How to Limit Initial Sympathetic Autonomic Stimulation Following Needle Placement to Avoid Vasovagal Response and Patient Discomfort During Dry Needling Treatment

Immediately upon needle insertion, the sympathetic autonomic nervous system (SANS) elevates above baseline for somewhere around 15 minutes. This has been confirmed in numerous needling and acupuncture studies using microneurography (gold standard ANS test) and heart rate variability (HRV). HRV is less precise, but cheaper and easier to perform. Lots of watches and even some beds have HRV capability nowadays. Acupuncturists figured this out thousands of years ago by trial and error, and for some reason, non-acupuncturists generally disregard this phenomenon. Big mistake. Following the initial sympathetic spike, the SANS drops below baseline and the parasympathetic autonomic nervous system (PANS) elevates above baseline. This shift towards ANS homeostasis should be the primary overall goal of the majority of needle treatments. ANS homeostasis is vital to improve every medical malady I’m aware of.

Remember, just about all PT, AT, OT, DC, psychotherapy, etc., patients present with sympathetic hyperactivity of the CNS / ANS. Also remember, the overall effect of needling, almost regardless of what you do, is SANS depression and PANS elevation. However, if you are working with patients presenting with significant SANS hyperactivity (anxiety, fibromyalgia, hyperalgesia, fear of needles, etc.), the initial sympathetic spike from getting poked with a sharp object is often enough to stimulate a vasovagal response. Vasovagal response and syncope are results of SANS stimulation occurring faster than the ANS can account for and regulate. At a certain sympathetic threshold (everyone is different), the SANS says screw it and just turns off for a sec. This leads to a rapid drop in blood pressure and fainting, in the most extreme cases.

Large nervous system responses are typically more easily elicited in highly athletic and or significantly messed up patients. “Significantly messed up” is a medical term, by the way… Therefore, if you are dealing with a patient presenting with initial, significant SANS hyperactivity, their threshold to reach vasovagal response is diminished. In these circumstances, just a few needles can create an uncomfortable situation for the patient. This is why you should always treat people in a position that, if they were to faint, they would not hit their head or something on the way down. This is the main safety issue with vasovagal responses. The response itself is not dangerous and I believe it to be quite healthy, kinda like an ANS reset, however, it is super uncomfortable and is not something you want to do to your patients.

OK, so, if you are treating someone with hyperactive sympathetics, which covers about everyone we treat, and we know from clinical experience and research that sympathetics spike for about the first 15 minutes following needle insertion before dropping below baseline, it makes sense to target the PANS with the first needles you place. This dramatically limits the amplitude and duration of the sympathetic spike, making treatment more comfortable and effective. I have never read a research article looking at this effect, but I can tell you with absolute certainty that targeting the PANS alone, or in conjunction with and prior to your other needles, limits the sympathetic spike and makes everything better – pain, speed of outcome and overall treatment efficacy. This is why you should always try to leave the needles in for about 20-30 minutes. Allowing the ANS transition from SANS to PANS dominance while the needles are in the body is far more effective, comfortable and lasting than simply poking someone for a few seconds then removing the needles.

Remember, targeting the PANS with needles has a homeostatic effect on the ANS, even if a patient has a rare case of PANS hyperactivity. We know so little about the mechanisms of action that lead to this, but we do know the overall result of PANS needling. There is a huge amount of high-quality research looking at direct vagus nerve (primary PANS nerve) stimulation with a metal cuff placed around the vagus nerves themselves and its effect on anxiety, chronic pain, autoimmune disease, insulin resistance, heart irregularities, and much more.

The most direct PANS treatment we can safely perform is needling the concha of the ears. This is the only piece of skin we have access to that is directly innervated by the vagus nerve, the auricular branch. The second-best place is the sacral plexus, S2-S4, and the third-best is the base of the C2 spinous process or the suboccipital periosteum. I like to connect all these locations to each other. Always add low frequency microcurrent, 1-5 Hz. I like 2 Hz. Low frequency stim produces a strong anti-sympathetic response by inducing a 4x increase in available endogenous opioids from the hypothalamic-pituitary-adrenal (HPA) axis, like beta-endorphin, which decrease sympathetics on their own, along with reducing pain, anxiety and the possibility of vasovagal response.

Along with the HPA axis, the other main portion of the ANS is the gut-brain axis, the brain and the enteric nervous system. Behind the brain, the enteric nervous system has the largest number of neurons per system in our body. This should indicate its importance and we are learning rapidly the vast potential a homeostatic enteric nervous system has on our general wellbeing. The intestines and their microbiota play an important role in many bodily functions, including our immune system, hormones, neurotransmitters, and more. Sympathetic hyperactivity negatively affects the gut-brain axis, limits gastric motility, disrupts serotonergic and dopaminergic neuronal activity, affects mood, and a lot more bad stuff.

By specifically targeting the PANS first, then proceeding with your other needling treatment, you will limit the initial sympathetic spike from being poked by needles. Limiting the duration and amplitude of the sympathetic spike reduces the likelihood of vasovagal response, improves patient comfort, and gives the patient more time with the needles in the body while the SANS is depressed below baseline and the PANS is elevated above baseline. This is a key to providing the most lasting and effective needling treatment possible. Aside from specifically treating certain impairments, making ANS homeostasis a primary goal of needling treatment improves all areas of health, both physical and mental, to the maximum extent possible.

Give this a try, you will see amazing improvements in your patients physical and mental wellbeing compared to what you see without implementing this technique and thought process. Let me know if anyone has any questions about anything.

Jason

Intricate Art Spine & Body Solutions and its affiliates are not responsible for any injury or damage that may result from the use of techniques taught or information being provided. This content is provided for informational purposes only and by participating you are doing so at your own risk.

References

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Electrical Needling

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