It Doesn’t Hurt!
I know, just the idea of having a needle poked into your pelvic floor muscles is enough for most people to get the same feeling you get when you think about eating a nice, hot spoonful of moldy mayonnaise. This is the logical reaction. However, it’s not true! The “forgotten nine” pelvic floor muscles are some of the most comfortable muscles to have needled in the entire body. I do this for my patients and have it done to me all the time, it’s bafflingly pleasant. The closer to the genitalia you get, the less you feel the needles. The needles I use for the pelvic floor muscles are .18 mm thick. This is thinner than the wall of many hollow needles. It really is surprisingly comfortable, and it works awesome, I promise!

Related: Click here to read my blog on "The Forgotten Nine: Pelvic Floor Musculature"

Pelvic Floor Neurophysiology
S2-S4 is the portion of the sacral plexus innervating the pelvic floor musculature. This also happens to be a parasympathetic dominant portion of the autonomic nervous system (PANS). This is awesome. People with stress, anxiety, and pain typically have sympathetic autonomic nervous system (SANS) hyperactivity. Most PT patients, for that matter, present with SANS hyperactivity. Targeting the PANS elevates parasympathetics, depresses sympathetics and stimulates the ANS toward homeostasis. This is beneficial for any impairment.

I don’t think it’s possible to regulate the ANS, to the maximum possible extent, without needling the pelvic floor.

Much of the time, trigger points in the pelvic floor musculature are latent. That is, a person may not be aware they have problems until the tissues are directly stimulated. Another good example of this phenomenon is the adductors. It seems these muscles also commonly develop latent, rather than active, trigger points. Feel on the inside of your leg, about 3/4 of the way up, that big band of tissue, and jab a finger into it. Oweee! Just because you don’t feel these trigger points the majority of the time, doesn’t mean they are not problematic. Negative afferent signals from hypoxic, chemical filled, pissed off tissues are detrimental to ANS homeostasis. If the source of these negative afferents, the pelvic floor musculature, in this case, is not addressed, the direct connection to the PANS is going to cause body wide dysfunction via ANS dysregulation. This is why needling the pelvic floor musculature is so important for a vast array of impairments, not just pelvic floor impairments. It is key to maximizing ANS homeostasis.

Pelvic floor needling is important and healing for all people and conditions. If it is necessary to needle the pelvic floor musculature to achieve maximal ANS homeostasis, which it is, it follows that all living humans would benefit from skilled needling of these oft-neglected muscles. Poor little guys, they need attention too! Normalizing length, blood perfusion, neurotransmitter concentrations, etc., of the pelvic floor musculature, which needling does in a snap, allows for improved pelvic joint alignment, muscle function and core stability. Pelvic stability is fundamental for spinal stability, both of which are necessary to achieve maximum overall health. Again, and I can’t stress this enough, it is impossible to achieve maximum ANS homeostasis and health, in the majority of patients, without addressing the pelvic floor structures. Every practitioner legally able to treat the pelvic floor should be competent in treating it. This leads to significantly improved patient outcomes.

Stress, anxiety and Pain activate the sympathetic nervous system, which stimulates the release of neurotransmitters, such as norepinephrine and cortisol. In abnormal concentrations, these substances, along with many others, stimulate and or perpetuate central sensitization of the central nervous system (sympathetic hyperactivity). This further amplifies stress, anxiety pain, allodynia, hyperalgesia, hypersensitivity and other nervous systems dysfunctions. These impairments are mostly treatable with normal methods, however, you will never fully address these impairments until the pelvic floor is treated. ANS homeostasis is key to health, and needling the pelvic floor is key to ANS homeostasis.

Remember: Trigger points in the pelvic floor are often latent. Secondary to the latent nature of pelvic floor trigger points, along with the fact that people are usually embarrassed to mention this area of the body, the pelvic floor musculature receives little to no attention from the vast majority of medical practitioners. Boooo!!!!

Pelvic Floor Needling for Low Back Pain
Numerous muscles crossing the low back and hips attach to the sacrococcygeal periosteum, along with some of the pelvic floor structures. The Gracilis blends right into the pelvic floor. Any abnormal muscle attaching to the sacrococcygeal region may deviate the coccyx and sacrum, which will, in turn, alter the orientation of the low back muscles. Let’s take a right, tight coccygeus muscle as a hypothetical example. If the coccygeus is tight on the right, it may pull the inferior sacrum and coccyx to the right. This would tilt the base of the sacrum (remember, some A-hole decided to name the top of the sacrum the “base”) to the left, causing right lumbar side-bending, compressing the right lumbosacral spine, placing abnormal stress on the lumbopelvic neurovasculature. Compensatory strategy would then lead to left cervical side bending, muscular shortening and neurovascular compromise. This is just one example of many illustrating kinetic chain and ANS dysregulation, secondary to pathologic pelvic floor musculature.

Not to mention, the coccygeus, part of the levator ani complex and pelvic floor, attaches right near our proximal hamstrings and piriformis. Are these common pathologies problem causers in PT-land? You would be hard-pressed to find me a typical PT patient without horribly, awfully insanely tight hamstrings. This directly affects the pelvic floor.

Even if the pelvic floor is not the initial cause of the problem, with just about any instance of low back pain, lower extremity neuropathy, abdominal pathology, etc., the pelvic floor is going to become pathologic.

At this point, it doesn’t matter why the pelvic floor was aggravated in the first place. If it is not treated in conjunction with all the typical muscles you think of when treating LBP, it will be a lingering, nagging, oftentimes subconscious disruption to your ANS. Pathologic pelvic floor structures are oftentimes the causative factor for subsequent bouts of LBP, even if they weren’t initially involved. I think of this just like I think of treating chronic epicondylitis (see specific blog). The epicondylar periosteum may not be the original cause of the problem. Once it’s inflamed, however, if it is not directly treated with needling, periostitis is often the lingering causative factor driving recurring epicodylopathy (I’m pretty sure that is not a medical term, but it should be. So, I’m using it.)

This is just one simple example of how pelvic floor pathology leads to, or stems from, then, in turn, causes, common impairments, like low back pain. LBP is one of the primary impairments for which people seek out physical therapy, chiropractic, athletic training and other such medical intervention. About $500 billion, annually, goes into medical treatment associated with LBP. Pelvic floor dry needling, needling in general, is cheap, easy and astoundingly effective as both a treatment and prophylaxis for LBP, along with numerous other common impairments. Not just pelvic health issues.

Thanks everyone. Let me know if anyone has any questions about anything.

Jason

References

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Neural Plasticity

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• 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.
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• 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.

Beta-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.

Enteric Nervous System, Gut-Brain Axis

• Furness, J.B., 2012. The enteric nervous system and neurogastroenterology. Nature reviews Gastroenterology & hepatology, 9(5), pp.286-294.
• Spencer, N.J. and Hu, H., 2020. Enteric nervous system: sensory transduction, neural circuits and gastrointestinal motility. Nature Reviews Gastroenterology & Hepatology, 17(6), pp.338-351
• Drokhlyansky, E., Smillie, C.S., Van Wittenberghe, N., Ericsson, M., Griffin, G.K., Eraslan, G., Dionne, D., Cuoco, M.S., Goder-Reiser, M.N., Sharova, T. and Kuksenko, O., 2020. The human and mouse enteric nervous system at single-cell resolution. Cell, 182(6), pp.1606-1622.
• Heiss, C.N. and Olofsson, L.E., 2019. The role of the gut microbiota in development, function and disorders of the central nervous system and the enteric nervous system. Journal of neuroendocrinology, 31(5), p.e12684.
• Fung, C. and Vanden Berghe, P., 2020. Functional circuits and signal processing in the enteric nervous system. Cellular and Molecular Life Sciences, 77, pp.4505-4522.
• De Vadder, F., Grasset, E., Holm, L.M., Karsenty, G., Macpherson, A.J., Olofsson, L.E. and Bäckhed, F., 2018. Gut microbiota regulates maturation of the adult enteric nervous system via enteric serotonin networks. Proceedings of the National Academy of Sciences, 115(25), pp.6458-6463.
• Niesler, B., Kuerten, S., Demir, I.E. and Schäfer, K.H., 2021. Disorders of the enteric nervous system—a holistic view. Nature Reviews Gastroenterology & Hepatology, 18(6), pp.393-410.
• Mayer, E.A., Tillisch, K. and Gupta, A., 2015. Gut/brain axis and the microbiota. The Journal of clinical investigation, 125(3), pp.926-938.
• Cryan, J.F., O’Riordan, K.J., Cowan, C.S., Sandhu, K.V., Bastiaanssen, T.F., Boehme, M., Codagnone, M.G., Cussotto, S., Fulling, C., Golubeva, A.V. and Guzzetta, K.E., 2019. The microbiota-gut-brain axis. Physiological reviews.
• Ma, Q., Xing, C., Long, W., Wang, H.Y., Liu, Q. and Wang, R.F., 2019. Impact of microbiota on central nervous system and neurological diseases: the gut-brain axis. Journal of neuroinflammation, 16(1), pp.1-14.
• Bonaz, B., Bazin, T. and Pellissier, S., 2018. The vagus nerve at the interface of the microbiota-gut-brain axis. Frontiers in neuroscience, 12, p.49.
• Benakis, C., Martin-Gallausiaux, C., Trezzi, J.P., Melton, P., Liesz, A. and Wilmes, P., 2020. The microbiome-gut-brain axis in acute and chronic brain diseases. Current opinion in neurobiology, 61, pp.1-9.
• Kim, N., Yun, M., Oh, Y.J. and Choi, H.J., 2018. Mind-altering with the gut: Modulation of the gut-brain axis with probiotics. Journal of Microbiology, 56(3), pp.172-182.
• Tan, H.E., Sisti, A.C., Jin, H., Vignovich, M., Villavicencio, M., Tsang, K.S., Goffer, Y. and Zuker, C.S., 2020. The gut–brain axis mediates sugar preference. Nature, 580(7804), pp.511-516.

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.

Orthopedic Conditions

• 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.
• 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.
• 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.
• 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.
• 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.
• 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.
• 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.
• 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.
• 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.
• 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.
• 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.
• 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.
• 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.
• 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.
• 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.
• 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.
• Dommerholt, J., 2011. Dry needling—peripheral and central considerations. Journal of Manual & Manipulative Therapy, 19(4), pp.223-227.
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