See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/315059512

Effectiveness of Different Deep Dry Needling Dosages in the Treatment of

Patients With Cervical Myofascial Pain: A Pilot RCT

Article  in  American Journal of Physical Medicine & Rehabilitation · March 2017

DOI: 10.1097/PHM.0000000000000733

CITATIONS READS

10 503

7 authors, including:

Josué Fernández-Carnero Jose VICENTE Leon Hernandez

King Juan Carlos University Universidad Autónoma de Madrid
93 PUBLICATIONS   1,806 CITATIONS    7 PUBLICATIONS   22 CITATIONS   

SEE PROFILE SEE PROFILE

Daniel Pecos-Martin Isabel Alguacil

University of Alcalá King Juan Carlos University
48 PUBLICATIONS   407 CITATIONS    66 PUBLICATIONS   686 CITATIONS   

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Adaptation and transcultural translation of the Rotator Cuff Quality of Life questionnaire into Spanish View project

musculoskeletal pain View project

All content following this page was uploaded by Jose VICENTE Leon Hernandez on 30 September 2017.

The user has requested enhancement of the downloaded file.

 ORIGINAL RESEARCH ARTICLE

Effectiveness of Different Deep Dry Needling Dosages in the

Treatment of Patients With Cervical Myofascial Pain
A Pilot RCT
Josué Fernández-Carnero, PT, PhD, MSc, Laura Gilarranz-de-Frutos, PT, PhD, MSc,
Jose Vicente León-Hernández, PT, PhD, MSc, Daniel Pecos-Martin, PT, PhD, MSc, Isabel Alguacil-Diego, MD, PhD,
Tomás Gallego-Izquierdo, PT, PhD, MSc, and Aitor Martín-Pintado-Zugasti, PT, PhD, MSc

Objective: To assess the effectiveness of different dosages of local twitch responses (LTRs) elicited by deep dry needling (DDN) in relation to pain
intensity, pressure pain threshold (PPT), cervical range of movement (CROM), and disability degree in cervical myofascial pain patients.
Design: A randomized, double-blind clinical trial.
Participants: Eighty-four patients (21 males, 63 females; 27.18 ± 10.91 yrs) with cervical pain.
Interventions: DDN in active myofascial trigger points (MTrPs) in the upper trapezius. Patients were randomly divided into four groups: (a) no
LTRs elicited, (b) four LTRs elicited, (c) six LTRs elicited, and (d) needling until no more LTRs were elicited.
Outcome Measures: Pain intensity, PPT, CROM, and disability degree were assessed before treatment, post-immediate, 48 hrs, 72 hrs, and 1 wk
after treatment.
Results: Significant differences were found in the time factor for all the variables (P < 0.005), but no significant changes were found in the group-
time interaction (P > 0.05).
Conclusions: DDN in the upper trapezius MTrP improved pain at a 1-wk follow-up, but improvements were not significantly different among
DDN dosages. A higher number of patients with neck pain improvements superior to the moderate clinically important differences were ob-
served when eliciting 6 LTRs and LTRs until exhaustion compared with not eliciting LTRs.
Key Words: Myofascial Pain Syndromes, Neck Pain, Needles, Pain Threshold, Rehabilitation, Trigger Points
(Am J Phys Med Rehabil 2017;00:00–00)

eck pain is one of the most common musculoskeletal
N disorders among individuals in developed societies,
affecting up to 71% of the adults in middle age and during
1
the most productive years of their lives.1 Although the exact
etiology of neck pain is not clearly understood, facet joints,
discs, and myofascial tissues have been proposed to be related
to the symptoms in patients with neck pain.2,3
A myofascial trigger point (MTrP) is defined as a spot
in a palpable taut band of a skeletal muscle that is painfully
hypersensitive to pressure and causes referred pain when is
stimulated. Clinically, MTrPs can be classified as active
MTrPs when they also produce spontaneous pain without
being stimulated or as latent MTrPs, which produce local
or referred pain only when stimulated.4
It has been reported that MTrPs from the neck and shoulder
muscles might play an important role in the genesis of
myofascial neck pain.3 Fernández-de-las-Penas et al.5 showed
that active MTrPs were more common in patients with mechan-
ical neck pain than in healthy controls. The upper trapezius mus-
cle was one of the most commonly affected muscles, with the
presence of MTrPs in 70% of the patients with neck pain.5
Deep dry needling (DDN) has been used as a treatment
option for MTrPs.6 One of the most commonly applied DDN
techniques is fast-in, fast-out technique by Hong,7 in which
the needle is rapidly inserted and withdrawn in and out of the
MTrP to obtain local twitch responses (LTRs), which are asso-
ciated with a higher effectiveness of treatment.7 In a recent sys-
tematic review and meta-analysis, dry needling has been
recommended for relieving MTrP pain, showing that it is supe-
rior to placebo in the short and medium term.8 Another system-
atic review recommended DDN for upper quadrant myofascial
pain with immediate pain reductions after treatment and at

From the Department of Physical Therapy, Occupational Therapy, Rehabilitation
and Physical Medicine, Rey Juan Carlos University, Madrid, Spain (JF-C,
LG-d-F, IA-D); Research Group on Movement and Behavioural Science
and Study of Pain, The Center for Advanced Studies University La Salle,
Autónoma University, Madrid, Spain (JF-C, JVL-H); La Paz Hospital Institute
for Health Research, IdiPAZ, Madrid, Spain (JF-C); Grupo Multidisciplinar de
Investigación y Tratamiento del Dolor, Grupo de Excelencia Investigadora
URJC-Banco de Santander, Madrid, Spain (JF-C); Department of Physiother-
apy, Faculty of Health Science, The Center for Advanced Studies University
La Salle, Autónoma University, Madrid, Spain (JVL-H); Department of Nurse
and Physical Therapy of Alcalá University, Alcalá de Henares, Spain (DP-M,
TG-I); Physiotherapy and Pain Group, Alcalá de Henares, Spain (DP-M,
TG-I); and Department of Physical Therapy, Faculty of Medicine, CEU-San
Pablo University, Madrid, Spain (AM-P-Z).
All correspondence and requests for reprints should be addressed to: Josué Fernández-
Carnero, PT, PhD, MSc, Department of Physical Therapy, Occupational Therapy,
Rehabilitation and Physical Medicine, Rey Juan Carlos University, Avda. Atenas s/n.
28922 Alcorcón, Madrid, Spain.
Clinical trial registration number: United States Clinical Trials Registry
number NCT02190890.
Financial disclosure statements have been obtained, and no conflicts of interest have been
reported by the authors or by any individuals in control of the content of this article.
Supplemental digital content is available for this article. Direct URL citations appear
in the printed text and are provided in the HTML and PDF versions of this article
on the journal’s Web site (www.ajpmr.com).
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0894-9115
DOI: 10.1097/PHM.0000000000000733

American Journal of Physical Medicine & Rehabilitation • Volume 00, Number 00, Month 2017 www.ajpmr.com 1

Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Fernández-Carnero et al.
4 wks.9 Deep dry needling is thought to damage or destroy the
dysfunctional motor endplates of the MTrP, as well as re-
lease the activation of opioids and activate inhibitory interneu-
rons and descending pathways.10
Moreover, DDN in the upper trapezius muscle has recently
shown to be effective in the treatment of neck pain and tender-
ness,11,12 improving the cervical range of motion (CROM)11
and the level of disability.12
Nevertheless, there is a lack of evidence about the ideal
dosage, in terms of the number of LTRs elicited, when per-
forming DDN procedures. Many different protocols have been
investigated, including not eliciting LTRs,13,14 eliciting one
LTR or five LTRs,15 or eliciting one LTR and continuing nee-
dling at 1 Hz for 25 to 30 secs11 or until no further LTRs are
obtained.7 Beyond the known beneficial effects of DDN, dif-
ferent DDN LTR dosages may influence the effectiveness of
the therapy.
To the authors' knowledge, there are no published studies
evaluating the effectiveness of different dry needling LTR
dosages in the treatment of myofascial pain. Previous research
has shown that little or no effect is obtained when there is an
absence of LTRs during DDN.7
The objective of the present study is to compare the effec-
tiveness of different dosages of MTrP DDN, in terms of the
number of LTRs elicited, on improving neck pain intensity,
MTrPs sensitivity, CROM, and neck disability in patients with
cervical myofascial pain.
METHODS
This research was conducted as a randomized, double-
blind clinical trial. There were 84 participants (21 males,
63 females) aged 18 to 53 yrs. The sample was recruited from
the university and local community through advertisements
posted at the university. Patients were included if they pre-
sented the following: (1) cervical musculoskeletal pain for
more than 1 month and current neck pain intensity of three
points or higher in the visual analogue scale (VAS) and (2) pres-
ence of an active MTrP based on the following criteria16: (a) a
hypersensitive spot in a taut band, (b) local pain to pressure, (c)
reproduction of referred pain recognized as a familiar symp-
tom, and (d) a painful limit induced by the full-stretch range
of motion. These criteria had good interexaminer reliability
in the diagnosis of MTrPs in the upper trapezius muscle.17
Participants were excluded if they presented any of the fol-
lowing criteria: (1) previous diagnosis associated with neck pain
not from myofascial MTrPs (e.g., arthritis, spondylolisthesis),
(2) radicular pain diagnosis based on the positive findings of
the clinical prediction rule of at least three of four items present
in the Wainner et al18 criteria, (3) whiplash according to the
Quebec Task Force criteria,19 (4) previous cervical surgical
intervention, (5) previous treatment of DDN, (6) fibromyalgia,
(7) thyroid disorders, and (8) dizziness and vertigo.
This study was conducted by five practitioners, including
two assessors and three therapists. Before starting the outcome
assessment or interventions, assessor 1 made the telephone
calls, verbally discussed inclusion and exclusion criteria with
enquirers, made appointments, generated a randomization
schedule, and prepared files.
The ethical committee of Rey Juan Carlos University
approved this research with the identification number 16/2013.
2 www.ajpmr.com
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Volume 00, Number 00, Month 2017
All patients signed a written informed consent before the start
of the study. This trial was conducted in accordance with the
CONSORT statement and was registered at the United States
Clinical Trials Registry under the identifier NCT02190890.
This study conforms to all CONSORT guidelines and reports
the required information accordingly (see Supplementary
Checklist, http://links.lww.com/PHM/A408).
Interventions
The participants blinded to the group allocation were
randomly divided into the following four groups by a block
randomization method using a Web-based random number
generator (GraphPad software): no LTR group (single DDN in-
sertion in the taut band, 1.5 cm lateral to the active MTrP, with-
out obtaining LTRs), four LTRs group (DDN until obtaining
four LTRs), six LTRs group (DDN until obtaining six LTRs),
and more than six LTRs group (DDN until no more LTRs were
elicited). It was considered that no more LTRs were elicited
when the needle was inserted 10 times in different directions
without eliciting any LTR.
Sealed opaque envelopes were prepared containing the
assigned treatment and numbered consecutively. The therapists
counted the number of LTRs elicited during dry needling based
on visual or tactile perception of the LTRs to elicit the exact
number of LTRs for each group, except for the group of nee-
dling until no more LTRs were elicited, in which the exact
number of LTRs was not recorded. Previous research has
shown that the LTRs elicited during MTrP needling procedures
in the upper trapezius muscle were always visually detected on
the basis of the confirmation of ultrasonography.20
One session of DDN in the previously diagnosed upper
trapezius active MTrPs was applied by one of the three thera-
pists. Solid filament needles (0.32  40 mm) (Suzhou Huanqiu
Acupuncture Medical Appliance Co, Ltd, Suzhou, China) were
used for the DDN procedure. The therapist first cleaned the
area with alcohol. Then, DDN was applied on the basis of the
technique described by Hong,7 in which several insertions of
the needle were performed to elicit LTRs, except for the no
LTR group, in which the needle was removed after a single in-
sertion. Upon removal of the needle, the area was compressed
firmly with a cotton swab for 90 secs. This procedure, includ-
ing dry needling application in each group, was initially trained
and consensually designed by the three therapists. During the
treatment and follow-up periods, the participants were advised
not to use medication or undergo other manual therapies so
that the effect of the DDN therapy could be observed.
Outcome Measures
Outcomes (pain intensity, pressure pain threshold [PPT],
CROM, and neck disability) were recorded by the second as-
sessor before treatment, immediately after treatment, 48 hrs,
72 hrs, and 1 wk after treatment. Disability was recorded only
before treatment and 1 wk after treatment. The assessor was
blinded to the experimental conditions and took the measure-
ments of all variables (pain intensity, PPT, CROM, and disabil-
ity degree). In addition, the participants were specifically told
not to discuss their interventions with the outcome assessor.
Moreover, the three therapists were blinded to all assessment
outcomes until the end of the entire data collection.
© 2017 Wolters Kluwer Health, Inc. All rights reserved.
Volume 00, Number 00, Month 2017
Pain intensity was measured using a VAS. It consisted of a
line of 10 cm, ranging from 0 (no pain) to 10 (worst imaginable
pain), in which the patient was asked to mark the line at the point
corresponding to their pain level. This has been demonstrated to
be a reliable and valid instrument for neck pain measurement.21
The Initiative on Methods, Measurement, and Pain Assess-
ment in Clinical Trials has proposed consensus recommenda-
tions for determining clinically important changes for outcome
measures for chronic pain trials. A decrease of two points more
than 10 or a 30% reduction in pain intensity on numerical or
VASs is considered moderately clinically meaningful differences
(MCID). It has been recommended to report the percentages of
patients responding with this degree of MCID pain relief in clin-
ical trials of chronic pain treatments because the MCID has more
meaning to patients in terms of being associated with not request-
ing medication or ratings of “much” or “some” improvement.22
Pressure pain threshold is defined as the minimum amount
of pressure needed for the sense of pressure to first change to
pain. It was specifically measured on the active MTrP by using
a digital algometer. (Model FDX 10; Wagner Instruments,
Greenwich, CT). An average of three measurements was calcu-
lated. It showed a high level of reliability23: high intraexaminer
reliability (intraclass correlation coefficient [ICC] = 0.94–0.97)
in the upper trapezius and good interexaminer reliability
(ICC = 0.82–0.97) for cervical pain. The minimal detectable
change described for the trapezius muscle was 0.45 kg/cm.23
Active CROM was assessed using a CROM device
(GraphPad Software, Inc., La Jolla, CA). The CROM device
presented a good intraexaminer and interexaminer reliability
(ICC > 0.80)24 and has been validated for CROM measure-
ments.24 Patients were seated with their back against a chair
and were asked to perform analytical cervical movements in
flexion, extension, lateral flexion, and rotation. Patients were
instructed to stop at the point where pain symptoms began or,
otherwise, to continue the cervical movements to the fullest ex-
tent of their mobility. The average of three measurements was
calculated. It has been reported that minimum detectable
changes range between 3.6 degrees and 6.5 degrees for the six
cervical movements when measured with the CROM device.24
Disability degree was measured using the validated Spanish
version of the Neck Disability Index (NDI).25 This is a reliable
and valid tool for the self-assessment of cervical pain and disabil-
ity.26 Neck Disability Index presents an acceptable level of reli-
ability (ICC = 0.50–0.98). It has been proposed that the
clinically important difference required for NDI is seven points.27
Patients were asked to report the presence of postneedling
soreness at any of the follow-up moments.
Statistical Analysis
Data were analyzed using the Statistical Package for Social
Sciences software, Version 20.0 (SPSS, Inc., Chicago, IL).
Mean, standard deviation (SD), and 95% confidence interval
were calculated for each variable. The Kolmogorov Smirnov
test did not detect significant departures from normality
(P > 0.05). A one-way analysis of variance (ANOVA) was used
to compare baseline continuous data, and χ2 tests were used to
test for independence of baseline categorical data. The VAS,
PPT, and CROM scores were submitted to a 4  5 repeated-
measure ANOVA with time (preintervention, immediately after
© 2017 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Different Dry Needling Dosages Myofascial Pain
the treatment, 48 hrs, 72 hrs, and 1 wk after needling) as the
within-subjects factor and group (no LTR, 4 LTRs, 6 LTRs,
>6 LTRs) as the between-subjects factor. The proportion of
subjects that reached an improvement superior to the MCID
of the VAS (2 points) was calculated for each group and com-
pared between groups by using χ2 test. Finally, NDI scores were
submitted to a 4  2 repeated-measure ANOVA with time
(preintervention and 1 wk after) as the within-subjects factor
and group (no LTR, 4 LTRs, 6 LTRs, >6 LTRs) as the
between-subjects factor. Bonferroni correction was applied to
the group and time comparisons for all variables. For all analy-
ses, the statistical significance was set at P < 0.05.
A pilot study was conducted to determine the effect size
between the four groups in neck pain intensity. This pilot study
was constituted by 12 patients for each group (no LTR group vs
4 LTRs group vs 6 LTRs group vs +6 LTRs group), and an
effect-size partial η2 value of 0.045 was obtained.
The sample size calculations were performed using the
G*Power software28 (Version 3.1) (G*Power; Franz Faul, De-
partment of Psychology, Kiel, Germany). Visual analogue
scale was chosen as the primary outcome measure. The effect
size of VAS was estimated (0.217). Considering a power of
0.95, an α level of 0.05, correlations among repetitive mea-
sures of 0.5, and nonsphericity correction of 1.0, a total sample
of 68 patients was required. Allowing for a 20% dropout rate, it
was necessary to recruit at least 84 patients.
RESULTS
One hundred sixty patients with cervical myofascial pain
were screened for possible eligibility criteria. Eighty-four pa-
tients (21 males, 63 females) were included in the study and
successfully completed the study protocol, with none of the pa-
tients lost to follow-up. Twenty-one subjects completed the
study in the no LTR group (4 males, 17 females; mean [SD]
age, 28.19[11.04] yrs), 21 in the four LTRs group (7 males,
14 females; mean [SD] age, 29.67[11.88] yrs), 21 in the six
LTRs group (5 males, 16 females; mean [SD] age, 24.25
[9.43] yrs), and 21 in the group of more than six LTRs
(5 males, 16 females; mean [SD] age, 26.45[10.72] yrs). In
all of the patients, the required number of LTRs for each group
could be elicited. Figure 1 shows the process of recruitment
and dropouts. A total of 91.4% of the patients reported
postneedling soreness immediately after the treatment. No
other adverse effects were reported. None of the patients used
any medication or underwent any other therapy for the treat-
ment of neck pain during the follow-up period.
The number of needle insertions during the dry needling
treatment in each group (mean [SD]) was the following:
18.35(15.88) in the four LTRs group; 23.64(18.66) in the six
LTRs group; and 50.40(41.99) in the +six LTRs group.
There were no significant differences between groups in
terms of demographic or clinical characteristics at the time of
the baseline screening (P > 0.05), except in the weight variable
(P < 0.05). Demographic and preintervention data are shown
in Table 1.
Pain Intensity
The 4  5 mixed-model ANOVA showed statistically sig-
nificant differences in the time factor (F = 41.264; P < 0.0001;
www.ajpmr.com 3
Fernández-Carnero et al. Volume 00, Number 00, Month 2017

FIGURE 1. Consolidated standards of reporting trials flow chart for the study.

2
p = 0.34). However, it did not show a significant change in the
group-time interaction (F = 1.365; P = 0.181; p2 = 0.049). No
other comparison between groups reached significance
(P > 0.05). χ2 test showed that the proportion of subjects with
a pain improvement that reached the MCID in the group of
needling of six LTRs and until no more LTRs were elicited
was significantly superior compared with the no LTR group
(P = 0.012). No other comparison between groups was signif-
icant (P > 0.05). The VAS scores obtained during all follow-up
moments are summarized in Table 2.

TABLE 1. Demographic and clinical data: comparisons between groups in baseline scores

Parameter No LTR Group (n = 21) 4 LTRs Group (n = 21) 6 LTRs Group (n = 21) +6 LTRs Group (n = 21) P
Sex, male/female, n/N (%) 4/17 (81.0) 7/14 (66.7) 5/16 (76.2) 5/16 (76.2) 0.75
Age, yr 28.19 (11.40) 29.67 (11.88) 24.25 (9.43) 26.45 (10.72) 0.43
Height, cm 1.64 (0.07) 1.70 (0.08) 1.67 (0.07) 1.66 (0.09) 0.22
Weight, kg 63.15 (12.95) 70.71 (15.67) 59.22 (9.34) 69.15 (17.11) 0.03
NDI, points 11.62 (5.94) 12.76 (7.09) 12.14 (4.94) 11.05 (5.01) 0.80
Pain duration, mo 8.43 (15.42) 9.76 (17.00) 16.86 (38.50) 19.19 (22.15) 0.42
Pain intensity, VAS 4.81 (1.86) 5.00 (1.89) 4.76 (1.72) 4.81 (1.91) 0.97
PPT 1.85 (0.92) 1.80 (0.95) 1.80 (0.61) 2.09 (1.02) 0.68
Flexion 47.87 (12.11) 48.66 (11.62) 51.44 (7.85) 48.41 (10.66) 0.70
Extension 59.52 (16.60) 58.15 (18.83) 59.25 (13.96) 58.47 (13.18) 0.99
Homolateral rotation 57.65 (8.97) 56.84 (13.06) 60.26 ( 5.21) 57.77 (8.23) 0.66
Contralateral rotation 61.87 (10.24) 60.04 (10.54) 65.31 (8.00) 62.44 (9.43) 0.36
Homolateral-lateral flexion 40.03 (9.13) 36.71 (8.18) 39.61 (5.38) 40.03 (8.31) 0.46
Contralateral-lateral flexion 37.55 (10.22) 35.52 (7.93) 38.93 (4.94) 40.03 (8.31) 0.37
Data are presented as mean(SD), unless otherwise indicated.

4 www.ajpmr.com © 2017 Wolters Kluwer Health, Inc. All rights reserved.

Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Volume 00, Number 00, Month 2017 Different Dry Needling Dosages Myofascial Pain

TABLE 2. Visual analogue scale scores over time

No. Patients
VAS VAS Who Achieved
Group Preintervention Postintervention VAS After 48 hrs VAS After 72 hrs VAS After 1 wk MCIDs (%)
a a
No LTR 4.81 (1.86, 4.00–5.61) 4.33 (1.98, 3.39–5.27) 3.71 (2.21, 2.81–4.61) 3.33 (2.45, 2.48–4.18) 3.52 (2.35, 2.57–4.46)a 6 (28)
4 LTRsb 5.00 (1.89, 4.19–5.80) 4.81 (2.06, 3.86–5.75) 3.57 (1.98, 2.67–4.46)a 3.76 (1.70, 2.91–4.61)a 3.05 (1.98, 2.10–3.99)a 13 (61.9)
6 LTRsb 4.76 (1.72, 3.95–5.56) 4.71 (2.14, 3.77–5.65) 2.86 (1.82, 1.96–3.75)a 2.43 (1.69, 1.57–3.27)ab 2.67 (2.30, 1.72–3.61)ab 14 (66.7)c
+6 LTRsb 4.81 (1.82, 4.00–5.61) 4.52 (2.46, 3.58–5.46) 2.81 (2.20, 1.91–3.70)ab 2.48 (1.88, 1.62–3.32)ab 2.24 (2.02, 1.29–3.18)ab 14 (66.7)c
Data are presented as mean(SD, 95% CI), unless otherwise indicated.
a
Significant differences from baseline (P < 0.01).
b
Moderate clinically important improvements (>2.0).
c
Significant differences compared to no LTR group.

Pressure Pain Threshold course of 1 wk, with no significant differences between

The 4  5 mixed-model ANOVA showed statistically sig-
nificant differences in the time factor (F = 11.089; P < 0.0001;
2
p = 0.122), but it did not show a significant change in the
group-time interaction (F = 1.610; P = 0.087; p2 = 0.057).
The PPT scores obtained during all follow-up moments are
summarized in Table 3.
Cervical Range of Movement
The ANOVA showed statistically significant differences
in the time factor in extension (F = 8.872; P = 0.0001;
2 ments did not reach the MCID and 42% of the patients had im-
p = 0.100), homolateral lateroflexion (F = 2.875; P = 0.02;
2 provements superior to the MCID (Table 2).
p = 0.035) and homolateral rotation (F = 4.354; P = 0.01;
2 In contrast with previous studies,9 in the present study,
p = 0.052). Cervical flexion, contralateral lateroflexion, and
rotation did not show statistically significant differences in
the time factor (P > 0.05). No group-time interactions were
identified for the rest of movements (P > 0.05). The CROM
scores obtained during all follow-up moments are summarized
in Table 4.
Neck Disability
The 4  2 mixed-model ANOVA showed statistically sig-
nificant differences in the time factor (F = 87.455; P < 0.0001;
2
p = 0.522). However, it did not show a significant change in
the group-time interaction (F = 1.183; P = 0.322; p2 = 0.042).
The NDI scores obtained during all follow-up moments are
summarized in Table 5.
DISCUSSION
Deep dry needling in the upper trapezius active MTrP has
shown to be effective in reducing cervical pain. A significant
level of pain reduction was obtained in all groups during the
groups. Nevertheless, it seems that needling until no more
LTRs were elicited was associated with clinically relevant pain
improvements significantly superior to the no LTR group,
because the proportion of patients who reached the MCID in
the group of needling until no more LTRs were elicited was
higher compared with the no LTR group. In addition, only
the six LTRs and the +six LTRs groups exceeded two-point
mean improvements at any of the follow-up moments and pain
improvements superior to the MCID in more than 50% of the
patients, whereas in the no LTR group, the mean improve-
DDN did not have an immediate effect on reducing myofascial
pain, but the effectiveness was found from 48 hrs to 1 wk after-
ward. It may be hypothesized that perception of postneedling
soreness, which is known to be higher immediately after nee-
dling,29 could have influenced the immediate ratings of
myofascial neck pain.
Based on the results of the present study, all groups,
including the no LTR group, exhibited improvements in neck
pain intensity. These results are in contrast with the study by
Hong study,7 in which patients who received dry needling
without LTR elicitation showed little or no effect in neck pain.
In the study by Hong study,7 patients received a different no
LTR DDN protocol in which the needle was withdrawn when
no LTRs were elicited after 10 to 20 needle insertions, so
DDN was performed with multiple insertions in MTrPs that
did not respond with LTRs when receiving DDN. In addition,
the DDN performed by Hong7 was applied using an empty sy-
ringe with a beveled needle and a spray and stretch technique
after DDN. In contrast, in the present study, the patients

TABLE 3. Pressure pain threshold scores over time

Group PPT Preintervention PPT Postintervention PPT After 48 hrs PPT After 72 hrs PPT After 1 wk
NO LTR 1.85 (0.92, 1.46–2.24) 1.66 (0.91, 1.24–2.08) 1.65 (.68, 1.25–2.06) 1.67 (0.87, 1.18–2.16) 1.85 (.87, 1.38–2.13)
4 LTRs 1.80 (.95, 1.42–2.19) 1.54 (0.94, 1.12–1.95) 1.73 (1.02, 1.32–2.13) 1.78 (1.13, 1.17–2.13) 1.87 (1.11, 1.41–2.34)
6 LTRs 1.80 (.61, 1.42–2.19) 1.59 (.64, 1.17–2.01) 1.76 (.70, 1.35–2.17) 1.86 (.75, 1.37–2.35) 1.91 (.74, 1.44–2.37)a
+6 LTRs 2.09 (1.02, 1.71–2.48) 1.88 (1.23, 1.46–2.30) 2.26 (1.22, 1.85–2.67)a 2.41 (1.56, 1.92–2.90)a 2.39 (1.40, 1.93–2.85)a
Data are presented as mean(SD, 95% CI).
a
Significant differences from postintervention (P < 0.05).

© 2017 Wolters Kluwer Health, Inc. All rights reserved. www.ajpmr.com 5

Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
 6
www.ajpmr.com
Fernández-Carnero et al.

TABLE 4. Cervical range of movement over time, expressed in degrees

Movement Direction Group Preneedling Postintervention After 48 hrs After 72 hrs After 1 wk
Flexion No LTR 47.87 (12.11, 43.2–52.5) 48.42 (10.69, 43.6–53.1) 46.95 (11.08, 42.2–51.6) 47.16 (9.09, 42.9–51.3) 49.20 (10.81, 44.6–53.7)
4 LTR 48.66 (11.62, 44.0–53.3) 46.46 (11.59, 41.7–51.2) 47.11 (11.63, 42.4–51.8) 49.06 (10.44, 44.8–53.2) 47.61 (11.49, 43.0–52.1)
6 LTR 51.44 (7.85, 46.8–56.0) 51.01 (8.99, 46.2–55.7) 51.76 (9.00, 47.0–56.4) 54.92 (7.82, 50.7–59.1) 52.65 (8.09, 48.1–57.1)
+6 LTR 48.41 (10.66, 43.7–53.0) 48.33 (12.17, 43.5–53.0) 49.30 (11.35, 44.6–54.0) 49.76 (11.02, 45.5–53.9) 50.79 (11.03, 46.2–55.3)
Extensionc No LTR 59.52 (16.60, 52.6–66.3) 59.55 (14.11, 53.3–65.7) 58.66 (15.10, 52.6–64.6) 60.22 (13.97, 54.1–66.2) 60.06 (14.97, 53.9–66.1)
4 LTR 58.15 (18.83, 51.2–65.0) 55.61 (16.29, 49.4–61.8) 57.09 (14.03, 51.1–63.0) 58.03 (13.93, 51.9–64.0) 62.85 (14.79, 56.7–68.9)b
6 LTR 59.25 (13.96, 52.3–66.1) 58.34 (12.90, 52.1–64.5) 59.65 (13.38, 53.6–65.6) 62.82 (13.07, 56.7–68.8) 64.12 (12.71, 58.0–70.2)b
+6 LTR 58.47 (13.18, 51.6–65.3) 56.38 (13.49, 50.1–62.5) 56.61 (12.46, 50.6–62.6) 58.73 (14.69, 52.6–64.7) 61.03 (13.55, 54.9–67.1)b
Homolateral lateroflexionc No LTR 40.03 (9.13, 36.6–43.4) 41.84 (8.83, 38.5–45.1) 41.33 (8.55, 38.2–44.3) 40.08 (9.43, 37.1–43.0) 40.04 (9.43, 36.7–43.3)
4 LTR 36.71 (8.18, 33.2–40.1) 37.22 (6.23, 33.9–40.4) 37.22 (6.11, 34.1–40.2) 39.30 (5.21, 36.3–42.2) 39.85 (6.74, 36.5–43.1)
6 LTR 39.61 (5.38, 36.1–43.0) 40.14 (6.51, 36.8–43.4) 40.22 (5.65, 37.1–43.2) 41.79 (4.56, 38.8–44.7) 42.30 (5.81, 39.0–45.5)
+6 LTR 40.03 (8.31, 36.6–43.4) 40.66 (8.16, 37.4–43.9) 41.30 (7.27, 38.2–44.3) 40.35 (6.80, 37.4–43.2) 41.26 (7.50, 37.8–44.5)
Contralateral lateroflexion No LTR 37.55 (10.22, 34.1–40.9) 41.12 (9.12, 37.8–44.4) 40.66 (8.21, 37.6–43.6) 39.09 (9.48, 15.2–62.9) 40.30 (9.53, 37.0–43.5)
4 LTR 35.52 (7.93, 32.0–38.9) 35.26 (7.54, 31.9–38.5) 36.38 (6.92, 33.4–39.3) 36.31 (5.49, 12.4–60.1) 37.30 (6.66, 34.0–40.53)
6 LTR 38.93 (4.94, 35.5–42.3) 39.23 (4.11, 35.9–42.5) 39.17 (4.92, 36.2–42.1) 64.76 (108.98, 40.9–88.5) 41.11 (5.35, 37.8–44.3)
+6 LTR 39.50 (7.59, 36.0–42.9) 39.95 (8.58, 36.6–43.2) 39.69 (6.90, 36.7–42.6) 41.17 (6.99, 17.3–65.0) 41.01 (7.61, 37.7–44.2)
Homolateral rotationc No LTR 57.65 (8.97, 53.6–61.6) 59.96 (10.01, 56.2–63.7) 59.73 (8.35, 56.3–63.1) 57.55 (12.36, 53.6–61.4) 59.49 (11.11, 55.8–63.1)
4 LTR 56.84 (13.06, 52.8–60.8) 56.79 (9.93, 53.0–60.5) 58.01 (8.95, 54.5–61.4) 57.42 (8.38, 53.5–61.3) 57.52 (9.03, 53.8–61.1)
6 LTR 60.26 (5.21, 56.2–64.3) 58.82 (7.58, 55.0–62.6) 61.55 (6.83, 58.1–64.9) 64.19 (5.61, 60.3–68.0) 64.61 (6.90, 60.9–68.2)b
+6 LTR 57.77 (8.23, 53.7–61.8) 60.77 (6.77, 57.0–64.5) 60.58 (7.18, 57.1–64.0) 60.73 (7.97, 56.8–64.6) 63.46 (5.08, 59.8–67.0)a
Contralateral rotation No LTR 61.87 (10.24, 57.7–66.0) 59.54 (11.08, 55.5–63.5) 58.35 (12.94, 53.9–62.7) 56.76 (11.81, 52.8–60.7) 57.68 (12.13, 53.3–62.0)
4 LTR 60.04 (10.54, 55.8–64.2) 61.21 (9.52, 57.1–65.2) 60.14 (11.52, 55.7–64.5) 62.11 (9.00, 58.1–66.0) 60.14 (10.67, 55.7–64.5)
6 LTR 65.31 (8.00, 61.1–69.4) 64.27 (8.79, 60.2–68.2) 65.89 (6.07, 61.5–70.2) 68.60 (7.76, 64.6–72.5) 68.42 (8.60, 64.0–72.7)
+6 LTR 62.44 (9.43, 58.2–66.6) 63.35 (7.12, 59.3–67.3) 63.52 (8.44, 59.1–67.9) 63.46 (7.08, 59.5–67.4) 62.46 (8.34, 59.2–68.0)
Data are presented as mean(SD, 95% CI).
a
Significantly higher than preintervention (P < 0.05).
b
Significantly higher than postintervention (P < 0.05).
c
Significant effect for time in the ANOVA.

Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Volume 00, Number 00, Month 2017

© 2017 Wolters Kluwer Health, Inc. All rights reserved.

Volume 00, Number 00, Month 2017
TABLE 5. Within-subjects' analysis of neck disability scores and between-group comparisons (post hoc analysis)
Mean Difference
Group Preneedling After 1 wk Preneedling vs After 1 wk
No LTR 11.62 (5.94) 8.19 (6.00) 3.42
4 LTR 12.76 (7.09) 7.05 (3.51) 5.71
NDI 6 LTR 12.14 (4.94) 7.14 (4.44) 5.00
+6 LTR 11.05 (5.01) 7.19 (5.95) 3.85
None of the differences between groups were significant (P < 0.05).
CID, clinically important difference.
received DDN in the no LTR group without needle insertions
intended to produce LTRs, and dry needling was performed
with solid filament needles.
To the authors' knowledge, there have not been any previ-
ous studies that evaluated the influence of the number of
LTRs elicited during DDN treatment on DDN effectiveness.
However, the effectiveness of a specific DDN dosage has
been assessed in several studies, including DDN without
eliciting LTRs,13,14 eliciting one LTR15 or until no more
LTRs were elicitated.7,12 According to our results, all DDN
techniques applied in these studies resulted in significant
improvements in neck pain.
Moreover, significant increases of PPT were obtained in
all groups at all follow-up moments during 1 wk, except for im-
mediately after treatment. In contrast with previous research,7
in the present study, all groups presented a decrease of PPT
over the needled muscle immediately after treatment, which
may be associated with postneedling soreness. Tenderness
immediately after MTrP DDN was previously reported in latent
MTrPs.29 The group that reached higher levels of PPT changes
was the group of LTRs elicited until exhaustion (0.32 kg/cm2)
but did not reach the minimal detectable change described for
the trapezius muscle (0.45 kg/cm2).23
Consistent with previous research, DDN improved PPT.12
However, in contrast to our results, one study12 reported im-
provements that were superior to the minimal detectable
change. This difference can be explained by the size of the
needles used, the number of LTRs elicited, or the neck pain
values at baseline. Mejuto-Vázquez et al.11 reported an imme-
diate increase of PPT (0.70 kg/cm2) in the facet joint region,
but PPT values in the needled muscle were not assessed. More-
over, compared with our results, Ziaeifar et al.12 found much
higher PPT improvements of 5.8 kg/cm2 on the upper trapezius
MTrP after DDN. However, those improvements were found
after three sessions of DDN.
The neck pain and PPT improvements after DDN could
be explained by a peripheral cause. A small clinical trial re-
ported the reduction of pronociceptive substances present in
MTrPs (substance P and calcitonin gene-related peptide)
when eliciting LTRs.30 Traditionally, another plausible
© 2017 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Different Dry Needling Dosages Myofascial Pain
No. Patients Who Mean Differences Between
P 95% CI Achieved CIDs (%) Groups (95% CI)
0.001* (1.51–5.34) 4 (19) No LTR vs 4 LTR: 1.143
No LTR vs 6 LTR: 1.048
No LTR vs +6 LTR: 1.000
0.0001* (3.79–7.62) 7 (33.3) 4 LTR vs no LTR: −1.143
4 LTR vs 6 LTR: −0.095
4 LTR vs +6 LTR: −0.143
0.0001* (3.08–6.91) 7 (33.3) 6 LTR vs no LTR: −1.048
6 LTR vs 4 LTR: 0.095
6 LTR vs +6 LTR: −0.048
0.0001* (1.94–5.77) 5 (23.8) +6 LTR vs no LTR: −1.000
+6 LTR vs 4 LTR: 0.143
+6 LTR vs 6 LTR: 0.048
mechanism of DDN is the mechanical destruction of dys-
functional endplates, stopping the release of the acetylcho-
line that sustains the muscle fiber contraction.10 A central
mechanism that could also explain these improvements is
that dry needling is thought to stimulate A-delta nerve fi-
bers, which may activate inhibitory dorsal horn interneurons
or the opioid descending inhibitory system.10 It could be hy-
pothesized that pain improvements observed in the no LTR
group may be predominantly due to central mechanisms
and the placebo effect, because the needle was not directly
inserted into the MTrP.
Consistent with previous research, DDN improved
CROM.14,27 A significant improvement was observed in cervi-
cal flexion, extension, homolateral lateroflexion, and rotation.
However, a significant improvement was not observed in con-
tralateral lateroflexion and rotation, in contrast with previous
studies that found improvements in all cervical movements.11
In addition, significant differences were not obtained between
groups, so the number of LTRs did not influence the range of
motion improvement. The relevance of the CROM improve-
ments obtained in the present study is limited because they
did not reach the minimal detectable change for any of the
cervical movements.24
The present study demonstrated that neck disability
improved significantly in all groups, regardless of the elicita-
tion of LTRs. Recent studies showed similar effects on improv-
ing NDI with a 1-wk follow-up.12 These data are consistent
with the present study because NDI improved 1 wk after
DDN, just as neck pain and PPT did. Nevertheless, NDI im-
provements are limited in relevance because the mean changes
did not reach the seven-point clinically important difference
and less than 30% of patients reached the minimal clinically
important difference in the group with the highest effect.
Study Limitations
The present study has several limitations. First, the study
sample included patients with neck pain that persisted for more
than 1 month, which could represent subacute or chronic neck
pain. Patients with subacute pain may react differently to
www.ajpmr.com 7
 Fernández-Carnero et al.
needling treatments than those with chronic pain. Second, there
were no placebo or control groups, so we cannot exclude the
placebo effect of DDN or the influence of the natural history
of neck pain, which probably plays a more important role in pa-
tients with subacute neck pain. Third, there was only a 1-wk
follow-up. The short follow-up length is an important source
of bias in this study. It will be important that future studies have
a longer follow-up period to demonstrate whether clinical ef-
fects could be modified over time. Fourth, other muscles that
could have presented active MTrPs and influenced neck pain
were not assessed or treated. In addition, the possible perpetu-
ating factors that could cause MTrPs to persist or be aggra-
vated, such as the patients' posture, were not considered.
Fifth, a single DDN session was performed. The outcomes
could have been different in cases of having more sessions
or taking on a more clinically used multimodal treatment ap-
proach. Sixth, the study population was limited by certain
characteristics such as the young age and the predominance
of women, which might be associated with specific re-
sponses to dry needling. Finally, although the global sample
size of 84 patients was large, the groups' size could be con-
sidered limited, and it is conceivable that a larger sample size
would highlight a significant difference between groups.
CONCLUSIONS
Deep dry needling in the upper trapezius active MTrPs in
patients with neck pain improved their pain at a 1-wk follow-
up period, but the improvements were not significantly differ-
ent among various DDN dosages. However, a higher number
of patients with neck pain improvements that reached the
MCID were observed when eliciting LTRs until exhaustion
compared with not eliciting LTRs.
Different dosages of DDN (including not eliciting LTRs,
eliciting six LTRs, six LTRs, or continuing until no further
LTRs are obtained) in the upper trapezius produce similar im-
provements in mechanical hyperalgesia, CROM and disability
in patients with cervical myofascial pain. Nevertheless, these
improvements are limited in relevance since they did not reach
the minimal detectable change or the minimal clinically
important difference.
REFERENCES
1. Hoy D, March L, Woolf A, et al: The global burden of neck pain: estimates from the global
burden of disease 2010 study. Ann Rheum Dis 2014;73:1309–15
2. Cooper G, Bailey B, Bogduk N: Cervical zygapophysial joint pain maps. Pain Med
2007;8:344–53
3. Simons DG, Travell JG, Simons LS: Travell & Simons Myofascial Pain and Dysfunction: The
Trigger Point Manual, 2nd ed. Baltimore, Williams & Wilkins, 1999
4. Cummings M, Baldry P: Regional myofascial pain: diagnosis and management. Best Pract
Res Clin Rheumatol 2007;21:367–87
5. Fernández-de-las-Peñas C, Alonso-Blanco C, Miangolarra JC: Myofascial trigger points in
subjects presenting with mechanical neck pain: a blinded, controlled study. Man Ther
2007;12:29–33
8 www.ajpmr.com
View publication stats Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Volume 00, Number 00, Month 2017
6. Giamberardino MA, Affaitati G, Fabrizio A, et al: Myofascial pain syndromes and their
evaluation. Best Pract Res Clin Rheumatol 2011;25:185–98
7. Hong CZ: Lidocaine injection versus dry needling to myofascial trigger point. The importance
of the local twitch response. Am J Phys Med Rehabil 1994;73:256–63
8. Liu L, Huang QM, Liu QG, et al: Effectiveness of dry needling for myofascial trigger points
associated with neck and shoulder pain: a systematic review and meta-analysis. Arch Phys
Med Rehabil 2015;96:944–55
9. Kietrys DM, Palombaro KM, Azzaretto E, et al: Effectiveness of dry needling for
upper-quarter myofascial pain: a systematic review and meta-analysis. J Orthop Sports Phys
Ther 2013;43:620–34
10. Dommerholt J, Mayoral del Moral O, Grobli C: Trigger point dry needling. J Man Manip Ther
2006;14:E70–87
11. Mejuto-Vázquez MJ, Salom-Moreno J, Ortega-Santiago R, et al: Short-term changes in neck
pain, widespread pressure pain sensitivity, and cervical range of motion after the application of
trigger point dry needling in patients with acute mechanical neck pain: a randomized clinical
trial. J Orthop Sports Phys Ther 2014;44:252–60
12. Ziaeifar M, Arab AM, Karimi N, et al: The effect of dry needling on pain, pressure pain
threshold and disability in patients with a myofascial trigger point in the upper trapezius
muscle. J Bodyw Mov Ther 2014;18:298–305
13. McMillan AS, Nolan A, Kelly PJ: The efficacy of dry needling and procaine in the treatment
of myofascial pain in the jaw muscles. J Orofac Pain 1997;11:307–14
14. Tekin L, Akarsu S, Durmuş O, et al: The effect of dry needling in the treatment of myofascial
pain syndrome: a randomized double-blinded placebo-controlled trial. Clin Rheumatol
2013;32:309–15
15. Itoh K, Katsumi Y, Hirota S, et al: Effects of trigger point acupuncture on chronic low
back pain in elderly patients—a sham-controlled randomised trial. Acupunct Med
2006;24:5–12
16. Simons D, Travell J, Simons L: Myofascial pain and dysfunction. The trigger point manual,
Baltimore, Williams & Wilkins, 1999
17. Gerwin RD, Shannon S, Hong CZ, et al: Interrater reliability in myofascial trigger point
examination. Pain 1997;69:65–73
18. Wainner RS, Fritz JM, Irrgang JJ, et al: Reliability and diagnostic accuracy of the clinical
examination and patient self-report measures for cervical radiculopathy. Spine (Phila Pa 1976)
2003;28:52–62
19. Spitzer WO, Skovron ML, Salmi LR, et al: Scientific monograph of the Quebec Task Force on
Whiplash-Associated Disorders: redefining “whiplash” and its management. Spine (Phila Pa
1976) 1995;20:1S–73S
20. Rha D, Shin JC, Kim YK, et al: Detecting local twitch responses of myofascial trigger
points in the lower-back muscles using ultrasonography. Arch Phys Med Rehabil
2011;92:1576–80.e1
21. Bijur PE, Silver W, Gallagher EJ: Reliability of the visual analog scale for measurement of
acute pain. Acad Emerg Med 2001;8:1153–7
22. Dworkin RH, Turk DC, McDermott MP, et al: Interpreting the clinical importance of
group differences in chronic pain clinical trials: IMMPACT recommendations. Pain
2009;146:238–44
23. Walton DM, Macdermid JC, Nielson W, et al: Reliability, standard error, and minimum
detectable change of clinical pressure pain threshold testing in people with and without acute
neck pain. J Orthop Sports Phys Ther 2011;41:644–50
24. Audette I, Dumas J-P, Côté JN, et al: Validity and between-day reliability of the
cervical range of motion (CROM) device. J Orthop Sports Phys Ther 2010;40:318–23
25. Andrade Ortega JA, Delgado Martínez AD, Almécija Ruiz R: Validation of the Spanish
version of the Neck Disability Index. Spine (Phila Pa 1976) 2010;35:E114–8
26. Vernon H, Mior S: The Neck Disability Index: a study of reliability and validity.
J Manipulative Physiol Ther 1991;14:409–15
27. MacDermid JC, Walton DM, Avery S, et al: Measurement properties of the neck
disability index: a systematic review. J Orthop Sports Phys Ther 2009;39:400–17
28. Faul F, Erdfelder E, Lang AG, et al: G*Power 3: a flexible statistical power analysis program
for the social, behavioral, and biomedical sciences. Behav Res Methods 2007;39:
175–91
29. Martín-Pintado Zugasti A, Rodríguez-Fernández ÁL, García-Muro F, et al: Effects
of spray and stretch on postneedling soreness and sensitivity after dry needling of
a latent myofascial trigger point. Arch Phys Med Rehabil 2014;95:1925–32
30. Shah JP, Danoff JV, Desai MJ, et al: Biochemicals associated with pain and inflammation are
elevated in sites near to and remote from active myofascial trigger points. Arch Phys Med
Rehabil 2008;89:16–23
© 2017 Wolters Kluwer Health, Inc. All rights reserved.