Dry Needling + Spinal Manipulation: The Benefits of Utilizing Both
Dry Needling (DN) and Spinal Manipulation (SM) are the two most powerful tools we have at our disposal to reduce neuromusculoskeletal dysfunction and improve homeostasis. If they are used in conjunction with each other properly, the efficacy and duration of results improves dramatically. DN and SM are synergistic and symbiotic treatments and complement each other wonderfully. Both treatments reduce pain and sympathetic overdrive and improve ROM, homeostasis, quality of life, and a bunch more stuff.
How Spinal Manipulation and Dry Needling Work Together
SM and DN both have similar mechanotransducive effects on biologic tissue and affect spinal and supraspinal reflex afferents and efferents to the neuromusculoskeletal system. Mechanotransduction is a neurophysiologic response to mechanical stress of biologic tissue. This happens with both SM and DN. Twisting the needles until they tighten and feeling the quick stinging sensation is a good example of mechanotransduction occurring. Cavitating a joint and the resulting endogenous opioid release, along with numerous other known neurophysiologic effects, is another example.
This is a very useful phenomenon that we can take advantage of to help our patients. Using DN to loosen the tissues surrounding a tight joint, followed by HVLA of that same joint or joints, makes the manipulation much easier and effective, and it requires less force. This improves safety, as it decreases global and local force produced across the spinal segments you are working with, and the same goes for the extremities. DN also makes tissues warmer, more mobile, and less restrictive as a result of improved microvascular dilation stemming from the release of numerous neuropeptides, including Calcitonin Gene Related Peptide (CGRP), Nerve Growth Factor (NGF), and Vaso Intestinal Peptide (VIP), to name a few. What is something that most DCs do before they manipulate? They heat up the surrounding tissue somehow.
I just read a new article about how long to leave needles in. This is one of my favorite and, I think, important topics in DN land, and it’s really cool besides. This article is from the Journal of Bodywork and Movement Therapies, which is also my favorite journal.
“Notably and to date, using a single needle to repeatedly prick trigger points one at a time with fast-in and fast-out pistoning maneuvers has not yet been shown to produce significant and clinically meaningful long term improvements in pain and disability in a wide array of musculoskeletal conditions. Insertion of multiple needles for typically 20-30 min durations has been shown to produce larger treatment effect sizes and longer-lasting outcomes than brief, single-needle strategies. Moreover, the number of needles and needle retention time are two variables associated with treatment dosage and must be carefully matched with specific musculoskeletal conditions and the patient's goals.”
The 20-30 minute duration continuously shows up in a lot of other DN and acupuncture research that has used advanced technology, such as microneurography, which is the gold standard for testing the ANS at the moment, as far as I know. A few of these papers are in the references below.
This is an excellent statement from a 2021 paper that highlights exactly my thoughts on this subject and is representative of the overwhelming majority of research performed on this topic, especially in acupuncture research. Dommerholt and Dunning, both PTs, do excellent research on DN and SM if you are looking for some research. Acupuncture has been around for thousands of years, and I find it extremely helpful to read as much acupuncture research as I can. The more scientific knowledge and understanding you have, the better practitioner you are going to be. I find it helpful to dabble in a lot of things as far as what I read, including a lot of neurophysiology research.
Both DN and SM have been shown to release endogenous opioids into the bloodstream, and this is helpful. Beta endorphin is a powerful one that helps reduce SANS overactivity, pain, blood pressure, and anxiety. All good. “The central hypothalamic Beta endorphin has a regulatory role in a variety of functions, including the ANS.12” So, think about what is happening here:
We are significantly affecting the brain with DN and SM. I think a lot of people forget how powerful an effect DN and manipulation both have on the brain. I am going to use an example from a urinary incontinence treatment I perform with needles into the foot and ankle. It is called Posterior Tibial Nerve Stimulation (PTNS), and it was first developed in the 1980s. And no, this is not witchcraft or wizardry; however, it might seem like it sometimes. And no, before you say, “Well, that sounds like acupuncture!” It is not. Acupuncturists have studied this the best, by far, that is for sure. It is using factual, western scientific medical knowledge to help our patients by inserting needles into the body based strictly on neuromusculoskeletal, physiologic, and anatomical understanding. The bottom line is that it should not matter. Helping the patient in a safe manner is all that should matter. There are never going to be too many people in this country using needles when compared to the number of patients who need treatment. The more people performing safe and effective needling, the better off we all are going to be.
The goal of this technique is to affect the brain via the sacral plexus, S2-S4, by stimulating the tibial nerve, an extension of the sacral plexus, with an electrified pair of needles into pathologic tissue somewhere in the distal tibialis posterior and into the arch of the foot, close to the medial plantar nerve, a branch of the tibial nerve. I won’t get into the specifics of the treatment here, but there have been excellent studies done on this using numerous, advanced brain imaging technologies in real time while the treatment is going on. Mostly acupuncture studies. Typically, people with urinary incontinence issues have central sympathetic hyperactivity, as seen in areas like the Pontine Micturition Center (PMC), insula, prefrontal cortex, and the limbic system, which have all been implicated in bladder control. Some call it the Brain Bladder Control Matrix. That’s a cool name, so I like it. During PTNS treatment, we can see a marked reduction in hyperactive electrical activity in these areas of the brain. It’s totally insane. This is a highly effective treatment, with success rates upwards of 80% according to some literature.
Now think about this: A young female patient comes in with SIJ pain. She had her first baby 1.5 years ago. Very athletic. Significant deviation of the SIJs and lumbar spine. Hypertonic global lumbopelvic musculature. After the eval, she mentioned that she had urinary incontinence only while running, and she thought this was totally normal. I hate this! This is a very common thought because of the unfortunate way most of our medical schools are operated today. Critical thinking has basically been removed. The pharmaceuticals are pushed so heavily because of the money ties with big pharma that extremely effective, simple, and cheap treatments, like DN or acupuncture, have been completely disregarded. PT schools aren’t any better at teaching their students about manual therapy or pelvic health either. It’s a huge fail all around.
What were we talking about? Ah, yes, so the patient we were speaking about. So, we know from research that S2-S4 have direct connections with the bladder and the brain, both with spinal and supraspinal reflexes. Remember that supraspinal reflexes bypass the spinal cord. It’s magic. Her SIJ was so far out of place that her nerves were getting pushed on by something, muscle, joint, ligament, tendon, whatever it was. So, I told her, yeah, I can fix that, easy. She was like, what? Really? I thought it was permanent. My doctor told me it was normal. Ahhhhh!!!! So, I fixed her.
I needled all the tight stuff around her lumbopelvic area and suboccipital area and corrected her whole spine as SIJ issues, over time, will cause suboccipital deviation. Remember, the suboccipital and upper cervical periosteum and the periosteum around the sacral plexus are the two most accessible areas for us to activate the parasympathetic portion of the ANS. This is something I do with all my patients. I like to connect the two areas with stim, 1-5 Hz. You will see amazing results, both mentally and physically. Very relaxing. So, I treated her 5 times and she was better. No more SIJ pain or urinary incontinence while running. A lot of the time, these things are quick, easy fixes if you think about them the proper way.
This is just one example of how effective Dry Needling and Spinal Manipulation can be when used together. They are neuromusculoskeletaly (I think I just invented a word!) symbiotic, synergistic. Each amplifies the other’s effect. These are the two most powerful tools available to us. This is why we teach 4 Dry Needling and 3 Manipulation classes! Hasta la proxima!
Raymond Butts, D.P.T., James Dunning, D.P.T., Clint Serafino, D.P.T. and Osteopractic, D., 2021. Dry needling strategies for musculoskeletal conditions: Do the number of needles and needle retention time matter? A narrative. Journal of Bodywork & Movement Therapies, 26, p.353e363.
Pickar, J.G., 2002. Neurophysiological effects of spinal manipulation. The spine journal, 2(5), pp.357-371.
Muhsen, A., Moss, P., Gibson, W., Walker, B., Jacques, A., Schug, S. and Wright, A., 2019. The association between conditioned pain modulation and manipulation-induced analgesia in people with lateral epicondylalgia. The Clinical journal of pain, 35(5), p.435.
Vieira-Pellenz, F., Oliva-Pascual-Vaca, Á., Rodriguez-Blanco, C., Heredia-Rizo, A.M., Ricard, F. and Almazán-Campos, G., 2014. Short-term effect of spinal manipulation on pain perception, spinal mobility, and full height recovery in male subjects with degenerative disk disease: a randomized controlled trial. Archives of physical medicine and rehabilitation, 95(9), pp.1613-1619.
Gallego-Sendarrubias, G.M., Rodríguez-Sanz, D., Calvo-Lobo, C. and Martín, J.L., 2020. Efficacy of dry needling as an adjunct to manual therapy for patients with chronic mechanical neck pain: a randomised clinical trial. Acupuncture in Medicine, pp.acupmed-2018.
Mayor, D., 2013. An exploratory review of the electroacupuncture literature: clinical applications and endorphin mechanisms. Acupuncture in Medicine, 31(4), pp.409-415.
Sillevis, R., Van Duijn, J., Shamus, E. and Hard, M., 2019. Time effect for in-situ dry needling on the autonomic nervous system, a pilot study. Physiotherapy Theory and Practice, pp.1-9.
Hagblad, J., Lindberg, L.G., Andersson, A.K., Bergstrand, S., Lindgren, M., Ek, A.C., Folke, M. and Lindén, M., 2010. A technique based on laser Doppler flowmetry and photoplethysmography for simultaneously monitoring blood flow at different tissue depths. Medical & biological engineering & computing, 48(5), pp.415-422.
Dommerholt, J., Thorp, J.N., Hooks, T. and Mayoral, O., 2020. MYOFASCIAL PAIN AND TREATMENT: EDITORIAL A Critical Overview of the Current Myofascial Pain Literature–October 2020.
Ottaviani, M.M., Wright, L., Dawood, T. and Macefield, V.G., 2020. In vivo recordings from the human vagus nerve using ultrasound‐guided microneurography. The Journal of Physiology, 598(17), pp.3569-3576.
Shoemaker, J.K., Klassen, S.A., Badrov, M.B. and Fadel, P.J., 2018. 50 Years of Microneurography: Insights into Neural Mechanisms in Humans: Fifty years of microneurography: learning the language of the peripheral sympathetic nervous system in humans. Journal of Neurophysiology, 119(5), p.1731.
Filshie, J., White, A. and Cummings, M. eds., 2016. Medical Acupuncture E-Book: A Western Scientific Approach. Churchill Livingstone. Chap 6.
Fowler, C.J. and Griffiths, D.J., 2010. A decade of functional brain imaging applied to bladder control. Neurourology and Urodynamics: Official Journal of the International Continence Society, 29(1), pp.49-55.
de Wall, L.L. and Heesakkers, J.P., 2017. Effectiveness of percutaneous tibial nerve stimulation in the treatment of overactive bladder syndrome. Research and reports in urology, 9, p.145.