Dry Needling + Post-Operative Recovery: Does it help?

Dry needling is, without question, the most powerful tool physical therapists have to significantly improve surgical outcomes. All surgeons should want properly trained therapists needling their patients day 1 post-op. Properly performed needling improves wound healing. It speeds it up and helps minimize scar formation, secondary to an exponential increase in blood perfusion, along with reduced tissue tension on the incision site. The massive increase in blood flowing through the tissues brings in the needed healing nutrients and flushes out the chemicals produced in healing tissue that, if not removed, inhibit further healing and amplify pain.

Why is Dry Needling Good for Post-Operative Recovery?

Calcitonin gene related peptide is a microvascular dilator released into the bloodstream that stimulates significant increases in blood perfusion. ß-endorphin is also released from the hypothalamic pituitary adrenal (HPA) axis, decreasing pain, sympathetic hyperactivity, and the need for post-operative narcotics. This is secondary to the autonomic nervous system (ANS) regulation induced by needling, bringing the ANS toward homeostasis. By regulating the ANS, the enteric nervous system, part of the ANS, is also regulated. This significantly improves immune function and bolsters our defenses against infection along with other helpful factors, like normalizing serotonin levels.

The overall effect of thoughtful needling is elevation of the parasympathetic portion of the autonomic nervous system (PANS). It turns it up, if you will. At the same time, the sympathetic portion of the ANS (SANS) is depressed, bringing the ANS back toward homeostasis. This is key to improving post-operative recovery. It typically takes about 12 weeks for full tissue healing to occur following surgery. This is obviously a generality, and this time period can be shortened with certain interventions, like needling. During post-operative recovery, the sympathetic portion of the ANS is going to be elevated. Trauma and pain are two things that cause SANS elevation. Surgery is trauma, and it causes pain. The damage to your body is going to make you aware of it so it can be taken care of. This causes sympathetic stimulation and the abnormal release of neurotransmitters like norepinephrine, cortisol and pro-inflammatory factors like tumor necrosis factor alpha (TNF-a) and interleukin 6, along with pain amplifiers, like substance P.

Related: Click here to learn more about our Dry Needling Course offerings

We have a bit of understanding of some of these processes. Following trauma/surgery, immune cells flood the area and release pro-inflammatory substances. Many of these substances lower the electrical threshold for an action potential in various cells and fibers, including nociceptive ones. This leads to spontaneous electrical activity. If enough inflammatory mediators enter into the equation, excessive afferent signals are sent to the brain, resulting in dysregulation of the HPA axis and the SANS. Cytokines like interleukin-6 and TNF-a are produced and sent to the site of the injury. Oftentimes, these substances become overproduced and trapped in pathologic tissue in and around surgical sites, secondary to decreased circulation. This reduces healing ability, amplifies pain, and hinders immune function. Needling regulates these factors via nudging the ANS toward homeostasis. Contrary to popular belief, needling reduces the risk of post-operative infection by allowing the body’s immune system to function better, via ANS homeostatic regulation.

The Body's Response + How Dry Needling Helps

Our body’s natural response to damage is to tighten everything up in the area, including blood vessels and muscles, to reduce further blood loss or injury. Anyone who has had surgery knows how your muscles and everything get tight around the surgical site. This can become detrimental to healing in a controlled environment. Super tight muscles, along with vasoconstriction, both induced by sympathetic hyperactivity, slow down blood flow through healing tissue. This leads to the visual swelling you see near surgical tissue. Lots of blood is going to the site of injury, but it is not flowing through it at normal speed. This leads to a backup of fluid, which allows chemicals that are typically helpful, such as CGRP, to become hyper-concentrated, at which point they become pain amplifiers. CGRP, like most substances in our bodies, is paradoxical. In the proper amounts, it is necessary and helpful, but in abnormal amounts, it is problematic.

By targeting the parasympathetic portion of the ANS via the concha of the ears (auricular branch of the vagus nerve), the sacral plexus (S2-S4), and the upper cervical or suboccipital periosteum, along with whatever other areas are being treated, we are able to depress sympathetic hyperactivity and elevate parasympathetic activity. Especially when the needles are connected with about 2 Hz of microcurrent. This leads to ß-endorphin release from the HPA axis, one method by which needling regulates the ANS. ß-endorphin is a powerful endogenous opioid and analgesic that dampens pain and sympathetic hyperactivity, bringing the ANS back towards homeostasis. This allows the body the best opportunity to better heal itself.

I like to needle the concha of the ear when treating most of my patients. I use this needle for a lot of stuff. The concha is the only tissue we can needle that is directly innervated by the vagus nerve, the auricular branch. Needling this area has been shown to have positive effects on all sorts of cool things like pain, depression, bowel dysfunction, psychosocial dysfunction, ANS regulation, migraines, and immune function, to name a few. Remember, the vagus innervates the enteric nervous system, which is part of the ANS and plays a primary role in regulating our immune system. The connection between the vagus and the enteric nervous system is commonly referred to as the gut-brain-axis. Think of the gut-brain axis as interoceptive awareness, what’s going on inside our bodies. The HPA axis regulates our body’s response to stress via hormone production and release. The gut-brain-axis and the HPA are primary controllers of physiologic homeostasis, as far as we know. If we have maximum ANS homeostasis, we should never get sick or really have any significant issues of any kind. Improved immune function and ANS homeostasis are 2 primary methods by which needling helps improve post-operative recovery.

If the ANS is not in homeostasis, which it certainly is not following surgery, the body does not function properly, at all. Central sensitization of the central nervous system develops, hypersensitivity and allodynia ensue, chemically induced pain becomes an issue secondary to tissue hypoxia, hormone production dysfunctions, and more. This combination of occurrences can lead to any number of impairments following surgery, depending on the individual. Some of the most common are pain, depression, and anxiety. All of these create a less than ideal circumstance for the body to heal. Needling helps with all this stuff.

Related: Check out my blog on needling for psychotherapy here

The amalgamation of issues following surgery, all of which lead to the ANS dysfunction, inhibit and slow down the body's innate ability to heal itself. Dry needling is the fastest and most effective way to regulate both the tissues surrounding the surgical site and the ANS back toward homeostasis. With more homeostatic tissues and nervous systems, the body can do incredibly awesome things, like heal itself. There is ground-breaking research currently being done looking into this innate healing ability by people like Dr. David Sinclair (Harvard Medical School) and Dr. Dan Engle (MD, Psychiatrist, ketamine-assisted psychotherapy). Very recently, for the first time ever, complete spinal cord severing in mice was repaired with a single injection into the dura, allowing the spine to heal itself over the course of a few weeks. The mice were able to walk again. No surgery. Crazy!!

Overall, dry needling significantly improves all aspects of post-operative recovery through ANS regulation. Thoughtful needling brings ANS components, such as the HPA axis and enteric nervous system, back toward homeostasis, allowing our systems to properly work together as a team, thus improving the body’s innate ability to heal itself. Having had numerous seriously traumatic injuries myself (playing D1 ice hockey, hitting stuff in my car and a plane crash), along with treating patients over the years, I have never seen any treatment as effective for post-operative recovery as dry needling.

Let me know if anyone has any questions about anything. Thanks.

Jason

Neural Plasticity

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• 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.

• Hsieh, Y.L., Yang, C.C., Liu, S.Y., Chou, L.W. and Hong, C.Z., 2014. 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 Research International, 2014.

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• Ren, L., Zhang, W.A., Fang, N.Y. and Wang, J.X., 2008. The influence of electro-acupuncture on neural plasticity in acute cerebral infarction. Neurological research, 30(9), pp.985-989.

• Xiao, L.Y., Wang, X.R., Yang, Y., Yang, J.W., Cao, Y., Ma, S.M., Li, T.R. and Liu, C.Z., 2018. Applications of acupuncture therapy in modulating plasticity of central nervous system. Neuromodulation: Technology at the Neural Interface, 21(8), pp.762-776

• Lo, Y.L., Cui, S.L. and Fook-Chong, S., 2005. The effect of acupuncture on motor cortex excitability and plasticity. Neuroscience letters, 384(1-2), pp.145-149.

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• Li, X. and Wang, Q., 2013. Acupuncture therapy for stroke patients. International review of neurobiology, 111, pp.159-179.

• Kong, J., Gollub, R., Huang, T., Polich, G., Napadow, V., Hui, K., Vangel, M., Rosen, B. and Kaptchuk, T.J., 2007. Acupuncture de qi, from qualitative history to quantitative measurement. The Journal of Alternative and Complementary Medicine, 13(10), pp.1059-1070.

• Lee, J.D., Chon, J.S., Jeong, H.K., Kim, H.J., Yun, M., Kim, D.Y., Kim, D.I., Park, C.I. and Yoo, H.S., 2003. The cerebrovascular response to traditional acupuncture after stroke. Neuroradiology, 45(11), pp.780-784.

• Yang, Y., Eisner, I., Chen, S., Wang, S., Zhang, F. and Wang, L., 2017. Neuroplasticity changes on human motor cortex induced by acupuncture therapy: a preliminary study. Neural plasticity, 2017.

• Jiang, H., Zhang, X., Wang, Y., Zhang, H., Li, J., Yang, X., Zhao, B., Zhang, C., Yu, M., Xu, M. and Yu, Q., 2017. Mechanisms underlying the antidepressant response of acupuncture via PKA/CREB signaling pathway. Neural Plasticity, 2017.

• Tang, H., Guo, Y., Zhao, Y., Wang, S., Wang, J., Li, W., Qin, S., Gong, Y., Fan, W., Chen, Z. and Guo, Y., 2020. Effects and Mechanisms of Acupuncture Combined with Mesenchymal Stem Cell Transplantation on Neural Recovery after Spinal Cord Injury: Progress and Prospects. Neural Plasticity, 2020.

• Lai, H.C., Chang, Q.Y. and Hsieh, C.L., 2019. Signal transduction pathways of acupuncture for treating some nervous system diseases. Evidence-Based Complementary and Alternative Medicine, 2019.

• Pirnia, B., Bazargan, N.M., Hamdieh, M., Pirnia, K., Malekanmehr, P., Maleki, F. and Zahiroddin, A., 2019. The Effectiveness of Auricular Acupuncture on the Levels of Cortisol in a Depressed Patient. Iranian journal of public health, 48(9), pp.1748-1750.

• Yang, J.W., Ye, Y., Wang, X.R., Li, F., Xiao, L.Y., Shi, G.X. and Liu, C.Z., 2017. Acupuncture attenuates renal sympathetic activity and blood pressure via beta-adrenergic receptors in spontaneously hypertensive rats. Neural plasticity, 2017.

• Ye, Y., Zhu, W., Wang, X.R., Yang, J.W., Xiao, L.Y., Liu, Y., Zhang, X. and Liu, C.Z., 2017. Mechanisms of acupuncture on vascular dementia—a review of animal studies. Neurochemistry international, 107, pp.204-210.

• Li, Y., Wang, Y., Liao, C., Huang, W. and Wu, P., 2017. Longitudinal brain functional connectivity changes of the cortical motor-related network in subcortical stroke patients with acupuncture treatment. Neural plasticity, 2017.

• Wang, T., Wu, L., Liao, D., Zhou, X., Chen, Y. and Takeda, A., 2002. Effect of acupuncture on the expression of NT3 in the process of spinal plasticity. Hua xi yi ke da xue xue bao= Journal of West China University of Medical Sciences= Huaxi yike daxue xuebao, 33(1), pp.46-49.

• B-endorphin

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• Roschina, O.V., Levchuk, L.A., Boiko, A.S., Michalitskaya, E.V., Epimakhova, E.V., Losenkov, I.S., Simutkin, G.G., Loonen, A.J., Bokhan, N.A. and Ivanova, S.A., 2021. Beta-Endorphin and Oxytocin in Patients with Alcohol Use Disorder and Comorbid Depression. Journal of Clinical Medicine, 10(23), p.5696.

• Rocchi, G., Sterlini, B., Tardito, S., Inglese, M., Corradi, A., Filaci, G., Amore, M., Magioncalda, P. and Martino, M., 2020. Opioidergic system and functional architecture of intrinsic brain activity: implications for psychiatric disorders. The Neuroscientist, 26(4), pp.343-358.

• Lu, Y., Ann, L. and McCarron, R., 2021. Steroid-induced psychiatric symptoms: What you need to know. Current Psychiatry, 20(4), p.33.

• Maslov, M.Y., Foianini, S., Orlov, M.V., Januzzi, J.L. and Lovich, M.A., 2018. A novel paradigm for sacubitril/valsartan: beta-endorphin elevation as a contributor to exercise tolerance improvement in rats with preexisting heart failure induced by pressure overload. Journal of cardiac failure, 24(11), pp.773-782.

• van der Venne, P., Balint, A., Drews, E., Parzer, P., Resch, F., Koenig, J. and Kaess, M., 2021. Pain sensitivity and plasma beta-endorphin in adolescent non-suicidal self-injury. Journal of Affective Disorders, 278, pp.199-208.

• Furness, J.B., 2000. Types of neurons in the enteric nervous system. Journal of the autonomic nervous system, 81(1-3), pp.87-96.

• McCullough, J.E., Liddle, S.D., Close, C., Sinclair, M. and Hughes, C.M., 2018. Reflexology: a randomised controlled trial investigating the effects on beta-endorphin, cortisol and pregnancy related stress. Complementary therapies in clinical practice, 31, pp.76-84.

• Maslov, M.Y., Foianini, S., Orlov, M.V., Januzzi, J.L. and Lovich, M.A., 2018. A novel paradigm for sacubitril/valsartan: beta-endorphin elevation as a contributor to exercise tolerance improvement in rats with preexisting heart failure induced by pressure overload. Journal of cardiac failure, 24(11), pp.773-782.

• Cui, L., Cai, H., Sun, F., Wang, Y., Qu, Y., Dong, J., Wang, H., Li, J., Qian, C. and Li, J., 2021. Beta-endorphin inhibits the inflammatory response of bovine endometrial cells through δ opioid receptor in vitro. Developmental & Comparative Immunology, 121, p.104074.

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.
• Johnson, R.L. and Wilson, C.G., 2018. A review of vagus nerve stimulation as a therapeutic intervention. Journal of inflammation research, 11, p.203.

Neurologic Conditions, Including TBI & CVA

• 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.

Orthopedic Conditions

• 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.
• Navarro-Santana, M.J., Gómez-Chiguano, G.F., Cleland, J.A., Arias-Buría, J.L., Fernández-de-Las-Peñas, C. and Plaza-Manzano, G., 2021. Effects of Trigger Point Dry Needling for Nontraumatic Shoulder Pain of Musculoskeletal Origin: A Systematic Review and Meta-Analysis. Physical Therapy, 101(2), p.pzaa216.
• Ma, Y.T., Li, L.H., Han, Q., Wang, X.L., Jia, P.Y., Huang, Q.M. and Zheng, Y.J., 2020. Effects of trigger point dry needling on neuromuscular performance and pain of individuals affected by patellofemoral pain: a randomized controlled trial. Journal of Pain Research, 13, p.1677.
• 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.
• Haser, C.H.R.I.S.T.I.A.N., Stöggl, T.H.O.M.A.S., Kriner, M.O.N.I.K.A., Mikoleit, J., Wolfahrt, B., Scherr, J., Halle, M. and Pfab, F., 2017. Effect of dry needling on thigh muscle strength and hip flexion in elite soccer players. Med Sci Sports Exerc, 49(2), pp.378-383.
• Ceballos-Laita, L., Jiménez-del-Barrio, S., Marín-Zurdo, J., Moreno-Calvo, A., Marín-Boné, J., Albarova-Corral, M.I. and Estébanez-de-Miguel, E., 2019. Effects of dry needling in HIP muscles in patients with HIP osteoarthritis: a randomized controlled trial. Musculoskeletal Science and Practice, 43, pp.76-82.
• Geist, K., Bradley, C., Hofman, A., Koester, R., Roche, F., Shields, A., Frierson, E., Rossi, A. and Johanson, M., 2017. Clinical effects of dry needling among asymptomatic individuals with hamstring tightness: a randomized controlled trial. Journal of sport rehabilitation, 26(6), pp.507-517.
• Osborne, N.J. and Gatt, I.T., 2010. Management of shoulder injuries using dry needling in elite volleyball players. Acupuncture in medicine, 28(1), pp.42-45.
• Albin, S.R., Koppenhaver, S.L., MacDonald, C.W., Capoccia, S., Ngo, D., Phippen, S., Pineda, R., Wendlandt, A. and Hoffman, L.R., 2020. The effect of dry needling on gastrocnemius muscle stiffness and strength in participants with latent trigger points. Journal of Electromyography and Kinesiology, 55, p.102479.
• Navarro-Santana, M.J., Sanchez-Infante, J., Gómez-Chiguano, G.F., Cleland, J.A., López-de-Uralde-Villanueva, I., Fernández-de-Las-Peñas, C. and Plaza-Manzano, G., 2020. Effects of trigger point dry needling on lateral epicondylalgia of musculoskeletal origin: a systematic review and meta-analysis. Clinical Rehabilitation, 34(11), pp.1327-1340.
• Segura-Ortí, E., Prades-Vergara, S., Manzaneda-Piña, L., Valero-Martínez, R. and Polo-Traverso, J.A., 2016. Trigger point dry needling versus strain–counterstrain technique for upper trapezius myofascial trigger points: a randomised controlled trial. Acupuncture in Medicine, 34(3), pp.171-177.
• Charles, D., Hudgins, T., MacNaughton, J., Newman, E., Tan, J. and Wigger, M., 2019. A systematic review of manual therapy techniques, dry cupping and dry needling in the reduction of myofascial pain and myofascial trigger points. Journal of bodywork and movement therapies, 23(3), pp.539-546.
• Mullins, J.F., Nitz, A.J. and Hoch, M.C., 2021. Dry needling equilibration theory: A mechanistic explanation for enhancing sensorimotor function in individuals with chronic ankle instability. Physiotherapy theory and practice, 37(6), pp.672-681.
• Cagnie, B., Castelein, B., Pollie, F., Steelant, L., Verhoeyen, H. and Cools, A., 2015. Evidence for the use of ischemic compression and dry needling in the management of trigger points of the upper trapezius in patients with neck pain: a systematic review. American journal of physical medicine & rehabilitation, 94(7), pp.573-583.
• Sánchez-Infante, J., Bravo-Sánchez, A., Jiménez, F. and Abián-Vicén, J., 2021. Effects of Dry Needling on Muscle Stiffness in Latent Myofascial Trigger Points: A Randomized Controlled Trial. The Journal of Pain.
• Alaei, P., Ansari, N.N., Naghdi, S., Fakhari, Z., Komesh, S. and Dommerholt, J., 2020. Dry Needling for Hamstring Flexibility: A Single-Blind Randomized Controlled Trial. Journal of Sport Rehabilitation, 30(3), pp.452-457.
• Dommerholt, J., 2011. Dry needling—peripheral and central considerations. Journal of Manual & Manipulative Therapy, 19(4), pp.223-227.
• Tough, E.A., White, A.R., Cummings, T.M., Richards, S.H. and Campbell, J.L., 2009. Acupuncture and dry needling in the management of myofascial trigger point pain: a systematic review and meta-analysis of randomised controlled trials. European Journal of Pain, 13(1), pp.3-10.
• Ansari, N.N., Alaei, P., Naghdi, S., Fakhari, Z., Komesh, S. and Dommerholt, J., 2020. Immediate effects of dry needling as a novel strategy for hamstring flexibility: a single-blinded clinical pilot study. Journal of sport rehabilitation, 29(2), pp.156-161.
• Mason, J.S., Crowell, M., Dolbeer, J., Morris, J., Terry, A., Koppenhaver, S. and Goss, D.L., 2016. The effectiveness of dry needling and stretching vs. stretching alone on hamstring flexibility in patients with knee pain: a randomized controlled trial. International journal of sports physical therapy, 11(5), p.672s

Needle Bacteria, Gloves, Alcohol & Infection

Hoffman, P., 2001. Skin disinfection and acupuncture. Acupuncture in medicine, 19(2), pp.112-116.

White, A., 2006. The safety of acupuncture–evidence from the UK. Acupuncture in Medicine, 24(1_suppl), pp.53-57.

Gittens, G. and Bunnell, T., 2009. Skin disinfection and its efficacy before administering injections. Nursing standard, 23(39), pp.42-45.

Gloves & Alcohol

Gloves & Alcohol 2

Skin Prep

Skin Prep 2

Infection

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.
• Sakatani, K., Kitagawa, T., Aoyama, N. and Sasaki, M., 2010. Effects of acupuncture on autonomic nervous function and prefrontal cortex activity. In Oxygen Transport to Tissue XXXI (pp. 455-460). Springer, Boston, MA
• 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.
• Shu, Q., Wang, H., Litscher, D., Wu, S., Chen, L., Gaischek, I., Wang, L., He, W., Zhou, H., Litscher, G. and Liang, F., 2016. Acupuncture and moxibustion have different effects on fatigue by regulating the autonomic nervous system: a pilot controlled clinical trial. Scientific reports, 6(1), pp.1-11.
• Matić, Z. and Bojić, T., 2020. Acupuncture, autonomic nervous system and biophysical origin of acupuncture system. Vojnosanitetski pregled, 77(1), pp.79-86.
• Uchida, C., Waki, H., Minakawa, Y., Tamai, H., Hisajima, T. and Imai, K., 2018. Evaluation of autonomic nervous system function using heart rate variability analysis during transient heart rate reduction caused by acupuncture. Medical acupuncture, 30(2), pp.89-95.
• Napadow, V., Beissner, F., Lin, Y., Chae, Y. and Harris, R.E., 2020. Neural Substrates of Acupuncture: From Peripheral to Central Nervous System Mechanisms. Frontiers in neuroscience, 13, p.1419.
• An, S. and Keum, D., 2021. Effect of Acupuncture at the Field of the Auricular Branch of the Vagus Nerve on Autonomic Nervous System Change. Journal of Korean Medicine Rehabilitation, 31(2), pp.81-97.
• Kupari, J. and Ernfors, P., 2020. Pricking into Autonomic Reflex Pathways by Electrical Acupuncture. Neuron, 108(3), pp.395-397.
• Kurita, K., Kiyomitsu, K., Ogasawara, C., Mishima, R., Ogawa-Ochiai, K. and Tsumura, N., 2019. Effect of acupuncture on the autonomic nervous system as evaluated by non-contact heart rate variability measurement. Artificial Life and Robotics, 24(1), pp.19-23.
• Dommerholt, J., Hooks, T., Chou, L.W. and Finnegan, M., 2019. A critical overview of the current myofascial pain literature–November 2018. Journal of bodywork and movement therapies, 23(1), pp.65-73.
• Morikawa, Y., Takamoto, K., Nishimaru, H., Taguchi, T., Urakawa, S., Sakai, S., Ono, T. and 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, p.186.
• Dommerholt, J., Mayoral, O. and Thorp, J.N., 2021. A critical overview of the current myofascial pain literature–January 2021.
• Pongratz, G. and Straub, R.H., 2014. The sympathetic nervous response in inflammation. Arthritis research & therapy, 16(6), pp.1-12.