4 AIM Castro-Sánchez et al.

acupuncture
IN MEDICINE
Original paper

Acupuncture in Medicine

Benefits of dry needling of myofascial 1­–10

https://doi.org/10.1136/acupmed-2017-011504
DOI:10.1136/acupmed-2017-011504
© The Author(s) 2020
trigger points on autonomic function Article reuse guidelines:
sagepub.com/journals-permissions

and photoelectric plethysmography in journals.sagepub.com/home/aim

patients with fibromyalgia syndrome

Adelaida María Castro-Sánchez1,2 , Hector Garcia-López3,

Manuel Fernández-Sánchez1, José Manuel Perez-Marmol2,4,
Guillaume Leonard5, Nathaly Gaudreault5,
María Encarnación Aguilar-Ferrándiz4
and Guillermo Adolfo Matarán-Peñarrocha2,6

Abstract
Background: Fibromyalgia syndrome (FMS) is a condition characterised by the presence of chronic, widespread musculoskel-
etal pain, low pain threshold and hyperalgesia. Myofascial trigger points (MTrPs) may worsen symptoms in patients with FMS.
Objective: The purpose of this randomised controlled trial was to compare the effects of dry needling and transcutaneous
electrical nerve stimulation (TENS) on pain intensity, heart rate variability, galvanic response and oxygen saturation (SpO2).
Methods: 74 subjects with FMS were recruited and randomly assigned to either the dry needling group or the TENS group.
Outcomes measures (pain intensity, heart rate variability, galvanic skin response, SpO2 and photoplethysmography) were
evaluated at baseline and after 6 weeks of treatment. 2×2 mixed-model analyses of variance (ANOVAs) were performed.
Results: The mixed-model ANOVAs showed significant differences between groups for the sensory dimension of pain,
affective dimension of pain, total dimension of pain, visual analogue scale (VAS) and present pain intensity (PPI) (P=0.001).
ANOVAs also showed that significant differences between groups were achieved for very low frequency power of heart
rate variability (P=0.008) and low frequency power (P=0.033). There were no significant differences in dry needling ver-
sus TENS groups on the spectral analysis of the photoplethysmography and SpO2.
Conclusions: This trial showed that application of dry needling therapy and TENS reduced pain attributable to MTrPs in
patients with FMS, with greater improvements reported in the dry needling group across all dimensions of pain. Additionally,
there were between-intervention differences for several parameters of heart rate variability and galvanic skin responses.
Trial registration number: NCT02393352

Keywords
dry needling, fibromyalgia, physical therapy modalities, transcutaneous electrical nerve stimulation, myofascial trigger
points

Accepted: 26 February 2018

1Department 6Andalusian
Health Service, Primary Health Medical, Distrito Sanitario
of Nursing, Physical Therapy and Medicine, University of
Almeria, Almeria, Spain Málaga, Málaga, Spain
2Instituto de Investigación Biosanitaria ibs. Granada, Granada, Spain
3Andalusian Health Service, Hospital de Poniente, Almeria, Spain Corresponding author:
4Department of Physical Therapy, University of Granada, Granada, Spain Adelaida María Castro-Sánchez, Facultad de Ciencias de la Salud,
5École de Réadaptation, Faculté de Médecine et des Sciences de la Santé, Universidad de Almería, Almería 04120, Spain.
Université de Sherbrooke, Sherbrooke, Québec, Canada Email: adelaid@ual.es

Acupuncture in Medicine, 00(0)

2 Acupuncture in Medicine
Introduction
Fibromyalgia syndrome (FMS) is a condition character-
ised by the presence of chronic, widespread musculoskel-
etal pain, low pain threshold and hyperalgesia.1 The
aetiology of FMS is not well defined at present, although
the presence of central neuronal hyperexcitability with
increased central sensitisation to peripheral stimuli has
been observed.2 Myofascial trigger points (MTrPs) may
worsen symptoms in patients with fibromyalgia.3
MTrPs are defined as hyperirritable spots within a taut
band of muscle, which are painful on compression and can
give rise to characteristic referred pain, tenderness and
autonomic phenomena.4 Trigger points are classified into:
active MTrPs, which are characterised by local pain on
pressure and a distinctive referred pain pattern that pro-
duces the clinical symptoms experienced by the patient;
and latent trigger points, which have similar clinical char-
acteristics to active trigger points but do not produce pat-
terns of referred pain.5 Patients with FMS present more
MTrPs compared with healthy subjects.6 The spontaneous
pain they experience can be caused by active MTrPs and
may exacerbate their symptoms.7 Treating MTrPs can
relieve both local and generalised pain symptoms.8
The Electro Interstitial Scan system is a non-invasive,
low cost, user-friendly device that provides data on heart
rate variability, galvanic skin response, oxygen saturation
(SpO2) and photoplethysmography.9 This device has been
widely used in biomedical applications, clinical trials, diag-
nosis and complementary monitoring of children with
attention deficit hyperactivity disorder, study of body com-
position, and as a complementary analysis in digital rectal
exams and prostate specific antigen testing.10–12
Dry needling is a therapeutic procedure that involves the
insertion of a needle, without medication or injection, into
a myofascial trigger point, allowing the mechanical effect
of the needle to deactivate the trigger point and thus achieve
pain relief.13 However, there is limited data on its effects on
the sympathetic nervous system, heart rate, galvanic
response and SpO2.14 The purpose of this randomised study
was to compare the effects of dry needling versus transcu-
taneous electrical nerve stimulation (TENS) on pain inten-
sity, heart rate variability, galvanic skin response and
oxygen saturation, and to conduct a photoelectric plethys-
mographic analysis in patients with FMS.
Methods
Patients with FMS were recruited from the fibromyalgia
associations of Murcia, Almeria and El Ejido (Spain). Study
subjects had received their diagnosis from the rheumatology
units of the Morales Meseguer (Murcia) and Torrecardenas
(Almeria) hospitals. This study was a single blind (outcome
assessor-blinded) comparative effectiveness trial of two
Acupuncture in Medicine, 00(0)
active interventions. The diagnostic criteria were those pro-
posed by the American College of Rheumatology.15
To be included, patients needed to be: (1) diagnosed
with FMS; (2) aged between 18–68 years; (3) report per-
sistent pain, defined as pain when performing activities of
daily living for at least 3 days over a period of 30 days
before intervention; (4) meet at least one indicator of clini-
cally significant pain—requesting assistance from health
professionals, use of drugs for pain on more than one occa-
sion or significant reduction in performance of activities of
daily living; (5) commit to attend morning treatment ses-
sions; and (6) not be engaged in any physical therapy or
sports activity. Exclusion criteria were: (1) rheumatic dis-
eases (for example, rheumatoid arthritis); (2) severe physi-
cal disability; (3) uncontrolled endocrine disorders (eg,
hyperthyroidism, diabetes); (4) toxicological disease (eg,
alcohol or substance abuse); (5) use of pain medication
other than as necessary (excluding long-term narcotics);
(6) tumours; (7) psychiatric disorders (eg, schizophrenia);
(8) pregnancy; (9) presence of metal pins or prosthetic
joints; (10) dermatological lesions; (11) excessive sweat-
ing (hyperhidrosis); and (12) severe joint disease (eg, oste-
oporosis or severe generalised osteoarthritis). Patient
selection was performed in accordance with the Declaration
of Helsinki, and all subjects signed informed consent
before inclusion in the study.
Patients provided clinical and demographic informa-
tion on age, height, weight, gender and level of education.
Pain was evaluated using the Short Form pain scale of the
McGill Pain Questionnaire (SF-MPQ). This instrument
consists of 11 verbal descriptors to assess the sensory
dimension of pain, four for the affective dimension (rang-
ing from 0 to 3 points) and a visual analogue scale (VAS)
to measure the intensity of pain during the preceding week
(scale from 0 to 10). For the evaluative dimension of pain,
the questionnaire contains six verbal descriptors evaluat-
ing present pain intensity (PPI) from 0 (no pain) to 5
(worst pain possible). All females of reproductive age
were evaluated when not in their menstrual phase because
female hormone fluctuations may have an impact on pain
parameters.16,17
Heart rate variability, galvanic skin response, SpO2 and
photoplethysmography were obtained by Electro Sensor
Complex v.2.5. This system is a computer-aided device
consisting of two modules. The first module measures
SpO2% saturation, number of beats, pulse amplitude
graph, photoplethysmogram (waveform of the pulse),
heart rate variability (heart rate variation in frequency and
time) and autonomic nervous system indicators. The sec-
ond module is an impedance system (Interstitial Electro
Scan) that provides galvanic responses at the skin level.
Diastolic and systolic arterial pressure were measured
using an Omron M6 Comfort Blood Pressure Monitor
(HEM-7221-E8 [V]).18
Castro-Sánchez et al. 3
Randomisation
After an initial baseline evaluation, patients were ran-
domised to dry needling or TENS therapy. Both groups
were treated by a physical therapist with over 12 years of
experience in treating patients with chronic pain and FMS.
Randomisation was performed using a computerised ran-
dom number generator before starting data collection by a
researcher not involved in the recruitment or treatment of
patients. Individual patient cards numbered sequentially
with the randomised allocation were prepared. The cards
were sealed inside opaque envelopes. A research assessor,
blinded to the baseline examination, opened the envelopes
and allocated each patient to their corresponding treat-
ment group.
Outcome measures were assessed at baseline (before the
first treatment session) and 24 hours after the 6-week inter-
vention period by an investigator blinded to the randomised
treatment received by each patient.
Interventions
Dry needling.  Active and latent MTrPs were identified and
highlighted in black and red, respectively, on the skin. All
deep dry needling procedures were performed by the same
investigator using Hong’s fast-in, fast-out technique until
a local twitch response was achieved, targeting active and
latent MTrPs, and using an 0.25-gauge sterilised stainless
steel needle 25 mm in length with a disposable guide tube
(Agupung ref A1038P).19 Dry needling was applied to the
following muscle pairs for 30 s: occipital, splenius capi-
tus, sternocleidomastoid (sternal and clavicular branch),
scalene (anterior, middle and posterior), trapezius, supra-
spinatus, infraspinatus, latissimus dorsi, iliocostal, mul-
tifidus (dorsal lumbar and cervical level), quadratus
lumborum, major and minor pectorals, abdominal, del-
toids, triceps, biceps, extensors of the fingers, finger flex-
ors, gluteus, quadriceps, hamstrings, calves and tibialis
anterior. Before needling, the skin was swabbed with
chlorhexidine (2%). Immediately after needling, com-
pression was applied to the treated MTrPs for 15 s, pro-
ducing hypoxia. All patients received one treatment
session every week for 6 weeks.
TENS.  Active and latent MTrPs were labelled in black and
red, respectively, as in the dry needling group, and TensMed
911 (Enraf   Nonius Iberica SA) stimulators were applied.
Each stimulator had two channels with two 2 mm cables
attached to two 32 mm diameter electrodes, giving a total of
four electrodes per stimulator. Two electrodes were applied
to the pain dermatome corresponding to the muscles present-
ing active and latent MTrPs. Muscle pairs were treated in the
following cranial to caudal sequence: trapezius, latissimus
dorsi, gluteus, quadriceps and tibialis anterior. The following
parameters were used: pulse width 200 µs; pulse frequency
100 Hz; and burst frequency 2 Hz for 10 min on each pain
dermatome.20 Before applying the electrodes, the skin was
cleaned with chlorhexidine (2%). Electrostimulation was
then applied to each active and latent MTrP for 10 min. All
patients received one treatment session every week for 6
weeks.
Statistical analysis
Statistical analyses were performed using SPSS statistical
software, version 22.0 (SPSS Inc., Chicago, IL, USA). A
value of P <0.05 was considered statistically significant.
After a descriptive analysis, the normal distribution of vari-
ables was verified by the Kolgomorov-Smirnov test. Mixed
model analyses of variance (ANOVAs) were used to ana-
lyse the time effects between both groups (dry needling vs
TENS therapy) and group interaction effects for the pri-
mary outcome (VAS from the SF-MPQ) and secondary out-
come measurements (heart rate variability, galvanic
response, SpO2 and photoplethysmography) between base-
line and post-treatment. Changes in variable scores within
and between groups were measured by means of a 95% CI
of t-tests for paired or independent samples as appropriate.
Effect sizes were calculated using Cohen’s d coefficient.
Based on best estimates of pre-post improvement after a
dry needling intervention,21 a clinically important difference
of 2.61 points on the pain scale (VAS 0–10) was used to calcu-
late the sample size, using G*power 3.1. A sample size of 10
participants per arm was estimated to provide a 95% CI with a
power of 80%, assuming a significance level (α) of 0.05.
Results
Of the 74 patients with FMS recruited for the present
study, 14 men and 60 women aged from 27 to 58 years
(mean 48.87, SD 6.80 years) met the selection criteria and
were randomly assigned to either the dry needling group
(n=37) or the TENS group (n=37) (see Table 1). A flow
chart of the participants’ recruitment and follow-up is
depicted in Figure 1.
The repeated measures ANOVAs showed significant dif-
ferences between groups for the sensory dimension of pain
(P=0.001), affective dimension of pain (P=0.001), total dimen-
sion of pain (P=0.001), VAS (P=0.001) and PPI (P=0.001).
The between-group effect sizes were large, showing a Cohen’s
d of 1.35 for the sensory dimension, 1.13 for the affective
dimension, 1.33 for the total dimension, 1.43 for the VAS and
1.40 for the PPI dimension of pain. Significant between-group
post-treatment differences are shown in Table 2 (post-inter-
vention values, and scores for between-group changes with
associated 95% CI for the pain dimensions of the SF-MPQ).
Pairwise comparisons to baseline values demonstrated sig-
nificant improvements in the dry needling group for the sen-
sory dimension of pain (P=0.001), affective dimension of pain
(P=0.001), total dimension of pain (P=0.001), VAS (P=0.001)
Acupuncture in Medicine, 00(0)
4 Acupuncture in Medicine

Table 1.  Patient characteristics at baseline.

Dry needling group TENS therapy group

(n=37) (n=37)
Average age (years) 49.35±5.82 47.84±8.12

Age range (years) 30–58 27–57

Weight (kg) 70.38 ± 13.27 70.70 ± 16.02

Height (cm) 162.08 ± 6.46 164.03 ± 8.12

Male/females 9/28 5/32

Educational level (N)

  No studies 15 10

  School level 7 16

  Bachelor level 12 8

  University level 3 3

Values are expressed as absolute and relative frequencies (n=74) for categorical variables and as mean±SD for continuous variables. TENS,
transcutaneous electrical nerve stimulation.

Figure 1.  Design and flow of participants through the trial. TENS, transcutaneous electrical nerve stimulation.

Acupuncture in Medicine, 00(0)

 Table 2.  Baseline, post-treatment, pre-/post-treatment differences and score changes in each group for pain: Short Form of the McGill Pain Questionnaire.
Castro-Sánchez et al.

Outcome/group Baseline 6 weeks Paired t-test Within-group Between-group

post-treatment P values score changes score changes

Sensory dimension of pain (0–33)  

  Dry needling 20.95±6.00 12.51±7.38 0.001* 8.43 (6.49 to 10.38) −8.81 (−11.84 to –5.78)

  TENS therapy 22.24±4.73 21.32±5.58 4.74 (3.34 to 6.14)  

Affective dimension of pain (0–12)

  Dry needling 10.05±2.24 5.51±3.75 0.001* 4.54 (3.52 to 5.56) −3.54 (−5 to −2.08)

  TENS therapy 10.03±1.89 9.05±2.39 2.79 (2.06 to 3.53)  

Total dimension of pain (0–45)

  Dry needling 31±7.06 18.03±10.72 0.001* 12.97 (10.38 to 15.56) −12.35 (−16.67 to −8.03)

  TENS therapy 32.27±6.08 30.38±7.66 7.53 (5.54 to 9.53)  

Visual analogue scale (0–10)

  Dry needling 7.86±1.18 4.81±1.98 0.001* 3.05 (2.31 to 3.80) −2.68 (−3.55 to − 1.80)

 TENS therapy 8.14±1.27 7.49±1.77 1.86 (1.36 to 2.37)  

Present pain intensity (0–5)

  Dry needling 3.49±0.87 2.03±0.99 0.001* 1.46 (1.06 to 1.86) −1.30 (−1.72 to −0.87)

 TENS therapy 3.86±0.67 3.32±0.85 1.01 (0.76 to 1.27)  

*P<0.05.
Values are expressed as mean±SD for baseline and 6 weeks post-treatment and as mean score change (95% CI) for within- and between-group values. TENS, transcutaneous electrical nerve stimulation.

Acupuncture in Medicine, 00(0)

5
6 Acupuncture in Medicine
and PPI (P=0.001); improvements were also observed in the
TENS group for the affective dimension (P=0.005) and total
dimension of pain (P=0.025), as well as the VAS (P=0.03) and
PPI (P=0.001). The effect sizes were large for the dry needling
group (minimum d=1.26, maximum d=1.94) and ranged from
negligible to moderate for the TENS group (minimum d=0.18,
maximum d=0.72) in these pain dimensions of the SF-MPQ.
Significant within-group pre-/post-treatment improvements
are shown in Table 2 (pre-/post-intervention values and scores
for within-group changes with associated 95% CI for the pain
dimensions of the SF-MPQ).
The mixed model ANOVAs showed that significant
differences between groups were achieved for very low fre-
quency power of heart rate variability (VLF) (P=0.008) and
low frequency power (LF) (P=0.033). For these rates,
between-groups differences showed a moderate effect size
(VLF d=0.62; LF d=0.76). Within-group analysis showed a
significant pre-/post-treatment difference in the dry needling
group for Valsalva ratio (P=0.030); significant differences
were also noted in the TENS group for quantity of NN inter-
vals (P=0.025) and for VLF (P=0.021). The effect size for
Valsalva ratio in the dry needling group was small (d=0.24)
and ranged from small to moderate in the TENS group (min-
imum=0.26, maximum d=0.60) (Supplemental Table 1).
The group*time interaction for the 2×2 mixed model
ANOVA showed no significant differences in the dry nee-
dling versus TENS groups in the spectral analysis of the SpO2
and photoplethysmography. However, pairwise comparisons
showed significant differences after dry needling for estimated
DO2 (P=0.014), with a Cohen’s d of 0.29 (small effect size).
Supplemental Table 2 shows baseline, post-intervention,
within-group and between-group differences with associated
95% CI for photoplethysmography and SpO2.
The mixed model ANOVAs only showed significant dif-
ferences between groups for the silver/silver chloride (Ag/
AgCl) forehead electrodes α parameter (EPA-SPA disper-
sion) (P=0.049), but with a between-group Cohen’s d of zero
(negligible effect size). Nevertheless, pairwise comparisons
with baseline values demonstrated significant changes in
the dry needling group for metal hand electrodes SDC+
(P=0.045) and for metal hand electrodes SDC− (P=0.028);
significant differences were also observed in the TENS group
for the Ag/AgCl forehead electrodes α parameter (EPA-SPA
dispersion) (P=0.021) and for δ of conductances (δ left foot–
right foot) (P=0.001). The effect sizes were small for the dry
needling group (minimum=0.29, maximum d=0.33) and
ranged from small to moderate for the TENS group (mini-
mum=0.35, maximum d=0.65). Table 3 shows baseline, post-
intervention, within-group and between-group differences
with associated 95% CI for galvanic skin responses.
Discussion
In the present study, 6 weeks dry needling therapy signifi-
cantly reduced the global, sensory, affective and evaluative
Acupuncture in Medicine, 00(0)
aspects of pain and the present pain intensity in comparison
to the TENS group, showing large between-group differ-
ences. In addition, dry needling showed a moderate differ-
ence compared with the TENS intervention for the very low
and low frequency power of heart rate variability. By con-
trast, the only between-group difference in the galvanic
skin responses was found for the Ag/AgCl forehead elec-
trodes α parameter, showing the EPA-SPA dispersion of the
current, but this was negligible. Both therapies generated
an improvement in all pain subscales, except for the sen-
sory dimension following TENS intervention; however, in
the dry needling group the effect sizes were large, while in
the TENS group they ranged from negligible to moderate.
The dry needling group showed small pre-post intervention
changes for the Valsalva ratio, estimated DO2, and metal
hand electrodes SDC positive and negative. In the TENS
group, the within-group changes ranged from small to
moderate for the quantity of normal-to-normal intervals
and very low power of heart rate variability, EPA-SPA dis-
persion and δ of conductances (δ left foot–right foot).
These results may be explained by the following hypoth-
esis regarding the effect of dry needling therapy: (1) A nor-
malisation of the altered chemical milieu from the MTrP.9,22
(2) A decrease in systemic stress, improving homeostasis
and restoring the normal physiology of soft tissues.9,23 This
therapy elicits a local twitch response that reduces the
trigger points and in turn the local tenderness of the bands
of fibres of MTrPs, decreasing the excessive release of ace-
tylcholine and the activation of nicotinic acetylcholine
receptors, disinhibiting the acetylcholinesterase at the
motor endplates. (3) A reduction of peripheral and central
sensitisation.9 Evidence suggests that dry needling therapy
hyperstimulates the pain-generating area, normalising the
local sensory inputs,9,24 and produces natural opioid-mediated
pain suppression by activating local α–δ nerve fibres.9 There
is also stimulation of the inhibitory interneurons, promot-
ing normal pain transmission to the sensory brain cortex.9,25
Hence, dry needling may have an impact on central pro-
cesses, removing nociceptive inputs and normalising syn-
aptic efficacy.26 (4) Dry needling may also increase local
tissue blood perfusion and produce a relaxation of the sar-
comeres by regulating the interaction of the actin–myosin
complex in the muscle fibre bands containing MTrPs.27
These mechanisms can effect local hypoalgesia in active
and latent trigger points.28 Furthermore, the decrease in the
combination of pain intensity, the number of active MTrPs
and the pressure pain threshold after dry needling therapy
support the relationship between these aspects and segmen-
tal and central sensitisation.27,28
Although both therapies in our study produced a reduc-
tion in pain dimensions in patients with FMS, the effect
sizes were higher after the dry needling therapy than the
TENS intervention. These results are in line with several
studies that have found an immediate reduction in pain
after a dry needling intervention.29–32 The meta-analysis
 Table 3.  Baseline, post-treatment, pre-/post-treatment differences and score changes in each group for galvanic skin responses.

6 weeks Paired t-test Between-group score

Outcome/group Baseline post-treatment P values Within-group score changes changes

Ag/AgCl forehead electrodes SDC+

  Dry needling 3.24±2.52 2.97±2.37 0.351 0.27 (−0.22 to 0.75) 0.40 (−0.45 to 1.26)
Castro-Sánchez et al.

  TENS therapy 2.84±1.54 2.57±1.11 0.27 (−0.24 to 0.78)  

Ag/AgCl forehead electrodes SDC−

  Dry needling 3.19±2.68 2.79 ± 1.60 0.779 0.40 (−0.15 to 0.94) 0.10 (−0.58 to 0.77)

  TENS therapy 2.95±1.77 2.69 ± 1.31 0.26 (−0.29 to 0.81)  

Ag/AgCl forehead electrodes α parameter (EPA-SPA dispersion)

  Dry needling 0.69±0.007 0.69±0.008 0.122 0.001 (− 0.002 to 0.004) −0.003 (−0.007 to 0.001)

  TENS therapy 0.69±0.007 0.69±0.009 −0.004 (−0.006 to −0.001)  

Metal hand electrodes SDC+

  Dry needling 9.86±5.49 8.29±5.40 0.250 1.57 (0.04 to 3.10) 1.33 (−0.95 to 3.62)

  TENS therapy 7.97±4.97 6.96±4.41 1.01 (−0.32 to 2.35)  

Metal hand electrodes SDC−

  Dry needling 22.56±19.40 17.23±13.06 0.890 5.33 (0.61 to 10.06) 0.54 (−7.28 to 8.37)

  TENS therapy 18.38±17.12 16.69±19.98 1.69 (−2.28 to 5.66)  

Metal foot electrodes SDC+

  Dry needling 10.11±4.93 8.79±7.54 0.688 1.33 (−0.85 to 3.50) 0.58 (−2.28 to 3.43)

  TENS therapy 9.58±4.53 8.21±4.35 1.37 (−0.16 to 2.91)  

Metal foot electrodes SDC−

  Dry needling 18.01±15.80 17.39±16.06 0.492 0.63 (−4.79 to 6.05) −2.38 (−9.25 to 4.49)

  TENS therapy 18.61±9.42 19.77±13.47 −1.16 (−5.12 to 2.81)  

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7

(Continued)
 8

Table 3. (Continued)

Acupuncture in Medicine, 00(0)

6 weeks Paired t-test Between-group score
Outcome/group Baseline post-treatment P values Within-group score changes changes

Delta of conductances (δ left foot–right foot)

  Dry needling −10.86±8.73 −13.78±7.90 0.006* 2.92 (−1.10 to 6.93) 4.62 (1.40 to 7.85)

  TENS therapy −14.89±4.93 −18.41±5.88 3.51 (1.51 to 5.52)  

Delta of conductances (δ left foot–right hand)

  Dry needling 11.30±9.50 12.05±8.74 0.407 −0.76 (−3.79 to 2.28) −1.59 (−5.40 to 2.21)

  TENS therapy 12.05±6.72 13.65±7.66 −1.59 (−3.99 to 0.81)  

EIS frequency domain or spectral analysis EIS HF (0.1875–0.50 Hz)

  Dry needling 26.62±8.51 24.59±11.37 0.628 2.03 (−1.05 to 5.10) −1.22 (−6.20 to 3.77)

  TENS therapy 28.38±9.42 25.81±10.11 2.57 (−0.73 to 5.87)  

*P<0.05.
Values are expressed as mean±SD for baseline and 6 weeks post-treatment and as mean score change (95% CI) for within- and between-group values.
Ag/AgCl, silver/silver chloride disposable electrodes (AgCl precipitation); EIS, Electro Interstitial Scan; HF, high frequency; SDC+, conductance in μS of each anode–cathode pathway; SDC−, conductance
in μS of each cathode–anode pathway. TENS, transcutaneous electrical nerve stimulation.
Acupuncture in Medicine
Castro-Sánchez et al. 9
published by Boyles et al.,14 including 19 studies of dry nee-
dling for MTrP, reported that this therapeutic approach is
effective at relieving pain associated with trigger points in
various body parts at several time points. Nine of those
investigations performed between-group comparisons and
reported a larger reduction of pain in dry needling therapy
groups versus control or comparative groups.14 In addition,
15 trials found pre-post treatment differences showing a sig-
nificant decrease in pain compared with baseline.14
Specifically, a research study evaluating the effectiveness of
dry needling and cross tape on MTrPs in spinal muscles in
FMS patients reported a reduction of MTrP algometry in
thoracic and lumbar muscles after the dry needling interven-
tion.27 Fernández-Carnero et al.33 reported a higher pressure
pain threshold in the masseter muscle after dry needling
therapy at active MTrPs.
There were also between-group differences in the very
low and low frequency power of heart rate variability. One
frequently used non-invasive method of autonomic func-
tion and balance assessment is based on power spectral
analysis of heart rate variability, by estimation of VLF and
LF parameters.34,35 Against this background, the between-
group differences of this study can be explained by
increased activity of the parasympathetic system in the dry
needling group in comparison with the TENS group. In turn,
we found a pre-post increase in the VLF parameter in the
TENS group, indicating a reduction of the parasympathetic
response and an increase in sympathetic activity. These
results may explain the greater decrease of pain in the dry
needling group relative to the TENS group, since local tis-
sue blood flow may increase at the site of local MTrPs.34,35
In patients with FMS receiving dry needling therapy, we
also found small differences within group for the Valsalva
ratio, estimated DO2 and metal hand electrodes SDC posi-
tive and negative. To the best of our knowledge, this is the
first study reporting these parameters as outcome measures
after a dry needling intervention.
The current study has some limitations. First, our out-
comes were only collected over a short-term follow-up
period. Second, we applied the dry needling intervention or
TENS therapy in an independent manner, whereas, in the
clinical setting, physical therapists usually use a multi-
modal approach. Future research should evaluate the effec-
tiveness of multimodal approaches for treating FMS
patients, including dry needling therapy combined with
other physical therapy approaches.27 Thirdly, there was not
a control or placebo group with which to perform compari-
sons. Finally, this study had a single blind design. It was
impossible to perform a double blind randomised con-
trolled trial due to the invasive nature of the interventions.
Fourthly, secondary outcomes should be interpreted in an
exploratory manner. Finally, an overall global evaluation of
the pain experience was performed. Future studies should
include a differentiation between pain components attribut-
able to MTrPs versus other aspects of FMS.
Conclusions
This trial has shown that dry needling therapy and TENS
may reduce pain in patients with FMS, with greater
improvements reported in the dry needling group across all
dimensions of pain. Additionally, there were between-inter-
ventions differences for several parameters of heart rate
variability and galvanic skin responses.
Contributors
AMC-S: substantial contributions to conception and design of the
study, writing and revision of the manuscript. HG-L: substantial
contributions to conception and design, acquisition of data, and
drafting of the article. JMP-M: substantial contributions to con-
ception and design, and acquisition of data. MEA-F, GAM-P:
analysis of data, and writing the manuscript. MF-S: contributions
to design and acquisition of data. GL, NG: revised the manuscript
critically for important intellectual content. All authors read and
approved the final version of the manuscript accepted for
publication.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, author-
ship, and/or publication of this article.
Patient consent
Obtained.
Ethics approval
The research committee of University of Almeria approved this
research.
Provenance and peer review
Not commissioned; externally peer reviewed.
Supplemental material
Supplemental material for this article is available online.
ORCID iD
Adelaida María Castro-Sánchez https://orcid.org/0000-0002
-9607-3241
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