Original research
Comparison of radial shockwave
and dry needling therapies in the treatment
of myofascial pain syndrome
Chomkajee Sukareechai, Lecturer1, Somchai Sukareechai, Lecturer1
1Department of
Rehabilitation,
Panyananthaphikkhu
Chonprathan Medical Center,
Srinakharinwirot University,
Nonthaburi, Thailand
Correspondence to:
Chomkajee Sukareechai
Email:
chomkajee@g.swu.ac.th;
chomkajees@gmail.com
International Journal of Therapy and Rehabilitation 2019 https://doi.org/10.12968/2016.0072 1
Abstract
Background/Aims Myofascial pain syndrome is a frequent problem in the
musculoskeletal system. As a method of treatment for myofascial pain syndrome, dry
needling therapy is an effective and convenient treatment for patients because they
do not need to be treated every day. However, as patients often have post-needle
soreness or some patients are afraid of needles, there are limitations to this treatment.
The purpose of this study is to compare the effectiveness of radial shockwave therapy
with dry needling therapy to treat myofascial pain.
Methods A total of 42 patients attending the rehabilitation department with at least
one myofascial pain trigger point in their upper back muscles, were randomly assigned
to receive radial shockwave therapy or dry needling therapy. Treatment was performed
once a week for 3 weeks in both groups. Participants’ pain pressure threshold,
measured using an algometer, and pain levels, measured using a numeric pain scale,
were assessed before the designated treatment was applied each week. Each patient
also performed upper trapezius, rhomboid and infraspinatus muscle stretches twice a
day throughout the study period.
Results There was no difference in pain pressure threshold at the three trigger points
before treatment with the different modalities commenced. At the end of the study,
the radial shockwave therapy group had a significant improvement in trapezius pain
pressure threshold, increasing from 11.7 at baseline to 14.8 at the end of study. There
was no significant between-group difference in pain level (P=3.4 vs P=2.6) at the end
of the study. Both treatments significantly reduced pain levels: from 7.2 to 3.4 in the
radial shockwave group (P<0.001) and from 6.8 to 2.6 in the dry needling therapy
group (P<0.001).
Conclusions Dry needling and radial shock wave therapies are effective in reducing
myofascial pain syndrome originating in the upper back muscles. Participants’
pain pressure threshold increased after 3 weeks of treatment with both therapies.
Radial shock therapy can be used as an alternative to dry needling in the treatment
of myofascial pain syndrome in patients who have trouble attending daily physical
therapy or in whom dry needling therapy is contraindicated.
Key words: ■ Acupuncture ■ Dry needling ■ Myofascial pain syndrome
■ Muscle pain ■ Shockwave ■ Trigger point
Submitted: 4 December 2016; accepted following double blind peer review: 14 December 2018
INTRODUCTION
Myofascial pain syndrome is a condition resulting in musculotendinous tenderness.
© 2019 MA Healthcare Ltd
Features include focal point tenderness, reproduction of pain, taut muscles upon
How to cite this article: Sukareechai C, Sukareechai S (2019) Comparison of radial shockwave and dry
needling therapies in the treatment of myofascial pain syndrome. Int J Ther Rehabil [online] 26(8):1–8.
https://doi.org/10.12968.ijtr.2016.0072
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 Original research

trigger point palpation, pseudo-weakness of the muscle involved, limited range

of motion and referred pain approximately 5 seconds after sustained trigger point
compression (Borg-Stein and Simons, 2002; Bennett, 2007). Myofascial pain
syndrome is a problem commonly seen in rehabilitation clinics and in general medical
practice settings (Skootsky et al, 1989; Borg-Stein and Simons, 2002; Borg-Stein,
2006). Treatment mainly comprises physical therapy modalities and needling of the
myofascial pain trigger point, which includes an injection of an analgesic agent, dry
needling or acupuncture (Daniels et al, 2003; Bennett, 2007; Cerezo-Téllez et al,
2016a; Gerber et al, 2016).
There are two types of shockwave therapies. Extracorporeal shockwave therapy is
a non-invasive procedure using waves to alleviate chronic pain in several disorders,
such as plantar fasciitis (Speed, 2014), lateral or medial epicondylitis (Lee et al, 2012).
It has been successfully applied in patients suffering from myofascial pain syndrome
(Jeon et al, 2012; Speed, 2014; Prateepavanich, 2016). However, the focused waves
generated by extracorporeal shockwave therapy are associated with some risks when
applied to the upper back, as the high energy intensity and deep waves produced
may cause penetrating injuries, such as pneumothorax. Radial shockwave therapy
uses compression to force projectiles against a solid body (ultrasound coupling gel)
to generate shockwaves. Kinetic energy is transmitted to the tissue, with maximal
energy transferred to the surface contact area – the skin – and there is a progressive
diminution as the waves travel deeper into the body. Radial pressure waves generate
oscillation in the tissue, which improves microcirculation and analgesia (Grecco et al,
2013). The energy of these conically dispersed waves is less intense and they do not
penetrate as deeply into the body as those generated by extracorporeal shockwave
therapy; therefore, radial shockwave therapy has been introduced to overcome
secondary complications to extracorporeal shockwave therapy.
Previous studies have shown that both radial shockwave therapy (Irnich, 2013;
Phumiphithakkun et al, 2014; Speed, 2014; Prateepavanich, 2016) and dry needling
therapy are effective in myofascial pain syndrome, significantly reducing the pain
associated with this condition (Hong, 1994; Phumiphithakkun, 2002; Irnich, 2013;
Cerezo-Téllez et al, 2016b; Prateepavanich, 2016). As yet, no direct comparison
has been made between radial shockwave therapy and dry needling therapy in the
treatment of myofascial pain syndrome.

METHODS

This randomised clinical trial was conducted at Panyananthaphikkhu Chonprathan

Medical Center at Srinakharinwirot University, Thailand.

Ethical approval
The study protocol was approved by the Panyananthaphikkhu Chonprathan Medical
Center Ethics Committee (approval number 23/2557). All participants signed an
informed consent form.

Participants
A total of 42 patients were recruited from the outpatient clinic of physical medicine
and rehabilitation department of the hospital. The patients were aged between
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18 and 60 years, had not received previous treatment for myofascial pain syndrome
and had a body mass index between 19 and 25 kg/m2. Participants were asked to
identify the point within the upper back area that had been most tender over the
previous 3 months or longer. A diagnosis of myofascial pain syndrome was made
clinically by the presence of one or more myofascial pain trigger points, with taut

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 Original research

bands being painful to palpate and reproducing referred pain (Hong, 1998; Borg-Stein
and Simons, 2002; Fernandez-de-Las-Penas and Dommerholt, 2018). Patients who
were pregnant, had coagulopathy, neoplasm, a history of corticosteroid injection in
the upper back or shoulder region, advanced osteopathic/arthropathic disorder of
the cervical spine/shoulder, neurological deficits, severe hepatic or renal disease,
epilepsy, cutaneous pathology or a psychological problem were excluded.
Participants’ baseline characteristics were recorded, including sex, age, duration
of myofascial pain syndrome, body mass index and the location of trigger points.
Pain score and pain pressure threshold were recorded at baseline and each week
before treatment. Self-reported pain was assessed using a numeric rating score, with
0 indicating no pain and 10 indicating maximum pain. Participants’ pain pressure
threshold was assessed using a digital algometer (Algometer Commander, JTECH
Medical, Salt Lake City, UT, USA) and reported in lb/cm2.

Intervention
Eligible patients were randomly assigned to the radial shockwave therapy group or
dry needling therapy group using a simple random sampling method, with 21 patients
in each group. The allocated treatment was performed once a week for 3 weeks.
In the radial shockwave therapy group, the pneumatic radial shockwave generator
(Masterpuls MP200, Storz Medical AG, Tägerwilen, Switzerland) was used. The R15
wide-area shock transmitter was applied at a frequency of 12 Hz and peak pressure of
1–2 bar for 300 pulses at each trigger point. Treatment did not exceed 6000 pulses in
total per session. Patients were asked to lie in a prone position while the 1 cm-wide
algometer disk was pressed perpendicularly with increasing force against the trigger
points of the upper trapezius, infraspinatus and rhomboid muscles. An examiner asked
participants to say ‘stop’ when they felt pain or any discomfort during the test. The
amount of pressure being exerted when they said ‘stop’ was noted. This procedure
was performed three times at 10-second intervals and the average was determined
as the pain pressure threshold.
In the dry needling therapy group, 0.25 × 50 Dong Bang needles were applied at
the trigger points using a multiple needle entry technique. Both groups of participants
performed upper trapezius, rhomboid and infraspinatus muscle stretches twice a day
throughout the study period.
The study sample size was calculated based on results reported by Jeon et al
(2012), where the improvement in pain pressure threshold using extracorporeal
shockwave therapy was 5.71. It was assumed that dry needling therapy would lead
to an improvement of 3.40. Using these figures, with a two-sided 95% confidence
interval and power of 90%, it was calculated that 19 patients were needed for each
therapeutic arm. This number was increased to 21 patients to account for a 10%
dropout rate.

Analysis
Descriptive statistics were used to evaluate the differences between both groups.
Repeated measure analysis of variance was used to compare the change in intra- and
intergroup numeric pain scores and pain pressure thresholds over time. All statistical
analyses were performed using SPSS statistical software, version 21 (Chicago, IL, US).
© 2019 MA Healthcare Ltd

RESULTS

Participants’ demographic information is given in Table 1. A total of 42 patients

enrolled in the study and none dropped out. There was no between-group difference
in pain pressure thresholds at the three trigger points before treatment was started

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 Original research

Table 1. Demographics of participants

Radial shockwave Dry needling therapy

therapy (n=21) (n=21) P-value

n (%) n (%)

Male 2 (9.5%) 0 (0.0%) 0.488

Female 19 (90.5%) 21 (100.0%)

Mean ± standard deviation Mean ± standard deviation

Age (years 38.2 ± 11.9 42.7 ± 12.4 0.241

Body mass index 22.5 ± 4.3 24.7 ± 4.6 0.108

Median (min, max) Median (min, max)

Onset (months), 24 (1, 120) 36 (3, 120) 0.657

Occupation n (%) n (%)

Office worker 9 (42.9%) 13 (61.9%)

Teacher 1 (4.8%) 2 (9.5%)

Businessmen 1 (4.8%) 1 (4.8%)

Nurse 2 (9.5%) 3 (14.3%)

Housekeeper 5 (23.8%) 1 (4.8%)

Engineer 3 (14.3%) 0

Hairdresser 0 1 (4.8%)

Affected trigger point n (%) n (%)

Upper trapezius 26 (23.0%) 35 (30.9%)

Infraspinatus 12 (10.6%) 7 (6.2%)

Rhomboid 14 (12.3%) 19 (16.8%)

Baseline measurements

Pain score 7.2 ± 1.6 6.8 ± 1.7 0.414

Upper trapezius pain 11.7 ± 4.0 12.1 ± 3.2 0.660

pressure threshold

Infraspinatus pain 13.5 ± 5.7 13.9 ± 4.6 0.818

pressure threshold

Rhomboid pain pressure 15.6 ± 5.4 11.8 ± 2.8 0.063

threshold

(Table 1). Radial shockwave therapy resulted in a significant improvement in pain

pressure threshold at the trapezius and infraspinatus trigger points after 3 weeks of
treatment (Table 2). Dry needling therapy improved the pain pressure threshold at
the trapezius trigger point only. Both treatment groups had significant improvements
in mean pain scores, with the radial shockwave therapy group score decreasing
from 7.2 to 3.4 (P<0.001) and the dry needling therapy group score from 6.8 to 2.6
(P<0.001) between baseline and the final treatment. The mean pain scores at the
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end of the study were not significantly different, with the radial shockwave therapy
group score being 3.4 and the dry needling therapy group score being 2.6 (Table 3).
Both radial shockwave therapy and dry needling therapy improved myofascial
pain syndrome in the upper back area after 3 weeks of treatment (Tables 2 and 3).
Overall pain scores were significantly lower in both groups at the end of study

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 Original research

Table 2. Change in mean trigger point pain pressure thresholds over time

Trigger
point Upper trapezius Infraspinatus Rhomboid

Radial Dry Radial Dry Radial Dry

shockwave needling shockwave needling shockwave needling
therapy therapy therapy therapy therapy therapy
(n=26) (n=35) P-value* (n=14) (n=19) P-value* (n=12) (n=7) P-value*

Baseline 11.7 ± 4.0 12.1 ± 3.2 0.907 13.5 ± 5.7 13.9 ±4.6 0.988 15.6 ± 5.4 11.8 ± 2.8 0.557

Week 1 12.8 ± 4.2 13.0 ± 2.5 14.6 ± 5.8 13.9 ± 4.7 15.0 ± 5.6 14.2 ± 2.9

Week 2 14.6 ± 4.6 14.1 ± 2.9 14.6 ± 5.1 15.6 ± 4.2 15.8 ± 5.6 15.2 ± 1.9

Week 3 14.8 ± 3.5 14.5 ± 2.9 16.9 ± 5.0 16.3 ± 4.2 16.3 ± 5.0 16.4 ± 4.2

P-value# <0.001§ <0.001§ 0.020§ 0.057 0.296 0.153

*Between-group comparison; #within-group comparison; §significant difference

Table 3. Change in mean numeric pain scores over time

Radial shockwave Dry needling therapy

therapy (n=21) (n=21) P-value*

Baseline 7.2 ± 1.6 6.8 ± 1.7 0.074

Week 1 5.1 ± 1.6 4.5 ± 2.1

Week 2 4.9 ± 2.3 3.4 ± 2.7

Week 3 3.4 ± 2.1 2.6 ± 2.2

P-value# <0.001§ <0.001§

*Between-group comparison; #within-group comparison; §significant difference

(Table 3). The reduction in pain was 52.8% in the radial shockwave therapy group
and 61.8% in the dry needling therapy group. Even though there was a greater
reduction in mean pain score in the dry needling therapy group, the difference was
not statistically significant (P=0.074).

DISCUSSION

The application of these two treatment modalities resulted in the release of muscle
tension, an outcome previously reported with the application of other treatment
modalities such as massage or lidocaine injection (Irnich, 2013; Prateepavanich, 2016).
To our knowledge, this is the first study to compare these two treatment modalities
in myofascial pain syndrome. Radial shockwave therapy seemed to result in better
treatment outcomes than dry needling therapy. It significantly increased pain pressure
thresholds in two of the three trigger points studied (trapezius and infraspinatus) vs
one trigger point (the trapezius) with dry needling therapy. These findings may be
partially explained by the location of the muscles. The rhomboid muscle is located
deeper than the trapezius, and may therefore have a poorer response to both treatments.
Another point in favour of radial shockwave therapy is that it is less invasive than
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dry needling therapy. Most patients felt comfortable during treatment with radial
shockwave therapy. They did not experience muscle strains or complications such
as petechiae, ecchymosis, haematoma or pneumothorax as a result of treatment.
Radial shockwave therapy resulted in no pain or discomfort after treatment. Some
participants experienced soreness after dry needling therapy. This occurred more

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 Original research

often in patients with a lot of pain and in those receiving their first treatment. In
the latter group, aches and pains were reduced in subsequent weeks of treatment.
Most dry needling therapy participants recovered from post-needling soreness after
2–3 days. One participant experienced fever in addition to soreness after treatment
and needed to take medication and sick leave. Participants with more local twist
responses suffered to a greater extent than those with fewer reactions. Referred pain
in the head and arms decreased. Moreover, some dry needling therapy participants
felt that needles were more accurately able to treat trigger points within the muscles
that were causing the pain.
A study of patients with myofascial pain syndrome comparing ultrasound with radial
shockwave therapy in the treatment of upper trapezius trigger point pain found the
latter to be more effective than the former in week 6 (Phumiphithakkun et al, 2014).
Research by Ji et al (2012) found that twice-weekly extracorporeal shockwave therapy
reduced pain by week 2 and could cure myofascial pain syndrome. The mechanism
by which shockwaves reduce muscle pain has yet to be determined; however, findings
from research suggest that shockwaves released directly into contracted muscles
result in muscle relaxation (Simons et al, 1999; Shah and Gilliams, 2008), increased
blood and nutrient flow to the myofascial pain trigger point, degeneration of C nerve
fibres (Hausdorf et al, 2008a) reduced substance P (Hausdorf et al, 2008b) and
calcitonin gene-related peptide (Takahashi et al, 2003) levels and increased nitric
oxide release (Mariotto et al, 2009). Selective destruction of unmyelinated nerve
fibres within the focal zone of the shockwaves might contribute to this analgesia.
Importantly, these small unmyelinated fibers, the so-called C fibres are known to be
responsible for throbbing, chronic pain. The results of these mechanisms of action
have resulted in extracorporeal shockwave therapy being well used in the treatment
of myofascial pain. The treatment modalities used in this study made it difficult to
blind participants to the treatment options they were receiving, therefore the main
strength of the study was patient randomisation to radial shockwave therapy or dry
needling therapy.

Limitations
There were several limitations to this study. There was no control group and the
sample size was small and predominantly female (95%). Further studies with a
larger sample size and a higher proportion of male patients are needed to confirm
the results of this study. Other suggestions include following patients for a longer
period of time and using the neck disability index and cervical spine range of motion
to assess the severity of and improvement in myofascial pain syndrome.

CONCLUSIONS

Both radial shockwave therapy and dry needling therapy effectively reduced pain
originating from trigger points in the upper back muscles of patients with myofascial
pain syndrome. Participants’ pain pressure threshold increased during 3 weeks of
treatment with both dry needling therapy and radial shockwave therapy. Radial
shockwave therapy can be used as an alternative to dry needling therapy in patients
with myofascial pain syndrome who have trouble attending daily physical therapy
sessions or are not permitted to receive dry needling therapy.
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Acknowledgment
The authors thank the patients who participated in this study and their relatives as
well as staff members at the Department of Rehabilitation, Panyananthaphikkhu
Chonprathan Medical Center of Srinakharinwirot University.

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 Original research

Conflicts of interest
The authors declare that there are no conflicts of interest.

REFERENCES

Bennett R. Myofascial pain syndromes and their evaluation. Best Pract Res Clin Rheumatol.
2007;21(3):427–445. https://doi.org/10.1016/j.berh.2007.02.014
Borg-Stein J. Treatment of fibromyalgia, myofascial pain, and related disorders. Phys Med Rehabil Clin N
Am. 2006;17(2):491–510. https://doi.org/10.1016/j.pmr.2005.12.003
Borg-Stein J, Simons DG. Focused review: myofascial pain. Arch Phys Med Rehabil. 2002;83(3 S1):S40–
7, S48–9
Cerezo-Téllez E, Lacomba MT, Fuentes-Gallardo I , Mayoral Del Moro O, Rodrigo-Medina B, Gutiérrez
Ortega C. Dry needling of the trapezius muscle in office workers with neck pain: a randomized clinical
trial. J Man Manip Ther. 2016a;24(4):223–232. https://doi.org/10.1179/2042618615Y.0000000004
Cerezo-Téllez E, Torres-Lacomba M, Fuentes-Gallardo I et al. Effectiveness of dry needling for chronic
nonspecific neck pain: a randomized, single-blinded, clinical trial. Pain. 2016b;157(9):1905–1917.
https://doi.org/10.1097/j.pain.0000000000000591
Daniels JM, Ishmael T, Wesley RM. Managing myofascial pain syndrome: sorting through the diagnosis
and honing treatment. Phys Sportsmed. 2003;31(10):39–45. https://doi.org/10.1080/00913847.2003.1
1439953
Fernandez-de-Las-Penas C, Dommerholt J. International consensus on diagnostic criteria and clinical
considerations of myofascial trigger points: a Delphi study. Pain Med. 2018;19(1):142–150. https://doi.
org/10.1093/pm/pnx207
Gerber LH, Sikdar S, Aredo JV et al. Beneficial effects of dry needling for treatment of chronic
myofascial pain persists for 6 weeks after treatment completion. PM R. 2016;9(2):105–112. https://doi.
org/10.1016/j.pmrj.2016.06.006
Grecco MV, Brech GC, Greve JM. One-year treatment follow-up of plantar fasciitis: radial shockwaves
vs. conventional physiotherapy. Clinics. 2013;68(8):1089–1095. https://doi.org/10.6061/
clinics/2013(08)05
Hausdorf J, Lemmens MA, Kaplan S et al. Extracorporeal shockwave application to the distal femur of
rabbits diminishes the number of neurons immunoreactive for substance P in dorsal root ganglia L5.
Brain Res. 2008a;1207:96–101. https://doi.org/10.1016/j.brainres.2008.02.013
Hausdorf J, Lemmens MA, Heck KD et al. Selective loss of unmyelinated nerve fibers after extracorporeal
shockwave application to the musculoskeletal system. Neuroscience. 2008b;155(1):138–144. https://
doi.org/10.1016/j.neuroscience.2008.03.062
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(4):256–263. https://doi.org/10.1097/00002060-
199407000-00006
Hong CZ, Simons DG. Pathophysiologic and electrophysiologic mechanisms of myofascial trigger points.
Arch Phys Med Rehabil. 1998;79(7):863–872
Irnich D. Myofascial trigger points: comprehensive diagnosis and treatment. Edinburgh: Churchill
Livingstone/Elsevier; 2013
Ji HM, Kim HJ, Han SJ. Extracorporeal shock wave therapy in myofascial pain syndrome of upper
trapezius. Ann Rehabil Med. 2012;36(5):675–680. https://doi.org/10.5535/arm.2012.36.5.675
Jeon JH, Jung YJ, Lee JY et al. The effect of extracorporeal shock wave therapy on myofascial pain
syndrome. Ann Rehabil Med. 2012;36(5):665–674. https://doi.org/10.5535/arm.2012.36.5.665
Lee SS, Kang S, Park NK et al. Effectiveness of initial extracorporeal shock wave therapy on the newly
diagnosed lateral or medial epicondylitis. Ann Rehabil Med. 2012;36(5):681–687. https://doi.
org/10.5535/arm.2012.36.5.681
Mariotto S, de Prati AC, Cavalieri E et al. Extracorporeal shock wave therapy in inflammatory diseases:
molecular mechanism that triggers anti-inflammatory action. Curr Med Chem. 2009;16(19):2366–
2372. https://doi.org/10.2174/092986709788682119
© 2019 MA Healthcare Ltd

Phumiphithakkun K, Soodnoreekun C, Sirisabya P. Treatment of myofascial pain syndrome by needling in

police general hospital. J Thai Rehabil Med. 2002;12:8–14
Phumiphithakkun K, Lekyingyong U, Thaprasop K, Lauhatirananda P, Chantawong P. A comparison of
the effectiveness of radial shock wave therapy and ultrasound in myofascial pain syndrome of upper
trapezius. J Thai Rehabil Med. 2014;24(2):49–54

International Journal of Therapy and Rehabilitation 2019 https://doi.org/10.12968/2016.0072 7

Downloaded from magonlinelibrary.com by 130.238.007.040 on September 15, 2019.

 Original research

Prateepavanich P. Myalgia, osteoporosis, pain syndrome=myofascial pain syndrome. Bangkok: Amarin

Printing and Publishing Company; 2016
Shah JP, Gilliams EA. Uncovering the biochemical milieu of myofascial trigger points using in vivo
microdialysis: an application of muscle pain concepts to myofascial pain syndrome. J Bodyw Mov
Ther. 2008;12(4):371–384. https://doi.org/10.1016/j.jbmt.2008.06.006
Simons DG, Travell JG, Simons LS. Myofascial pain and dysfunction: upper half of body. 2nd edn.
Baltimore: Williams & Wilkins; 1999
Skootsky SA, Jaeger B, Oye RK. Prevalence of myofascial pain in general internal medicine practice.
West J Med. 1989;151(2):157–160
Speed C. A systematic review of shockwave therapies in soft tissue conditions: focusing on the evidence.
Br J Sports Med. 2014;48(21):1538–1542. https://doi.org/10.1136/bjsports-2012-091961
Takahashi N, Wada Y, Ohtori S, Saisu T, Moriya H. Application of shock waves to rat skin decreases
calcitonin gene-related peptide immunoreactivity in dorsal root ganglion neurons. Auton Neurosci.
2003;107(2):81–84. https://doi.org/10.1016/S1566-0702(03)00134-6

© 2019 MA Healthcare Ltd

International Journal of Therapy and Rehabilitation 2019 https://doi.org/10.12968/2016.0072 8

Downloaded from magonlinelibrary.com by 130.238.007.040 on September 15, 2019.