How Does Dry Needling Work?

Online Dry Needling Education: Part 1

A lot of students have asked me to recap how I explain the mechanisms of action, that we somewhat understand, regarding how dry needling works. This is typically what I say to other medical professionals:

Dry Needling works on two primary levels – mechanical and neurologic, although I believe the mechanical changes are primarily driven by the nervous systems changes induced by needling. On a mechanical level, there are a bunch of things that need to happen for a muscle to contract, but there are three primary processes that need to occur. Let’s think about this in terms of a sarcomere and the actin-myosin cross-bridge formation.

Normal Skeletal Muscle Contraction

The primary things that need to happen for an actin-myosin cross-bridge to form are: Acetylcholine, a neurotransmitter, needs to cross the synaptic cleft to the post-synaptic terminal, which signals the Sodium-Potassium pump to depolarize the cell. Troponin needs to be present inside the sarcomere and calcium needs to be released from the sarcoplasmic reticulum, which is already intracellular. Troponin and calcium bind together and form the cross-bridge site for the actin-myosin attachment.

Related: Click here to read my blog on Dry Needling Scar Tissue to Regulate the Autonomic Nervous System & Improve Health

Normal Skeletal Muscle Relaxation

The primary things that need to happen to disconnect the actin-myosin cross-bridge are: Tropomyosin enters the cell and breaks the calcium-troponin bond. Calcium gets reabsorbed into the sarcoplasmic reticulum. Acetylcholine esterase needs to be present in sufficient concentration to gobble up all the acetylcholine and the sarcomere becomes repolarized.

Note: Remember, normal resting muscle cell potential for skeletal muscle is about -35 millivolts, or so. An action potential typically occurs at -70 millivolts, or so. Also remember, the vast majority of PT patients present with sympathetic hyperactivity of both the ANS and CNS. With hyperactive sympathetics, the resting potential of the sarcomere is more negative, maybe at -45 millivolts, and the action potential is less negative, maybe around -60 millivolts. In this instance, the electrical potential of the cell needs to change far less to stimulate an action potential. This is one of the reasons that sympathetically hyperactive sarcomeres produce spontaneous electrical activity.

Abnormal Skeletal Muscle Contraction & Relaxation Secondary to Sympathetic Hyperactivity

With hyperactive sympathetics, as mentioned above, the action potential threshold is diminished. Hyperactive sympathetics also lead to skeletal muscle vasoconstriction and trigger points, which are just groups of hypercontracted sarcomeres. This leads to hypoxic tissues with excessive CO2 concentration. Excessive CO2 concentration makes the cell more acidic, making muscles more likely to spontaneously fire and hindering enzyme function.

Hyperactive sympathetics lead to excessive acetylcholine production / release and diminished acetylcholine esterase production / release, along with excessive intracellular calcium concentration. These factors make it impossible for the actin-myosin cross-bridge to disconnect. A negative feedback loop ensues where the muscles hurt, they contract more, become more hypoxic, even more detrimental concentrations of chemicals arise, many of which are pain amplifiers, and the cycle continues.

Another thing that happens with chronically hyperactive sympathetics is, rather than just the post synaptic cleft being receptive to acetylcholine, the entire epimysium (muscle lining) becomes receptive to acetylcholine. With excessive concentrations of acetylcholine and the entire epimysium becoming receptive to it, a slow, chemical shortening of muscles begins. This is not active, spontaneous electrical contraction, it is a chemical contraction, which may not show up on an EMG.

Hyperactive sympathetics also dysregulate the hypothalamic-pituitary-adrenal (HPA) axis and the gut-brain-axis (enteric nervous system + brain), both part of the ANS. If these axes are dysregulated, all of our hormones, peptides, neurotransmitters, immune systems, etc., become dysregulated and malfunction. This can lead to just about any medical impairment.

Dry needling is, without question, the most powerful tool PT’s have at their disposal to quickly and effectively regulate the CNS and ANS toward homeostasis.

Without CNS / ANS homeostasis, nothing in our body works properly. Remember, the overall effect of needling, almost regardless of how it is performed, results in CNS / ANS sympathetic depression below baseline and parasympathetic elevation above baseline. This works out well for us, since the significant majority of PT patients present with sympathetic hyperactivity. This works especially well if you specifically target the PANS with needles, along with whatever else you are needling. This decreases the time of the initial sympathetic spike following needle insertion, which typically lasts about 15 minutes, according to numerous heart rate variability and microneurography (gold standard ANS test) studies. If PANS-specific needles are implemented, the amplitude and duration of the sympathetic spike are significantly diminished, making treatment more effective, lasting and comfortable.

Now, these are a few of the things we think we have a decent grasp on. However, to remind you, we don’t even know for sure how a muscle contracts! It is still called the sliding filament theory for a reason, it's still a theory. I always think about this; if it was possible to quantitatively assess all the medical knowledge available out there in the ether, I bet we know less than 5% of the whole. If you really think about it, we have very few 100% fixes for any medical condition. Most of the treatments we have today are just Band-Aids that mask the symptoms of the underlying problem. They don’t actually cure the problem. This, in part, is because the pharmaceutical companies would rather not have any 100% cures for diseases. It is much more profitable to keep people partially sick for life. That way, you give them medicines which only mask symptoms, and if the medicine causes side effects, you get more medicine to counter the side effects of the original medicine you were taking. It’s disgusting. Unfortunately, the one thing that rarely gets addressed, the most important aspect of medicine, is treating everyone as an individual and addressing the root cause of the problem, along with the symptoms. Not just the symptoms.

Dry needling is one of the few treatments that addresses both the cause of the problem and the symptoms, for just about any impairment out there. Again, I don’t know of any medical impairment that is not helped by improved CNS / ANS homeostasis, and needling is the most powerful tool PT’s have at their disposal to regulate the neuromusculoskeletal system. I believe it is one of the most powerful tools in all of medicine, to regulate the nervous systems towards homeostasis, the key to health.

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

Jason

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

References

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Neural Plasticity

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B-endorphin

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Enteric Nervous System, Gut-Brain Axis

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Vagus Nerve Stimulation

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• 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
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• 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.
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Neurologic Conditions, Including TBI & CVA

• Ghayour Najafabadi, M., Shariat, A., Dommerholt, J., Hakakzadeh, A., Nakhostin-Ansari, A., Selk-Ghaffari, M., Ingle, L. and Cleland, J.A., 2021. Aquatic Therapy for improving Lower Limbs Function in Post-stroke Survivors: A Systematic Review with Meta-Analysis. Topics in Stroke Rehabilitation, pp.1-17.
• Pourahmadi, M., Dommerholt, J., Fernández-de-Las-Peñas, C., Koes, B.W., Mohseni-Bandpei, M.A., Mansournia, M.A., Delavari, S., Keshtkar, A. and Bahramian, M., 2021. Dry needling for the treatment of tension-type, cervicogenic, or migraine headaches: A systematic review and meta-analysis. Physical Therapy, 101(5), p.pzab068.
• Fernández-de-Las-Peñas, C., Pérez-Bellmunt, A., Llurda-Almuzara, L., Plaza-Manzano, G., De-la-Llave-Rincón, A.I. and Navarro-Santana, M.J., 2021. Is Dry Needling Effective for the Management of Spasticity, Pain, and Motor Function in Post-Stroke Patients? A Systematic Review and Meta-Analysis. Pain Medicine, 22(1), pp.131-141.
• Sánchez-Mila, Z., Salom-Moreno, J. and Fernández-de-Las-Peñas, C., 2018. Effects of dry needling on post-stroke spasticity, motor function and stability limits: a randomised clinical trial. Acupuncture in Medicine, 36(6), pp.358-366.
• Mendigutia-Gómez, A., Martín-Hernández, C., Salom-Moreno, J. and Fernández-de-Las-Peñas, C., 2016. Effect of dry needling on spasticity, shoulder range of motion, and pressure pain sensitivity in patients with stroke: A crossover study. Journal of manipulative and physiological therapeutics, 39(5), pp.348-358.
• Mendigutía-Gómez, A., Quintana-García, M.T., Martín-Sevilla, M., de Lorenzo-Barrientos, D., Rodríguez-Jiménez, J., Fernández-de-Las-Peñas, C. and Arias-Buría, J.L., 2020. Post-needling soreness and trigger point dry needling for hemiplegic shoulder pain following stroke. Acupuncture in Medicine, 38(3), pp.150-157.
• Valencia-Chulián, R., Heredia-Rizo, A.M., Moral-Munoz, J.A., Lucena-Anton, D. and Luque-Moreno, C., 2020. Dry needling for the management of spasticity, pain, and range of movement in adults after stroke: A systematic review. Complementary Therapies in Medicine, 52, p.102515.
• Calvo, S., Navarro, J., Herrero, P., Del Moral, R., De Diego, C. and Marijuán, P.C., 2015. Electroencephalographic changes after application of dry needling [DNHS© technique] in two patients with chronic stroke. Myopain, 23(3-4), pp.112-117.
• Cuenca Zaldívar, J.N., Calvo, S., Bravo-Esteban, E., Oliva Ruiz, P., Santi-Cano, M.J. and Herrero, P., 2020. Effectiveness of dry needling for upper extremity spasticity, quality of life and function in subacute phase stroke patients. Acupuncture in Medicine, p.0964528420947426.
• Hernández-Ortíz, A.R., Ponce-Luceño, R., Sáez-Sánchez, C., García-Sánchez, O., Fernández-de-Las-Peñas, C. and de-la-Llave-Rincón, A.I., 2020. Changes in muscle tone, function, and pain in the chronic hemiparetic shoulder after dry needling within or outside trigger points in stroke patients: A crossover randomized clinical trial. Pain Medicine, 21(11), pp.2939-2947.
• Tavakol, Z., Shariat, A., Ansari, N.N., Ghannadi, S., Honarpishe, R., Dommerholt, J., Noormohammadpour, P. and Ingle, L., 2021. A Double-blind Randomized Controlled Trial for the Effects of Dry Needling on Upper Limb Dysfunction in Patients with Stroke. Acupuncture & Electro-Therapeutics Research, 45(2-3), pp.115-124.
• Ghaffari, M.S., Shariat, A., Honarpishe, R., Hakakzadeh, A., Cleland, J.A., Haghighi, S. and Barghi, T.S., 2019. Concurrent effects of dry needling and electrical stimulation in the management of upper extremity hemiparesis. Journal of acupuncture and meridian studies, 12(3), pp.90-94.
• Ghannadi, S., Shariat, A., Ansari, N.N., Tavakol, Z., Honarpishe, R., Dommerholt, J., Noormohammadpour, P. and Ingle, L., 2020. The effect of dry needling on lower limb dysfunction in poststroke survivors. Journal of Stroke and Cerebrovascular Diseases, 29(6), p.104814.
• Bynum, R., Garcia, O., Herbst, E., Kossa, M., Liou, K., Cowan, A. and Hilton, C., 2021. Effects of dry needling on spasticity and range of motion: a systematic review. American Journal of Occupational Therapy, 75(1), pp.7501205030p1-7501205030p13.
• DiLorenzo, L., Traballesi, M., Morelli, D., Pompa, A., Brunelli, S., Buzzi, M.G. and Formisano, R., 2004. Hemiparetic shoulder pain syndrome treated with deep dry needling during early rehabilitation: a prospective, open-label, randomized investigation. Journal of Musculoskeletal Pain, 12(2), pp.25-34.
• Carusotto, A.F., Hakim, R.M., Oliveira, R.G., Piranio, A., Coughlan, C.P. and MacDonald, T.J., 2021. Effects of dry needling on muscle spasticity in adults with neurological disorders: a systematic review. Physical Therapy Reviews, pp.1-6.
• Sánchez-Mila, Z., Salom-Moreno, J. and Fernández-de-Las-Peñas, C., 2018. Effects of dry needling on post-stroke spasticity, motor function and stability limits: a randomised clinical trial. Acupuncture in Medicine, 36(6), pp.358-366.
• Salom-Moreno, J., Sánchez-Mila, Z., Ortega-Santiago, R., Palacios-Ceña, M., Truyol-Domínguez, S. and Fernández-de-las-Peñas, C., 2014. Changes in spasticity, widespread pressure pain sensitivity, and baropodometry after the application of dry needling in patients who have had a stroke: A randomized controlled trial. Journal of manipulative and physiological therapeutics, 37(8), pp.569-579.
• Valencia-Chulián, R., Heredia-Rizo, A.M., Moral-Munoz, J.A., Lucena-Anton, D. and Luque-Moreno, C., 2020. Dry needling for the management of spasticity, pain, and range of movement in adults after stroke: A systematic review. Complementary Therapies in Medicine, 52, p.102515.
• Núñez-Cortés, R., Cruz-Montecinos, C., Latorre-García, R., Pérez-Alenda, S. and Torres-Castro, R., 2020. Effectiveness of Dry Needling in the Management of Spasticity in Patients Post Stroke. Journal of Stroke and Cerebrovascular Diseases, 29(11), p.105236.
• Bynum, R., Garcia, O., Herbst, E., Kossa, M., Liou, K., Cowan, A. and Hilton, C., 2021. Effects of dry needling on spasticity and range of motion: a systematic review. American Journal of Occupational Therapy, 75(1), pp.7501205030p1-7501205030p13.

Electrical Needling

• Dunning, J., Butts, R., Henry, N., Mourad, F., Brannon, A., Rodriguez, H., Young, I., Arias-Buría, J.L. and Fernández-de-Las-Peñas, C., 2018. Electrical dry needling as an adjunct to exercise, manual therapy and ultrasound for plantar fasciitis: A multi-center randomized clinical trial. PloS one, 13(10), p.e0205405.
• 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.
• 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.
• Brennan, K., Elifritz, K.M., Comire, M.M. and Jupiter, D.C., 2021. Rate and maintenance of improvement of myofascial pain with dry needling alone vs. dry needling with intramuscular electrical stimulation: a randomized controlled trial. Journal of Manual & Manipulative Therapy, 29(4), pp.216-226.
• Fernández-Carnero, J., 2021. Effectiveness of Dry Needling with Percutaneous Electrical Nerve Stimulation of High Frequency Versus Low Frequency in Patients with Myofascial Neck Pain. Pain physician, 24, pp.135-143.
• WALSH, S., GOULT, C. and GILLETT, B., 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), p.73.
• Dunning, J., 2019. Effectiveness of Electrical Dry Needling for Lower Extremity Pain Disorders.
• Hadizadeh, M., Tajali, S.B., Moghadam, B.A., Jalaei, S. and Bazzaz, M., 2022. Effects of Intramuscular Electrical Stimulation through Dry Needling on Pain and Dysfunction Following Trigger Points in Upper Trapezius Muscle: A Double-blind Randomized Controlled Trial. Journal of Modern Rehabilitation.
• 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.

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.