Dry Needling Scar Tissue to Regulate the Autonomic Nervous System & Improve Health

Untreated scar tissue is problematic. Anyone with a pain-in-the-ass scar knows exactly what I’m talking about – stiff, restricts movement and oftentimes hurts. Even if you don’t actively notice or feel an untreated scar you have, it is still sending negative afferent signals to the brain, disrupting autonomic nervous system (ANS) homeostasis. Remember, the ANS is the primary control center regulating our neurophysiology. ANS homeostasis is necessary to attain maximal health and cannot be achieved if scars are left untreated, whether they are painful or not.

Scar tissue has an unusually strong connection to the ANS. The ANS is a poorly understood system in our bodies, and ironically, it is the primary component of our nervous systems that keeps us alive. Exactly why scar tissue forms instead of just regrowing whatever was damaged is poorly understood. This is a fascinating area of study and some amazing breakthroughs are being made as we speak. This is a super exciting time for medical advancements. The optic nerve and the spinal cord in mice have both been able to regenerate and function with the help of a few simple injections, enhancing our natural, innate ability to heal. Crazy!

Reference: Check out Dr. David Sinclair’s work for more on this.

Why needling scars works so awesome is largely unknown. There is more acupuncture research on scar treatment than DN research, but overall, very little is scientifically understood.

I can tell you from personal experience, having had numerous, large surgical scars treated, and from having treated thousands of other scars, needling is the best scar tissue treatment I know of.

Remember, most Physical Therapy patients present with hyperactivity of the sympathetic autonomic nervous system (SANS). Anything that damages the body enough to induce fibroblastic proliferation, collagen deposition and scar tissue formation, is going to crank up our SANS. The SANS controls our fight-or-flight response, is typically stimulating, and is most active during the day. Norepinephrine is the primary neurotransmitter. Untreated scars are constant, nagging irritants and stimulants to the SANS. Thus, it behooves us to target the parasympathetic portion of the ANS (PANS), at the same time we treat the scar tissue itself. Targeting the PANS depresses the SANS, elevates the PANS, and brings the ANS toward homeostasis. The PANS is the calming part of the ANS and is most active at night. Acetylcholine is the primary neurotransmitter.

Reference: check out this article for more info on the ANS

There are numerous theories and hypotheses concerning how, precisely, needling improves scar tissue. The precise pathways are unknown. However, we do know some things, and the positive results are not surprising. We know tissue damage and scar tissue attract and trap pro-inflammatory cytokines, such as TNF-a and Interlukin-6. These are detrimental to healing in abnormal concentrations and stimulate excessive collagen deposition (scar tissue). We also know that thoughtful needling has a regulatory and homeostatic effect on pro-inflammatory substances throughout the body.

Needling the scar itself and the surrounding tissue, especially with the addition of low frequency microcurrent, significantly increases blood flow to and through the area. This brings healing nutrients, like oxygen and minerals, and flushes out the old chemicals stuck in the hypoxic scar tissue.

All of these effects seem pretty obvious they would help normalize scar tissue. Other substances thought to play a role in scar tissue healing are transforming growth factor (TGF-beta-1) and endothelin-1. These stimulate fibroblast survival through various pathways and may help improve scar tissue. Regardless of the mechanism action, needling scar tissue is beneficial for numerous reasons, ANS homeostasis being the most important.

What I would really like to know is, does needling scar tissue, or near unclosed wounds, along with targeting the PANS, increase intracellular expression of the Sirtuin genes (silent information regulators), especially Sirtuin-6 and Sirtuin-1 (the most powerful healers of the 7 Sirtuins)? I can almost promise they do. If anyone capable of testing this is reading, let me know! Sirtuins are relatively newly discovered genes, present in every cell in our body, that help clean up the cell and make sure our DNA is expressed properly. They are part of our epigenome, which controls DNA expression. Properly expressed DNA leads to properly functioning proteins and other stuff. Improperly expressed DNA leads to misfolded proteins and other issues that lead to impairments like cancer, Parkinson’s and Alzheimer’s.

Sirtuins, especially #1 and #6, reverse cellular aging, degeneration, and make you biologically younger, by a significant degree. If needling acutely following tissue damage does improve intracellular expression of Sirtuins, before hyperactive fibroblastic proliferation and excessive collagen deposition (scarring) occurs, this would certainly be a logical pathway through which needling improves scar mobility and functionality. In other words, I think acutely needling around scars, and once closed, needling the scar itself, limits collagen (scar) formation and maximizes sarcomere (muscle) regeneration, leading to reduced pain, maximal functionality and improved patient outcomes.

Needling Scar Tissue to flatten, mobilize & Awesomize (good word, huh?)
I am constantly amazed at how, on the surface, scars treated without needling may feel relatively OK. Mobile, supple, smooth, etc. Then you stick a needle into them and you find thick, fibrotic, immobile nastiness. It feels like trying to put a thin sowing needle through a thick piece of leather. Then you get those scars that are obviously horrid. They have not been treated, are stiff, either raised off the skin or indented, like they are glued to the bone, and have weird, contrasting colors compared to normal skin tone. They can also really freaking hurt and refer pain to anywhere in the body.

Needling is by far the fastest, most effective and comfortable tool to loosen up scars, flatten them out, and change them to as close to normal skin tone as possible. Again, little is understood about the neurophysiologic processes that accomplish this awesomeness. The mechanical effect of puncturing thick, fibrotic tissue is a little easier to understand. However, we still don’t even understand exactly how a muscle contracts, sooo... What we do know is this: Untreated scar tissue has collagen fibers like tangled fishing line or cooked spaghetti noodles. I like fishing line more than spaghetti, so I’m going with that. Tendons get the same tangled fishing line orientation when they heal without normal stress placed through them. Both tendons and scar tissue are over 99% collagen, although the collagen type is slightly different. Tangled fishing line collagen is not strong, mobile, or functional. Collagen fibers in parallel are stronger, more mobile, less painful, and increase function.

Needling scars takes tangled fishing line collagen fibers and straightens them out. This occurs on a mechanical level and a neurophysiologic level. We know, thanks in large part to Dr. Helen Langevin, that rotating the needle one direction, or the other, wraps collagen fibers around the needle. This is why the needle stops rotating and why it stings for a sec when it does. This creates a mechanotransducive effect, stimulating a neurophysiologic response in the ANS. The real magic lies in enticing the ANS and our body to reorient the collagen fibers to parallel all on their own! The underlying goal of all medical treatment should be aimed at enhancing our bodies breathtakingly wonderful, powerful, innate ability to heal.

Does tension on healing scars matter?
Now, the question is, why do scars heal with this chaotic fiber orientation? There are all sorts of theories and speculation out there, but when it boils down to it, it is some type of ANS dysfunction. Our body’s self-preserving responses can get carried away, both over and underproducing certain proteins and neurotransmitters, causing unwanted scar formation and pathophysiology. The way plastic surgeons are trained, they try to minimize perpendicular stresses on healing scars. This can be accomplished with repeated application of steri-strips, placed to decrease horizontal tension on the scar during healing. Needling around newly sutured, stapled or glued skin significantly reduces stress on the scar in all directions, way better than steri-strips do, secondary to exponentially increased microvascular vasodilation, increased muscle length, decreased sarcomere tonicity, increased endogenous opioid perfusion, SANS depression, PANS elevation and ANS homeostasis.

NOTE: All surgeons should require needling to be performed around the scar, immediately after closure. This overwhelmingly improves healing time, reduces the risk of infection, and stimulates healing with less scarring. Overactive fibroblastic proliferation, secondary to ANS dysfunction following injury, creates those horrid scars we discussed earlier and increases risk of infection. If any surgeons read this and have questions, please let me know.

Summary
We know for a fact that thoughtful needling has a formidable ability to improve ANS homeostasis. ANS homeostasis allows the body to use its mind-bogglingly awe-inspiring, innate ability to heal itself to the maximal extent possible. What if, with enough induced ANS homeostasis immediately after wound formation, our bodies would regenerate without scarring? We know this to be theoretically possible. Remember, bodily trauma, which is typically necessary to stimulate scar tissue production, severely elevates our SANS and depresses the PANS. Unbalanced ANS activity is like a swift kick in the junk, detrimental to general well-being. Far beyond normal cellular healing is being accomplished as we speak, in both mice and humans, using natural substances already present in our body to upregulate our healing ability. Thoughtful needling is the cheapest, most accessible and effective treatment that exists to normalize scar tissue, reduce pain, improve function and patient outcomes.

Let me know if anyone has any questions about anything. My contact info is on the website. Thanks.

Jason

References

Scars & Wound Healing

• Wilgus, T.A., 2020. Inflammation as an orchestrator of cutaneous scar formation: A review of the literature. Plastic and aesthetic research, 7.
• Cañedo-Dorantes, L. and Cañedo-Ayala, M., 2019. Skin acute wound healing: a comprehensive review. International journal of inflammation, 2019
• Corr, D.T. and Hart, D.A., 2013. Biomechanics of scar tissue and uninjured skin. Advances in wound care, 2(2), pp.37-43.
• Cano Sanchez, M., Lancel, S., Boulanger, E. and Neviere, R., 2018. Targeting oxidative stress and mitochondrial dysfunction in the treatment of impaired wound healing: a systematic review. Antioxidants, 7(8), p.98.
• Millán-Rivero, J.E., Martínez, C.M., Romecín, P.A., Aznar-Cervantes, S.D., Carpes-Ruiz, M., Cenis, J.L., Moraleda, J.M., Atucha, N.M. and García-Bernal, D., 2019. Silk fibroin scaffolds seeded with Wharton’s jelly mesenchymal stem cells enhance re-epithelialization and reduce formation of scar tissue after cutaneous wound healing. Stem cell research & therapy, 10(1), pp.1-14.
• Krzyszczyk, P., Schloss, R., Palmer, A. and Berthiaume, F., 2018. The role of macrophages in acute and chronic wound healing and interventions to promote pro-wound healing phenotypes. Frontiers in physiology, 9, p.419.
• Opneja, A., Kapoor, S. and Stavrou, E.X., 2019. Contribution of platelets, the coagulation and fibrinolytic systems to cutaneous wound healing. Thrombosis research, 179, pp.56-63.
• Deflorin, C., Hohenauer, E., Stoop, R., van Daele, U., Clijsen, R. and Taeymans, J., 2020. Physical management of scar tissue: A systematic review and meta-analysis. The Journal of Alternative and Complementary Medicine, 26(10), pp.854-865.
• Wilgus, T.A., 2020. Inflammation as an orchestrator of cutaneous scar formation: A review of the literature. Plastic and aesthetic research, 7.
• Fernandez-de-Las-Penas, 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.
• Ozer, A.F., Oktenoglu, T., Sasani, M., Bozkus, H., Canbulat, N., Karaarslan, E., Sungurlu, S.F. and Sarioglu, A.C., 2006. Preserving the ligamentum flavum in lumbar discectomy: a new technique that prevents scar tissue formation in the first 6 months postsurgery. Operative Neurosurgery, 59(suppl_1), pp.ONS-126.
• Chevalier, A., Armstrong, K., Norwood-Williams, C., & Gokal, R. (2016). DC Electroacupuncture Effects on Scars and Sutures of a Patient with Postconcussion Paina. Medical Acupuncture, 28(4), 223–229. https://doi.org/10.1089/acu.2016.1188.
• Fang, S. (2014). The Successful Treatment of Pain Associated with Scar Tissue Using Acupuncture. Journal of Acupuncture and Meridian Studies, 7(5), 262–264. https://doi.org/10.1016/j.jams.2014.05.001
• Tuckey, C., Kohut, S. and Edgar, D.W., 2019. Efficacy of acupuncture in treating scars following tissue trauma. Scars, burns & healing, 5, p.2059513119831911.
• Rozenfeld, E., Sapoznikov Sebakhutu, E., Krieger, Y. and Kalichman, L., 2020. Dry needling for scar treatment. Acupuncture in Medicine, 38(6), pp.435-439.

Neural Plasticity

• Dommerholt, J., Mayoral del Moral, O. and Gröbli, C., 2006. Trigger point dry needling. Journal of Manual & Manipulative Therapy, 14(4), pp.70E-87E.
• 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.
• Sollie, M., Pind, R., Madsen, C.B. and Sørensen, J.A., 2021. Acupuncture (superficial dry-needling) as a treatment for chronic postherpetic neuralgia–a randomized clinical trial. British Journal of Pain, p.20494637211023075.
• 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.
• Liu, C.Z., Kong, J. and Wang, K., 2017. Acupuncture therapies and neuroplasticity. Neural plasticity, 2017, p.6178505.
• 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

• Bernstein, H.G., Dobrowolny, H., Bogerts, B., Keilhoff, G. and Steiner, J., 2019. The hypothalamus and neuropsychiatric disorders: psychiatry meets microscopy. Cell and tissue research, 375(1), pp.243-258.
• 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.

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.