I’ll cut to the chase (and consider just another reason you should take a dry needling pelvic floor course): With 5 treatments of dry needling and spinal manipulation, you can fix the majority of incontinence in your patients. If you have been told that incontinence is normal, you have been lied to. If your patients think they are doomed to suffer these issues for life, they are wrong.

If I had to put a number on it, I would bet that at least 50% off all PT, AT, and DC patients, male and female, of all ages, have some type of incontinence. Up that number to about 75% for OBGYNs. Over 90% of these impairments are quickly and easily fixable, barring some type of significant underlying pathology like a spinal cord injury. Aside from these rare cases involving structural damage, nobody should have incontinence. Period. End of story. I don’t care if they are 15 years old or 95. Electrical dry needling is, by far, the fastest, longest-lasting, and most dramatically effective treatment for incontinence that I know of.

Click here for more information on dry needling courses

The most distressing aspect of incontinence-related impairments is the fact that it is so incredibly easy to fix without typical medicine, like pills. Unfortunately, this is almost never related to the patient for a variety of reasons, none of them acceptable. Any of you reading this with this type of impairment know how this goes for you at the doctor… If you bring up the problem, the vast majority of medical professionals tells you it’s normal. Whether you are a high school athlete, male or female, or a 90-year-old, the answer is always the same. “It’s normal, here, take these pills.” Booo!!!!

Can pelvic floor exercise treat incontinence?

The few medical professionals out there, and I mean few, who actually treat incontinence-related impairments, typically do it without dry needling. This is a mistake. Pelvic floor exercises, for the most part, are not needed, and are sometimes counterproductive to treating incontinence. How many with incontinence, who have sought treatment, have been told to do kegels with no results? People’s pelvic floor muscles don’t need to be stronger, they just need to work correctly. If any muscle is not in the proper anatomical position, secondary to trigger points (muscle shortening) or joint deviation or both, for example, it cannot contract or function properly.

Sarcomeres + incontinence treatment

Think of sarcomeres as the building blocks for our muscles. To make muscles mechanically stronger, you need to add sarcomeres in series and in parallel to existing muscle. For the average PT patient, it takes a minimum of 3 sessions a week for 8 weeks, 30-45 minutes a session, fatiguing muscle to failure to create new sarcomeres to add onto existing muscle. That’s 24 visits.

Consider the following:

• How many patients get 24 visits of PT where they are able to exercise?
• How many PT patients could tolerate that treatment, even if they had the visits?
• How many patients actually do their home exercises to supplement in-clinic treatment?

The answer to these questions is close to zero. The only patients in my experience who receive that many treatments are post-operative. Typical post-operative patients seen in PT are restricted from forceful exercise for at least 2 months.

So, if it is impossible to begin to add sarcomeres to muscles during a regular course of PT, how many, if any, patients significantly improve mechanical strength? Most muscle strength gains achieved during the course of typical PT treatment are secondary to neurologic alterations rather than mechanical. These alterations result from normalized muscle length and autonomic nervous system (ANS) homeostasis. If there are chronic trigger points present in the pelvic floor musculature (trigger points are hypercontracted, hypoxic bundles of sarcomeres), exercising these muscles typically will not alleviate the trigger points, oftentimes making them worse. If you are asking a muscle with trigger points in it to contract forcefully, over and over, you are forcing the pissed off, hypercontracted bundles of sarcomeres (trigger points) to contract more. This leads to significant decreases in blood perfusion throughout the pathologic tissue, abnormal chemical concentrations, chemically amplified pain, streams of negative afferents to brain, ANS dysfunction, abnormal pelvic floor muscle function, Sympathetic Autonomic Hyperactivity, and incontinence.

Using dry needling to treat incontinence

Remember: The majority of physical and psychotherapy patients suffer from sympathetic hyperactivity. Impairments resulting from parasympathetic hyperactivity typically fall outside the PT scope of practice, so we don’t see a whole lot of that. They are also less common than sympathetic-hyperactivity-related impairments. That is not to say we can’t target and treat both parts of the ANS, the PANS and SANS, but the majority of our patients have sympathetic hyperactivity. So, let’s assume that our goal is sympathetic depression, parasympathetic elevation, and ANS homeostasis.

Note: The three areas of the body PTs have safe access to target the PANS are the sacral periosteum (S2-S4, innervates the pelvic floor), the upper cervical and suboccipital periosteum (brainstem nuclei), and the concha of the ears (direct vagus nerve innervation, auricular branch). Connecting all 3 with about 2 Hz of microcurrent induces amazingly positive responses. I use the combination of these needles with the majority of my patients, sometimes on their own, sometimes along with whatever else I am treating. Give it a shot, and you will see awesome improvements physically and mentally.

Normalizing the ANS and muscle length improves muscle recruitment, muscle firing patterns, nerve conduction velocity, and strength of pelvic floor musculature. This, in turn, facilitates improved muscle function of surrounding musculature like the glutes, hip flexors, and low back. Low back pain anyone? Yes,it is intimately related to pelvic floor dysfunction. Hmmm… Attempting to strengthen short, pathologic muscles is detrimental to function, often making things worse. Pelvic floor muscles are rarely weak from disuse. That is, they retain the ability to contract and relax properly (the relaxing part is the key), but something is hindering that contraction / relaxation cycle, like trigger points (muscle shortening) and ANS dysfunction. This leaves the muscles in a constant state of elevated toxicity, which provides rigid pelvic support but inhibits them from performing their other duties.

Here is another way to think about this: Think about trying to seal a hole in the side of a tank with a rigid, stiff piece of rubber that is way bigger than the hole. Ummm… problem. Unless you have superpowers… Now, think about that same hole and the same piece of rubber, but instead of the rubber being rigid, it is nice and malleable. Now we can fill the whole. This is just like trying to seal holes in our bodies with super stiff muscles compared to proper, malleable muscles.

The amazing results I see on a consistent basis with my incontinence patients are not possible without the implementation of needling and manipulation. Needling regulates muscle length and the ANS. Manipulation regulates joint deviation and the ANS. The two used together will give you better results, where you thought none were possible.

If anyone has any questions about any of these, or would like to learn where they can find an Intricate Art Trained Practitioner, let me know. Talk to you soon.

Jason

Pelvic Floor References

• Liu, B., Liu, Y., Qin, Z., Zhou, K., Xu, H., He, L., Li, N., Su, T., Sun, J., Yue, Z. and Zang, Z., 2019, January. Electroacupuncture versus pelvic floor muscle training plus solifenacin for women with mixed urinary incontinence: a randomized noninferiority trial. In Mayo Clinic Proceedings (Vol. 94, No. 1, pp. 54-65). Elsevier.
• Wang, Y., Zhishun, L., Peng, W., Zhao, J. and Liu, B., 2013. Acupuncture for stress urinary incontinence in adults. Cochrane Database of Systematic Reviews, (7).
• Itza, F., Zarza, D., Serra, L., Gomez-Sancha, F., Salinas, J. and Allona-Almagro, A., 2010. Myofascial pain syndrome in the pelvic floor: a common urological condition. Actas Urológicas Españolas (English Edition), 34(4), pp.318-326.
• Kalichman, L. and Vulfsons, S., 2010. Dry needling in the management of musculoskeletal pain. The Journal of the American Board of Family Medicine, 23(5), pp.640-646.
• Dunning, J., Butts, R., Mourad, F., Young, I., Flannagan, S. and Perreault, T., 2014. Dry needling: a literature review with implications for clinical practice guidelines. Physical therapy reviews, 19(4), pp.252-265.
• Montenegro, M.L., Braz, C.A., Rosa-e-Silva, J.C., Candido-dos-Reis, F.J., Nogueira, A.A. and Poli-Neto, O.B., 2015. Anaesthetic injection versus ischemic compression for the pain relief of abdominal wall trigger points in women with chronic pelvic pain. BMC anesthesiology, 15(1), p.175.
• Halle, J.S. and Halle, R.J., 2016. Pertinent dry needling considerations for minimizing adverse effects–part two. International journal of sports physical therapy, 11(5), p.810.

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.
• Arnouk, A., De, E., Rehfuss, A., Cappadocia, C., Dickson, S. and Lian, F., 2017. Physical, complementary, and alternative medicine in the treatment of pelvic floor disorders. Current urology reports, 18(6), p.47.
• FitzGerald, M.P., Anderson, R.U., Potts, J., Payne, C.K., Peters, K.M., Clemens, J.Q., Kotarinos, R., Fraser, L., Cosby, A., Fortman, C. and Neville, C., 2013. Randomized multicenter feasibility trial of myofascial physical therapy for the treatment of urological chronic pelvic pain syndromes. The Journal of urology, 189(1), pp.S75-S85.
• Tadros, N.N., Shah, A.B. and Shoskes, D.A., 2017. Utility of trigger point injection as an adjunct to physical therapy in men with chronic prostatitis/chronic pelvic pain syndrome. Translational andrology and urology, 6(3), p.534.
• McDowell, J.M., Kohut, S.H. and Johnson, G.M., 2015. Trigger point acupuncture (dry needling) and associated fecal incontinence in multiple sclerosis: a case report. Medical Acupuncture, 27(4), pp.283-287.
• Kim, D.S., Jeong, T.Y., Kim, Y.K., Chang, W.H., Yoon, J.G. and Lee, S.C., 2013. Usefulness of a myofascial trigger point injection for groin pain in patients with chronic prostatitis/chronic pelvic pain syndrome: a pilot study. Archives of physical medicine and rehabilitation, 94(5), pp.930-936.
• Sandalcidi, D. and Dommerholt, J., 2013. Deep dry needling of the hip, pelvis and thigh muscles. In Trigger Point Dry Needling (pp. 133-150). Churchill Livingstone.
• Lee, S.H. and Lee, B.C., 2011. Use of acupuncture as a treatment method for chronic prostatitis/chronic pelvic pain syndromes. Current urology reports, 12(4), pp.288-296.
• Bonder, J.H., Chi, M. and Rispoli, L., 2017. Myofascial pelvic pain and related disorders. Physical Medicine and Rehabilitation Clinics, 28(3), pp.501-515.
• Liu, L., Huang, Q.M., Liu, Q.G., Thitham, N., Li, L.H., Ma, Y.T. and Zhao, J.M., 2018. Evidence for dry needling in the management of myofascial trigger points associated with low back pain: a systematic review and meta-analysis. Archives of physical medicine and rehabilitation, 99(1), pp.144-152.
• Kearns, G., Gilbert, K.K., Allen, B., Sizer Jr, P.S., Brismée, J.M., Pendergrass, T., Lierly, M. and York, D., 2018. Accuracy and safety of dry needle placement in the piriformis muscle in cadavers. Journal of Manual & Manipulative Therapy, 26(2), pp.89-96.
• Sung, S.H., Sung, A.D.M., Sung, H.K., An, T.E.B., Kim, K.H. and Park, J.K., 2018. Acupuncture Treatment for Chronic Pelvic Pain in Women: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Evidence-Based Complementary and Alternative Medicine, 2018.
• Bartley, J., Han, E., Gupta, P., Gaines, N., Killinger, K.A., Boura, J.A., Farrah, M., Gilleran, J., Sirls, L.T. and Peters, K.M., 2019. Transvaginal trigger point injections improve pain scores in women with pelvic floor hypertonicity and pelvic pain conditions. Female pelvic medicine & reconstructive surgery, 25(5), pp.392-396.
• Zhang, Y. and Smith, C.P., 2018. Botulinum toxin to treat pelvic pain. Toxicon, 147, pp.129-133.
• Mansfield, C.J., Vanetten, L., Willy, R., Di Stasi, S., Magnussen, R. and Briggs, M., 2019. The Effects of Needling Therapies on Muscle Force Production: A Systematic Review and Meta-analysis. journal of orthopaedic & sports physical therapy, 49(3), pp.154-170.
• Morrissey, D., El-Khawand, D., Ginzburg, N., Wehbe, S., O’Hare III, P. and Whitmore, K., 2015. Botulinum toxin A injections into pelvic floor muscles under electromyographic guidance for women with refractory high-tone pelvic floor dysfunction: a 6-month prospective pilot study. Female pelvic medicine & reconstructive surgery, 21(5), pp.277-282.
• Koppenhaver, S.L., Walker, M.J., Rettig, C., Davis, J., Nelson, C., Su, J., Fernández-de-las-Peñas, C. and Hebert, J.J., 2017. The association between dry needling-induced twitch response and change in pain and muscle function in patients with low back pain: a quasi-experimental study. Physiotherapy, 103(2), pp.131-137.
• Téllez-García, M., de-la-Llave-Rincón, A.I., Salom-Moreno, J., Palacios-Ceña, M., Ortega-Santiago, R. and Fernández-de-las-Peñas, C., 2015. Neuroscience education in addition to trigger point dry needling for the management of patients with mechanical chronic low back pain: a preliminary clinical trial. Journal of bodywork and movement therapies, 19(3), pp.464-472.
• Brennan, K.L., Allen, B.C. and Maldonado, Y.M., 2017. Dry needling versus cortisone injection in the treatment of greater trochanteric pain syndrome: a noninferiority randomized clinical trial. journal of orthopaedic & sports physical therapy, 47(4), pp.232-239.
• Kearns, G., Fernández-De-Las-Peñas, C., Brismée, J.M., Gan, J. and Doidge, J., 2019. New perspectives on dry needling following a medical model: are we screening our patients sufficiently?. Journal of Manual & Manipulative Therapy, pp.1-8.
• Sheikhhoseini, R. and Arab, A.M., 2018. Dry needling in myofascial tracks in non-relaxing pelvic floor dysfunction: A case study. Journal of bodywork and movement therapies, 22(2), pp.337-340.
• George, A., VanEtten, L. and Briggs, M., 2018. Dry Needling for Female Chronic Pelvic Pain: A Case Series. Journal of Women’s Health Physical Therapy, 42(1), pp.8-16.
• Singh, R., Soriano, E.T. and Gordon, D.A., 2017. Chronic Pelvic Pain: Pudendal Neuralgia and Therapeutic Neural Blockade. In Pelvic Floor Dysfunction and Pelvic Surgery in the Elderly (pp. 269-277). Springer, New York, NY.
• Alappattu, M., Hilton, S. and Bishop, M., 2019. An International Survey of Commonly Used Interventions for Management of Pelvic Pain. Journal of Women’s Health Physical Therapy, 43(2), pp.82-88.
• Aredo, J.V., Heyrana, K.J., Karp, B.I., Shah, J.P. and Stratton, P., 2017, January. Relating chronic pelvic pain and endometriosis to signs of sensitization and myofascial pain and dysfunction. In Seminars in reproductive medicine (Vol. 35, No. 01, pp. 088-097). Thieme Medical Publishers.
• Rajkannan, P. and Vijayaraghavan, R., 2019. Dry needling in chronic abdominal wall pain of uncertain origin. Journal of bodywork and movement therapies, 23(1), pp.94-98.
• Filocamo, M.T., Marzi, V.L., Del Popolo, G., Cecconi, F., Marzocco, M., Tosto, A. and Nicita, G., 2005. Effectiveness of early pelvic floor rehabilitation treatment for post-prostatectomy incontinence. European urology, 48(5), pp.734-738.
• Rosenbaum, T.Y., 2007. REVIEWS: Pelvic floor involvement in male and female sexual dysfunction and the role of pelvic floor rehabilitation in treatment: a literature review. The journal of sexual medicine, 4(1), pp.4-13.
• Sapsford, R.R. and Hodges, P.W., 2001. Contraction of the pelvic floor muscles during abdominal maneuvers. Archives of physical medicine and rehabilitation, 82(8), pp.1081-1088.
• Moldwin, R.M. and Fariello, J.Y., 2013. Myofascial trigger points of the pelvic floor: associations with urological pain syndromes and treatment strategies including injection therapy. Current urology reports, 14(5), pp.409-417.
• Itza, F., Zarza, D., Serra, L., Gomez-Sancha, F., Salinas, J. and Allona-Almagro, A., 2010. Myofascial pain syndrome in the pelvic floor: a common urological condition. Actas Urológicas Españolas (English Edition), 34(4), pp.318-326.
• Doggweiler-Wiygul, R. and Wiygul, P.J., 2002. Interstitial cystitis, pelvic pain, and the relationship to myofascial pain and dysfunction: a report on four patients. World journal of urology, 20(5), pp.310-314.
• Montenegro, M.L., Gomide, L.B., Mateus-Vasconcelos, E.L., Rosa-e-Silva, J.C., Candido-dos-Reis, F.J., Nogueira, A.A. and Poli-Neto, O.B., 2009. Abdominal myofascial pain syndrome must be considered in the differential diagnosis of chronic pelvic pain. European Journal of Obstetrics & Gynecology and Reproductive Biology, 147(1), pp.21-24.
• Shin, J.H. and Howard, F.M., 2011. Management of chronic pelvic pain. Current pain and headache reports, 15(5), p.377.
• Kotarinos, R., 2012. Myofascial pelvic pain. Current pain and headache reports, 16(5), pp.433-438.
• Doggweiler-Wiygul, R., 2004. Urologic myofascial pain syndromes. Current pain and headache reports, 8(6), pp.445-451.
• Butrick, C.W., 2009. Pelvic floor hypertonic disorders: identification and management. Obstetrics and Gynecology Clinics, 36(3), pp.707-722.
• Huang, Q.M. and Liu, L., 2014. Wet needling of myofascial trigger points in abdominal muscles for treatment of primary dysmenorrhoea. Acupuncture in Medicine, 32(4), pp.346-349.
• Spitznagle, T.M. and Robinson, C.M., 2014. Myofascial pelvic pain. Obstetrics and Gynecology Clinics, 41(3), pp.409-432.
• Polackwich, A.S., Li, J. and Shoskes, D.A., 2015. Patients with pelvic floor muscle spasm have a superior response to pelvic floor physical therapy at specialized centers. The Journal of urology, 194(4), pp.1002-1006.
• Spitznagle, T.M. and Robinson, C.M., 2014. Myofascial pelvic pain. Obstetrics and Gynecology Clinics, 41(3), pp.409-432.
• George, A., VanEtten, L. and Briggs, M., 2018. Dry Needling for Female Chronic Pelvic Pain: A Case Series. Journal of Women’s Health Physical Therapy, 42(1), pp.8-16.
• Bartley, J., Han, E., Gupta, P., Gaines, N., Killinger, K.A., Boura, J.A., Farrah, M., Gilleran, J., Sirls, L.T. and Peters, K.M., 2019. Transvaginal trigger point injections improve pain scores in women with pelvic floor hypertonicity and pelvic pain conditions. Female pelvic medicine & reconstructive surgery, 25(5), pp.392-396.
• Mahmoudzadeh, A., Rezaeian, Z.S., Karimi, A. and Dommerholt, J., 2016. The effect of dry needling on the radiating pain in subjects with discogenic low-back pain: a randomized control trial. Journal of research in medical sciences: the official journal of Isfahan University of Medical Sciences, 21.
• Zeng, B.Y., Salvage, S. and Jenner, P., 2013. Effect and mechanism of acupuncture on Alzheimer’s disease. In International review of neurobiology (Vol. 111, pp. 181-195). Academic Press.
• Kang, K.S. and Kwon, K.R., 2003. Clinical Studies on 5 Cases of Multiple Sclerosis by Acupuncture Therapies. Journal of Acupuncture Research, 20(1), pp.209-217.
• Huang, W., Pach, D., Napadow, V., Park, K., Long, X., Neumann, J., Maeda, Y., Nierhaus, T., Liang, F. and Witt, C.M., 2012. Characterizing acupuncture stimuli using brain imaging with FMRI-a systematic review and meta-analysis of the literature. PLoS One, 7(4), p.e32960.