Sympathetic autonomic nervous system (ANS) hyperactivity, fight-or-flight response, is only potentially beneficial for human wellbeing in short durations. A few minutes to a few days, at most. After that, chronic sympathetic autonomic hyperactivity becomes detrimental to all aspects of health. The natural response of the human mind and body to mental or physical stress, strain, pain, or trauma is to elevate sympathetic activity. Therefore, almost all physical therapy patients present with chronic sympathetic hyperactivity. Almost all psychotherapy patients present this way as well. Most of humanity presents this way, for that matter. This is a massive problem which goes almost completely unaddressed. To counter this, it is necessary to remove as many sympathetic stressors from the joints and tissues throughout the body as possible, while concomitantly targeting the parasympathetic autonomic nervous system (PANS) to inhibit sympathetic activity and nudge the autonomic nervous system toward homeostasis, the key to health. A primary factor limiting the amount of treatment an individual can tolerate is how much sympathetic autonomic stimulation you induce while inserting needles.

Each time you get poked with a sharp object, the sympathetics are stimulated. The more pokes, the more sympathetic stimulation. The more sympathetic stimulation, the more likely you are to push your patient vasovagal. Needle-induced vasovagal response is secondary to sympathetics elevating too much too fast for the individual’s threshold, leading to a rapid increase in blood pressure. This stimulates the baroreceptors in the carotids and ignites the opposing part of the autonomic nervous system, the parasympathetic autonomic nervous system (PANS). The parasympathetic autonomic nervous system overreacts and cranks all the way up to rapidly depress the sympathetics. This rapidly drops blood pressure. This is an uncomfortable experience for patients, especially if the body overreacts to the point of induced fainting. I have never had a patient lose consciousness on me in almost a decade of needling.

What is Pistoning?

The pistoning technique involves a sowing-machine, or jack-hammer-like motion of the needle going in and out of tissue. The needle is not fully removed from tissue following initial insertion, but is poked in and out of the tissue at varying angles, with the goal of puncturing numerous locations of trigger points (hypercontracted groups of sarcomeres), or other pathologic tissue. Once the poking is done, the needle is removed. Get your mind out of the gutter people!… This is how the majority of practitioners dry needle in the United States. This approach to needling completely disregards the neurophysiologic state of our patient’s mind and body. Sympathetic autonomic nervous system hyperactivity.

For this discussion, let’s define pistoning as 10 advances of a 0.2 mm diameter needle into an area of tissue in a cone shape, without rotating the needle. Following the 10 advances, the needle is removed. This is common practice. In the image below, think of the red line as the skin, the black line is the needle, and the blue cone as the tissue the needle is inserted into. Advancing a 0.2 mm diameter needle 10 times allows you to treat a circle of tissue with a 2 mm diameter (0.2 mm x 10 = 2 mm). A circle with a 2 mm diameter has an area of 3.14 square mm. So, the bottom of the cone is about 3.14 square mm.

Should I Piston?

The short answer? No, you should not, in general. Now, there are instances when pistoning is useful. However, it should only be utilized in specific circumstances, with specific patients. There are numerous reasons for this. You should never piston over the lung field, bladder, or anything else you do not want to hit. In reality, you can likely hit just about anything in the body 1 time with a solid, 0.2 mm thick needle and never cause any noticeable damage. Remember, normal needles, hollow needles are typically somewhere between 1-2 mm. Hitting something more than once in a small area is when you run an increased risk of significant damage. Not pistoning removes a huge amount of risk from the treatment as far as vasovagal response and organ damage goes.

Remember, MD’s take chunks out of organs to biopsy them in the lab. The intestines and heart can be sutured, the lungs and bladder can be drained. All this is done with needles or cutting instruments exponentially larger than the tiny, solid, 0.2 mm thick needles we utilize. Aside from increasing safety and efficacy, not pistoning is exponentially more comfortable for the patient. This is important.

Pistoning, in general, makes negative neurophysiologic sense. One goal of dry needling should be to remove as much pathologic tissue throughout body as possible with the express intent of depressing sympathetics, elevating parasympathetics, and bringing the autonomic nervous system toward homeostasis. This involves treating the body as an intricately interconnected complex system, which it is.

If a pistoner inserts a single needle 10 times into the same small area of tissue, you are stimulating the sympathetics 10 times. If you use 2 needles, that is 20 times the sympathetics are stimulated in the process of treating an overall area of 6.28 square mm of tissue.

Now, take a peek at the ultrasound image below from Helen Langevin, a world renown researcher on the effects of acupuncture on soft tissue. The black dot in the left picture is a needle placed in tissue without rotating the needle. I look at this as the needle treating only the tiny bit of tissue it is through, the black dot. The picture on the right is after the needle has been rotated until it won’t turn anymore. In this picture, the entire square and more is being treated. I copied the scale bar and imposed it over the right picture in the blue lines. Each of the blue lines is 1 mm. There are 7 lines there. So, the area of each square image is about 49 square mm.

By inserting 2 needles one time each and rotating them until tight (49 mm x 2), you treat about 98 square mm of tissue with 2 needle advances, or two stimuli to the sympathetics. Compare this to pistoning, where with 20 needle advances and no needle rotation, 20 stimuli to the sympathetics, you are treating only 6.28 square mm of tissue. So, with pistoning, you are eliciting 10 times the sympathetic autonomic stimulation and treating 16 times less tissue area. Which one seems better to you?

Furthermore, if you advance each needle once and twist it, rather than 10 times each without twisting, you can use 20 needles, treat 980 square mm of tissue, and stimulate the sympathetics the same amount as if you pistoned with only 2 needles, covering only 6.28 square mm of tissue.

Pistoning Technique

2 needles x 10 needle advances per needle = 20 sympathetic stimuli covering 6.28 square mm of tissue.

Intricate Art single Advancement Technique

20 needles x 1 needle advance per needle = 20 sympathetic stimuli covering 20 x 49 square mm = 980 square mm of tissue.

980 square mm divided by 6.28 square mm = 156. That means with 1 advancement into tissue plus rotation per needle you can treat 156 times the area of tissue with the same amount of sympathetic stimulation as you can compared to using pistoning. Or, you can treat the same amount of tissue area with our technique as with pistoning, and stimulate the sympathetics 16 times less.

If the goal is to treat as much pathologic tissue with as little sympathetic stimulation as possible, with the end-goal is sympathetic depression, which option seems more logical? The very last thing patients need is more sympathetic autonomic hyperactivity. They are already suffering specifically because they are living with chronic sympathetic hyperactivity.

The only time I will utilize pistoning is if I get a twitch out of the muscle and I want to see if I can elicit more twitches. When you hit a knot with a needle, a lot of the time you elicit a twitch, or muscle contraction. This is secondary to a bunch of sarcomeres unlocking from each other. This can really hurt, which is not a negative thing, but it will scare a lot of people away from future needling treatment. However, you never want to piston the first few treatments when introducing a patient to needling, and you should never do pistoning if the patients is hypersensitive or prone to vasovagal response, as this significantly amplifies pain and sympathetic stimulation. Again, our patients live with chronic sympathetic hyperactivity. Everything in our power should be done to depress sympathetics and elevate parasympathetics, not the other way around.

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

Jason

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References

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