Differential Diagnosis – The Functional Dry Needling® Approach

Enjoy this Clinical Pearl written by KinetaCore Faculty Member, Clay Jowers, PT, DPT, CSCS

The WHAT and the WHY

Clinical examination and differential diagnosis can be tough! Like many clinicians, I spent the early part of my career treating the WHAT. The WHAT is the symptom — it’s the presentation but not necessarily the “cause”. It seemed obvious to me at the time and, honestly, I felt justified because many of the patients I was treating were achieving successful outcomes.

However, over time I began to realize that I was missing something in my patient care. I was consistently met with challenging cases that brought me to the realization that my responsibility as a PT was to find out the WHY, not just the WHAT. It was easy to identify what symptom/impairments had brought my patients in, but the real question was, “Why had this occurred, and why had it perpetuated?”

KinetaCore has really helped me expand my thought process over the past few years. They have adopted a more comprehensive and multi-faceted model that emphasizes the neuromuscular system and how it impacts the body. This model, Functional Dry Needling (FDN), puts more emphasis on investigating the musculoskeletal system AND the way it ultimately interacts with the neurologic system. It highlights the commonly underestimated role the nervous system has, not only on the perception and experience of pain, but also on the compensatory and/or dysfunctional movement patterns that develop over time.  In many cases, the dysfunctional movement is what precedes the tissue damage and onset of pain.

I had a patient care interaction that really highlighted this concept. I evaluated a patient who, by all accounts, appeared to have predominantly mechanical discogenic Low Back Pain (LBP). The patient presented with bandform LBP, 50-75% ROM ability with standing trunk flexion/extension/rotation, and all movements occurred with moderate pain and aberrant motion. The patient had moderate pain with lumbar spring testing, and minimal to moderate pain with palpation of the lumbar paraspinals and glutes. I initially wanted to treat the patient using FDN, primarily to knock down some of the resting spasm and potentially give me some space to address the discogenic condition more directly. I treated the multifidi for about ten minutes at the corresponding vertebral
segments with neuromuscular stimulation.

The patient’s overall presentation was significantly improved: 90% trunk flexion with minimal pain and no aberrant motion, 100% full standing trunk extension and rotation ROM with minimal to no pain, minimal to no pain with lumbar spring, and minimal to no pain with palpation of the lumbar paraspinals and glutes. Strange enough, much of the clinical signs I thought were discogenic were gone! I quickly realized that I was not taking into consideration the significance of somatic referred pain from the muscle, its neurologic connection to the surrounding tissues, and how they affect each other.

The easy answer is to walk away from there. “Fix it, then dismiss it”. But I needed to look further. I wanted to identify the reason this happened. I think I was missing that piece for a long time — missing the connection between neurologic and muscular structures — treating the WHAT instead of the WHY.

The Real Question: How did it all Start?

  • Was it an actual strain of the lumbar paraspinals/multifidi?
  • Was it a dysfunctional compensatory movement pattern that led to the multifidi and paraspinals becoming irritated (postural deviation/scoliosis, instability, leg length discrepancy/pelvic mal-alignment, etc.)?
  • Was it a disc injury? Did the chemical irritation from the disc lead to the nerve becoming irritated and the multifidi protective guarding/spasm, which eventually led to pain?

Anatomy Alert!

The disc is innervated by the sinuvertebral nerve, a branch that originates from the spinal nerve. It just so happens that this nerve lies in very close proximity to the dorsal rami, which is where the medial branch arises. This group innervates the multifidi as well as the facet joint. The multifidi have a pain referral pattern that overlaps with and is similar to the referral pattern of varying types of disc pain (IDD, Annular Tear, DDD, Chemical Soup/sensitized disc).

Ok, So What About the Case?

Although this patient likely had disc irritation, the majority of the pain being experienced by the patient at this time was not from the disc itself but rather from the surrounding neuromuscular tissues. Treatment of the multifidi not only diminished the patient’s pain during reassessment of movements, palpation and spring of the lumbar segments, but they also immediately demonstrated an improved movement pattern/motor control with all trunk movements. It is completely justified to lean on treatment to rectify and confirm your examination diagnosis. Specific tissues have a unique pain presentation and function; therefore, when you treat that dysfunctional tissue in a specific way, you should be looking for a specific result. In this example, if the multifidi and other paravertebral muscles were irritated (more than I realized from the history and exam), they generated a pain pattern, (which mirrored disc pain), and were also contributing to poor motor control/movement patterns. Following this logic, if I treat the dysfunctional tissue, I should be able to see a change in any or all of those areas. Isn’t this the same logic we use every time we examine and then treat patients — testing our findings by specific treatments? FDN is no different and has become a valuable tool to help localize and identify neuromuscular dysfunction and improve my clinical accuracy!

Pearls for the Road Ahead: Using FDN in Your Practice

  • Door #1: You evaluate a patient, identify what seems to be a straightforward cluster of findings and get to work! You intervened and they improved. No need for supplemental tools or deep neuromuscular retraining principles. They now move appropriately, and their symptoms remain controlled. It was likely a minor acute injury and your intervention helped facilitate the healing process. Pass Go, collect $200.Seems intuitive… If only they were all this easy!
  • Door #2: You examine a patient and this case does not look like it’s going to be as quick as Door #1. They seem to have a bit more “grey” and you are having trouble identifying cause from effect. You treat the patient for a few visits and they show improvement, but then symptoms gradually return. Sure, you are doing them a service, but you are likely treating and calming the symptomatic tissue (more treating the WHAT). Sensible enough, they continue to have a dysfunctional movement pattern, which is likely leading to this continued irritation.

Nothing novel there. We know we should be looking toward causative factors such as hypo/hypermobilities or poor movement patterns/control. Perhaps, we overlooked the neuromuscular impact to the patient. How can we do that effectively?

The Take Home: Neuro and Needling

The novelty and the pearl here is using FDN and its impact on the neuromuscular system to your advantage. FDN can have profound impacts on pain, muscular recruitment, motor control, and neurogenic based dysfunction, which can be incredibly difficult at times to identify. FDN can be extremely tissue and diagnostically specific. More so than palpation, superficial soft tissue strategies, or joint manipulation, FDN offers both a tool for evaluation and intervention. Do not be afraid to challenge yourself to utilize FDN outside of the trigger point intervention model, but consider its effects on neuromuscular facilitation and inhibition, not just in the local tissue of the WHAT, but regionally as well to try to find the WHY behind the WHAT. A whole new world of neuromuscular exploration is at the tip of the needle!

 

KinetaCore, a partner of Evidence In Motion Institutes of Health Professions, offers the highest quality dry needling education courses for the manual therapist, while actively participating in elevating the profession of physical therapy across the globe. Learn more about Functional Dry Needling® courses near you at www.kinetacore.com.

9 responses to “Differential Diagnosis – The Functional Dry Needling® Approach

  1. GB says:

    So…FDN is amazing. References?

    Do students at Kinetacore ask for some evidence? (because most of it suggests TDN actually adds no value). Or are they just happy being told of the “amazingness” of TDN?

    “Profound impacts”….really?

    I know of many subluxation based chiropractors who speak similarly about the “profound impacts” that rectifying a subluxation has on their patients health…

    Let’s not be overzealous here.

    I recognize that what I am saying (and how I am saying it) may be perceived as being negative but let’s remember that the evidence (key word particularly on this site) is sparse so when I read entries like this one with such a high level of certitude…it concerns me.

  2. Josh says:

    “FDN can be extremely tissue and diagnostically specific. More so than palpation, superficial soft tissue strategies, or joint manipulation, FDN offers both a tool for evaluation and intervention.”

    I just can’t see how the evidence supports this claim. We can’t ignore basic science anymore. These claims echo so many that have come and gone before us, it’s sad to see us repeating the same mistakes again.

  3. John Ware, PT says:

    Why are peripheral pain generators still an emphasis of the clinical exam? I feel like I just read a case from the early 90s when I got out of school. The assumptions made in this piece are beyond the pale indefensible. Is this the EIM page? The same EIM that recently partnered with ISPI (Adriaan Louw, Kory Zimney et al)? Did someone steal ya’ll’s domain? I don’t even recognize what I just read.

  4. Matthew says:

    In the last two weeks I’ve read two blog postings here from KinetaCore faculty.

    In the first, needling was promoted without references. No one commented on this omission. Many references were provided, none defending the use of needling. From a clinical reasoning perspective, I’m struggling to find justification for this practice pattern. It seems this is what some would call “low value healthcare.” Provide the customer with what they want. From a business model perspective, it makes perfect sense. From a healthcare perspective, its troubling.

    http://www.journalofphysiotherapy.com/article/S1836-9553(17)30016-4/fulltext

    Furthermore, this practice pattern has flipped the evidence hierarchy upside down and fails to enter the “evidence based funnel.”

    http://thesciencept.com/flush-your-stool-down-the-funnel/

    This blog post, continues to promote (with much certitude as GB mentions) needling without supporting evidence. I understand this may be a promotional, advertising, marketing strategy. If that is the case, I hope anyone on the cusp of spending thousands think and question (like GB, Josh and John) before implementing practice patterns lacking supporting evidence.

  5. Barrett L. Dorko says:

    I’m with John Ware on this.

    Dry needling is here to stay. No evidence, no references and no sense – all elements of science and reading and fact and discussion. All have been absent from any form of therapy for some time.

    Barrett L. Dorko

    1. Geoff says:

      Where is the evidence for simple contact and ideomotion reducing a mechanical deformation in the literature? I don’t see how you can attack FDN and still defend your own therapy. Both are without evidence.

  6. John Ware, PT says:

    Is that what this “blog” has become? A marketing strategy? If so, then I think the honest thing to do is address the pitfalls of marketing in an industry that’s rife with perverse incentives and the profound ethical issues this presents to us as conservative providers of healthcare. That may be a discussion that is long overdue in the PT profession.

  7. gb says:

    It’s not just the lack of evidence that is troubling, but even more so that even identified “experts” struggle with consensus on what the heck they are treating:

    http://www.fmperplex.com/2017/10/09/more-trouble-in-the-land-of-the-trigger-point/

    Plenty of things lack solid evidence but when we are talking about highly invasive techniques with documented adverse consequences (some severe), then I think we cannot afford to be cavalier.

    The entry from Clay is rife with post hoc fallacy, wild leaps and confirmation bias. Extrapolating when we are talking about the best way to load the Achilles tendon is one thing….but when we are going to jab pointy instruments into people (literally taking a stab in the dark)….then things need to be more robust in my opinion.

  8. Clay Jowers says:

    Hello Mr. Dorko, Mr. Ware, Matthew, Josh, and GB.
    Thank you all for the dialogue and feedback. I acknowledge that no research was cited in the commentary, unfortunately, which was a bit of a mistake on my end. The hope of the pearl was to recognize the role the nervous system plays in pain presentation, motor control/function, and identify when and how these are affected by dry needling. I meant to present it as more of a casual clinical commentary, but I recognize it could have been a bit better referenced. Not mentioned in the pearl were any of the follow-up treatments provided: manual therapy, exercise/re-ed, etc. To that point, I strongly agree with Dommerholt’s1 statement that needling is not a stand-alone kind of intervention and should be used where clinical exam and history deem appropriate, as one aspect of a comprehensive manual physical therapy approach. I hope that point is continuously driven across with every pearl; dry needling is a tool and should be viewed as a part of a comprehensive treatment program, whatever and however that may look to each clinician and patient uniquely!
    To your remarks and questions regarding the clinical pearl example, there is literature that demonstrates how dry needling affects inflammatory mediators at the neuromuscular junction and dorsal horn, which are responsible for pain (substance P among others), but also biochemicals that help the body regulate pain (beta-endorphins/neuropeptides). 2,3,4,5,6,7,8,9,10 There is also research demonstrating the neurophysiologic changes with increased activation of the hypothalamus and primary somatosensory-motor cortex during dry needling.11 And finally, there is also research indicating improvement in muscle function of the lumbar multifidi with dry needling.12
    We also recognize the current conflicting landscape of dry needling literature regarding clinical efficacy and outcomes. We have some publications supporting the benefits of dry needling, as well as those that report otherwise.13 Regrettably, the same can be said for many types of interventions, tools, and constructs in medicine. Suffices to say, studying these mediums are difficult and often cumbersome. The goal of my pearl was to highlight my understanding, problem solving, and management while using dry needling. I apologize if that came across as a salesman pitch; that was not the intent. It excites me to dialogue and discuss the field, especially regarding the evolution of standard of practice. Without a doubt, a strong understanding of the neurophysiologic effects that dry needling can have on the local and peripheral tissues, along with the central and peripheral nervous systems, will continue to help guide further research. I certainly hope it continues to help build our clinical reasoning in the application and interpretation of the results we see with the patient.
    Thank you again for your feedback and remarks. If you would like to have a further discussion off line regarding the topic discussed in this clinical pearl, feel free to contact me off-line: education@kinetacore.com. See below for the references for the above reports relevant to the article.
    -Clay Jowers

    1. Dommerholt J. Dry needling – peripheral and central considerations. J Man Manip Ther. 2011;19(4):223-237
    2. Ahsin S, Saleem S, Bhatti AM, Iles RK, Aslam M. Clinical and endocrinological changes after electro-acupuncture treatment in patients with osteoarthritis of the knee. Pain. December 2009;147(1):60-66
    3. Chen L, Zhang J, Li F, et al. Endogenous anandamide and cannabinoid receptor-2 contribute to electroacupuncture analgesia in rats. J Pain. 2009 Jul;10(7):732-739
    4. Su T, Zhang L, Peng M, et al. Cannabinoid CB2 receptors contribute to upregulation of beta-endorphin in inflamed skin tissues by electroacupuncture. Mol Pain. 2011;7:98
    5. Sprouse-Blum A, Smith G, Sugai D, Parsa D. Understanding endorphins and their importance in pain management. Hawaii Med J. 2010;69(3): 70-71. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3104618/
    6. Hsieh YL, Yang CC, Liu SY, Chou LW, Hong CZ. Remote dose-dependent effects of dry needling at distant myofascial trigger spots of rabbit skeletal muscles on reduction of substance P levels of proximal muscle and spinal cords. BioMed Res Int. 2014; Article ID 982121
    7. Hsieh YL, Yang SA, Yang CC, Chou LW. Dry needling at myofascial trigger spots of rabbit skeletal muscles modulates the biochemical associated with pain, inflammation, and hypoxia. Evid Based Complement. and Alternat. Med. 2012; Article ID 342165
    8. Hseih YL, Chou LW, Joe YS, Hong CZ. Spinal cord mechanism involving the remote effects of dry needling on the irritability of myofascial trigger spots in rabbit skeletal muscle. Arch Phys Med Rehab. 2011;92:1098-1105
    9. Hsieh YL, Kao MJ, Kuan TS, Chen SM, Chen JT, Hong CZ. Dry needling to a key myofascial trigger point may reduce the irritability of satellite MTrPs. Arch Phys Med Rehab. 2007;86:397-403
    10. Shah JP, Gilliams EA. Uncovering the biochemical milieu of myofascial trigger points using in vivo microdialysis: An application of the muscle pain concepts to myofascial pain syndrome. J Bodyw Mov Ther. 2008;12:371-384
    11. Wu MT, Sheen JM, Chuang KH, et al. Neuronal specificity of acupuncture response: an fMRI study with electroacupuncture. Neuroimage. 2002;16(4):1028-37
    12. Koppenhaver S, Walker M, Su J, et al. Changes in lumbar mulifidus muscle function and nociceptive sensitivity in low back pain patient responders versus non-responders after dry needling treatment. Manual Therapy. 2015; 20(6):769-776. http://dx.doi.org/10.1016/j.math.2015.03.003
    13. Furlan AD, van Tulder MW, Cherkin D, et al. Acupuncture and dry-needling for low back pain. Cochrane Database Syst Rev 2005 Jan: CD001351

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