Improving Performance in a High-Level Golfer with Spinal Manipulative Therapy and Dry Needling - A Case Report.

Golf is one of the fastest growing sports in the United States among all age groups. A sport that was originally considered for older adults has now gained tremendous popularity among younger highly trained athletes. Golf courses have continually increased yardage and distance to accommodate these young athletes. With such a focus now on power, strength, and performance; becoming strong is crucial in golf. This study’s aim was to evaluate the effectiveness of Dry Needling (DN) and Spinal Manipulative Therapy (SMT) on improving high-level golfer’s abilities on the course. Over the past several decades, physical therapists have utilized SMT to stimulate healing in a variety of musculoskeletal conditions,1 including looking at improvements in muscle performance. In the following case report, a high-level golfer was treated utilizing a series of SMT alongside DN into the lumbar spine.

SPINAL MANIPULATIVE THERAPY: EFFECTIVENESS & MECHANISMS

Spinal Manipulation is an intervention utilized by Physical Therapists (PTs) to improve various forms of musculoskeletal conditions. It is a localized high-velocity low-amplitude thrust to a joint segment in the body. Spinal Manipulation has been differentiated from mobilization techniques in that it occurs in a thrust technique through anatomically set barriers and does not occur in a lower velocity repetitive oscillation or sustained hold2.

After reviewing 52 articles specific to physical therapists performing spinal manipulation therapy, Kuczynski et al concluded that SMT is an effective and safe option for patients that suffer from low back pain or associated musculoskeletal conditions.3 However, this study did not look at the use of SMT on increasing sports performance and strength.  

Alvarenga et al took this information and conducted a study looking at SMT of the lumbar spine on asymptomatic atheltes.4 The results of Alvarenga’s study showed that postural asymmetries improved, leading to a better ability for the athlete to compete at a high level. Robinson et al also examined symmetry with gait and posture for athletes following SMT. This study also validated SMT for athletes by utilizing force platforms to show the immediate improvement in gait and symmetry with SMT.5

Lastly, grip strength has been shown to be a great determinate of strength and power.6 In a study by Marcelo et al, grip strength in Judo athletes was measured pre and post SMT.7 It showed a marked increase in grip strength leading to improved sports performance following SMT.

DRY NEEDLING TREATMENT FOR SPORTS PERFORMANCE: EFFECTIVENESS & MECHANISMS

Sports performance has been defined as an athlete’s ability to execute or implement strength, dexterity, and focus on their sport. In golf, the major focus of movement is spinal segmental rotation and use of accessory core musculature.8,9 Power is a major determinate in golf to enable these athletes to reach peak performance, demonstrating longer distance and more accurate shots.10,11

As deficiencies in strength and power have been shown to be caused by musculoskeletal deficiencies, dry needling treatment can prove to be an effective means of treatment strategy. DN is a form of neuromuscular treatment where the individual undergoes monofilament needle insertion into target musculature to improve blood flow, muscular recruitment, and firing strategies.12,13 This intervention has been shown to improve muscle strength through the neuro-musculoskeletal system.14

EVALUATION OF IMPROVED SPORTS PERFORMANCE

Athlete is a 24-year-old male who presented to outpatient physical therapy with reports of low back stiffness that he felt limited his performance in golf. Patient reported that over the last 10 years he has been focused on golf getting his handicap down to a 2. He cannot seem to get lower than a 2 handicap and was in search of an intervention to help improve his game. He states that he currently undergoes resistance training three times a week at a local gym, runs for 3 miles two times a week, and meets with a golf professional weekly to review swing mechanics.

During the initial evaluation, patient reported significant tightness in the region of the left paraspinal muscles (PSM) of L2-L5. Although he maintained full AROM of the lumbar spine, hip, and knee; rotational movement elicited 1-2/10 “pain” reported as stiffness on the numeric pain rating scale (NPRS). Manual muscle testing revealed 5/5 strength in bilateral lower extremities. He was tender to palpation over the region of the left PSM with no obvious defect or ecchymosis. At initial evaluation, patient was put through the SFMA test with all movements shown to be functional and non-painful; except for spinal segmental rotation being dysfunctional and non-painful.15

TREATMENT FOR HIGH LEVEL GOLFER TO IMPROVE PERFORMANCE

On the same day as the evaluation, the patient received a lumbar mamillary process rotatory high velocity low amplitude thrust (HVLAT) to L2-L5 in lateral recumbent) biasing the left lumbar spine. Patient was side lying on his right with the physical therapist standing on the front side of the body (to manipulate the left). Patient placed one hand behind his head and the other on his ribcage. Physical therapist then delivered a HVLAT to the left thigh region in an inferior direction (thigh-to-thigh contact with a “body drop”).16

In addition, the patient then went into the prone position and was dry needled at the level of the lumbar spine (L3-L5). Serien G-Type Monofilament Needles .30x50mm were inserted bilaterally into acupoints Bladder 24, Bladder 25, and Bladder 26. All six needles were then manually stimulated by winding in a counterclockwise position until the patient verbally reported discomfort.

On his first follow-up 10 days post-initial evaluation, the patient reported to physical therapy with 0/10 pain/stiffness and a subjective ability to drive the golf ball consistently 5-10 yards longer in distance post-treatment. Treatment was performed again the same as the initial visit; however, this time the HVLAT was performed bilaterally secondary to improved patient trust of this treatment intervention.

RESULTS

Patient was treated 8 times over a two-month span (1x per week for eight weeks during golf season) with SMT and DN at each session. Immediately following the patient’s initial treatment with SMT and DN at the lumbar spine, he was reporting less stiffness, pain-free, and a subjective improvement in strength. His SFMA improved to functional non-painful with left rotation but continued dysfunctional non-painful with right rotation.

CONCLUSION

This case report suggests that the combination of Spinal Manipulation Therapy and Dry Needling may be a useful treatment strategy in golf athletes looking to improve distance and power. However, no cause-and-effect claim can be made as there is an absence of a comparison or control group. Also, current research is heavily weighted towards SMT alone for athletic performance and not in combination with DN.17,18,19,20 A well-designed controlled trial is required to fully determine the additive potential of SMT and DN for this athletic population.

AUTHOR

Jay Rosania, PT, DPT, OCS
Fellow-in-Training, AAMT Fellowship in Orthopaedic Manual Physical Therapy

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