Pelvic Floor Dry Needling to Reduce Stress, Anxiety & Pain Associated with Any Impairment, Including Low Back Pain

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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Beta-endorphin

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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.
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• 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.
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• 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.
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Vagus Nerve Stimulation

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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.
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