Have you had patients with hypersensitivity, hyperalgesia, or any other type of sympathetic hyperactivity? As PTs, ATs, and DCs, the majority of patients we see have sympathetic autonomic hyperactivity to some degree or another. There are lots of impairments that involve parasympathetic hyperactivity; however, most of them fall outside our scope of practice. Remember: The parasympathetic portion of the ANS (PANS) primarily controls subconscious activities such as digestion, organ function, breathing, etc., and the primary nerve of the PANS is cranial nerve X—the vagus nerve.

Lucky for us, with the right knowledge, it is relatively simple to significantly dampen and reverse sympathetic hyperactivity by targeting the PANS, bringing the ANS towards homeostasis. There are numerous ways to accomplish this, although there is one way that we can most directly access the vagus nerve, the primary nerve of the PANS. The auricular branch of the vagus nerve, directly innervating the concha of the ear.

Needling the concha of the ear, especially with about 2 Hz stim bilateral, has been shown to significantly depress sympathetic hyperactivity. The other areas to target for parasympathetic stimulation with resultant sympathetic depression are the sacral plexus (S2-S4) and the suboccipital / upper cervical periosteum. (I like the base of C2 spinous process). I like to connect these 3 areas to each other in different ways with low frequency microcurrent, followed by manipulation. There is something amazing that occurs in the brain when you do this. I think it involves significant increases in neural plasticity secondary to changes in quantum relationships within the body. (Check out my blog on quantum needling for an intro into some weird stuff. I have more blogs on this coming).

We know that needling regulates spontaneous electrical activity and blood perfusion in the brain somehow, depending on where the needle is placed. This helps both sides of the body. The effect that needling and manipulation have on the brain is poorly understood; however, I believe it is the primary method by which they work. They both have awesome effects on mechanical structures, don’t get me wrong, but the primary method by which they work, I believe, is nervous system regulation, particularly the ANS. Needling has a stronger effect on the nervous systems than does manipulation; however, when used together, they have powerful, synergistic, and healing effects on the body and mind.

One of the mechanisms by which this occurs is beta-endorphin release from certain brain centers, along with white blood cell (WBC) perfusion, secondary to increased microvascular circulation, nervous system regulation, and other mechanisms we do not yet understand. Remember: Calcitonin gene-related peptide (CGRP) is a potent microvascular dilator that is released into the bloodstream when targeting the PANS. Like many substances in the body, CGRP is paradoxical. In proper concentrations, it is essential and helpful. In certain concentrations, it is a potent pain amplifier, along with other bad stuff. Needling and manipulation, when applied thoughtfully, have an overall regulatory and homeostatic effect on CGRP concentration along with other peptides. Remember: Tribonucleation of the joint capsule, or cavitation, also induces significant beneficial neurophysiologic responses.

Aside from depressing sympathetics, beta-endorphin is a powerful, morphine-like analgesic. How many patients go see any doctor with zero pain? With the combination of most of our patients being in some sort of pain and having sympathetic hyperactivity, it is beneficial to target the PANS with your treatments along with whatever else is going on. Although treating areas like the thoracic spine will elevate sympathetic response, if you dampen this effect by stimulating a parasympathetic response, the nervous system will more quickly calm down after the needles are inserted. This allows the sympathetic spike following initial insertion to resolve more quickly, providing the patient more time with the needles in the body with a more homeostatic nervous system. This significantly improves treatment efficacy. I like to leave my needles in for 30 minutes, if tolerated. I promise that you will see longer lasting and more beneficial results with your patients. Helping the nervous systems return to homeostasis is the most healing thing I know how to do.

We know for a fact that needling the concha of the ear directly induces beta-endorphin release, and it has been shown in studies to have greater pain dampening effects than NSAIDs along with the ability to reduce opioid dosage by up to 40% postoperatively. The specific mechanism of action by which this occurs is only in the early stages of understanding.

Quantum biology / mechanics, including quantum tunneling, cohesion, entanglement, and other quantum phenomena (I have new ideas), as we come to understand them better, will be the key to unlocking a vast array of medical advancements. The way quantum stuff is studied at the moment precludes the study of quantum phenomena in warm environments, such as the human body. We just don’t know how to study this weird stuff very well…yet. This is why it’s so exciting! We are on the frontier of new, extremely powerful forms of medicine that have yet to be conceptualized and understood. If we could put a number to the total amount of medical knowledge available in the universe, I would bet we understand less than 5% of the total, if that.

The crazy things I see on a consistent basis—like black magic—when needling and manipulating, have no other current explanation, as far as I can tell, other than quantum biological / mechanical theories or something similar. Needling, I believe, is the best, safest, easiest, and most obvious treatment to employ to specifically study the effects of quantum strangeness in the human body. Microneurography, as far as I know, is currently the gold standard for monitoring the ANS. If you are a physicist reading this, let’s discover something! I am relatively sure that quantum theory and its future are the key to more fully understanding health and the planet, in general.

There is something else going on when we target the PANS, something incapable of proper description with our current knowledge. The results you see from regulating the ANS are nothing less than stunning. There is some type of quantum entanglement, coherence, or something that is established, maintained, and altered from conception throughout life. Due to the proximity of our 3 original cell lines, endoderm, mesoderm, and ectoderm, along with organelle separation, communication and the vast majority of biologic processes we don’t understand, it seems there is some completely misunderstood aspect or aspects to our universe that we have yet to discover. This is so cool! Think about all the awesome stuff we have yet to discover!

There are significant, obvious, immediate, and positive effects of needling and manipulation on the nervous systems. The primary and most influential effect of needling, as far as I can discern, is the homeostatic alteration of the ANS, in particular, regulating the SANS and PANS towards homeostasis. The ANS is one of the most important mechanistic systems in our body. Proper ANS function is essential for a healthy and happy life. If your ANS is dysfunctional, the consequences are innumerable, many of them unknown and detrimental.

Check out my other blogs for more cool and strange ideas!

Jason

DISCLAIMER: The content on the blog for Intricate Art Spine & Body Solutions, LLC is for educational and informational purposes only, and is not intended as medical advice. The information contained in this blog should not be used to diagnose, treat or prevent any disease or health illness. Any reliance you place on such information is therefore strictly at your own risk. Please consult with your physician or other qualified healthcare professional before acting on any information presented here.

References

Manipulation
Kawchuk, G.N., Fryer, J., Jaremko, J.L., Zeng, H., Rowe, L. and Thompson, R., 2015. Real-time visualization of joint cavitation. PloS one, 10(4), p.e0119470

Herzog, W., 2010. The biomechanics of spinal manipulation. Journal of bodywork and movement therapies, 14(3), pp.280-286.

Pickar, J.G., 2002. Neurophysiological effects of spinal manipulation. The spine journal, 2(5), pp.357-371.

Fernández-de-Las-Peñas, C., Alonso-Blanco, C., Cleland, J.A., Rodríguez-Blanco, C. and Alburquerque-Sendín, F., 2008. Changes in pressure pain thresholds over C5-C6 zygapophyseal joint after a cervicothoracic junction manipulation in healthy subjects. Journal of manipulative and physiological therapeutics, 31(5), pp.332-337.

Dishman, J.D. and Bulbulian, R., 2000. Spinal reflex attenuation associated with spinal manipulation. Spine, 25(19), pp.2519-2525.

Vlaar, M.P., Birpoutsoukis, G., Lataire, J., Schoukens, M., Schouten, A.C., Schoukens, J. and Van Der Helm, F.C., 2017. Modeling the nonlinear cortical response in EEG evoked by wrist joint manipulation. IEEE Transactions on Neural Systems and Rehabilitation Engineering, 26(1), pp.205-215.

Christiansen, T.L., Niazi, I.K., Holt, K., Nedergaard, R.W., Duehr, J., Allen, K., Marshall, P., Türker, K.S., Hartvigsen, J. and Haavik, H., 2018. The effects of a single session of spinal manipulation on strength and cortical drive in athletes. European journal of applied physiology, 118(4), pp.737-749.

Haavik, H., Niazi, I.K., Jochumsen, M., Uginčius, P., Sebik, O., Yılmaz, G., Navid, M.S., Özyurt, M.G. and Türker, K.S., 2018. Chiropractic spinal manipulation alters TMS induced I-wave excitability and shortens the cortical silent period. Journal of Electromyography and Kinesiology, 42, pp.24-35.

García-Peñalver, U.J., Palop-Montoro, M.V. and Manzano-Sánchez, D., 2020. Effectiveness of the Muscle Energy Technique versus Osteopathic Manipulation in the Treatment of Sacroiliac Joint Dysfunction in Athletes. International Journal of Environmental Research and Public Health, 17(12), p.4490.

Pain Management Using Vagus Nerve Stimulation
Sprouse-Blum, A.S., Smith, G., Sugai, D. and Parsa, F.D., 2010. Understanding endorphins and their importance in pain management. Hawaii medical journal, 69(3), p.70.

Usichenko, T.I., Dinse, M., Hermsen, M., Witstruck, T., Pavlovic, D. and Lehmann, C., 2005. Auricular acupuncture for pain relief after total hip arthroplasty–a randomized controlled study. Pain, 114(3), pp.320-327.

Usichenko, T.I., Kuchling, S., Witstruck, T., Pavlovic, D., Zach, M., Hofer, A., Merk, H., Lehmann, C. and Wendt, M., 2007. Auricular acupuncture for pain relief after ambulatory knee surgery: a randomized trial. Cmaj, 176(2), pp.179-183.

Jaić, K.K., Turković, T.M., Pešić, M., Djaković, I., Košec, V. and Košec, A., 2019. Auricular acupuncture as effective pain relief after episiotomy: a randomized controlled pilot study. Archives of gynecology and obstetrics, 300(5), pp.1295-1301

Taylor, S.L., Giannitrapani, K.F., Ackland, P.E., Thomas, E.R., Federman, D.G., Holliday, J.R., Olson, J., Kligler, B. and Zeliadt, S.B., 2021. The Implementation and Effectiveness of Battlefield Auricular Acupuncture for Pain. Pain Medicine.

Shah, A.N., Moore, C.B. and Brigger, M.T., 2020. Auricular acupuncture for adult tonsillectomy. The Laryngoscope, 130(8), pp.1907-1912.

Garner, B.K., Hopkinson, S.G., Ketz, A.K., Landis, C.A. and Trego, L.L., 2018. Auricular acupuncture for chronic pain and insomnia: a randomized clinical trial. Medical acupuncture, 30(5), pp.262-272.

Kang, H.R., Lee, Y.S., Kim, H.R., Kim, E.J., Kim, K.H., Kim, K.S., Jung, C.Y. and Lee, J.K., 2017. A clinical study of electroacupuncture and auricular acupuncture for abdominal pain relief in patients with pancreatitis: A pilot study. Korean Journal of Acupuncture, 34(1), pp.47-55.

Moura, C.D.C., Chaves, E.D.C.L., Cardoso, A.C.L.R., Nogueira, D.A., Azevedo, C. and Chianca, T.C.M., 2019. Auricular acupuncture for chronic back pain in adults: a systematic review and metanalysis. Revista da Escola de Enfermagem da USP, 53.

Tsai, S.L., Fox, L.M., Murakami, M. and Tsung, J.W., 2016. Auricular acupuncture in emergency department treatment of acute pain. Annals of emergency medicine, 68(5), pp.583-585.

Yeh, C.H., Chiang, Y.C., Hoffman, S.L., Liang, Z., Klem, M.L., Tam, W.W., Chien, L.C. and Suen, L.K.P., 2014. Efficacy of auricular therapy for pain management: a systematic review and meta-analysis. Evidence-Based Complementary and Alternative Medicine, 2014.

Sator-Katzenschlager, S.M., Szeles, J.C., Scharbert, G., Michalek-Sauberer, A., Kober, A., Heinze, G. and Kozek-Langenecker, S.A., 2003. Electrical stimulation of auricular acupuncture points is more effective than conventional manual auricular acupuncture in chronic cervical pain: a pilot study. Anesthesia & Analgesia, 97(5), pp.1469-1473.

Usichenko, T.I., Lehmann, C. and Ernst, E., 2008. Auricular acupuncture for postoperative pain control: a systematic review of randomised clinical trials. Anaesthesia, 63(12), pp.1343-1348.

Neurologic Conditions

Ghayour Najafabadi, M., Shariat, A., Dommerholt, J., Hakakzadeh, A., Nakhostin-Ansari, A., Selk-Ghaffari, M., Ingle, L. and Cleland, J.A., 2021. Aquatic Therapy for improving Lower Limbs Function in Post-stroke Survivors: A Systematic Review with Meta-Analysis. Topics in Stroke Rehabilitation, pp.1-17.

Pourahmadi, M., Dommerholt, J., Fernández-de-Las-Peñas, C., Koes, B.W., Mohseni-Bandpei, M.A., Mansournia, M.A., Delavari, S., Keshtkar, A. and Bahramian, M., 2021. Dry needling for the treatment of tension-type, cervicogenic, or migraine headaches: A systematic review and meta-analysis. Physical Therapy, 101(5), p.pzab068.

Fernández-de-Las-Peñas, C., Pérez-Bellmunt, A., Llurda-Almuzara, L., Plaza-Manzano, G., De-la-Llave-Rincón, A.I. and Navarro-Santana, M.J., 2021. Is Dry Needling Effective for the Management of Spasticity, Pain, and Motor Function in Post-Stroke Patients? A Systematic Review and Meta-Analysis. Pain Medicine, 22(1), pp.131-141.

Sánchez-Mila, Z., Salom-Moreno, J. and Fernández-de-Las-Peñas, C., 2018. Effects of dry needling on post-stroke spasticity, motor function and stability limits: a randomised clinical trial. Acupuncture in Medicine, 36(6), pp.358-366.

Mendigutia-Gómez, A., Martín-Hernández, C., Salom-Moreno, J. and Fernández-de-Las-Peñas, C., 2016. Effect of dry needling on spasticity, shoulder range of motion, and pressure pain sensitivity in patients with stroke: A crossover study. Journal of manipulative and physiological therapeutics, 39(5), pp.348-358.

Mendigutía-Gómez, A., Quintana-García, M.T., Martín-Sevilla, M., de Lorenzo-Barrientos, D., Rodríguez-Jiménez, J., Fernández-de-Las-Peñas, C. and Arias-Buría, J.L., 2020. Post-needling soreness and trigger point dry needling for hemiplegic shoulder pain following stroke. Acupuncture in Medicine, 38(3), pp.150-157.

Valencia-Chulián, R., Heredia-Rizo, A.M., Moral-Munoz, J.A., Lucena-Anton, D. and Luque-Moreno, C., 2020. Dry needling for the management of spasticity, pain, and range of movement in adults after stroke: A systematic review. Complementary Therapies in Medicine, 52, p.102515.
Calvo, S., Navarro, J., Herrero, P., Del Moral, R., De Diego, C. and Marijuán, P.C., 2015. Electroencephalographic changes after application of dry needling [DNHS© technique] in two patients with chronic stroke. Myopain, 23(3-4), pp.112-117.

Cuenca Zaldívar, J.N., Calvo, S., Bravo-Esteban, E., Oliva Ruiz, P., Santi-Cano, M.J. and Herrero, P., 2020. Effectiveness of dry needling for upper extremity spasticity, quality of life and function in subacute phase stroke patients. Acupuncture in Medicine, p.0964528420947426.

Hernández-Ortíz, A.R., Ponce-Luceño, R., Sáez-Sánchez, C., García-Sánchez, O., Fernández-de-Las-Peñas, C. and de-la-Llave-Rincón, A.I., 2020. Changes in muscle tone, function, and pain in the chronic hemiparetic shoulder after dry needling within or outside trigger points in stroke patients: A crossover randomized clinical trial. Pain Medicine, 21(11), pp.2939-2947.

Tavakol, Z., Shariat, A., Ansari, N.N., Ghannadi, S., Honarpishe, R., Dommerholt, J., Noormohammadpour, P. and Ingle, L., 2021. A Double-blind Randomized Controlled Trial for the Effects of Dry Needling on Upper Limb Dysfunction in Patients with Stroke. Acupuncture & Electro-Therapeutics Research, 45(2-3), pp.115-124.

Ghaffari, M.S., Shariat, A., Honarpishe, R., Hakakzadeh, A., Cleland, J.A., Haghighi, S. and Barghi, T.S., 2019. Concurrent effects of dry needling and electrical stimulation in the management of upper extremity hemiparesis. Journal of acupuncture and meridian studies, 12(3), pp.90-94.

Ghannadi, S., Shariat, A., Ansari, N.N., Tavakol, Z., Honarpishe, R., Dommerholt, J., Noormohammadpour, P. and Ingle, L., 2020. The effect of dry needling on lower limb dysfunction in poststroke survivors. Journal of Stroke and Cerebrovascular Diseases, 29(6), p.104814.

Bynum, R., Garcia, O., Herbst, E., Kossa, M., Liou, K., Cowan, A. and Hilton, C., 2021. Effects of dry needling on spasticity and range of motion: a systematic review. American Journal of Occupational Therapy, 75(1), pp.7501205030p1-7501205030p13.

DiLorenzo, L., Traballesi, M., Morelli, D., Pompa, A., Brunelli, S., Buzzi, M.G. and Formisano, R., 2004. Hemiparetic shoulder pain syndrome treated with deep dry needling during early rehabilitation: a prospective, open-label, randomized investigation. Journal of Musculoskeletal Pain, 12(2), pp.25-34.

Carusotto, A.F., Hakim, R.M., Oliveira, R.G., Piranio, A., Coughlan, C.P. and MacDonald, T.J., 2021. Effects of dry needling on muscle spasticity in adults with neurological disorders: a systematic review. Physical Therapy Reviews, pp.1-6.

Sánchez-Mila, Z., Salom-Moreno, J. and Fernández-de-Las-Peñas, C., 2018. Effects of dry needling on post-stroke spasticity, motor function and stability limits: a randomised clinical trial. Acupuncture in Medicine, 36(6), pp.358-366.

Salom-Moreno, J., Sánchez-Mila, Z., Ortega-Santiago, R., Palacios-Ceña, M., Truyol-Domínguez, S. and Fernández-de-las-Peñas, C., 2014. Changes in spasticity, widespread pressure pain sensitivity, and baropodometry after the application of dry needling in patients who have had a stroke: A randomized controlled trial. Journal of manipulative and physiological therapeutics, 37(8), pp.569-579.

Valencia-Chulián, R., Heredia-Rizo, A.M., Moral-Munoz, J.A., Lucena-Anton, D. and Luque-Moreno, C., 2020. Dry needling for the management of spasticity, pain, and range of movement in adults after stroke: A systematic review. Complementary Therapies in Medicine, 52, p.102515.
Núñez-Cortés, R., Cruz-Montecinos, C., Latorre-García, R., Pérez-Alenda, S. and Torres-Castro, R., 2020. Effectiveness of Dry Needling in the Management of Spasticity in Patients Post Stroke. Journal of Stroke and Cerebrovascular Diseases, 29(11), p.105236.

Bynum, R., Garcia, O., Herbst, E., Kossa, M., Liou, K., Cowan, A. and Hilton, C., 2021. Effects of dry needling on spasticity and range of motion: a systematic review. American Journal of Occupational Therapy, 75(1), pp.7501205030p1-7501205030p13.

Electrical Needling

Ahmed, A.F., Elgayed, S.S. and Ibrahim, I.M., 2012. Polarity effect of microcurrent electrical stimulation on tendon healing: biomechanical and histopathological studies. Journal of Advanced Research, 3(2), pp.109-117.
Yazdan-Shahmorad, A., Kipke, D.R. and Lehmkuhle, M.J., 2011. Polarity of cortical electrical stimulation differentially affects neuronal activity of deep and superficial layers of rat motor cortex. Brain stimulation, 4(4), pp.228-241.

Gentzkow, G.D., 1993. Electrical stimulation to heal dermal wounds. The Journal of dermatologic surgery and oncology, 19(8), pp.753-758.

Hayashi, K. and Ninjouji, T., 2004, September. Two-point discrimination threshold as a function of frequency and polarity at fingertip by electrical stimulation. In The 26th Annual International Conference of the IEEE Engineering in Medicine and Biology Society (Vol. 2, pp. 4256-4259). IEEE.
Demir, H., Balay, H. and Kirnap, M., 2004. A comparative study of the effects of electrical stimulation and laser treatment on experimental wound healing in rats. Journal of rehabilitation Research & development, 41(2).
Balakatounis, K.C. and Angoules, A.G., 2008. Low-intensity electrical stimulation in wound healing: review of the efficacy of externally applied currents resembling the current of injury. Eplasty, 8.
Ashrafi, M., Alonso‐Rasgado, T., Baguneid, M. and Bayat, A., 2016. The efficacy of electrical stimulation in experimentally induced cutaneous wounds in animals. Veterinary dermatology, 27(4), pp.235-e57.

Krause, B. and Cohen Kadosh, R., 2014. Not all brains are created equal: the relevance of individual differences in responsiveness to transcranial electrical stimulation. Frontiers in systems neuroscience, 8, p.25.

Asadi, M.R., Torkaman, G. and Hedayati, M., 2011. Effect of sensory and motor electrical stimulation in vascular endothelial growth factor expression of muscle and skin in full-thickness wound. J Rehabil Res Dev, 48(3), pp.195-201.

Deriu, F., Tolu, E. and Rothwell, C., 2003. A short latency vestibulomasseteric reflex evoked by electrical stimulation over the mastoid in healthy humans. The Journal of physiology, 553(1), pp.267-279.

Wang, J., Wang, H., Thakor, N.V. and Lee, C., 2019. Self-powered direct muscle stimulation using a triboelectric nanogenerator (TENG) integrated with a flexible multiple-channel intramuscular electrode. ACS nano, 13(3), pp.3589-3599.

Nussbaum, E.L., Houghton, P., Anthony, J., Rennie, S., Shay, B.L. and Hoens, A.M., 2017. Neuromuscular electrical stimulation for treatment of muscle impairment: critical review and recommendations for clinical practice. Physiotherapy Canada, 69(5), pp.1-76.

Asadi, M.R. and Torkaman, G., 2014. Bacterial inhibition by electrical stimulation. Advances in wound care, 3(2), pp.91-97.

Snyder, A.R., Perotti, A.L., Lam, K.C. and Bay, R.C., 2010. The influence of high-voltage electrical stimulation on edema formation after acute injury: a systematic review. Journal of sport rehabilitation, 19(4), pp.436-451.

Feger, M.A., Goetschius, J., Love, H., Saliba, S.A. and Hertel, J., 2015. Electrical stimulation as a treatment intervention to improve function, edema or pain following acute lateral ankle sprains: A systematic review. Physical Therapy in Sport, 16(4), pp.361-369.

Hamid, S. and Hayek, R., 2008. Role of electrical stimulation for rehabilitation and regeneration after spinal cord injury: an overview. European Spine Journal, 17(9), pp.1256-1269.

Reilly, J.P., 2012. Applied bioelectricity: from electrical stimulation to electropathology. Springer Science & Business Media.
Gordon, T., Amirjani, N., Edwards, D.C. and Chan, K.M., 2010. Brief post-surgical electrical stimulation accelerates axon regeneration and muscle reinnervation without affecting the functional measures in carpal tunnel syndrome patients. Experimental neurology, 223(1), pp.192-202.

Hwang, I.H. and Thompson, J.M., 2001. The effect of time and type of electrical stimulation on the calpain system and meat tenderness in beef longissimus dorsi muscle. Meat science, 58(2), pp.135-144.

Autonomic Nervous System

Li, Q.Q., Shi, G.X., Xu, Q., Wang, J., Liu, C.Z. and Wang, L.P., 2013. Acupuncture effect and central autonomic regulation. Evidence-Based Complementary and Alternative Medicine, 2013.

Park, S.U., Jung, W.S., Moon, S.K., Park, J.M., Ko, C.N., Cho, K.H., Kim, Y.S. and Bae, H.S., 2008. Effects of acupuncture on autonomic nervous system in normal subjects under mental stress. The Journal of Korean Medicine, 29(2), pp.107-115.

Haker, E., Egekvist, H. and Bjerring, P., 2000. Effect of sensory stimulation (acupuncture) on sympathetic and parasympathetic activities in healthy subjects. Journal of the autonomic nervous system, 79(1), pp.52-59.

Bäcker, M., Grossman, P., Schneider, J., Michalsen, A., Knoblauch, N., Tan, L., Niggemeyer, C., Linde, K., Melchart, D. and Dobos, G.J., 2008. Acupuncture in migraine: investigation of autonomic effects. The Clinical journal of pain, 24(2), pp.106-115.

Uchida, C., Waki, H., Minakawa, Y., Tamai, H., Miyazaki, S., Hisajima, T. and Imai, K., 2019. Effects of acupuncture sensations on transient heart rate reduction and autonomic nervous system function during acupuncture stimulation. Medical acupuncture, 31(3), pp.176-184.

Uchida, C., Waki, H., Minakawa, Y., Tamai, H., Miyazaki, S., Hisajima, T. and Imai, K., 2019. Effects of acupuncture sensations on transient heart rate reduction and autonomic nervous system function during acupuncture stimulation. Medical acupuncture, 31(3), pp.176-184.

Butts, r., dunning, j. And serafino, c., 2020. Dry needling strategies for musculoskeletal conditions: do the number of needles and needle retention time matter? A narrative review of the literature. Journal of bodywork and movement therapies.

Castro-Sánchez, A.M., Garcia-López, H., Fernández-Sánchez, M., Perez-Marmol, J.M., Leonard, G., Gaudreault, N., Aguilar-Ferrándiz, M.E. and Matarán-Peñarrocha, G.A., 2020. Benefits of dry needling of myofascial trigger points on autonomic function and photoelectric plethysmography in patients with fibromyalgia syndrome. Acupuncture in Medicine, 38(3), pp.140-149.

Loaiza, L. A., Yamaguchi, S., Ito, M., & Ohshima, N. (2002). Electro-acupuncture stimulation to muscle afferents in anesthetized rats modulates the blood flow to the knee joint through autonomic reflexes and nitric oxide. Autonomic Neuroscience : Basic & Clinical, 97(2), 103–109. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/12132642.

Morikawa, Y., Takamoto, K., Nishimaru, H., Taguchi, T., Urakawa, S., Sakai, S., … Nishijo, H. (2017). Compression at myofascial trigger point on chronic neck pain provides pain relief through the prefrontal cortex and autonomic nervous system: A pilot study. Frontiers in Neuroscience, 11(APR). https://doi.org/10.3389/fnins.2017.00186.

Sillevis, R., Van Duijn, J., Shamus, E. and Hard, M., 2021. Time effect for in-situ dry needling on the autonomic nervous system, a pilot study. Physiotherapy theory and practice, 37(7), pp.826-834.

Lázaro-Navas, I., Lorenzo-Sánchez-Aguilera, C., Pecos-Martín, D., Jiménez-Rejano, J.J., Navarro-Santana, M.J., Fernández-Carnero, J. and Gallego-Izquierdo, T., 2021. Immediate Effects of Dry Needling on the Autonomic Nervous System and Mechanical Hyperalgesia: A Randomized Controlled Trial. International Journal of Environmental Research and Public Health, 18(11), p.6018.

Abbaszadeh-Amirdehi, M., Ansari, N.N., Naghdi, S., Olyaei, G. and Nourbakhsh, M.R., 2017. Therapeutic effects of dry needling in patients with upper trapezius myofascial trigger points. Acupuncture in Medicine, 35(2), pp.85-92.

Castro-Sánchez, A.M., Garcia-López, H., Fernández-Sánchez, M., Perez-Marmol, J.M., Leonard, G., Gaudreault, N., Aguilar-Ferrándiz, M.E. and Matarán-Peñarrocha, G.A., 2020. Benefits of dry needling of myofascial trigger points on autonomic function and photoelectric plethysmography in patients with fibromyalgia syndrome. Acupuncture in Medicine, 38(3), pp.140-149.

Skorupska, E., Rychlik, M. and Samborski, W., 2015. Intensive vasodilatation in the sciatic pain area after dry needling. BMC complementary and alternative medicine, 15(1), pp.1-9.

Clark, N.G., Hill, C.J., Koppenhaver, S.L., Massie, T. and Cleland, J.A., 2021. The effects of dry needling to the thoracolumbar junction multifidi on measures of regional and remote flexibility and pain sensitivity: A randomized controlled trial. Musculoskeletal Science and Practice, 53, p.102366.

Sánchez-Infante, J., Navarro-Santana, M.J., Bravo-Sánchez, A., Jiménez-Diaz, F. and Abián-Vicén, J., 2021. Is Dry Needling Applied by Physical Therapists Effective for Pain in Musculoskeletal Conditions? A Systematic Review and Meta-Analysis. Physical Therapy, 101(3), p.pzab070.

Eftekharsadat, B., Babaei-Ghazani, A. and Zeinolabedinzadeh, V., 2016. Dry needling in patients with chronic heel pain due to plantar fasciitis: A single-blinded randomized clinical trial. Medical journal of the Islamic Republic of Iran, 30, p.401.

Li, Q.Q., Shi, G.X., Xu, Q., Wang, J., Liu, C.Z. and Wang, L.P., 2013. Acupuncture effect and central autonomic regulation. Evidence-Based Complementary and Alternative Medicine, 2013.

Mori, H., Nishijo, K., Kawamura, H. and Abo, T., 2002. Unique immunomodulation by electro-acupuncture in humans possibly via stimulation of the autonomic nervous system. Neuroscience Letters, 320(1-2), pp.21-24.

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