Approximately 35% of people who have suffered an ischaemic or haemorrhagic stroke develop spasticity.⁵ This condition tends to become chronic and causes significant changes in soft tissues, such as muscle fibrosis and abnormal enlargement of muscle fibres and the extracellular matrix.⁶

In terms of rehabilitation and treatment, spasticity can complicate programmes designed to help patients regain function. Current interventions, such as oral antispasticity medications (e.g., baclofen, tizanidine), botulinum toxin injections, and physical therapies, often present significant limitations in both efficacy and side effects.⁷ Conventional treatments for spasticity, such as oral medications and botulinum toxin, often present limitations due to side effects, repeated dosing, or restricted applicability in generalised spasticity.⁸ Physical therapies alone typically offer only short-term benefits and require adjunctive strategies for sustained impact.⁹ In this context, dry needling has emerged as a relevant technique. As a minimally invasive intervention targeting muscle and subcutaneous tissue, it has shown promising results in managing spasticity.¹⁰ The combination of dry needling with other physical therapies can significantly improve mobility and reduce pain, facilitating rehabilitation and improving patients’ quality of life.¹¹ The efficacy of dry needling in musculoskeletal conditions – such as myofascial pain syndrome, tendinopathies and joint dysfunction – has been demonstrated, particularly when integrated into multimodal rehabilitation programmes.¹² Positive effects on pain and function in lateral epicondylalgia and patellar tendinopathy support its wider therapeutic relevance.

Recent studies¹³ suggest that dry needling in combination with neurorehabilitation may reduce spasticity, increase mobility and improve quality of life. However, its use in stroke patients remains inconsistent and there is no clear consensus. This study aims to identify expert recommendations using the Delphi method to guide clinical decision making and optimize outcomes in neurological rehabilitation.

Methodology

A modified Delphi technique was employed, which entailed iterative rounds of anonymous expert surveys and structured feedback. The objective of this technique was to reach a consensus on the application of dry needling in the treatment of stroke patients. To ensure the correct presentation of the methods, results, and discussion, the guidelines from the Checklist for Reporting of Survey Studies (CROSS) were followed.¹⁴

The Steering Group (NEUMUSK research group from the Catholic University of Ávila) was composed of professionals with over 15 years of experience in managing stroke patients. It included four physical therapists specializing in neurological rehabilitation and three physicians. This group was responsible for the planning and supervision of all the study phases.

The steering group conducted preparatory work to ensure that all relevant evidence was represented in the consensus process. Relevant treatments were identified from the literature by performing a search with the following keywords: “('Stroke’[MeSH] OR ‘Cerebrovascular Accident’[MeSH]) AND (‘Dry Needling’ OR ‘Acupuncture Therapy’[MeSH]) AND ‘Trigger Points’[MeSH])” and Steering Group meetings. Key recommendations were developed into a Delphi survey presented to the panellists.

The panel selection focused on international multidisciplinary professionals experienced in managing stroke patients and trained in dry needling (Figure 1). Invitations were made through professional associations and international networks, and social networks such as LinkedIn were used to increase participation. No identifying data beyond an email address or basic demographic data were requested from the participants.

Figure 1.

Expert recruitment diagram.

The Delphi process took place between November 2023 and September 2024. All the surveys were developed and presented through the REDCap data management system,¹⁵ led by the steering group and the study's data manager. Each survey round was interactive and was based on queries and feedback. Before the first round was distributed, a pilot test was conducted with a small group of clinicians, and the survey was adjusted based on their feedback. Each round of the survey was open for four weeks, with reminders sent to no responders to encourage participation. The duration of each round was approximately fifteen minutes (Figure 2).

Figure 2.

Consensus and four expert rounds.

Round 1

In the first round, 35 key questions about the application of dry needling in stroke patients were presented, asking the panellists to rate their level of agreement with each question via a 6-point Likert scale (‘strongly agree’, ‘agree’, ‘somewhat agree’, ‘somewhat disagree’, ‘disagree’ and ‘strongly disagree’).¹⁶ After this round, questions that did not reach a 70% consensus in either agreement or disagreement were eliminated. This resulted in the elimination of 10 questions, with no new questions introduced.

Round 2

In the second round, the remaining 25 questions were included, providing participants with their previous responses along with group consensus. Again, questions that did not meet the 70% consensus threshold were eliminated, reducing the number to 14 questions. Each participant was provided with their individual score from the first round, along with a summary of the changes made to the recommendations and the group's average scores. They were then asked to reassess their level of agreement with each recommendation while considering this new information.

Round 3

In the third round, the same procedure used in the second round was followed, ensuring that there were two rating rounds for each included question, confirming consensus on all of them. These questions were integrated into the final guide and taken to the final consensus meeting for final review (Round 4).

Round 4

In the final phase of the modified Delphi process, a consensus meeting was organized with the goal of ensuring final agreement on the key recommendations to be included in the final expert consensus guide. Since there were no clear guidelines on how to structure such a meeting, the steering group (the NEUMUSK research group from the Catholic University of Ávila) decided to follow a custom approach. Twenty percent of the participants in the Delphi process were randomly selected along with members of the steering group to ensure the representativeness and diversity of opinions at this critical stage of the study.

The meeting was conducted virtually via the TEAMS platform at a previously agreed-upon date and time, with the objective of facilitating the attendance of international participants. During this session, each of the recommendations was presented and subjected to detailed examination. The meeting provided a forum for open dialogue, enabling experts to contribute their views and clarify any potential ambiguities. The recommendations that had previously reached consensus were reviewed to ensure their practical feasibility and relevance in the clinical context. Once the meeting had concluded and the necessary agreements had been reached, a final document containing the consensus recommendations was produced. This document was sent to all attendees for final review, and they were asked to confirm their approval by email, thus ensuring the validity and endorsement of the group as a whole.

This phase was pivotal in guaranteeing that the guidelines were not only founded upon evidence-based best practices but also reflected the consensus views of a multidisciplinary panel. This contributes to the robustness and applicability of the final document in daily clinical practice.

Results

A total of 102 experts in the use of dry needling, representing diverse geographical and professional backgrounds, participated in the Delphi study. Among the participants, 53% were men, and 47% were women. In terms of occupation, the majority were physiotherapists (68%), followed by doctors (17%) and physician assistants (10%). All the panellists reported being trained in the dry needling technique, ensuring that their opinions were based on practical clinical experience. The participants came from different regions, with Europe (41%) and Asia (19%) being the most represented areas (Table 1).

Table 1.

Delphi participant characteristics at study registration.

Participants (n = 102)	Frecuency (%)
Gender
Female	48 (47%)
Male	54 (53%)
Profession
Physiotherapist	69 (68%)
Physician associate	10 (10%)
Physician	18 (17%)
Professor of physiotherapy/lecturer	5 (5%)
Dry needling training
Yes	102 (100%)
No	0 (0%)
Country territory
Europe	42 (41%)
South America	11 (11%)
North America	17 (18%)
Asia	20 (19%)
Africa	5 (5%)
Oceanía	7 (6%)

The Delphi study revealed significant consensus on various aspects of dry needling use in neurological patients (Table 2). Regarding the treatment phases, the highest consensus was reached for initial spasticity (87% “strongly agree”) and hypertonia (91%), highlighting these as the most appropriate phases for intervention. In contrast, only 69% of the panellists agreed on its application during hypotonia, suggesting doubts about the technique's effectiveness in this condition. For hypersensitivity, 84% were in favour of using dry needling, but only 17% were “strongly agree” for its use in hyposensitivity, with 71% in “somewhat agree.”

Table 2.

Questionnaire.

	Strongly agree	Agree	Somewhat agree	Somewhat disagree	Disagree	Strongly disagree
Question 1. in which phase do you use dry needling in the neurological patient?
Initial spasticity		71%	20%	9%
Onset of spasticity	87%	11%	2%
Hypotonia		69%	30%	1%
Hypertonia	91%	9%
Hypersensitivity	84%	12%	4%
Hyposensitivity		17%	71%	10%	2%
Question 2. Do you perform the technique on antagonist/synergist musculature?
Do you perform the technique on antagonist/synergist musculature?	79%	14%	5%		2%
Question 3. Indicate the selection criteria for the implementation of the technique
Presence of taut band	72%	7%	21%
Presence of referred pain	11%	10%	11%	41%	27%
Presence of local pain		8%	60%	32%
Other…(please indicate which)
Question 4. Do you consider it a necessary criterion to obtain local spasm responses in order to perform the technique?
Do you consider it a necessary criterion to obtain local spasm responses in order to perform the technique?
the technique?	91%	9%
Question 5. What effects do you perceive after performing the technique?
Decreased spasticity	84%	10%	6%
Improvement of active ROM	21%	79%
Improved postural control	35%	65%
Question 6. How long do you think the effects of dry needling remain on the neurological patient?
24 h					10%	90%
48 h		58%	31%	11%
72 h	86%	14%
1 week	5%	41%	54%
More
Question 7. In case your patients feel referred pain; how would you define it
Burning	10%	9%	30%	41%	10%
Tingling	1%	38%	61%
Heaviness	78%	20%	2%
Stinging		51%	39%	10%
Other
Question 8. How often do you perform the technique on the same patient?
The day after application					2%	98%
2-day					3%	97%
3-day					3%	97%
4-day				5%	15%	80%
5-day				20%	70%	10%
6-day				57%	33%	10%
7-day		9%	70%	11%
8-day	21%	79%
9-day	87%	13%
10-day	94%	6%
Other
Question 9. Is it performed on the same target musculature?
Yes			60%	40%
No			39%	61%
According to therapeutic objective	98%	2%
Other
Question 10. Does it position the muscle or segment in any particular position?
Maximum stretch					1%	99%
Submaximal stretch	97%	3%
Neutral	8%	68%	24%
Shortened					9%	91%
Other
Question 11. At what point in the therapy do you introduce the dry needling tool?
Initial	90%	9%	1%
Between			61%	20%	19%
The end				1%	9%	90%
Only uses, dry needling						100%
Other
Question 12. What type of dry needling do you perform?
Baldry						100%
Hong	100%
Gunn						100%
Other
Question 13. Do you use the ultrasound scanner to perform the technique?
Yes	87%		13%
No					10%	90%
Maybe	20%	75%	5%
Question 14. If you use ultrasound, why do you use it?
Avoid involvement of vasculonervous areas.	90%	10%
Control of the dry needling site	8%	82%	10%
Visualisation of the needle	19%	71%	10%
Visualisation of the spasm response	20%	70%	10%

With respect to the application in the antagonist and synergist muscles, there was a high level of agreement, with 79% “strongly agree” and 14% “agree.” These findings support the idea that dry needling is effective not only in directly affected muscles but also in those that are functionally related.

For the selection criteria, the presence of taut bands was the primary criterion for implementing the technique, with 72% consensus. However, referred pain generated significant disagreement, with 41% of participants being “disagree.” Local pain elicited divided responses, with 60% agreeing that this is a useful criterion but without wide consensus.

Ninety-one percent of the panellists agreed that obtaining local twitch responses is necessary for effectively performing the technique, highlighting its importance as a key indicator of treatment success. This high level of consensus reinforces the idea that local twitches are a positive clinical marker of dry needling.

The perceived effects of the technique included a decrease in spasticity (84% of respondents indicated agreement) and an improvement in the active range of motion (79%). However, there was less consensus regarding improvements in postural control, with only 65% of respondents indicating agreement. This finding suggests that this benefit may be contingent on other factors or the use of combined therapies.

With respect to the duration of effects, the panellists indicated that the benefits of dry needling lasted primarily between 48 and 72 h, with 86% agreeing with the latter interval. A mere 5% of respondents considered that the effects extend over a week, thereby underscoring the temporary nature of the technique's benefits.

With respect to the frequency of application, most panellists expressed a preference for longer intervals. Specifically, 87% indicated their support for performing the technique every 9 days, and 94% endorsed its repetition every 10 days. The majority of speakers expressed opposition to the proposal of implementing a more frequent request system, with 87% indicating a preference for intervals of 2 or 3 days.

The utilization of ultrasound to direct the technique was endorsed by 87% of the panellists, who cited the ability of this tool to circumvent vasculonervous areas and enhance procedural precision as key benefits. Additionally, 71% of the panellists identified visualization of the needle as a significant advantage of ultrasound.

Discussion

The results of the Delphi study provide meaningful insights into the application of dry needling in the rehabilitation of neurological patients. The consensus on applying the technique during the initial spasticity and hypertonia phases aligns with previous studies demonstrating its effectiveness in reducing muscle tone during these stages. Li et al.¹⁷ suggested that spasticity can significantly interfere with functional recovery after a stroke, and early intervention with dry needling can enhance mobility and reduce muscle stiffness. This is consistent with recommendations emphasising the importance of addressing spasticity in the early stages to optimise neurorehabilitation.¹⁸ The rationale for the use of dry needling in poststroke rehabilitation is grounded in its potential to modulate disrupted neuromuscular activity, reduce abnormal muscle tone, and deactivate myofascial trigger points that may contribute to secondary stiffness and pain. Beyond mechanical effects, dry needling may also influence local circulation, neurogenic inflammation, and spinal segmental excitability – physiological processes commonly impaired after stroke. Targeting these mechanisms may facilitate voluntary movement, improve joint mobility, and enhance the effectiveness of other therapeutic strategies.¹⁹ The inclusion of dry needling during the early stages of spasticity management not only provides direct physiological benefits but may also offer a broader therapeutic window for functional recovery. Some research conducted in chronic patients suggests that reducing spasticity earlier can create more favourable conditions for adjunct rehabilitative interventions, such as physical and occupational therapy.²⁰

In contrast, the lower consensus regarding the hypotonia phase reflects clinical uncertainty about the effectiveness of dry needling when muscle tone is diminished. Some studies suggest that other interventions, such as electrical stimulation or therapeutic exercise, may be more suitable in such cases, as dry needling is primarily aimed at reducing excessive muscle tone rather than improving low tone.^21–23 This difference highlights the need for further research evaluating dry needling's role in the treatment of hypotonia, given the current limited evidence.

Consensus on selection criteria was also considered essential. The presence of taut bands was identified as the main criterion for application of the technique, which aligns with research highlighting dry needling's effectiveness in deactivating myofascial trigger points.²⁴ Its effects are mainly mechanical and neurophysiological, including disruption of contractile elements within taut bands, modulation of the motor endplate, and localised microtrauma that separates actin and myosin filaments within contracted sarcomeres.²⁵ These mechanisms are thought to reduce muscle hyperactivity, restore sarcomere length, and improve the local circulatory and biochemical environment.²⁶ However, identifying taut bands and eliciting local contraction responses in stroke patients may differ from musculoskeletal populations. This variation can be attributed to altered motor unit recruitment, spasticity-induced muscle fibrosis, abnormal enlargement of muscle fibres and extracellular matrix changes – particularly involving type I and III collagen isoforms – and impaired sensory feedback.²⁷ Nevertheless, the lack of consensus regarding referred pain indicates it is not seen as a definitive indicator for dry needling in neurological patients. This may be due to heterogeneity in pain expression within this population. According to Liporaci et al.,²⁸ myofascial pain in neurological patients is frequently muscular in origin, resulting from sustained contraction that increases energy demand. Local microcirculation cannot meet this demand due to capillary compression, creating ischaemic conditions, depleting ATP, and impairing active calcium reuptake. This disrupts muscle fibre relaxation and contributes to trigger point development, characterised by prolonged and exaggerated muscle contraction and fatigue. The combined effect of ischaemia, extracellular imbalance, and algogenic substance release perpetuates a self-sustaining cycle of contraction – ischaemia – contraction, contributing to central and peripheral sensitisation.

The local contraction response, a key indicator of technique efficacy, was widely supported by the panellists. This is consistent with studies indicating that local twitch responses confirm proper needle stimulation, resulting in immediate muscle relaxation and spasticity reduction.^29,30 A systematic review by Bymun et al.³¹ reported that twitch responses during dry needling correlate with improved pain relief and range of motion. However, some authors^32,33 argue that the absence of fasciculations does not necessarily indicate treatment failure – particularly in patients with hypersensitivity or chronic pain, where gentler stimulation may be preferable. Spasticity reduction was the most frequently cited effect by the panellists, aligning with literature supporting dry needling's capacity to reduce muscle tone in individuals with severe spasticity.^34,35 Improvement in active range of motion was also commonly reported, reinforcing the idea that dry needling not only alleviates pain but can enhance functionality and promote greater independence in daily activities.³⁶ Perceived improvements in postural control were more variable, suggesting these effects may depend on spasticity severity or the integration of dry needling with other modalities such as balance training or active physical therapy.³⁷

A relevant observation from the panel was the short duration of dry needling effects. Most respondents reported benefits lasting between 48 and 72 h, consistent with studies describing temporary relief of spasticity and pain.³⁸ This highlights the importance of integrating dry needling into ongoing rehabilitation to maintain its effects. Evidence supports combining it with active therapies to extend its benefits and promote sustained functional gains.³⁹ However, the panellists agreed that long-term effects, such as those lasting more than a week, are less frequent, highlighting the need for further research to optimize application frequency and maximize therapeutic benefits.

The use of ultrasound to guide dry needling received broad support. Panellists noted that ultrasound improves precision and reduces the risk of damaging vasculonervous structures. This is particularly important in neurological patients with significant muscle alterations. It suggests that ultrasound-guided dry needling offers a safer and more effective approach, enabling clinicians to treat complex anatomical regions with greater confidence.⁴⁰

These findings suggest that dry needling can be effectively integrated into early-stage stroke rehabilitation to reduce spasticity and improve soft tissue mobility. However, treatment should be individualised, based on clinical presentation and combined with other therapeutic strategies to maximise long-term functional outcomes.

Despite the methodological strengths of this modified Delphi study, several limitations must be acknowledged. Firstly, the effects of dry needling were reported by experts to last between 48 and 72 h, indicating that the technique, when used in isolation, may offer only short-term clinical benefits. Nevertheless, its integration into a broader rehabilitation programme could enhance the duration and functional impact of its effects.

Secondly, there is a potential for selection bias, as participants were recruited via professional networks and social media platforms, which may have favoured clinicians with a specific interest or expertise in dry needling.

Finally, it must be noted that the recommendations derived from this consensus process have not yet been validated in prospective clinical trials, which limits their generalisability and application across different healthcare settings.

Clinical messages

Dry needling shows a potential role in managing early-stage spasticity after stroke, improving range of motion and reducing hypertonia when integrated into comprehensive rehabilitation programmes.

The use of imaging tools, such as ultrasound, also represents a key area for maximizing the precision and safety of the procedure.

The clinical responses to dry needling may vary according to muscle tone and sensory integrity, underlining the necessity for individualized assessment.

Footnotes

Acknowledgements

We would like to thank the work of the expert committee to carry out the Delphi Consensus, without their inestimable help and collaboration, this project would not have been possible.

Author contributions

Conceptualization: JVS and ACC; methodology: JMBC, RFL, and ZSM; software: VAP and ZSM; validation: JMBC and ZSM; formal analysis: VAP and JVS; investigation: JVS, RFL, JMBC; resources: ACC and ZSM; data curation: JVS, RFL, ZSM and JMBC; writing – original draft preparation: JVS and ZSM; writing – review and editing: ZSM, JVS, JMBC and RFL; visualization: JVS and ACC; supervision: ZSM and VAP; project administration: JVS; funding acquisition: ZSM; All authors have read and agreed to the published version of the manuscript.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Jorge Velázquez-Saornil

Vanesa Abuín-Porras

Zacarías Sánchez-Milá

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