Dry Needling and Spinal Manipulation: Why You Need Both
Dry Needling (DN) and Spinal Manipulation (SM) are the two most powerful and synergistic tools that PTs, DCs and ATs have at their disposal. In my clinical and teaching experience over the years, I have not come across any other treatments available to us that have as profound, quick, and lasting impacts on a patient’s well-being and overall function. The reasons for this are numerous, and many of them we have yet to understand.
We know a lot about both DN and SM; however, the amount that we do not yet know far exceeds that of our current understanding. This is an undeniable truth, and it is one of the reasons I find both of these subjects so fascinating.
How SM + DN Work Together: Which to use first?
From the techniques at my disposal:
- DN is the fastest way to mobilize tissue
- SM is the fastest way to mobilize joints.
For this reason alone, It makes simple sense to use these two together. However, which one to use first in the course of a treatment? This is a question I frequently get in class and is a question I frequently pose to other practitioners who utilize these two techniques.
To me, it makes the most clinical, anatomical, and physiologic sense to DN first and manipulate second with the vast majority of patients.
Needling first loosens tissue, improves blood flow, and improves homeostasis of the tissues surrounding joints. This makes it easier for me to manipulate joints with minimal force and soft tissue restriction, which makes the manipulation more comfortable and effective for the patient and easier for the practitioner. This also makes the manipulation safer. It is much easier to feel small intricacies and anomalies in the joint when the surrounding muscles are not compressing the crap out of the joint, and you are able to take the patient through a larger ROM prior to the manipulation to test and see if they have pain with the pre-manipulative position.
Reasons why adverse events happen during or following a manipulation
The number one reason that adverse events happen during or following a manipulation is a lack of proper history taking an assessment. The vast majority of complications are easily avoidable simply by taking more time to speak with the patient and to assess the joints in question. If you take your time with both of these, the chances of an adverse event drop significantly. This is verified throughout research. For me, part of the assessment process includes DN. Each time I insert a needle into a patient, I am feeling with the point of the needle for anomalies, unusual tissue resistance, abnormal periosteum, etc. DN also incites a strong nervous system response that may indicate some abnormality, depending on the patient’s response to the needling.
Take, for example, an older patient who comes in with only 20 degrees of cervical side-bending and 20 degrees of rotation. I do not attempt manipulating a patient such as this without first needling and doing some lower grade mobilizations. In this case, it may be difficult to tell if the restriction is primarily capsular, muscular, or some combination of factors prior to needling. However, once the patient has been needled, it is quite easy for a skilled practitioner to reassess the patient and form a more complete picture of what is going on in the neck. This makes treatment safer for everyone involved. There is zero reason to guess if we have the ability to know, and this is a good philosophy to employ in life in general. This is also the reason that it is complete insanity to restrict DPTs who manipulate from ordering radiographs. Why would we restrict our own ability to be safe when we are fully capable of being safer with the addition of radiographs? I find it strange that PTs are the only doctoral level medical profession that I know of who cannot order radiographs while, at the same time, behind DCs, we perform the most spinal manipulative treatment. That’s all I want to say on that, and I could go on for pages about this, but some people may get a little grumpy with me…
When I manipulate my patients, I have a certain level of maximal force that I will use and no more than that. Ever. Trying to force your way through significant soft tissue or other restrictions while manipulating is an excellent way to hurt your patients. I advise all manipulators to adopt a philosophy similar to this when treating patients. I have never had a significant adverse event with a patient over the years, and I DN and manipulate over 90% of my patients. Needling prior to manipulation allows me to use the minimal amount of force necessary to manipulate a joint.
DN and SM together = better patient success
DN and SM are synergistic treatments for humans, just like water and sunlight are synergistic treatments for plants. Using one or the other may lead to success, but using both in the proper quantities is ideal. Both DN and SM serve to mobilize structures, both joints and tissues, and both help improve ROM, reduce pain, and improve function. DN and SM also have similar effects on the Autonomic Nervous System (ANS), help release endogenous opioids, stimulate certain mechanoreceptors in tissues and joint capsules, and restore the body to a more homeostatic level.
I currently treat all my patients pro-bono throughout the week when I am not teaching. The main things I do with my patients are DN manipulation. I do teach them how to properly perform exercises and stretches that they can do at home to promote long term management. However, I do not use the limited time I have to supervise them while they perform general exercises. Those who are not motivated to do their exercises on their own, can utilize personal trainers. I focus on the most effective, efficient, and long-lasting treatments I know how to perform. Being a competent manual therapist is by far the most effective skill you can perfect as a PT, and I highly recommend learning these techniques from as many people and professions as possible. I promise you will see your patient outcome improve drastically.
Now, an issue with this is the lovely, crooked insurance companies who are somehow able to determine what the skill level of certain techniques are and then base reimbursement on this. According to most insurers, There is the most skilled, and therefore the highest reimbursed treatment. Often over double what manual is reimbursed. This is a complete disgrace and is highly offensive to our profession as a whole, just like our salaries. More on these topics to come. I’m off to go catch a steelhead, I hope!