Complementary Therapies in Clinical Practice 47 (2022) 101571

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Complementary Therapies in Clinical Practice

journal homepage: www.elsevier.com/locate/ctcp

Effect of dry-needling and exercise treatment on myofascial trigger point: A

single-blind randomized controlled trial
Merve Damla Korkmaz a, *, Cansın Medin Ceylan b
a
Department of Physical Medicine and Rehabilitation, Kanuni Sultan Suleyman Training and Research Hospital, University of Health Sciences, Istanbul, Turkey
b
Department of Physical Medicine and Rehabilitation, Istanbul Physical Medicine and Rehabilitation Training and Research Hospital, Istanbul, Turkey

A R T I C L E I N F O A B S T R A C T

Keywords: Aim: To investigate the effectiveness of dry-needling(DN) together with exercise therapy on pain, ultrasono­
Dry-needling graphic parameters of myofascial trigger points(MTrPs), and upper trapezius(UT) muscles, and neck disability in
Trapezius patients with myofascial pain syndrome.
Trigger point
Material and methods: This was a single-blind, prospective, randomized, and controlled trial. Participants aged
Pain intensity
Ultrasonography
18–45 years with persistent neck pain for >3 months caused by the active MTrPs in the UT muscles were
included. The exercise therapy was performed 3 times/week for 3 months. DN therapy was applied once a week,
for a total of three sessions. The pain intensity, ultrasonographic measurements of the thickness of the UT muscle,
and diameter of the MTrPs in the UT muscle were the primary outcomes. The secondary outcome was the neck
disability.
Results: Seventy participants were randomized into two groups: the dry-needling together with exercise group
(DNG, n = 35) and the exercise-only group(EG, n = 35). A total of 8 participants dropped out of the study, and
the study was completed with 62 participants(DNG = 33; EG = 29). There was a significant difference in terms of
VAS(at night, at rest, and during activity)(p < 0.001) at post-treatment and after 3 months, the thickness of UT
muscle(p = 0.004), and diameter of MTrP(p = 0.021) at post-treatment between the groups. No statistical dif­
ferences were identified in terms of NDI(p = 0.065).
Conclusion: This study demonstrated the effects of DN applied together with exercise therapy on reduction of the
pain intensity at short(post-treatment) and mid-term(after 3 months), and the ultrasonographic parameters of
MTrPs and UT muscles at short-term(post-treatment).

1. Introduction dysfunction which results in referred pain, allodynia, and hyperalgesia

Myofascial pain syndrome (MPS), is a common type of chronic
musculoskeletal pain characterized by motor, sensory and autonomic
findings [1]. The syndrome is associated with myofascial trigger points
(MTrPs). MTrPs are palpable and hyperirritable nodules in the affected
muscles and cause localized and referred pain [1,2]. The upper trapezius
(UT) muscle is often affected by MTrPs. Restricted neck movements,
persistent pain, dizziness or vertigo, and headache are the common
symptoms of the MTrPs in this muscle [2].
The etiology of MPS is not fully clarified. It is hypothesized that an
algogenic substance in the aseptic inflammation stimulates the sensory
nerves and the inflammatory edema compresses the tissues. Addition­
ally, prolonged abnormal body posture leads to the impaired blood
circulation of the skin. Accumulated metabolites cause sensory nerve
[3,4]. Nonsteroidal anti-inflammatory drugs, exercise, local injections,
and physical therapy are the treatment methods for MPS [1,4].
Posture, range of motion, cardiovascular fitness, strengthening and
stretching exercises are some of the important and effective techniques
for management of myofascial pain [5]. Especially, stretching exercise is
the fundamental in initial MPS treatment [6].
Dry-needling (DN) is a treatment method that attributes the thera­
peutic effects by mechanical, neurophysiological, and chemical effects
[7]. The mechanical disruption of the trigger point by the needle is the
main therapeutic mechanism. Thus, the shortened sarcomeres within
the trigger point stretch and return their resting length [1]. Additionally,
A-delta nerve fibers can be stimulated by the DN and this provides
opioid-mediated pain relief. Some chemicals such as bradykinin, sub­
stance P, calcitonin gene-related peptide are related to local twitch

* Corresponding author. Atakent mh, Turgut Özal Blv, No: 46/1, 34303, Kucukcekmece, Istanbul, Turkey.
E-mail addresses: mervedml@gmail.com (M.D. Korkmaz), cansinmedin@hotmail.com (C. Medin Ceylan).

https://doi.org/10.1016/j.ctcp.2022.101571
Received 20 November 2021; Received in revised form 27 February 2022; Accepted 2 March 2022
Available online 5 March 2022
1744-3881/© 2022 Elsevier Ltd. All rights reserved.
M.D. Korkmaz and C. Medin Ceylan Complementary Therapies in Clinical Practice 47 (2022) 101571

response and referred to pain in MPS. DN may influence the blood cir­
culation in the muscle [2].
There are several studies that investigate the effectiveness of the DN
on MTrP in UT muscles. The results obtained in those studies are
complicated due to the short follow-up period [8,9], alternative appli­
cation methods, and varied treatment duration [10,11]. However,
evaluation of the results was subjective because of using scales based on
patients’ statements [12–14]. In this study, it is aimed to investigate the
effectiveness of DN therapy on pain, ultrasonographic parameters of
MTrPs and UT muscles, and neck disability in patients with MPS.
the same point throughout the study. After cleansing the skin with
alcohol, an acupuncture needle of 0.25 mm diameter and 25 mm length
(Hualong, China) was inserted into active MTrPs of the UT muscle of the
participants in the seated position (Fig. 1). It was inserted as much as
5–15 mm depending on the depth of MTrP. Two additional needles were
inserted 1 or 2 mm away from the first needle. The insertions of the
needles in TrPs were performed using the fast-in, fast-out technique until
a local twitch response was obtained. After local twitch response, the
needles were kept in the MTrP for 10 min [2,15,16]. All dry-needling
procedures were performed by the same investigator.

2. Methods 2.3. Ethical considerations

2.1. Study design and participants The study protocol was approved by the Clinical Research Ethical
Committee (KAEK/2021.03.88) in conformity with the Declaration of
A single-blind, prospective, randomized, and controlled trial was Helsinki. All participants were informed in writing and orally about the
performed to investigate the effect of dry-needling on pain, the diameter study. A signed Informed Volunteer Consent Form was obtained from
of the MTrPs in the UT muscle, the thickness of the UT muscle, and neck each participant before including the study. This study was registered at
disability. The study was conducted between April and October 2021. Clinicaltrials.gov (ID number: NCT05066529).
A sample of participants aged 18–45 years who were admitted to
Physical Medicine and Rehabilitation Outpatient Clinic because of 2.4. Outcome measures
persistent neck pain for >3 months caused by the active MTrPs in the UT
muscles were recruited in the study. The diagnostic criteria for active Outcome measures were assessed before, immediately after (3rd
MTrPs were: (I) the presence of a palpable taut band in the trapezius week), and 3 months after the intervention period for both groups by the
muscle; (II) the presence of a hypersensitive tender spot in the taut band; blinded investigator.
(III) the patient’s recognition of existing pain when pressure was applied
on the tender spot in the taut band; (IV) the presence of a local twitch 2.3.1. Pain intensity
response after palpation, and (V) the presence of referred pain away Pain intensity was measured using a 10 cm visual analog scale (VAS).
from the MTrPs [1]. The other inclusion criteria were as follows: not The scale consists of a 10 cm horizontal line between ‘’no pain’’ and ‘’the
receiving any treatment for MTrPs within 6 months, agreement to attend
dry-needling and/or exercise therapy program, and agreement not to
receive any other treatments (drugs, physical therapy, injections, etc.)
during the study. The medical diagnosis of cervical radiculopathy
and/or myelopathy, previous history of cervical injury and surgery for
the cervical region, presence of any contraindications for dry needling
treatment (allergies, blood coagulation disorders, use of anticoagulants,
history of psychiatric illness, etc.) were the exclusion criteria.
Participants who met the inclusion criteria were randomized into
two groups (1:1): Dry-needling and exercise group (DNG) or the
exercise-only group (EG). Randomization was performed using
computer-generated list of random numbers on Excel© 2019 for Mac
(Microsoft, Redmond, WA, USA) software.
Both groups received the interventions from the same investigator.
Initial and follow-up evaluations were performed by another investi­
gator who was blinded to the group assignment.

2.2. Interventions

All participants received the exercise therapy for 3 times a week,

with 20 repetitions for each exercise in a set for 3 months. In the initial
evaluation, the exercises were taught practically to the participants in a
30-min training session, and afterward, they were asked to do the
remaining sessions at home due to difficulty coming to the hospital for 3
months. Participants were also given a brochure with pictures and ex­
planations of the exercises. An exercise diary was also given and
compliance with exercise therapy of the participants was checked
monthly. The exercise therapy includes a cervical range of motion and
stretching of the cervical paravertebral and trapezius muscles actively.
The participants in the DNG received dry-needling therapy once a
week, for a total of 3 sessions. Only one MTrP was selected for needling.
If there was more than one MTrP, the most painful one and/or side was
selected for receiving the treatment. Participants were asked to rest in a
sitting position in the same room for standardization. The MTrP was
identified by clinical examination and the localization of MTrP was
confirmed using ultrasonographic imaging. Afterward, the MTrP was
mapped and described on a body chart. The needling was performed on Fig. 1. Example of the dry-needling application.

2
M.D. Korkmaz and C. Medin Ceylan
worst imaginable pain’’ [17]. In this study, the participants were asked
to state their pain at rest, during activity, and at night.
2.3.2. Trapezius muscle thickness and diameter of MTrP
The ultrasonographic examination was performed using Digital
Sonoace 5500® ultrasonographic device (Medison America Inc., Cy­
press, CA) with an 8–10 linear array transducer, and the procedure was
performed in an upright sitting position. The UT muscle was visualized
transversely and longitudinally.
The thickness of the upper trapezius muscle was defined as the
largest distance between the lower and upper borders of the muscle in
millimeters (Fig. 2).
The MTrP was seen as a focal hypoechoic (darker) area with a het­
erogeneous echotexture. The diameter of MTrP was measured as the
distance between the two furthest points of the hypoechoic area [18].
Taheri N. et al. evaluated the reliability of ultrasonographic evalu­
ation of MTrP and trapezius muscle, and they found that the sensitivity
and specificity of ultrasonographic diagnosis were 91% and 75%,
respectively. Also, the inter-rater reliability was determined to a higher
agreement [18].
2.3.3. Neck disability
The Neck Disability Index (NDI) score was used to assess neck
disability. It is a 10-item instrument to measure pain, personal care,
concentration, headache, work, driving, sleeping, recreation, and lifting.
Each section of the instrument is scored from 0 to 5 points (from ‘no
pain’ to ‘worst imaginable pain’). The maximum score is 50 points (or
100%). Disability categories are ranged from ‘no disability’ (0–8%) to
‘complete disability’ (70–100%). The scale has a high degree of test-
Fig. 2A. Ultrasonographic imaging of the upper trapezius and MTrP. 2b. Ul­
trasonographic imaging (marked); Left: The thickness of the upper trapezius
muscle; Right: The shape of the trigger point.
3
Complementary Therapies in Clinical Practice 47 (2022) 101571
retest reliability, internal consistency, and an acceptable level of val­
idity [19]. 10 point change is required for clinical meaningfulness [20].
The clinimetric properties of the Turkish translation of the NDI were also
performed [21].
2.4. Statistical analysis
Statistical analysis was performed using SPSS software version 23.0
(MacOs, IBM Corp., Armonk, NY, USA). The sample size was calculated
using G*Power software (G*Power version 3.1.9, Germany) based on the
change in pain intensity. According to the calculation of sample size, in
order to achieve α < 0.05 and β = 95% according to the VAS scores with
an effect size of 0.96, it was calculated that a minimum of 25 partici­
pants would be required for each group as described Ziaeifar et al. [2].
Assuming a 10% dropout rate, a total of 55 participants were needed for
the study.
The normal distribution of variables was examined by the Shapiro-
Wilk test. The nonparametric test was used for statistical analysis due
to skewed distribution. Descriptive statistics were presented as mean
(standard deviation), median, minimum and maximum values. For
within-group analysis, Friedman Test was used to present the difference
between baseline, immediately after treatment and after 3rd month
follow-up values in outcome assessments in DNG and EG. When a sig­
nificant difference was found in the within-group analysis, Bonferonni-
Corrected Wilcoxon’s Signed Ranks Test was used for within-group
comparisons of repeated measures in the two groups. For between-
group comparisons, the Kruskal Wallis test was used. When a signifi­
cant difference was found, Bonferonni- Corrected Mann Whitney U test
was used. The confidence interval was 95%, and p-values of <0.05 were
considered statistically significant. Additionally, statistical significance
was considered as p < 0.0167 for the analysis using Bonferonni
correction.
For effect size calculation, Cohen’s d was determined by calculating
the mean difference between two groups, and then dividing the results
by the pooled standard deviation. Based on Cohen’s d results, effect sizes
of 0.2, 0.5, and 0.8 were considered as small, medium and large,
respectively [22].
3. Results
Ninety-two participants with cervical pain and MTrP in UT muscle
who visited to Physical Medicine and Rehabilitation outpatient clinic
were evaluated for eligibility. Seventy of them met the inclusion criteria
and agreed to participate in the study. The participants were random­
ized into two groups: Dry-needling with Exercise Group (DNG; n = 35)
and Exercise-only Group (EG; n = 35). One participant in DNG dropped
out because of an allergic reaction caused by acupuncture needles and,
another participant refused to continue dry-needling sessions. In EG, 2
participants were lost due to starting another medical treatment and, 4
participants were lost during the follow-up period. The study was
completed with 62 participants (DNG = 33; EG = 29) (presented in
CONSORT diagram, Fig. 3). All participants, in the final analysis
attended all treatment sessions. Demographic characteristics and base­
line measurements are shown in Table 1.
3.1. Within-group analysis
According to post hoc analysis, the mean values of VAS during ac­
tivity and at rest, and NDI scores were significantly decreased after
treatment and at third-month follow-up as compared to before treatment
scores in both groups (Table 2). However, based on the comparison
between the measurements immediately after treatment and third-
month follow-up sessions, there was no significant change in VAS at
night in EG, the thickness of UT muscle in DNG, and diameter of MTrP in
both groups. Also, there was a significant change between three follow-
up measurements in terms of VAS scores at night in DNG, and thickness
M.D. Korkmaz and C. Medin Ceylan
Fig. 3. Consort diagram of the study.
of UT muscles in EG (Table 2).
3.2. Between-group analysis
Upon comparison of the DNG and EG, there was a statistically sig­
nificant decrease in terms of VAS (at rest, during activity, and at night)
(p < 0.001) at short and mid-term stages in the DNG. Also, the thickness
of UT muscle (p = 0.04), and diameter of MTrP (p = 0.021) was found
significantly decreased at short-term stages in DNG. No statistical dif­
ferences were identified in terms of NDI at all stages (p = 0.024, 0.845,
and 0.065, respectively) in between-group analysis (Table 3).
The effect size of the VAS (at rest, during activity, and at night), and
the diameter of the MTrP were found as 0.65(medium effect size), 0.65
(medium effect size), 0.75(medium effect size), and 0.86(large effect
size), respectively.
4
Complementary Therapies in Clinical Practice 47 (2022) 101571
4. Discussion
This is the first study to investigate the short and mid-term effects of
DN and exercise therapy on ultrasonographic imaging features of UT
muscle and MTrPs in UT muscle. As the results of the present study, DN
with exercise therapy was found to be more effective in reducing the
thickness of trapezius muscle, and the diameter of MTrPs at short-term,
and pain intensity at short and mid-term than exercise therapy alone.
However, both approaches (dry-needling and exercise therapy) were
effective in reducing neck disability after treatment.
The mechanism of DN therapy has not been clarified yet [23]. Ac­
cording to several studies, local effect on the taut band or local vaso­
dilatation, pain inhibition by activation descending pathways at the
central nervous system, and peripheral segmental inhibition are
considered as possible mechanisms of the DN for pain relief [24,25].
Study results showed strong evidence for DN therapy to decrease the
M.D. Korkmaz and C. Medin Ceylan Complementary Therapies in Clinical Practice 47 (2022) 101571

Table 1 Table 2
Demographic and clinical characteristics of the participants. Intra group analysis of the outcome measures.
Variable DNG (n = 33) EG (n = 29) p value DNG (n pa pb EG (n = pa pb
= 33) 29)
Age (year) 34.9 (7.3) 34.2 (7.5) 0.894
Mean (SD) VAS(at rest) 5.03 ± <0.001 PosT- 4.31 ± <0.001 PosT-
Sex (male/female) 7/26 5/24 0.436 PreT 1.16 PreT 1.5 PreT
Occupation n(%) 0.847 PosT 2.48 ± P< 3.24 ± P<
Not working 12 (36.4%) 9 (31%) Third month 1.32 0.001 1.18 0.001
Working at desk 9 (27.3%) 8 (27.5%) 1.78 ± Thr- 2.58 ± Thr-
Physically demanding 12 (36.4%) 12 (41.4%) 1.38 PosT 1.05 PosT
Marital status n(%) 0.527 P< P=
Married 24 (72.7%) 20 (69%) 0.001 0.001
Unmarried 9 (27.3%) 9 (31%) Thr- Thr-
Education n(%) 0.392 PreT PreT
Primary school 15 (45.4%) 13 (44.8%) P< P<
High school 10 (30.3%) 6 (20.7%) 0.001 0.001
University 8 (24.3%) 10 (34.5%) VAS(during 7.03 ± <0.001 PosT- 6.55 ± <0.001 PosT-
Laterality n(%) 0.111 activity) 1.24 PreT 1.45 PreT
Right trapezius 22 (66.7%) 16 (55.2%) PreT 4.33 ± P< 5.44 ± P<
Left trapezius 11 (33.3%) 13 (44.8%) PosT 1.74 0.001 1.18 0.001
VAS(at rest) 5.0(1.1) 4.3(1.5) 0.053 Third month 3.30 ± Thr- 4.27 ± Thr-
Mean (SD) 1.61 PosT 1.36 PosT
VAS(during activity) 7.0(1.2) 6.5(1.4) 0.051 P< P<
Mean (SD) 0.001 0.001
VAS(at night) 3.4(1.2) 2.6(1.0) Thr- Thr-
Mean (SD) PreT PreT
Thickness of UT muscle Mean (SD) 11.4(1.8) 10.6(1.7) 0.712 P< P<
Diameter of MTrP 5.4(1.8) 5.3(1.5) 0.260 0.001 0.001
Mean (SD) VAS(at night) 3.45 ± <0.001 PosT- 2.62 ± <0.001 PosT-
NDI Mean (SD) 15.9(6.2) 15.4(5.5) 0.367 PreT 1.23 PreT 0.98 PreT
PosT 1.45 ± P< 1.86 ± P<
DNG: Dry-needling with exercise group; EG: Exercise-only group; VAS: Visual Third month 1.40 0.001 1.02 0.001
analog scale; UT: Upper trapezius; MTrP: Myofascial trigger point; NDI: Neck 0.85 ± Thr- 1.69 ± Thr-
disability index; p: Homogenity of variances. 1.17 PosT 1.10 PosT
P= P=
0.001 0.248
pain intensity [23,26]. A systematic review on the effects of DN for
Thr- Thr-
myofascial trigger points presented that there was no statistical PreT PreT
improvement in pain intensity at mid-term. However, in the short term, P< P=
DN was found to be effective for reducing pain intensity [27]. 0.001 0.001
Thickness of 11.45 PosT- 10.65 PosT-
Cerezo-Tellez et al. reported the superior efficacy of DN with passive <0.001 <0.001
UT muscle ± 1.79 PreT ± 1.68 PreT
stretching compared to passive stretching alone in reducing the pain in PreT 9.90 ± P< 10.14 P=
patients with chronic nonspecific neck pain at both short and long-term PosT 1.36 0.001 ± 1.60 0.001
follow-ups [14]. Gerber LH. et al. [28] reported the efficacy of DN on Third month 9.76 ± Thr- 9.80 ± Thr-
pain reduction and changing MTrP status from active to latent. In the 1.52 PosT 1.45 PosT
P= P=
current study, DN with exercise therapy was found to be more effective
0.377 0.009
for reducing the pain levels at night, during activity, and at rest than Thr- Thr-
exercise therapy alone. PreT PreT
Ultrasonography has been found to be a highly sensitive method for P< P<
the diagnosis and monitoring of MPS [18]. In the present study, ultra­ 0.001 0.001
Diameter of 5.39 ± <0.001 PosT- 5.33 ± <0.001 PosT-
sonographic evaluation of the diameter of MTrPs and thickness of the UT the MTrP 1.85 PreT 1.54 PreT
muscles was used to determine the effects of DN and exercise therapy in PreT 3.62 ± P< 4.76 ± P=
participants with MPS. Müller et al. [29] evaluated the effectiveness of PosT 1.44 0.001 1.65 0.001
acupuncture and electro-acupuncture treatment on the UT trigger points Third month 3.25 ± Thr- 4.44 ± Thr-
1.41 PosT 1.35 PosT
by ultrasonographic evaluation. According to the results, improvement
P= P=
of tissue conditions was determined at post-treatment evaluation using 0.176 0.046
2D ultrasonographic imaging. Similarly, in the present study, it was Thr- Thr-
found the DN with exercise treatment contributed to the reduction of the PreT PreT
UT muscle thickness and diameter of the MTrPs at short term. It was P< P<
0.001 0.001
observed that the effect of DN with exercise therapy on the UT muscle NDI 15.88 <0.001 PosT- 15.45 <0.001 PosT-
and MTrP continued in the mid-term, but it was not superior to exercise PreT ± 6.22 PreT ± 5.54 PreT
therapy alone. PosT 10.15 P< 11.45 P<
Ziaeifar M. et al. [2] compared the efficacy of dry-needling and Third month ± 6.01 0.001 ± 4.72 0.001
8.06 ± Thr- 9.86 ± Thr-
trigger point compression treatments on neck disability, and they re­
5.15 PosT 4.76 PosT
ported that both treatment methods reduced the neck disability after 3 P< P<
months. In one study which evaluated the effectiveness of DN for 0.001 0.001
chronic nonspecific neck pain on neck disability determined that there Thr- Thr-
was no significant difference between the DN with stretching and PreT PreT
P< P<
stretching only groups at medium (3 months) and long-term follow-up 0.001 0.001
(6 months) [14]. Segura-Orti E. et al. [30] compared the effect of DN and
stretching therapy in participants with MTrPs on UT muscle at DNG: Dry-needling with exercise group; EG: Exercise-only group; VAS: Visual
analog scale; UT: Upper trapezius; MTrP: Myofascial trigger point; NDI: Neck

5
M.D. Korkmaz and C. Medin Ceylan Complementary Therapies in Clinical Practice 47 (2022) 101571

disability index; PreT: Pre-treatment; PosT: Post-treatment; Thr: Third-month; months. Additionally, we found that the reduction of pain intensity and
pa <0.05 is considered as significant (Friedman Test); pb (<0.0167 is consid­ ultrasonographic measurements of MTrPs is possible with only 3 ses­
ered as significant for post-hoc analysis for the Friedman Test). sions of DN therapy in addition to exercise therapy.
The short follow-up period can be shown as a limitation (up to 3
months after sessions). Nevertheless, most studies on DN therapy for
Table 3
myofascial neck pain evaluated its immediate [12,13] or short-term
Pairwise comparison between the treatment sessions in DNG and EG.
effects [12,13]. Additionally, the participants did only the first session
Mean 95% CI for p
of the exercises with an investigator. Also, 2-dimensional ultrasono­
difference difference
graphic imaging of the 3-dimensional trigger points can be counted as a
Lower Upper technical limitation. We aim to use 3-dimensional ultrasonography in
bound bound
future researches. Nonetheless, the reported findings were important for
VAS(at rest) DNG − 2.54 − 2.93 − 2.15 PosT-PreT: understanding the evaluation of MTrP and the efficacy of DN in MPS.
PosT-PreT − 0.70 − 0.97 − 0.42 <0.001*
Thr-PosT − 3.24 − 3.74 − 2.74 Thr-PosT:
Thr-PreT − 1.07 − 1.46 − 0.67 0.811 5. Conclusion
EG − 0.65 − 0.95 − 0.36 Thr-PreT:
PosT-PreT − 1.72 − 2.24 − 1.21 <0.001* The present study demonstrated the efficacy of DN and exercise
Thr-PosT
therapy for MTrPs of UT muscle at short and mid-term. Reduction of
Thr-PreT
VAS(during DNG − 2.70 − 3.28 − 2.10 PosT-PreT:
pain intensity at post-treatment evaluation and 3rd-month follow-up,
activity) PosT-PreT − 1.03 − 1.37 − 0.69 <0.001* and reduction of the ultrasonographic measurements of the thickness
Thr-PosT − 3.73 − 4.25 − 2.62 Thr-PosT: of the UT muscle, and diameter of the MTrPs at post treatment evalua­
Thr-PreT − 1.10 − 1.46 − 0.75 1.000 tion have been observed for DN with exercise therapy. However, both of
EG 1.17 1.55 0.79 Thr-PreT:
the treatment programs had a similar efficacy on neck disability.
− − −
PosT- − 2.27 − 2.87 − 1.68 <0.001*
PreTThr-
PosT Declaration of competing interest
Thr-PreT
VAS(at DNGPosT- − 2.0 − 2.48 − 1.52 PosT-PreT:
night) PreT − 0.60 − 0.91 − 0.30 <0.001*
The authors declare that they have no known competing financial
Thr-PosT − 2.60 − 3.07 − 2.14 Thr-PosT: interests or personal relationships that could have appeared to influence
ThrPreT − 0.76 − 1.07 − 0.44 0.044 the work reported in this paper.
EG − 0.17 − 0.49 − 0.15 Thr-PreT:
PosT-PreT 0.93 1.37 0.49
Acknowledgements
− − − <0.001*
Thr-PosT
Thr-PreT
Thickness of DNG − 1.55 − 2.09 − 0.99 PosT-PreT: This research did not receive any specific grant from funding
UT muscle PosT-PreT − 0.14 − 0.53 0.23 0.004* agencies in the public, commercial, or not-for-profit sectors.
Thr-PosT − 1.69 − 2.35 − 1.03 Thr-PosT:
Thr-PreT − 0.50 − 0.78 − 0.23 0.343
EG − 0.36 − 0.60 − 0.09 Thr-PreT: References
PosT-PreT − 0.86 − 1.16 − 0.56 0.04
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