The Forgotten Nine:

• Obturator Internus
• Coccygeus
• Iliococcygeus
• Pubococcygeus
• Puborectalis
• Deep Transverse Perineal
• Superficial Transverse Perineal
• Bulbospongiosus
• Ischiocavernosus

Nine of the most important muscles in the body are also nine muscles that, for the most part, are left 100% untreated by the vast majority of practitioners.

Let’s get something out of the way right off the bat here – barring significant structural and/or neural damage, nobody should have incontinence.

I can’t freaking stand seeing and hearing the adult depends or night catheter commercials. Or hearing patient’s say they have been told for decades that it is normal. NOOOO!!!! This is our “Sick Care” system at its best. Or worst, depending how you look at it. A huge percentage of the population, especially physical therapy (PT), athletic training (AT) and chiropractic (DC) patients, at all ages, has some type of incontinence and or pelvic dysfunction. A primary reason for this is, most medical professionals, for some completely illusory reason, tell their patients it is just a normal part of life. Especially if you are female. Even more so following childbirth. I’m not talking about like for 3 months after birth. This is a lifetime problem for a lot of people. And it Shouldn’t be. If I had to put a number on it, I would say that 90% of all this is easily fixable. You just have to understand how to fix it. Or have superpowers. Or both…

I believe it is impossible to regulate the Autonomic Nervous System (ANS), to the fullest capacity possible, without treating the Forgotten Nine. Regulating the ANS toward homeostasis, in turn, will facilitate homeostatic epigenetic expression. Furthermore, it is impossible to properly treat the vast majority of PT-related impairments without specifically focusing on regulating the ANS. Therefore, it is impossible to properly treat the majority of PT patients without treating the pelvic floor. See what I did there? I’m sneaky like that. Haha. But seriously, I’m not joking. It is also impossible to fully address many other impairments, like low back pain, hip pain, knee pain, bla bla bla, without treating the Forgotten Nine. Just think about it. All these muscles are attached to our pelvis and our ANS, via the sacral plexus, S2-S4. Our pelvis is the center of our mass. If your pelvis is pathologic, it leads to lots of bad stuff, both on a neurophysiologic and musculoskeletal level.

Remember: The majority of patients we see in PT, athletic training, chiropractic and psychotherapy are suffering from sympathetic hyperactivity. Impairments resulting from parasympathetic hyperactivity typically fall outside our scope of practice, so we don’t see a whole lot of that. That is not to say that we can’t target and treat both parts of the ANS, but the majority of our patients have sympathetic hyperactivity. So, let’s assume that our goal is sympathetic depression & ANS homeostasis.

Related: Check out another blog of mine about the ANS

In theory, if our ANS is in perfect homeostasis, we would never get sick. If you don’t believe me, find me any sick person, with anything, who has a homeostatic ANS, and we can talk. This is quickly turning from theory to fact, as we learn more about the human body. Dr. David Sinclair is a pioneer in this area of study. He is one of the dudes responsible for figuring out how to regrow the optic nerve in mice. They can blind mice by damaging the optic nerve and repair their vision without surgery. They can also reverse cellular senescence via epigenetic alteration with natural substances like nicotinamide mononucleotide (NMN). Mouse spinal cords have been non-surgically repaired from complete severing by injecting a cool new viscous fluid into the spinal canal that allows the spine to heal itself. Our bodies have an incredible ability to heal, if given the proper chance and a little help from time to time.

Epigenetics is the study of how our brain health, thoughts, behaviors, environment, etc., can change the way our genes express themselves. Epigenetic alteration can stem from mental practices such as meditation, psychotherapy, natural substances like NMN and NAD+, psychedelics, and a variety of other practices. Many studies have been performed looking into this, however, we are just at the beginning stages of understanding. This is a relatively new area of study and the implications are astounding. This type of stuff, along with a more advanced understanding of quantum biology, will lead to mind boggling improvements in medical care in the near future. Needling combined with manipulation is the most powerful tool set we have at our disposal, as PT’s, AT’s or DC’s, to regulate autonomic function and, therefore, epigenetic regulation. Regulating the ANS toward homeostasis has incredibly powerful and positive effects on improving overall health, including gut health, immune function, psychologic well-being, physiologic well-being, pain and more.

Treating the Forgotten Nine

Treating the Forgotten Nine is essential to improving ANS homeostasis and epigenetic regulation, because these muscles are all innervated by the sacral plexus. Remember, S2-S4 is a parasympathetic portion the ANS. Needling the sacral periosteum and the structures that the sacral plexus innervates, is a great way to stimulate the PANS and depress the SANS, bringing the ANS toward homeostasis. It has been shown in research that treating in proximity to the distal tibial nerve and medial plantar nerve, with certain frequencies, regulates electrical sympathetic hyperactivity in brain areas associated with urination, via their connection to the sacral plexus (see PTNS treatment for urinary incontinence). This has been confirmed with fMRI studies. So, if we know that needling a muscle distal to the sacral plexus, with only partial innervation from the sacral plexus, significantly dampens sympathetic hyperactivity in the brain via parasympathetic stimulation, what does needling muscles directly innervated by the sacral plexus do? Some pretty awesome stuff, that’s what. There are some cool acupuncture studies out there about this type of stuff. Some of them are included in the references.

I have treated many patients, males and females, young and old, with the combination of needling and manipulation to address years, sometimes decades, of incontinence issues. Here are 2 examples from my classes. mind you, these are not out of the ordinary responses to this treatment. I basically treated both women with the same philosophy and chose the most pathologic tissue I could find to place needles.

1. A 40-year-old mom who’s youngest is 11. Has had urinary incontinence for 11 years. Told me in class that she leaks urine with stress and can’t hold it in if she needs to go. Also, couldn’t stop the flow of urine once started. Felt as though she could not contract her pelvic floor. Has worked to improve this over the years, with no success. 1 needling treatment to the low back, sacral plexus periosteum, levator ani through the glutes, posterior greater trochanter tendon attachments and the concha of the ear. All bilateral and connected with 4 channels of 2 Hz stim for 20 mins. After this singular treatment, she could stop the flow of urine for the first time in 11 years. Could hold urine in when she had to go for the first time in 11 years. Felt as though she could contract her pelvic floor for the first time in 11 years. 1 treatment for 20 mins. 11 years of unnecessary suffering fixed.
2. This one is insane. Female, early 30’s, has an identical twin. Neither sister had ever been able to hold urine in when they felt like they had to go. I literally watched her run to the bathroom the first day of class because she was about to have an accident. Couldn’t stop the flow once started. Had been treated for years by all sorts of people with zero result. I did a similar treatment to the one described above. She came in to class the next day crying. Said it was the first time she could remember being able to hold urine when she felt the need to go. She could stop the flow of urine for the first time in memory as well. We are talking 20+ years of dysfunction here. 20 plus years of suffering fixed in 20 minutes. I asked her to ask her sister if she noticed anything, but she didn’t. Booo! That would have been something.

Homeostasis

I like to needle the concha of the ear when treating the pelvis as well. I use this needle for a lot of stuff. The concha is the only tissue where we can needle that is directly innervated by the auricular branch of the vagus. Needling this area has been shown to have positive effects on all sorts of cool things, like depression, bowel dysfunction, ANS regulation, and immune function, to name a few. Remember, the vagus innervates the enteric nervous system, which is part of the ANS. The connection between the vagus and the enteric nervous system is called the gut-brain-axis, which includes the hypothalamic-pituitary-adrenal axis (HPA). The HPA regulates our bodies response to stress via hormone production and release. These 2 systems are primary controllers of physiologic homeostasis, as far as we know. The endocannabinoid system is another super important one. I will write a blog on that in a bit. Again, if we have maximum ANS homeostasis, we should never get sick, or really have any significant issues of any kind.

Vagus and parasympathetic stimulation have been shown to reduce pro-inflammatory cytokines and TNF-a, bringing the body back toward homeostasis, giving us the best shot at maximally using our incredible innate ability to heal ourselves. Vagus nerve stimulation (VNS) is also used to control anxiety, pain, depression and other autonomic dysfunction. VNS has also been shown to significantly improve immune function via regulation of the ANS and enteric nervous system. The enteric nervous system is thought to have somewhere between 100 and 500 million neurons. One of the largest collections of neurons in a specific system we have found thus far. Think about 500 million pissed off neurons sending oftentimes subconscious signals to our brain, telling it that something is wrong. Yeah, no bueno is right.

80-90% of the vagus fibers are afferent. That is a lot. It appears the vagus’ main function is to tell the brain what is going on in our gut and organs so the body and brain can properly self-regulate. These are mainly subconscious functions, however, have been shown to be susceptible to conscious control. Like I said before, Superpowers. These functions are vital to mental and physical well-being. There are lots of really cool studies on this, I have included some in the references. So, Imagine a person with bowel or organ pathology. This produces a constant stream of negative afferents to the brain, which eventually overload the ANS and cause dysfunction. Think about this as similar to central sensitization of the CNS. ANS dysfunction can cause central sensitization, along with a host of other health issues, without much problem.

Quantum Entanglement

Needling, in particular, is primarily effective secondary to the significant changes we can make to the nervous systems. The ANS in particular, as we have talked about. Adding manipulation into the equation amplifies and improves these effects. I believe this effect is regulated by some type of quantum biologic entanglement of groups of particles in our body. I think the acupuncture meridians exist, but change throughout time, based on physical and mental alterations. If we could figure out just a bit more about quantum processes, especially in warm biologic settings, we could learn to treat and cure an insane amount of stuff with simple tools, like needling, manipulation and psychotherapy.

One of my ideas is this: Our sclerotomal cells become quantumly entangled at conception, and as they differentiate to form our bodies, we end up with different parts of our bodies entangled. I think this is different for everyone, with some consistency across people. The trick is, figuring out how to specifically identify the entangled fields. We need more research on the direct effects needling has on specific brain areas to learn more about this. But just imagine, what if we could figure how to identify entangled fields in our bodies and how they interacted with each other? Then we could really start learning some crazy stuff by experimenting with electrical needling and manipulation to see what positive affects we could produce. It would be so cool and so incredibly helpful!

Needling the structures of the pelvic floor, especially with low frequency stim (I like 2 Hz), has innumerable advantages. Aside from pelvic health issues, needling this area has incredibly powerful and positive effects on everything from neck pain to foot pain to wrist pain and everything in between. Secondary to its powerful homeostatic effect on the ANS, along with residing at the center of our mass, treating this area is vital to achieve the best outcomes possible with the majority of patients we see. I prefer to needle first to loosen up tightness and then manipulate the tissues and joints back to neutral. Remember, joints don’t move themselves. This provides better, faster and more permanent results. Remember to leave the needles in for 20-30 minutes, if possible.

Let me know if anyone has any questions about any of this. Talk to you soon.

Jason

References

Pain Management Using Vagus Nerve Stimulation

• Breit, S., Kupferberg, A., Rogler, G. and Hasler, G., 2018. Vagus nerve as modulator of the brain–gut axis in psychiatric and inflammatory disorders. Frontiers in psychiatry, 9, p.44.
• 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.

Gut-Brain Axis & the Enteric Nervous System

• Yaklai, K., Pattanakuhar, S., Chattipakorn, N. and Chattipakorn, S.C., 2021. The Role of Acupuncture on the Gut–Brain–Microbiota Axis in Irritable Bowel Syndrome. The American journal of Chinese medicine, 49(02), pp.285-314.
• Jang, J.H., Yeom, M.J., Ahn, S., Oh, J.Y., Ji, S., Kim, T.H. and Park, H.J., 2020. Acupuncture inhibits neuroinflammation and gut microbial dysbiosis in a mouse model of Parkinson’s disease. Brain, Behavior, and Immunity, 89, pp.641-655.
• Zhang, X., Chen, H. and Val-Laillet, D., 2021. Hypothesis paper: electroacupuncture targeting the gut–brain axis to modulate neurocognitive determinants of eating behavior—toward a proof of concept in the obese minipig model. Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity, 26(1), pp.61-74.
• Wang, H., Wang, Q., Liang, C., Su, M., Wang, X., Li, H., Hu, H. and Fang, H., 2019. Acupuncture regulating gut microbiota in abdominal obese rats induced by high-fat diet. Evidence-based complementary and alternative medicine, 2019.
• Fang, J., Wang, D., Zhao, Q., Hong, Y., Jin, Y., Liu, Z., Zhou, K., Jing, X., Yu, X., Pan, R. and Chang, A., 2015. Brain-gut axis modulation of acupuncture in functional dyspepsia: a preliminary resting-state fcMRI study. Evidence-based complementary and alternative medicine, 2015.
• Zhu, L.S., Wang, J., Lu, J., Liu, H.Q., Jin, X.Q., Shu, Z.Y. and Li, L.H., 2020. Effect of hemodynamic characteristic changes of the carotid artery on 6-OHDA-induced Parkinson’s disease model rats treated by Gut-acupuncture. Journal of King Saud University-Science, 32(6), pp.2675-2681.
• Mi, Z.H., Li, Y., Ma, Y.L., Jin, P.M., Song, L.Z.X. and Xu, T.C., 2021. Clinical Application and Mechanism of Acupuncture in the Brain-Gut Interaction. Psychosomatic Medicine Research, 3(3), pp.108-121.
• Ma, Q., Xing, C., Long, W., Wang, H.Y., Liu, Q. and Wang, R.F., 2019. Impact of microbiota on central nervous system and neurological diseases: the gut-brain axis. Journal of neuroinflammation, 16(1), pp.1-14.
• Tang, H.Y., Jiang, A.J., Wang, X.Y., Wang, H., Guan, Y.Y., Li, F. and Shen, G.M., 2021. Uncovering the pathophysiology of irritable bowel syndrome by exploring the gut-brain axis: a narrative review. Annals of Translational Medicine, 9(14).
• Wei, P., Keller, C. and Li, L., 2020. Neuropeptides in gut-brain axis and their influence on host immunity and stress. Computational and structural biotechnology journal, 18, pp.843-851.
• Sun, J., Wu, X., Meng, Y., Cheng, J., Ning, H., Peng, Y., Pei, L. and Zhang, W., 2015. Electro-acupuncture decreases 5-HT, CGRP and increases NPY in the brain-gut axis in two rat models of Diarrhea-predominant irritable bowel syndrome (D-IBS). BMC Complementary and Alternative Medicine, 15(1), pp.1-7.
• Hong, J., Chen, J., Kan, J., Liu, M. and Yang, D., 2020. Effects of acupuncture treatment in reducing sleep disorder and gut microbiota alterations in PCPA-induced insomnia mice. Evidence-Based Complementary and Alternative Medicine, 2020.
• Sun, J., Wang, F., Hu, X., Yang, C., Xu, H., Yao, Y. and Liu, J., 2018. Clostridium butyricum attenuates chronic unpredictable mild stress-induced depressive-like behavior in mice via the gut-brain axis. Journal of agricultural and food chemistry, 66(31), pp.8415-8421.
• Takeshita, K., 2020. Sharpening the Focus: Acupuncture Interrupts the Brain–Gut Vicious Cycle Underlying Functional Dyspepsia.

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.
• 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.