Author: Edo Zylstra PT, DPT, OCS
I am often asked on courses what I prefer with regards to manipulation and dry needling treatment planning. In other words, should I dry needle before or after Spinal Manipulation? I try to keep this as simple as possible as it is often difficult to ascertain whether the restriction is due to a joint/capsular issue, neuromyofascial tightness, or both.
As an example, I recently had the pleasure of treating a military athlete presenting with chronic limitation of all cervical movements accompanied with pain in extension and left rotation. The pain occurred just right of the C2-C4 spinous processes and was palpable in the myofascial tissues. The symptoms were reported to be present for many years. He denied any trauma and concomitant headaches. For treatment, he reported consistent osteopathic manipulation and MET which would improve cervical mobility and temporarily reduce discomfort by 30-50%.
Upon physical exam, he presented with normal upper extremity myotomal and sensory testing, reduced isometric hold with cranio-cervical flexion testing, restricted cervical side glides and segmental rotation, with pain at perceived end-range passive rotation. Palpation of right C2-4 cervical paravertebral musculature reproduced his complaints of pain.
Pre-manipulation hold to ascertain possibility of manipulation also reproduced the patient’s pain.
FDN was then performed to the superficial, intermediate and deep cervical musculature at C2, C3 and C4 bilaterally with bias to the right side, resulting in reproduction of patient’s pain. Electric stimulation was applied to the needle with intensity and frequency set to patient’s comfort level, resulting in a motor response of the muscles being treated.
After treatment, the patient reported 75% decrease in discomfort with all cervical AROM. Pre-manipulation hold resulted in cavitation without HVLA thrust and reports of no discomfort at passive end range of motion.
This is an example of what I see clinically on a regular basis. My bias is to treat with techniques to reduce the neuromyofascial restriction of mobility prior to manipulation. In my experience, this is safer, more comfortable, and results in faster progression of corrective exercise programs.