Incorporating Dry Needling Into Chiropractic Practice (Pt. 1)

We’re all aware of the various stages of healing, as well as the different phases of care in which we find each of our patients when they walk into our offices (acute, subacute or chronic). The simple truth is that the vast majority of chiropractic patients present when they’re motivated by pain. They’ve been through the common stages of denial, bargaining, frustration and eventually submission as they often begrudgingly relent to the fact that they need some kind of outside help.

As a result, most practices tend to provide the same four or five passive modalities designed to address the actute patient: adjust + stim + soft tissue + heat; repeat. Often, the modalities used on the acute patient never change, even though the patient presentation clearly has. This approach is the antithesis of anything remotely resembling the best evidence for addressing anything outside of the first week or two of care.

The goal should be to get the patient achieving pain-free motion and function by introducing active care as soon as possible. With that in mind, let’s discuss how dry needling can be integrated into a common chiropractic rehab care plan throughout the various phases of care.

The Benefits of Dry Needling

There is a plurality of evidence to support dry needling’s efficacy for a myriad of NMSK conditions. In the past year, the search results for “dry needling” on PubMed has grown from around 600 citations to 900 citations – that’s about a 50% growth in the literature in just one year!

Dry needling has an extremely low cost of delivery and can often be performed in just a few minutes. Perhaps most importantly, your patient has likely already heard about it. There’s a reason the ads on TV say, “Ask your doctor if XYZ is right for you.” The ad just explained what it does and who needs it. Now all that’s left is the patient going to the doctor to demand their self-diagnosis be rewarded with a prescription. Big Pharma isn’t going to risk the task of sales on the personality of the doctor. In today’s doctor-patient, role-reversed dynamic, the less need for explanations / “education,” the better.

Having a patient who believes their condition is “muscular” and has heard that dry needling addresses “the muscles” can be a welcomed reprieve from the insurmountable task of achieving a “paradigm shift” during a report of findings.

Clinically, dry needling has the potential to change how we approach each patient during each phase of care due to its multifaceted utility in affecting physiology.

My General Formula

My general formula for delivering a patient-centric visit that’s as effective as it is expedient, is as follows:

1. Choose an outcome you and the patient would like to improve.
2. Choose three modalities, and their order, that will address the underlying physiology.
3. Re-evaluate that outcome. If there has been a perceptible change that’s positive and meaningful to the patient, send the patient home with exercises that reinforce the outcome.

One aspect of dry needling that changed how I’ve thought about practice, is the fact that it addresses physiology on multiple levels. Rather than following typical recipes for each condition, dry needling made me start developing protocols on the fly depending on the pain profile of each patient. Was I addressing local inflammation, neurogenic pain, muscle tone within the kinetic chain, joint lubrication, etc.?

Depending on how, when and where it’s applied, dry needling can endow the practitioner with the ability to increase local circulation, stimulate fibrosis of repair, mobilize scar tissue, manipulate fascia, increase muscle tone, gate pain locally and centrally, etc. The capacity of dry needling to facilitate each of these phenomena inclines one to really contemplate the state of the individual in front of them, and what specific interventions are the most appropriate for that day.

Be a Chef, Not a Cook

I ask my students if they want to be “cooks” or “chefs.” Cooks follow recipes. Chefs create them. Each condition can be broken down into a soft tissue, neurological and osseous component. Dry needling, the adjustment, and rehabilitative exercises address each as part of a multimodal care plan that should evolve as the patient does, depending on which aspect of their condition is the most prominent at the time of the visit.

A chiropractic “chef” can use their tools to choose the most appropriate modality combination; and dry needling can have utility within that plan at nearly all phases of healing.

Editor’s Note: In part 2, Dr. Wiegand provides specific examples of multimodal approaches to care that include dry needling; and discusses coding and scope implications.