Clinical Pearl: How I Use Manual Therapy with Dry Needling: Perspective from the Clinical World

By Jeremy Snyder PT, DPT, OCS, CSCS

I am frequently asked how often I use manual therapy in conjunction with Functional Dry Needling (FDN). My answer is typically, “It depends!” but a more honest answer is, “Almost always!”.

I truly believe that FDN is an extension of our manual techniques. I use other joint and soft tissue techniques for evaluation before the application of FDN, as a test/re-test following FDN to see if my needling has made a change, and as a way to provide another (less invasive and more comfortable) input following treatment. The application of different techniques or tools will always depend on the clinical presentation of our patient, the therapeutic goal of our intervention, and most importantly, the treatment preference of our patients.

In Functional Therapeutics: Applications for Functional Dry Needling (FT), which I teach multiple times a year as a lead instructor with KinetaCore, we take a deep dive into exactly how to blend the use of FDN with our other treatment methods.

I want to share a concept with you that we often discuss in the FT course: Hilton’s Law.

I was introduced to Hilton’s Law a few years ago by KinetaCore founder and CEO, Edo Zylstra. John Hilton was a British surgeon who gave lectures in 1860-1862, based on his observations of anatomy and dissection. Hilton’s Law states that the nerve supplying any given joint will also innervate the muscles acting on that joint and the skin overlying the insertions of those muscles. For instance, the musculocutaneous nerve (C5, C6, C7) supplying the elbow capsule also innervates the coracobrachialis, biceps brachii, and brachialis, as well as innervating the skin near the insertion of those muscles.

With this in mind, it gives us an opportunity to direct both our evaluation and treatment. You can use manual techniques to determine if a joint is moving correctly, the tissue quality and myotomal competency of the muscles surrounding the joint, and the skin sensitivity directly over the joint and muscle insertions.

In terms of treatment, this concept gives a clinician three different ways to provide input to a specific spinal segment:

  1. You could use your hands or a tool to stimulate the skin in the same dermatome as the target
  2. You could use manual techniques to mobilize a joint and affect the receptors at the joint level
  3. You could use FDN to directly impact the neuromuscular system at a target myotome

I routinely try to address all three inputs in any given treatment session, just to cover all the bases!

My manual therapy approaches have also evolved after listening to Adriaan Louw PT, PhD, CSMT and others from the International Spine and Pain Institute. Now, I understand that even when my manual technique is directed at a local tissue, the effects may be continued through the spinal cord and ultimately have an effect on the central nervous system. When I started utilizing manual techniques, my focus was always on what I was doing “to” a tissue. However, lately my focus has been more on how my patient “perceives” that tissue.

How many times in practice does a patient comment, “I didn’t realize that muscle/joint/area was so sore or tight until you touched it!”? I think many of our manual therapy techniques are most effective if we can build the patient’s awareness of that body area and improve their “mental map” of that area. As I frequently joke in the FT course, all of our manual techniques are really about touching the patient’s homunculus!

Manual therapy encompasses a wide variety of inputs, so let’s discuss some common treatment techniques.

I typically use joint accessory motions and passive range of motion to assess how well a joint is moving by comparing it to the patient’s other side. Then, I apply grade I-II mobilizations for pain control, decreased tone, and improved joint circulation. Grade III mobilizations (large amplitude to end ranges) can be helpful for desensitizing end ranges and improving mobility.

If a patient does not want to include dry needling in their treatment, grade V mobilizations can also provide a similar (though not as dramatic or long lasting, in my opinion) reset. Following dry needling, I will re-assess the joint mobility to see if we have produced a change. I also commonly use instrument-assisted soft tissue mobilization or light cupping following dry needling, for input to the skin with light pressure, to stimulate a dermatome, and to desensitize a target tissue.

Let’s give this concept some life and discuss an example case study.

Scenario: A forty-five-year-old male presents with complaints of insidious onset of right lateral and anterior shoulder pain, increasing in the last two months. He sits with forward head posture and slightly increased thoracic kyphosis, with a downward sloping right scapula compared to left. Aggravating factors include lifting overhead (painful 7/10 active scaption in arc of impingement starting at 70 degrees), reaching behind to lift objects in car, and sleeping on his right side. Patient reports decreased symptoms with rest, ibuprofen, and ice. Patient demonstrates slightly restricted right cervical rotation, hypomobile AA rotation right and OA flexion bilaterally, and hypomobile mid-thoracic spine. Light touch sensation is intact and symmetric, but with abnormal C5 and C6 myotome testing on the right. Negative labral dysfunction tests and negative apprehension tests, but positive impingement signs.

Treatment: Muscle energy techniques applied to the upper cervical spine for increased right AA rotation, grade V mobilization to mid thoracic spine. Grade I-II oscillation of right shoulder at GH joint in neutral for short arc external and internal rotation. Soft tissue mobilization to bilateral cervical paraspinals as well as the posterior cuff and deltoids (trigger points noted at right > left cervical paraspinals from C4-C6, right infraspinatus and middle deltoids with sensitivity to light palpation).

FDN was applied with a segmental, myotomal circuit approach. Needles were placed with one circuit directed at bilateral C5 multifidus and another at right infraspinatus/middle deltoid, 3 pulses per second at an intensity high enough to produce a palpable, comfortable muscle contraction and continued until patient and clinician noticed a change in intensity, frequency or quality of contraction (approximately two minutes in this case).

Immediately following FDN, manual palpation of the infraspinatus and deltoid showed decreased tone and tenderness. IASTM was applied with light, effleurage type strokes in a C5 dermatomal pattern and erythema was noted over the infraspinatus. Upon re-test, patient reported improved active scaption ROM with decreased pain (2/10 pain at lateral shoulder reported at 90 degrees scaption) and right cervical rotation equal to the left.

Patient was instructed in thoracic self-mobilization using a foam roller, deep cervical flexion and cervical AROM, scapular stabilization using shoulder tap activity on a counter for his HEP. Further treatment will be directed at improving scapular upward rotation, improving and maintaining thoracic and upper cervical mobility, and progression of scapular and GH stabilization exercises.


Manual therapy can be used for both evaluation and treatment within the same session. Evidence based practice is a great way to identify effective tools for certain conditions, but the art of what we do is how we apply those tools to successfully treat the individual in front of us.

The condensed answer to, “How do you use manual therapy in conjunction with Functional Dry Needling?” is: We can use manual therapy techniques . . .

  • Prior to FDN to inform our technique by identifying and localizing the target tissue,
  • As a feedback mechanism following our treatment to determine if we affected change,
  • And as a way to further improve feedback for the nervous system.

 

How do you pair FDN and manual therapy in your clinic?

 

Jeremy Snyder PT, DPT, OCS, CSCS is a Physical Therapist with over 18 years of clinical experience as a PT and over 25 years in rehabilitation settings. He owns Rocky Mountain Rehabilitation, P.C. in Colorado Springs, CO. Jeremy has been performing Dry Needling since 2009 and has been an assistant instructor for KinetaCore® since 2010. He is a lead instructor for Functional Therapeutics.