Dry needling and manipulation are two of the most powerful tools at our disposal, especially when it comes to hockey players. If you’re working with hockey players (or athletes in general), getting certified in these areas is a great way to help your clients.

Hockey players might just be the toughest and most beat up players in any major sport. They constantly require quick and effective fixes for a variety of injuries in order to stay on the ice and perform at their maximum potential. Dry Needling (DN) and Manipulation are the two most powerful, quick, and effective treatments that we have at our disposal, especially when used together.

 

 

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Is dry needling good for athletes + hockey players?

The short answer is yes. Needling, when performed properly, regulates muscular physiology by returning our ANS and CNS toward homeostasis making dry needling good for athletes, especially hockey players.

There is evidence that needling can also positively affect the enteric nervous system, which plays a significant role in maintaining homeostasis along the with ANS and the endocannabinoid system. Although there are conditions that involve parasympathetic hyperactivity, the vast majority of patients we see as PTs, ATs, or DCs involve sympathetic hyperactivity with concomitant parasympathetic depression. The natural response of the human body to tissue damage and pain is to tighten everything up in the area to prevent further potential damage. This can be helpful acutely, but this process often persists to the point where it impedes healing, and the body cannot correct itself without outside intervention. If this occurs, the initial sympathetic elevation that occurs post-injury does not subside, which leads to significant detrimental effects on the body as a whole and harms players’ ability to perform on the ice.

On a muscular cellular level, excessive Ach is released, and instead of just the post-synaptic cleft being receptive to it, which is normal, the entire muscle epimysium becomes receptive to Ach. At the same time, less acetylcholinesterase (AchE) is produced. This leads to lots of Ach and not enough AchE. Over time, a chemically-induced muscle shortening occurs. There are a lot of processes that occur that we are starting to better understand with advancements in technology. The following is from a few of the best DN researchers out there. Remember, the combination of DN and manipulation is the best treatment available to us to reverse these abnormal physiologic processes and restore homeostasis for hockey players and athletes.

“The most accepted hypothesis for the development of myofascial TrPs is called the ‘integrated hypothesis’,30 which stipulates that dysfunctional motor endplates release an excessive amount of non-quantal acetylcholine (ACh), leading to localised contractures. The contractures may cause decreased blood flow within the tissue,31,32 which in turn can lead to local ischaemia, a lowered tissue pH and a subsequent release of pro-inflammatory substances and some chemical mediators including bradykinin, cytokines, substance P, calcitonin gene-related peptide (CGRP), glutamate, tumour necrosis factor-α (TNF-α), cyclo-oxygenase-2 (COX-2), hypoxia-inducible factor 1-alpha (HIF-1α), inducible nitric oxide synthase (iNOS), and vascular endothelial growth factor (VEGF) among others.33,34 These chemical mediators can activate and maintain muscle nociceptors, resulting in the experience of pain and muscle tenderness. The acidic pH contributes to the inhibition of acetylcholinesterase (AChE) at the motor endplate, thereby preventing the breakdown of ACh in the synaptic cleft, but also activates acid sensing ion channels (ASIC 1 and ASIC 3), vanilloid receptors, especially the transient receptor potential cation channel subfamily V member 1 (TRPV1), and short transient receptor potential channel 4 and 5 (TRPC-4 and TRPC-5).”34

“At the motor endplate, CGRP contributes to the up-regulation of ACh receptors, increases the release of ACh from the motor nerve terminal and inhibits AChE, which contributes to an increased quantity of ACh in the synaptic cleft, an increase in the frequency of end-plate potentials, sarcomere contraction, and taut band formation.30 At the dorsal horn lamina, CGRP can potentiate substance P, activate second messenger pathways protein kinase A and C (PKA and PKC), and enhance the release of brain derived neurotrophic factor (BDNF), which all contribute to the experience of pain.”
“Active and latent myofascial TrPs have altered chemical milieus as compared to normal muscle.33,35,36 As described, the local biochemical changes may activate muscle nociceptors and contribute to peripheral and central sensitisation mechanisms and also to functional changes within the dorsal horn.”37

Basically, all sorts of bad stuff happens when tissues become pathologic, and they all lead to hindered on-ice performance. The nice thing is that DN, in conjunction with manipulation, happen to be excellent tools to reverse these abnormal processes. The above is just a small percentage of all that we know about what happens in pathologic muscle, which is a small percentage of all that actually takes place. We have so much to learn, and it’s really exciting! One thing we do understand is that these processes facilitate sympathetic hyperactivity (or is it sympathetic hyperactivity that facilitates these processes?), which, in turn, inhibits our parasympathetic activity. When the ANS becomes stuck in this negative feedback loop, as it does in most chronic conditions we deal with, the body is unable to function properly. If DN and manipulation are used on a regular basis, or used acutely following injury, we can stop these processes from starting in the first place and keep the ANS and CNS in a more homeostatic condition. This facilitates the body’s own ability to heal itself. There is nothing more powerful than helping our body arrive at a state where maximum function and healing occur at homeostasis.

DN and manipulation both release endogenous opioids into the bloodstream, regulate the concentration of peptides such as calcitonin gene related peptide (CGRP), and have an overall effect of sympathetic depression and parasympathetic elevation. These techniques can be specifically targeted at regulating the autonomic nervous system (ANS) to lower sympathetic and increase parasympathetic tone. The two most accessible and safe areas of the body we have to specifically target the PANS with needles are the periosteum of the occiput / cervical spine and the sacral periosteum. Connecting these areas and adding 1-5 Hz of stim, which has been shown to be the most effective frequency we have found to stimulate endogenous opioid release, significantly helps with depressing sympathetic and increasing parasympathetic tone. This helps to quickly regulate the above-mentioned abnormal processes and allows the body to function at the highest level possible.

By regulating the ANS and other portions of the nervous system, along with restoring normal mechanical and physiological properties of muscle, we allow the body to heal and perform at its highest potential. Nerve conduction velocity and muscle firing patterns improve, shortened muscles are returned to their optimal length, and microvascular dilation and muscular blood perfusion improve, all of which facilitate increased power, strength, speed, and performance on the ice.

I used to pull my right adductors in college all the time when I was playing hockey. It was probably my adductor longus, but who knows. Let’s assume it was. To take a proper stride, the adductors need to be pliable enough to allow for a full stride length and they need to be powerful enough to pull the leg back into position to push off for another stride. With any type of groin pathology, the muscles are almost always going to be tight unless they are completely torn off, which is rare. With just 1 trigger point in the adductor longus, the muscle immediately loses length. This leads to a loss of power, strength, speed, and pliability, to name a few. This also leads to the negative feedback loop of events discussed above. This, in turn, significantly impedes a player’s ability to take a normal stride while playing, which harms their ability to perform. Needling, in combination with manipulation, is by far the quickest and most effective way to treat this condition along with a multitude of other common hockey-related impairments.

It is important to understand that there is very little “high quality” research out there on DN and manipulation. The research overlords—the people who determine what “works” and what doesn’t, require long-term, longitudinal randomized control trials (RCTs) to validate the efficacy of a treatment. Now listen, I love research. I read research about all sorts of things: DN, manipulation, quantum theory, neurology, salmon migration, physics, you name it. It is totally fascinating. However, people’s all out obsession with only believing something works if a longitudinal RCT says so is harmful to the evolution of efficacious science in our country. This leads people to think completely inside the box until the general public or scientific community accepts something new as effective.

To get a new drug or treatment approved by the FDA, it typically takes 3 levels of RCTs. Phase 1, 2, and 3. On average, phase 1 costs $4 million, phase 2 costs $13 million, and phase 3 costs $20 million. So, let’s say we wanted to get DN implemented as a mainstream treatment for nerve pain to reduce the number of opioids people are taking. Just the research necessary would cost about $37 million… Anyone? 37 million for DN research? Ha, ha, ha!! The pharmaceutical companies cannot make money off of DN or manipulation, so unless I win the lottery, I wouldn’t hold my breath waiting for any “high quality” research to come out on either subject any time soon.

So, when you see a research article on DN or manipulation that concludes with something like, “it may or may not be superior to control or placebo,” as they almost all do, look at how the study was conducted. A large percentage of the studies are conducted over 1-5 treatment sessions with a small sample size, and many do not even have a control. These types of studies do not lend much validity, specificity, or sensitivity to any of the outcomes. I can tell you from 10 years of experience needling and manipulating patients and from playing hockey in college that these are the two most valuable treatments we have at our disposal.

When used properly, DN and manipulation dramatically improve the performance of healthy athletes and facilitate the body’s ability to recover quicker, stronger, and more completely following activity or injury. DN and manipulation are, by far, the most powerfully effective tools hockey players should be aware of and seeking from their medical staff for the majority of their injuries. They are safe, quick, and effective. These techniques can be used not only to mechanically improve the body, but also to improve the function of the nervous systems, which includes the mind. Every single pro team should have multiple competent practitioners that combine Dry Needling and manipulation. I promise this will give your players a physical and mental edge over their opponents.

References

• 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.
• 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.
• 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.
• Albrecht, D., Isenberg, A.L., Stradford, J., Monreal, T., Sagare, A., Pachicano, M., Sweeney, M., Toga, A., Zlokovic, B., Chui, H. and Joe, E., 2020. Associations between vascular function and tau PET are associated with global cognition and amyloid. Journal of Neuroscience.
• 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.
• 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.
• Breuer, B., Sperber, K., Wallenstein, S., Kiprovski, K., Calapa, A., Snow, B. and Pappagallo, M., 2004. Folk medicine/herbal remedies: Can muscle needling relieve hand pain in patients with carpal tunnel syndrome?. The Journal of Pain, 5(3), p.S52.
• 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.
• 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.
• 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.
• 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.
• 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.
• 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.
• 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.
• 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.
• 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.
• 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.
• Chen, N., Wang, J., Mucelli, A., Zhang, X. and Wang, C., 2017. Electro-acupuncture is beneficial for knee osteoarthritis: the evidence from meta-analysis of randomized controlled trials. The American journal of Chinese medicine, 45(05), pp.965-985.
• 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.
• 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.
• de Almeida, M.D.S., Guerra, F.D.R., de Oliveira, L.P., Vieira, C.P. and Pimentel, E.R., 2014. A hypothesis for the anti-inflammatory and mechanotransduction molecular mechanisms underlying acupuncture tendon healing. Acupuncture in Medicine, 32(2), pp.178-182.
• de Wall, L.L. and Heesakkers, J.P., 2017. Effectiveness of percutaneous tibial nerve stimulation in the treatment of overactive bladder syndrome. Research and reports in urology, 9, p.145.
• de-la-Llave-Rincón, A.I., Fernández-de-Las-Peñas, C., Laguarta-Val, S., Ortega-Santiago, R., Palacios-Ceña, D. and Martínez-Perez, A., 2011. Women with carpal tunnel syndrome show restricted cervical range of motion. journal of orthopaedic & sports physical therapy, 41(5), pp.305-310.
• 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.
• Dommerholt, J., 2011. Dry needling—peripheral and central considerations. Journal of Manual & Manipulative Therapy, 19(4), pp.223-227.
• 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.
• Dommerholt, J., Mayoral, O. and Thorp, J.N., 2021. A critical overview of the current myofascial pain literature–January 2021.
• Dommerholt, J., Thorp, J.N., Hooks, T. and Mayoral, O., 2020. MYOFASCIAL PAIN AND TREATMENT: EDITORIAL A Critical Overview of the Current Myofascial Pain Literature–October 2020.
• Dunning, J., Butts, R., Fernandez-De-Las-Penas, C., Walsh, S., Goult, C., Gillett, B., Arias-Buría, J.L., Garcia, J. and Young, I.A., 2021. Spinal manipulation and electrical dry needling in patients with subacromial pain syndrome: a multicenter randomized clinical trial. journal of orthopaedic & sports physical therapy, 51(2), pp.72-81.
• Dunning, J., Butts, R., Mourad, F., Young, I., Flannagan, S. and Perreault, T., 2014. Dry needling: a literature review with implications for clinical practice guidelines. Physical therapy reviews, 19(4), pp.252-265.
• Dunning, J., Butts, R., Young, I., Mourad, F., Galante, V., Bliton, P., Tanner, M. and Fernández-de-Las-Peñas, C., 2018. Periosteal electrical dry needling as an adjunct to exercise and manual therapy for knee osteoarthritis: a multicenter randomized clinical trial. The Clinical journal of pain, 34(12), p.1149.
• Dunning, J., Butts, R., Zacharko, N., Fandry, K., Young, I., Wheeler, K., Day, J. and Fernández-de-Las-Peñas, C., 2021. Spinal manipulation and perineural electrical dry needling in patients with cervicogenic headache: a multicenter randomized clinical trial. The Spine Journal, 21(2), pp.284-295.
• 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.
• Elbadawy, M.A., 2017. Effectiveness of periosteal stimulation therapy and home exercise program in the rehabilitation of patients with advanced knee osteoarthritis. The Clinical journal of pain, 33(3), pp.254-263.
• Fang, S., 2014. The successful treatment of pain associated with scar tissue using acupuncture. Journal of acupuncture and meridian studies, 7(5), pp.262-264.
• Fernández-de-Las-Peñas, C. and Nijs, J., 2019. Trigger point dry needling for the treatment of myofascial pain syndrome: current perspectives within a pain neuroscience paradigm. Journal of pain research, 12, p.1899.
• Fernández-de-Las-Peñas, C., Layton, M. and Dommerholt, J., 2015. Dry needling for the management of thoracic spine pain. Journal of Manual & Manipulative Therapy, 23(3), pp.147-153.
• 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.
• Filshie, J., White, A. and Cummings, M. eds., 2016. Medical Acupuncture E-Book: A Western Scientific Approach. Churchill Livingstone.
• Fowler, C.J. and Griffiths, D.J., 2010. A decade of functional brain imaging applied to bladder control. Neurourology and Urodynamics: Official Journal of the International Continence Society, 29(1), pp.49-55.
• Gadau, M., Yeung, W.F., Liu, H., Zaslawski, C., Tan, Y.S., Wang, F.C., Bangrazi, S., Chung, K.F., Bian, Z.X. and Zhang, S.P., 2014. Acupuncture and moxibustion for lateral elbow pain: a systematic review of randomized controlled trials. BMC complementary and alternative medicine, 14(1), pp.1-19.
• Gallego-Sendarrubias, G.M., Rodríguez-Sanz, D., Calvo-Lobo, C. and Martín, J.L., 2020. Efficacy of dry needling as an adjunct to manual therapy for patients with chronic mechanical neck pain: a randomised clinical trial. Acupuncture in Medicine, pp.acupmed-2018.
• Gascon-Garcia, J., Bagur-Calafat, C., Girabent-Farrés, M. and Balius, R., 2018. Validation of the range of dry needling with the fascial winding technique in the carpal tunnel using ultrasound. Journal of bodywork and movement therapies, 22(2), pp.348-353.
• 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.
• 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.
• Gittens, G. and Bunnell, T., 2009. Skin disinfection and its efficacy before administering injections. Nursing standard, 23(39), pp.42-45.
• Greenhill, S.D., Ranson, A. and Fox, K., 2015. Hebbian and homeostatic plasticity mechanisms in regular spiking and intrinsic bursting cells of cortical layer 5. Neuron, 88(3), pp.539-552.
• Hadianfard, M., Bazrafshan, E., Momeninejad, H. and Jahani, N., 2015. Efficacies of acupuncture and anti-inflammatory treatment for carpal tunnel syndrome. Journal of Acupuncture and Meridian Studies, 8(5), pp.229-235.
• Hagblad, J., Lindberg, L.G., Andersson, A.K., Bergstrand, S., Lindgren, M., Ek, A.C., Folke, M. and Lindén, M., 2010. A technique based on laser Doppler flowmetry and photoplethysmography for simultaneously monitoring blood flow at different tissue depths. Medical & biological engineering & computing, 48(5), pp.415-422.
• 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.
• Hansson, Y., Carlsson, C. and Olsson, E., 2008. Intramuscular and periosteal acupuncture in patients suffering from chronic musculoskeletal pain–a controlled trial. Acupuncture in Medicine, 26(4), pp.214-223.
• 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.
• 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.
• Hoffman, P., 2001. Skin disinfection and acupuncture. Acupuncture in medicine, 19(2), pp.112-116.
• Hsing, W.T., Imamura, M., Weaver, K., Fregni, F. and Azevedo Neto, R.S., 2012. Clinical effects of scalp electrical acupuncture in stroke: a sham-controlled randomized clinical trial. The Journal of Alternative and Complementary Medicine, 18(4), pp.341-346.
• Hui, K.K., Liu, J., Makris, N., Gollub, R.L., Chen, A.J., I. Moore, C., Kennedy, D.N., Rosen, B.R. and Kwong, K.K., 2000. Acupuncture modulates the limbic system and subcortical gray structures of the human brain: evidence from fMRI studies in normal subjects. Human brain mapping, 9(1), pp.13-25.
• Hui, K.K., Marina, O., Liu, J., Rosen, B.R. and Kwong, K.K., 2010. Acupuncture, the limbic system, and the anticorrelated networks of the brain. Autonomic Neuroscience, 157(1-2), pp.81-90.
• Jardine, D.L., Wieling, W., Brignole, M., Lenders, J.W., Sutton, R. and Stewart, J., 2018. The pathophysiology of the vasovagal response. Heart Rhythm, 15(6), pp.921-929.
• Javier, C.F.D.L.P., Iglesias, G. and Weissmann, C.G.R., 2013. Deep dry needling of the arm and hand muscles.
• Khan, K.J. and Das, G., 2019. Dry needling a novel treatment option for post-scar neuralgia: A case report. Pain, 5(1), pp.29-31.
• Khosrawi, S., Moghtaderi, A. and Haghighat, S., 2012. Acupuncture in treatment of carpal tunnel syndrome: A randomized controlled trial study. Journal of research in medical sciences: the official journal of Isfahan University of Medical Sciences, 17(1), p.1.
• 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.
• Kvist, K.B., Hilland, R., Enehaug, R., Schjelderup, J., Lie, S.A. and Halse, A.K., 2021. The treatment effect of intramuscular stimulation on carpal tunnel syndrome: A blinded randomized trial on 75 patients. Journal of Bodywork and Movement Therapies.
• Langevin, H.M., Bouffard, N.A., Churchill, D.L. and Badger, G.J., 2007. Connective tissue fibroblast response to acupuncture: dose-dependent effect of bidirectional needle rotation. The Journal of Alternative and Complementary Medicine, 13(3), pp.355-360.
• 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.
• Li, J., Sun, M., Ye, J., Li, Y., Jin, R., Zheng, H. and Liang, F., 2019. The mechanism of acupuncture in treating essential hypertension: A narrative review. International journal of hypertension, 2019.
• 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.
• Li, Z., Zeng, F., Yin, T., Lan, L., Makris, N., Jorgenson, K., Guo, T., Wu, F., Gao, Y., Dong, M. and Liu, M., 2017. Acupuncture modulates the abnormal brainstem activity in migraine without aura patients. NeuroImage: Clinical, 15, pp.367-375.
• Li, Z., Zeng, F., Yin, T., Lan, L., Makris, N., Jorgenson, K., Guo, T., Wu, F., Gao, Y., Dong, M. and Liu, M., 2017. Acupuncture modulates the abnormal brainstem activity in migraine without aura patients. NeuroImage: Clinical, 15, pp.367-375.
• Liu, B. and Dong, Y., 2018. A New Interpretation of Nei Jing’s Multiple Needling Technique: Scar Tissue Acupuncture Release Technique (START) and It’s Application on Myofascial Scar Tissue. International Journal of Clinical Acupuncture, 27(2).
• Liu, B. and Dong, Y., 2018. A New Interpretation of Nei Jing’s Multiple Needling Technique: Scar Tissue Acupuncture Release Technique (START) and It’s Application on Myofascial Scar Tissue. International Journal of Clinical Acupuncture, 27(2).
• Liu, C., Chao, L., Li, Z., Lv, W., Jia, C., Shi, D. and Guo, S., 2018. Meta-analysis of Electro-acupuncture in Human Clinical Trials for the Treatment of Post-Stroke Urgency Urinary Incontinence and Possible Application in Canine Lower Urinary Tract Dysfunction. American Journal of Traditional Chinese Veterinary Medicine, 13(2).
• 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.
• 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.
• Maeda, Y., Kim, H., Kettner, N., Kim, J., Cina, S., Malatesta, C., Gerber, J., McManus, C., Ong-Sutherland, R., Mezzacappa, P. and Libby, A., 2017. Rewiring the primary somatosensory cortex in carpal tunnel syndrome with acupuncture. Brain, 140(4), pp.914-927.
• Mansfield, C.J., Vanetten, L., Willy, R., Di Stasi, S., Magnussen, R. and Briggs, M., 2019. The effects of needling therapies on muscle force production: a systematic review and meta-analysis. journal of orthopaedic & sports physical therapy, 49(3), pp.154-170.
• 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.672.
• Matić, Z. and Bojić, T., 2020. Acupuncture, autonomic nervous system and biophysical origin of acupuncture system. Vojnosanitetski pregled, 77(1), pp.79-86.
• Mayo, E., 2012. Acupuncture and Wound Healing. American Journal of Traditional Chinese Veterinary Medicine, 7(1).
• Mayor, D., 2013. An exploratory review of the electroacupuncture literature: clinical applications and endorphin mechanisms. Acupuncture in Medicine, 31(4), pp.409-415.
• McCowen, S.A., Liu, G. and Lee, M., 2006. PR_173: hypertrophic scar tissue modification using acupuncture on a burn patient: a case report. Archives of Physical Medicine and Rehabilitation, 87(11), p.e34
• 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.
• Moore, T.J., Zhang, H., Anderson, G. and Alexander, G.C., 2018. Estimated costs of pivotal trials for novel therapeutic agents approved by the US Food and Drug Administration, 2015-2016. JAMA internal medicine, 178(11), pp.1451-1457.
• 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.
• 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.
• 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.
• 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.
• 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.
• Napadow, V., Kettner, N., Liu, J., Li, M., Kwong, K.K., Vangel, M., Makris, N., Audette, J. and Hui, K.K.S., 2007. Hypothalamus and amygdala response to acupuncture stimuli in carpal tunnel syndrome. Pain, 130(3), pp.254-266.
• Napadow, V., Liu, J., Li, M., Kettner, N., Ryan, A., Kwong, K.K., Hui, K.K. and Audette, J.F., 2007. Somatosensory cortical plasticity in carpal tunnel syndrome treated by acupuncture. Human brain mapping, 28(3), pp.159-171.
• 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.
• 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.
• 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.
• 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.
• Öksüz, C.E., Kalaycıoğlu, A., Uzun, Ö., Kalkışım, Ş.N., Zihni, N.B., Yıldırım, A. and Boz, C., 2019. The efficacy of acupuncture in the treatment of bell’s palsy sequelae. Journal of acupuncture and meridian studies, 12(4), pp.122-130.
• 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.
• Peters, K.M., MacDiarmid, S.A., Wooldridge, L.S., Leong, F.C., Shobeiri, S.A., Rovner, E.S., Siegel, S.W., Tate, S.B., Jarnagin, B.K., Rosenblatt, P.L. and Feagins, B.A., 2009. Randomized trial of percutaneous tibial nerve stimulation versus extended-release tolterodine: results from the overactive bladder innovative therapy trial. The Journal of urology, 182(3), pp.1055-1061.
• Rabinowitch, I. and Segev, I., 2008. Two opposing plasticity mechanisms pulling a single synapse. Trends in neurosciences, 31(8), pp.377-383.
• Rayman, G., Hassan, A. and Tooke, J.E., 1986. Blood flow in the skin of the foot related to posture in diabetes mellitus. Br Med J (Clin Res Ed), 292(6513), pp.87-90
• 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
• 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.
• 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.
• 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.
• 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.
• 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.
• 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.
• 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.
• Sillevis, R., Van Duijn, J., Shamus, E. and Hard, M., 2019. Time effect for in-situ dry needling on the autonomic nervous system, a pilot study. Physiotherapy Theory and Practice, pp.1-9.
• 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.
• Sillevis, R., Van Duijn, J., Shamus, E., & Hard, M. (2019). Time effect for in-situ dry needling on the autonomic nervous system, a pilot study. Physiotherapy Theory and Practice, 1–9. https://doi.org/10.1080/09593985.2019.1644691
• Sim, H., Shin, B.C., Lee, M.S., Jung, A., Lee, H. and Ernst, E., 2011. Acupuncture for carpal tunnel syndrome: a systematic review of randomized controlled trials. The Journal of Pain, 12(3), pp.307-314.
• 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.
• Song, H., Mu, J. and Wang, J., 2011. Clinical study on treatment of hypertrophic scar by acupuncture. Journal of Acupuncture and Tuina Science, 9(3), pp.159-161.
• Stener-Victorin, E., Lundeberg, T., Waldenström, U., Manni, L., Aloe, L., Gunnarsson, S. and Janson, P.O., 2000. Effects of electro-acupuncture on nerve growth factor and ovarian morphology in rats with experimentally induced polycystic ovaries. Biology of Reproduction, 63(5), pp.1497-1503.
• Stenhouse, G., Sookur, P. and Watson, M., 2013. Do blood growth factors offer additional benefit in refractory lateral epicondylitis? A prospective, randomized pilot trial of dry needling as a stand-alone procedure versus dry needling and autologous conditioned plasma. Skeletal radiology, 42(11), pp.1515-1520.
• 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.
• Tortora, S., Messina, C., Albano, D., Serpi, F., Corazza, A., Carrafiello, G., Sconfienza, L.M. and Gitto, S., 2021. Ultrasound-guided musculoskeletal interventional procedures around the elbow, hand and wrist excluding carpal tunnel procedures. Journal of Ultrasonography, 21(85), p.e169.
• 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.
• Tuckey, C., Kohut, S. and Edgar, D.W., 2019. Efficacy of acupuncture in treating scars following tissue trauma. Scars, burns & healing, 5, p.2059513119831911.
• 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.
• 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.
• 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.
• Van Lieshout JJ, Wieling W, Karemaker JM, Eckberg DL. The vasovagal response. Clin Sci (Lond). 1991 Nov;81(5):575-86. doi: 10.1042/cs0810575. PMID: 1661644.
• Weiner, D.K., Moore, C.G., Morone, N.E., Lee, E.S. and Kwoh, C.K., 2013. Efficacy of periosteal stimulation for chronic pain associated with advanced knee osteoarthritis: a randomized, controlled clinical trial. Clinical therapeutics, 35(11), pp.1703-1720.
• White, A., 2006. The safety of acupuncture–evidence from the UK. Acupuncture in Medicine, 24(1_suppl), pp.53-57.
• Yamamoto, H., Kawada, T., Kamiya, A., Miyazaki, S., & Sugimachi, M. (2011). Involvement of the mechanoreceptors in the sensory mechanisms of manual and electrical acupuncture. Autonomic Neuroscience, 160(1–2), 27–31. https://doi.org/10.1016/J.AUTNEU.2010.11.004
• Yang, C.P., Hsieh, C.L., Wang, N.H., Li, T.C., Hwang, K.L., Yu, S.C. and Chang, M.H., 2009. Acupuncture in patients with carpal tunnel syndrome: a randomized controlled trial. The Clinical journal of pain, 25(4), pp.327-333.
• Yang, C.P., Hsieh, C.L., Wang, N.H., Li, T.C., Hwang, K.L., Yu, S.C. and Chang, M.H., 2009. Acupuncture in patients with carpal tunnel syndrome: a randomized controlled trial. The Clinical journal of pain, 25(4), pp.327-333.
• Zhang, R., Wu, T., Wang, R., Wang, D. and Liu, Q., 2019. Compare the efficacy of acupuncture with drugs in the treatment of Bell’s palsy: a systematic review and meta-analysis of RCTs. Medicine, 98(19).
• Zhong, W., Yu, H., Rao, X., Wu, J., Gou, Y., Cui, H., Huang, X. and Wang, L., 2020. Efficacy of Manipulative Acupuncture Therapy Monitored by LSCI Technology in Patients with Severe Bell’s Palsy: A Randomized Controlled Trial. Evidence-Based Complementary and Alternative Medicine, 2020.