Low Back Pain (LBP) is one of the most expensive and debilitating diagnoses in the United States on a year-by-year basis. The mean annual medical cost associated with LBP across the United States is somewhere between 80 and 100 billion, depending on the source. Lucky for us, dry needling and manipulation, especially when used together, have an incredibly positive, powerful, and synergistic effect on LBP.

The Multifidus + LBP

The multifidus is an unusual muscle, and for whatever reason, with pretty much any type of chronic LBP, the multifidus gets infiltrated by adipose tissue. There are really cool studies using MRI over a period of time in patients with LBP showing the multifidus turning from normal, healthy-looking muscle to dysfunctional muscle infiltrated with fat. When this happens, the multifidus becomes dysfunctional secondary to hypoxia, chemical imbalance, decreased sarcomere recruitment, etc.

Remember, the multifidus is a postural muscle made to be actively firing low grade contractions throughout the day to help maintain our spinal stability. When it stops functioning normally, our larger, more superficial muscles, like the latissimus, take over. However, these muscles are not made to perform the job of the multifidus. Therefore, they get super pissed having to do the job of some other slacker muscle. So, they cause problems. Bastards…. This turns into a negative feedback loop that plagues many people, and unless the source of the problem is addressed, it can be difficult to stop.

What is the root cause of LBP?

Here’s the tricky question: What is the root cause of the LBP? This can be a tough question to answer, and here are some questions we ask:

• Did it start with a neurologic dysfunction that led to muscle imbalance that led to LBP?
• Did it start with a mechanical dysfunction, like a strained tendon, that then led secondarily to a neurologic dysfunction and fatty infiltration of the multifidus?

Regardless of the cause, if the situation has been going on for any significant period of time, the entire body must be addressed if you hope to have consistent success with LBP patients.

How DN + Manipulation can help LBP

The thoughtful use of DN in conjunction with manipulation addresses both the mechanical and neurologic basis for LBP. Remember, just about every patient we see as PTs, ATs, and DCs has some type of sympathetic hyperactivity going on. Pain does this. How many people come to us with zero pain? Almost zero. I would say pain is the number 1 reason people want to see any of us. Lucky for us, DN has a depressing effect on the sympathetic and an elevating effect on the parasympathetic portions of the ANS. This effect can be amplified with proper knowledge and skill.

Related: Click here to learn more about our Dry Needling Courses

What about exercise for LBP?

Exercise is the least useful tool in the PT setting for the vast majority of patients, including LBP patients. Yes, that is correct. The thing most highly reimbursed by insurance companies is the most ineffective treatment for LBP. Now, don’t get me wrong, exercise is awesome. I have exercised most of my life. I grew up playing hockey and was exposed to high-level trainers and strength & conditioning coaches from about age 10 through college where I played D1 ice hockey, and our strength & conditioning coach in college was a former player for the New York Jets in the NFL. I totally go over how to exercise with my patients once or twice if they need to review what they are doing, then they do the exercises at home (which they won’t do). I prefer to spend my time with my patients providing the most effective and lasting treatment I know how to perform. This includes DN, manipulation, and other manual techniques.

Why? Maybe the answer lies in this question: How long does it take to build new sarcomeres to make your muscle physically larger? 8 weeks minimum of something like 30 minutes, 3 times a week of strenuous exercise to muscle failure, more or less. That’s 24 visits. How many of you see people that are able to strenuously exercise, to muscle failure, 3 times a week for 24 visits? How many insurance companies will even give 24 visits for non-surgical impairments? Will any of those people ever actually perform their exercises at home or continue to do so once PT is discontinued? The only time I have ever seen someone consecutively that long is post-surgical, when they were restricted from exercise for most of the time.

What I am getting at is, with the majority of PT patients, we do not even have enough time with them to see actual muscle growth. Therefore, the short-term strength gains and potential pain reduction are primarily neurologic. Exercising muscles with significant pathology, like trigger points and shortening, which almost all our patients have, can be detrimental to healing the cause of their problem. Weakness does not cause pain. Muscle, joint, and nervous system dysfunction cause pain.

Pathway to treating with DN

I like to assess the patient and needle prior to manipulating. I find it much easier for me and more comfortable for my patients if I needle first and manipulate second. I also find this to produce more effective and longer lasting nervous effects. Depressing the sympathetic nervous systems is my goal with almost all my patients, as almost all of them have sympathetic hyperactivity, secondary to pain and other factors. There are many parasympathetic impairments; however, the majority of them fall outside our scope of practice, so we do not see a lot of that. This works out well for us because the overall effect of needling is sympathetic depression, even if we don’t try to do it. If you do try to lower sympathetics by stimulating the parasympathetics, along with treating pathologic tissue, you can stimulate dramatic and healing effects on the human body. Check out my other blogs about the ANS for more information on this.

I seem to find that in patients with LBP, almost all of them have significant pathology in the adductor muscles, tendons, periosteum, and other tissues in that area. However, few of them are consciously aware of the problem. For some reason or another, it seems to me that the trigger points that develop in the adductors are typically latent, rather than active. Remember, they both send equivalent amounts of negative afferents to the brain, but we are only aware of the latent ones if someone pushes on them or sticks a needle into them.

Bottom line: Active and latent trigger points are equally problematic, and in people with LBP, the adductors seem to produce primarily latent trigger points, which leads this area to go unnoticed and untreated.

The pubic attachments are my favorite place to treat these muscles. You get stronger nervous responses when needling tendons, ligaments, and periosteum. This is also an excellent area to treat for just about all pelvic floor impairments. Although it may seem like this would be a painful area to be needled, it is typically one of the most comfortable areas of the body to be needled.

This is a powerful treatment, especially if you needle down to the periosteum and connect the pubic needles to needles down to the lamina of the corresponding spinal levels and the sacral plexus, S2-S4. I like to add in the sacral needles to specifically target the PANS. This is also a common pathologic area. Add about 2 Hz stim. Perform bilaterally.

Note: If you really want to target the PANS, add in needles to the concha of the ears and connect these to needles just past S4 with about 2 Hz stim. This is the only area on the body that we can safely needle a portion of tissue directly innervated by the vagus nerve (auricular branch). Remember, Cranial nerve X is the primary nerve controlling the PANS.

Although we know some about how needling in certain areas affects brain function (electrical activity, blood perfusion, etc.), we know very little overall. If you would like a good example of one cool thing we know about, there are some awesome studies on PTNS needling for urinary incontinence. It’s really cool to see the brain change from needles in the distal leg and help urinary incontinence. Anyway, there is something that happens when we connect the spinal level of the nerve root(s) to the distal area of primary complaint. This effect is amplified when you treat bilaterally (I only put a few needles into the unaffected side).

Try out this methodology for your LBP and other patients. You will see some awesome results. Let me know if anyone has any questions about anything in the comments below!

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