Page 19 - Journal of Special Operations Medicine - Spring 2016

Treatment subsequent response is provided in Table 1. The patient
After completion of the initial evaluation, the plan of care reported a reduction of neck pain from 9/10 to 0–2/10
(POC) was discussed with the patient, and consent for within five treatment sessions (1 month), achieving his
treatment obtained. The POC for this patient included symptom goals and facilitating increased participation
initial treatment with education on the pathokinesiology in home and work responsibilities. The patient also re-
of his neck pain, DN, BFA, and instrument-assisted ported a 90% reduction in the use of medication to con-
soft-tissue mobilization of the cervicothoracic myofas- trol pain and an 85% reduction in medication to assist in
cial tissues. Additional interventions including postural sleep, correlating to reduced prescription refills, accord-
awareness, ergonomic education, and therapeutic ex- ing to his electronic health records. The number of PT
ercise prescription emphasizing cervicothoracic motor treatments required to maintain the patient’s pain levels
control were integrated during the course of treatment. averaged three visits per month over the next 6 months,
Specific joint-mobilization techniques were mostly and fewer than one visit per month over an additional 6
avoided because of a past medical history of multilevel months. He was followed for 29 months, during which
fusion, as well as low patient tolerance. he engaged in an independent PT maintenance program.

DN treatment included intervention to tender tissues of Discussion
the cervical paraspinals including splenius capitis and
semispinalis capitis, the upper and middle fibers of the The patient’s symptoms and physical examination were
trapezius, the levator scapula, and the infraspinatus indicative of somatic nociceptive (degenerative disc,
(Figure 1). Deeper muscles, including the cervical and myofascial), and neuropathic (nerve root) pain genera-
thoracic portions of the multifidus, were subsequently tors in the cervical spine. The convergent, overlapping
treated as patient sensitivity and pain levels reduced. nature of afferent input to the spinal cord made it un-
A twitch response with needle insertion and gentle ma- likely that the clinical examination would be able to
nipulation occurred at most of the muscle belly sites, identify all of the specific painful tissue(s). Additionally,
while needling of primarily fascial tissues often elicited the long duration of symptoms and disruption to activi-
a dynamic grabbing or winding phenomenon around the ties of daily living described a chronic pain state involv-
needle. The needles were typically left in place for 15 ing both central and peripheral sensitization that further
minutes, with the patient reporting several sensations, in- complicated the patient’s pain presentation. Previous
cluding pressure, twitching, and warmth, which resolved treatment involving a pharmacologic management ap-
over the treatment time. BFA was delivered per protocol proach yielded unsatisfactory pain relief with unaccept-
and included the placement of five auricular acupuncture able side-effects interfering with this patient’s ADLs and
needles in each ear that were then left in place for 3 days work duties. For these reasons, a PT treatment approach
as the patient went about his usual activities. using DN was selected to address sensitized peripheral
nervous system tissues in conjunction with restoring
Outcomes mobility and motor control of the cervical spine.
The patient in this study, suffering from chronic pain as-
sociated with multilevel cervical spondylosis, achieved Treatment points for needle placement were selected
excellent outcomes with the addition of DN and BFA based upon a combination of patient self-reported ten-
to the PT POC. A summary of treatment course and der tissues as well as neuroanatomic regions associated
with spinal segmental sensory-nerve pathways related to
Figure 1 Dry needle placement.
the cervical region. Palpable bands of increased muscle
tone that were tender, referred to as trigger points, were
also used in guiding needle placement to specific mus-
cles and nerve root levels. Trigger points can be directly
responsible for a patient’s pain via several proposed lo-
cal theories, including the energy crisis theory, the motor
end plate hypothesis, and the radicular denervation su-
persensitivity model. 14,16 Trigger points may also develop
from viscerosomatic or somatic–somatic mechanisms in
which afferent nerves situated at the proximal site of pa-
thology (e.g., cervical spine degeneration) and exposed
to chronic inflammation can produce neurogenically
mediated pain and hypertonicity at distal sites along the
peripheral nerve pathways. DN, as with other forms
17
of acupuncture, has been shown to exert its analgesic
effects via CNS-mediated neuromodulation. 21

Needling Techniques for Chronic Neck Pain 3