912254 AIM Acupuncture in MedicineArias-Buría et al.

acupuncture
IN MEDICINE
Original Paper

Acupuncture in Medicine

Effects of dry needling of active trigger 1­–8

https://doi.org/10.1177/0964528420912254
DOI: 10.1177/0964528420912254
© The Author(s) 2020
points in the scalene muscles in Article reuse guidelines:
sagepub.com/journals-permissions

individuals with mechanical neck pain: journals.sagepub.com/home/aim

a randomized clinical trial

José L Arias-Buría1,2 , Álvaro Monroy-Acevedo3,

César Fernández-de-las-Peñas1,2 , Gracia M Gallego-Sendarrubias4,
Ricardo Ortega-Santiago1,2 and Gustavo Plaza-Manzano5,6

Abstract
Objective: The aim of this study was to compare the effects of dry needling (DN) versus pressure release over scalene
muscle trigger points (TrPs) on pain, related disability, and inspiratory vital capacity in individuals with neck pain.
Methods: In this randomized, single-blind trial, 30 patients with mechanical neck pain and active TrPs in the scalene
musculature were randomly allocated to trigger point dry needling (TrP-DN; n = 15) or pressure release (n = 15) groups. The
DN group received a single session of DN of active TrPs in the anterior scalene muscles, and the pressure release group
received a single session of TrP pressure release over the same muscle lasting 30 s. The primary outcome was pain intensity
as assessed by a numerical pain rate scale (NPRS, 0–10). Secondary outcomes included disability (neck disability index, NDI)
and inspiratory vital capacity. Outcomes were assessed at baseline and 1 day (immediately post), 1 week, and 1 month after
the treatment session. Data were expressed as mean score difference (Δ) and standardized mean difference (SMD).
Results: Patients receiving DN exhibited a greater decrease in pain intensity than those receiving TrP pressure release
at 1 month (Δ 1.2 (95% CI–1.8, –0.6), p = 0.01), but not immediately (1 day) or 1 week after. Patients in the DN group
exhibited a greater increase in inspiratory vital capacity at all follow-up time points (Δ 281 mm (95% CI 130, 432) imme-
diately after, Δ 358 mm (95% CI 227, 489) 1 week after, and Δ 310 mm (95% CI 180, 440) 1 month after treatment)
than those in the pressure release group (p = 0.006). Between-group effect sizes were large at all follow-up time points
(1.1 > SMD > 1.3) in favor of DN.
Conclusion: This trial suggests that a single session of DN over active TrPs in the scalene muscles could be effective at
reducing pain and increasing inspiratory vital capacity in individuals with mechanical neck pain. Future studies are needed
to further confirm these results.

Keywords
dry needling, neck pain, respiratory function, scalene, trigger point release
Accepted: 16 February 2020

6
1
 epartment of Physical Therapy, Occupational Therapy, Rehabilitation
D Instituto de Investigación Sanitaria del Hospital Clínico San Carlos,
and Physical Medicine, Universidad Rey Juan Carlos, Alcorcón, Spain Madrid, Spain
2
Cátedra de Investigación y Docencia en Fisioterapia: Terapia Manual,
Punción Seca y Ejercicio Terapéutico, Universidad Rey Juan Carlos, Corresponding author:
Alcorcón, Spain César Fernández-de-las-Peñas, Departamento de Fisioterapia,
3
Department of Physical Therapy, Hospital Guadarrama, Madrid, Spain Terapia Ocupacional, Rehabilitación y Medicina Física, Universidad
4
Department of Physiotherapy, Universidad Camilo José Cela, Madrid, Rey Juan Carlos, Avenida de Atenas s/n, 28922 Alcorcón, Madrid,
Spain Spain.
5
Department Radiology, Rehabilitation and Physiotherapy, Universidad Email: cesar.fernandez@urjc.es
Complutense de Madrid, Madrid, Spain

Acupuncture in Medicine, 00(0)

2 Acupuncture in Medicine
Introduction
Neck pain has a lifetime and point prevalence almost as
high as low back pain1 and results in substantial disability
and costs to society. In the last Global Burden of Disease
Study, neck pain accounted for the fourth highest number
of years lived with disability.2 A recent systematic review
reported a mean incidence of neck pain of 16.5% with no
clear specific risk factors identified.3
There is evidence supporting the observation that subjects
with neck pain exhibit several muscle disturbances, with
overactivity of superficial neck flexors, for example, sterno-
cleidomastoid and scalene muscles, being one of the most
commonly observed.4 This overactivity could lead to activa-
tion of trigger points (TrPs) in the affected muscles. A TrP can
be defined as a hypersensitive spot in a taut band of skeletal
muscle that is painful on stimulation, elicits a referred pain
sensation, and induces motor disturbances.5 Muscle TrPs can
be clinically classified as active, that is, those inducing
referred pain that reproduces the patient’s symptoms, or
latent, that is, those not responsible for sensory symptoms
experienced by the patient.5 Several studies have shown that
the referred pain elicited by active TrPs within the neck and
shoulder muscles reproduce neck pain symptoms, with the
upper trapezius being most commonly affected.6 Nevertheless,
other neck muscles can also exhibit active TrPs in individuals
with neck pain. In fact, a recent systematic review reported
that the sternocleidomastoid and scalene muscles are also
highly affected by TrPs (48%–65%) in patients with whip-
lash-associated neck pain.7 However, no clear data about the
presence and relevance of TrPs in the scalene muscles are
available in mechanical neck pain.6
Since neck pain is a multifactorial pain condition associ-
ated with changes in cervical range of motion, muscle dis-
turbances, kinesiophobia, and catastrophizing, some authors
have claimed the presence of respiratory dysfunction in this
population.8 Dimitriadis et al.9 found that individuals with
neck pain exhibit reduced spirometry values, such as vital
capacity, expiratory reserve volume, and maximum volun-
tary ventilation, compared to healthy people, and that mus-
cle dysfunction and pain intensity were mostly associated
with respiratory dysfunction. Similarly, the same authors
also observed that individuals with neck pain exhibit weak-
ness of the respiratory muscles.10
The presence of respiratory dysfunction in individuals with
neck pain could be partially attributable to the common function
of the superficial neck flexors, for example, scalene and sterno-
cleidomastoid, on cervical movement and inspiration. It has
been hypothesized that muscle disturbances in the scalene mus-
cles may have a direct effect on respiratory function, although
this is still debatable.11 Therefore, it is possible that the scalene
muscles play a relevant role in both pain and respiratory distur-
bances observed in patients with mechanical neck pain.
Several therapeutic interventions have been proposed to
inactivate TrPs, with manual therapy and dry needling
Acupuncture in Medicine, 00(0)
(DN) being most commonly used.5,12 Interestingly, proper
treatment of upper trapezius TrPs, either with DN or TrP
pressure release,13 has been found to be effective at reduc-
ing neck pain symptoms. No study has previously investi-
gated the effects of DN or TrP pressure release applied over
scalene muscle TrPs in patients with neck pain. Therefore,
the purpose of this randomized clinical trial was to compare
the effects of a single session of TrP-DN versus TrP pres-
sure release over scalene muscle TrPs on clinical outcomes,
that is, pain and related disability, and respiratory outcomes
(i.e. inspiratory vital capacity) in patients with mechanical
idiopathic neck pain. We hypothesized that patients receiv-
ing TrP-DN would experience greater improvements than
those receiving TrP pressure release.
Methods
Study design
This randomized, parallel-group, controlled clinical trial
compared the application of a single session of DN to a
pressure release intervention over active TrPs in the scalene
muscles in patients with mechanical neck pain. The pri-
mary end-point was the change in the intensity of neck pain
over 1 month as assessed by a numerical pain rate scale
(NPRS). Secondary outcomes included related disability
(neck disability index, NDI) and inspiratory vital capacity
(mm). This trial followed the CONSORT (Consolidated
Standards of Reporting Trials) extension for pragmatic
clinical trials.14 The study was approved by the Institutional
Ethical Board of Universidad Rey Juan Carlos, Spain (ref:
URJC 2018-12-10), conducted according to the Declaration
of Helsinki and prospectively registered at ClinicalTrials.
gov (ref. NCT03762252) on 3 December 2018.
Participants
Consecutive subjects with mechanical neck pain referred by
their physician were screened for eligibility criteria from
December 2018 to May 2019. In the current study, mechani-
cal neck pain was defined as neck–shoulder pain symptoms
provoked by neck posture, neck movement, or palpation of
the cervical musculature. Participants were also screened for
signs of vertebrobasilar insufficiency15 and upper cervical
spine ligamentous instability. In addition, they had to exhibit
an active TrP in one scalene muscle reproducing their neck
pain symptoms. Active TrPs were identified following the
diagnostic criteria originally described by Simons et al.5 and
confirmed in a Delphi study:16 (1) presence of a palpable taut
band in the scalene muscle; (2) presence of a sensitive spot
within the taut band; (3) referred pain sensation elicited by
manual palpation of the spot; and (4) reproduction of neck
pain symptoms with referred pain sensation. In general, these
criteria have demonstrated moderate to good inter-examiner
reliability (kappa = 0.64–0.88) when applied by an expert
Arias-Buría et al. 3
clinician.17 Participants were examined for the presence of
TrPs in the scalene musculature by a clinician with more than
20 years of experience in the diagnosis and management of
TrPs. Participants were excluded if they exhibited any of the
following criteria: (1) less than 18 or greater than 45 years of
age; (2) whiplash injury; (3) previous cervical and/or thoracic
surgery; (4) cervical radiculopathy or myelopathy; (5) diag-
nosis of fibromyalgia syndrome; (6) having undergone physi-
cal therapy intervention during the previous 6 months; (7) fear
of needles; (8) any contraindication to DN, for example, use
of anticoagulants or psychiatric disorder; or (9) any respira-
tory disease, for example, chronic bronchitis.
Randomization and masking
Patients were randomly assigned to DN or pressure release
groups. Concealed allocation was conducted using a computer-
generated randomized table of numbers. Individual and
sequentially numbered cards with the random assignment were
prepared, folded, and placed in sealed opaque envelopes. An
external researcher opened the sealed envelope and proceeded
with appropriate allocation. Treatment allocation was revealed
to the participants after collection of baseline outcomes.
Trigger point dry needling
Patients within the DN group received a single session of
trigger point dry needling (TrP-DN) using disposable stain-
less steel needles (0.3 mm × 30 mm; Novasan©, Spain) that
were inserted through the skin overlying the active TrP
located in the anterior scalene muscle (Figure 1). In this
study, the fast-in and fast-out technique described by Hong18
was applied. Once the active TrP was located with flat palpa-
tion of the anterior scalene muscle, the overlying skin was
cleaned with alcohol. The needle was inserted, penetrating
the skin, and advanced to a depth of 10–15 mm into the TrP,
until the first local-twitch response was obtained. Hong18
suggested that local-twitch responses should be elicited dur-
ing the needling intervention for a successful outcome; how-
ever, no consensus exists in how many local-twitch responses
are needed to obtain a positive outcome.19 Once the first
local-twitch response was obtained, the needling was manip-
ulated in and out of the anterior scalene muscle (3–5 mm ver-
tical motions, no rotations) at approximately 1 Hz for 25–30 s.
This time period permitted at least 2–3 local-twitch responses,
which is reportedly sufficient to obtain a positive outcome in
patients with mechanical neck pain.20
TrP pressure release
Patients within the pressure release group received a single
session of TrP pressure release over the anterior scalene
muscle. Gay et al.21 found evidence supporting the use of
muscle-biased manual therapies, including TrP pressure
release, for pain sensitivity. Briefly, the pressure was
Figure 1.  Trigger point dry needling (TrP-DN) applied over
the anterior scalene muscle of a patient with mechanical
neck pain.
progressively increased over the TrP until the clinician’s
finger encountered an increase in tissue resistance (barrier).
This pressure was maintained until the clinician perceived
relief of the taut band. At that time, the pressure was
increased again until the clinician felt an increase in tissue
resistance. This process was repeated for 30 s.
Outcome measures
Outcomes were assessed at baseline (before), 1 day (imme-
diately post), 7 days (1 week), and 30 days (1 month) after
the intervention by an assessor blinded to the treatment
allocation group.
The primary outcome in the current trial was neck pain
intensity. Participants rated their intensity of their neck pain
at rest on an 11-point NPRS (0 = no pain, 10 = maximum
pain).22 It has been found that the minimal clinically impor-
tant difference (MCID) for the NPRS in patients with
mechanical neck pain is 2.1 points.23
Secondary outcomes included neck pain–related disabil-
ity (NDI) and inspiratory vital capacity. The NDI is a self-
administered questionnaire consisting of 10 questions
addressing functional activities as well as pain intensity, con-
centration, and headache.24 The possible responses for each
question range from no disability (0) to total disability (5).
The NDI is scored from 0 to 50, with higher scores indicating
greater disability. The MCID for the NDI in patients with
neck pain has been estimated at 7 points.25 Due to the fact
that the NDI assesses functional activities during the previ-
ous week, it was not assessed 1 day after the intervention.
Maximum inspiratory vital capacity, that is, the maximum
amount of air that can be inhaled after a full expiration, was
assessed with an incentive spirometer DHD Coach 2® (Smiths
Medical, USA) according to the manufacturer’s instructions
Acupuncture in Medicine, 00(0)
4 Acupuncture in Medicine
Table 1.  Baseline characteristics by treatment assignment.
Dry needling group
(n = 15)
Gender (male/female) 10 / 5
Age (years) 21 ± 3
Weight (kg) 63 ± 5.1
Height (cm) 174 ± 7.5
2
Body mass index (kg/cm ) 20.9 ± 2.4
Months with neck pain 7.5 ± 1.3
Mean pain intensity (NPRS, 0–10) 5.5 ± 1.4
NDI (0–50) 21.7 ± 2.2
Inspiratory vital capacity (mL) 3502 ± 661
NPRS: numerical pain rating scale; NDI: neck disability index.
and following American Thoracic Society and European
Respiratory Society recommendations.26 Participants were
seated comfortable with a nose clip to avoid any potential air
leakage. They were asked to put their mouths around the tube
and expire fully and then urged to take a deep breath with no
hesitation. They were verbally encouraged to ensure maximal
performance in all attempts. The maximum score of three
acceptable values was considered in the main analysis.
Treatment side effects
Patients were asked to report any adverse event that they
experienced after the needling intervention and during the
1-month follow-up. In this study, an adverse event was
defined as sequelae of medium-term duration with any
symptom perceived as unacceptable to the patient and
requiring further treatment.27 Adverse effects were self-
reported by the patients and reported to an external clinician
during the study period.
Sample size determination
The sample size was calculated using Ene 3.0 software
(Autonomic University of Barcelona, Spain). Assuming a
standard deviation of 1.6, a two-tailed alpha level (α) of
0.05, and a desired power (1 – β) of 90%, it was estimated
that at least 14 subjects per group would be required to detect
a difference of 2.1 units (MCID) on the 11-point NPRS.23
Statistical analysis
Statistical analysis was performed using the Statistical Package
for the Social Sciences (SPSS) version 22.0 (SPSS Inc.,
Chicago, IL, USA), and it was conducted according to the
principle of intention-to-treat, with participants analyzed in the
Acupuncture in Medicine, 00(0)
Pressure release group p-value
(n = 15)
11 / 4 0.628
22 ± 2 0.726
62 ± 7.2 0.799
172 ± 9.0 0.674
21.3 ± 2.3 0.514
8.0 ± 1.1 0.501
5.7 ± 1.7 0.659
20.0 ± 2.1 0.686
3438 ± 595 0.681
groups to which they were originally allocated. Means with
standard deviations or 95% confidence intervals were calcu-
lated. The Kolmogorov–Smirnov test revealed a normal distri-
bution of the quantitative variables (p  > 0.05). Baseline
demographic and clinical data were compared between groups
using independent Student’s t-tests for continuous data and χ2
tests of independence for categorical data. Different 4 × 2
repeated-measured analysis of covariance (ANCOVA) with
time (baseline, immediately post, 1 week, and 1 month after)
as the within-subject factor, group (DN or pressure release) as
the between-subject factor with adjustment for baseline data,
was used to evaluate between-group differences in pain inten-
sity and inspiratory vital capacity. A 3 × 2 repeated-measures
ANCOVA with time (baseline, 1 week, and 1 month after) as
the within-subject factor and group (DN or pressure release) as
the between-subject factor, with adjustment for baseline data,
was used to evaluate between-group differences in related dis-
ability. The hypothesis of interest was the group × time inter-
action with a Bonferroni-corrected alpha of 0.0125 (four time
points). To enable comparison of between-group effect sizes,
standardized mean differences (SMDs) for the scores were
calculated by dividing mean score differences by the pooled
standard deviation.
Results
Between December 2018 and May 2019, 50 consecutive
patients with neck pain were screened for eligibility crite-
ria. Of which, 30 (mean age = 21 years, 30% female) satis-
fied all criteria, agreed to participate, and were randomly
allocated into DN (n = 15) or pressure release (n = 15)
group. Randomization resulted in similar baseline features
with no significant differences (Table 1). The reasons for
ineligibility can be found in Figure 2, which provides a
flow diagram of patient recruitment and retention. Six
Arias-Buría et al. 5
Figure 2.  Flow diagram of patients throughout the course of the study.
NDI: neck disability index. TrP: trigger point.
patients (40%) assigned to the TrP-DN group experienced
post-needling soreness, but it resolved spontaneously
within 36–48 h. No other adverse event was reported by
any patient during the study.
Adjusting for baseline outcomes, the mixed-model
ANCOVA revealed significant group × time interactions
for neck pain intensity (F = 6.750, p = 0.01) and inspiratory
vital capacity (F = 8.876, p = 0.006). Patients receiving
TrP-DN exhibited a greater decrease in neck pain intensity
than those receiving TrP pressure release 1 month after
treatment (Δ = 1.2, 95% CI = (–1.8, –0.6)) but not imme-
diately (1 day) or 1 week after treatment. Similarly, patients
in the TrP-DN group exhibited a greater increase in inspir-
atory vital capacity at all follow-up periods (Δ = 281 mm
(130, 432) immediately after, Δ = 358 mm (227, 489)
1 week after, and Δ = 310 mm (180, 440) 1 month after;
p < 0.01) than those in the TrP pressure release group
(Table 2). Between-group effect sizes were large at all fol-
low-up periods (1.1 > SMD > 1.3) in favor of the DN
group.
Discussion
The current clinical trial found that a single session of DN
over active TrPs in the scalene muscles was more effective
than pressure release at reducing pain and increasing inspira-
tory vital capacity in individuals with mechanical neck pain.
This is the first trial investigating the effect of DN of the
scalene muscles in patients with mechanical neck pain. The
data indicate that patients receiving a single session of
TrP-DN experienced statistically and clinically significant
Acupuncture in Medicine, 00(0)
6 Acupuncture in Medicine

Table 2.  Primary and secondary outcomes at baseline, 1 day, 1 week, and 1 month after treatment and within-group mean scores by
randomized treatment assignment.

Outcomes Timeline scores: mean ± SD (95% CI)

Within-group changes in score: mean (95% CI)

Trigger point dry needling Trigger point pressure release

a
Intensity of neck pain (NPRS, 0–10)
 Baseline 5.5 ± 1.4 (4.7, 6.3) 5.7 ± 1.7 (4.9, 6.5)
  One day after 4.7 ± 2.1 (3.6, 5.8) 5.1 ± 1.9 (4.0, 6.2)
  Change baseline → 1 day –0.8 ± 0.2 (–1.2, –0.4) –0.6 ± 0.2 (–1.0, 0.2)
  One week after 3.8 ± 2.0 (2.8, 4.8) 4.8 ± 1.7 (3.8, 5.8)
  Change baseline → 1 week –1.7 ± 0.2 (–2.1, –1.3) –0.9 ± 0.3 (–1.3, –0.5)
  One month after 3.4 ± 2.2 (2.2, 4.4) 4.8 ± 2.1 (3.7, 5.9)
  Change baseline → 1 month –2.1 ± 0.3 (–2.6, –1.6) –0.9 ± 0.4 (–1.4, –0.4)
NDI (0–50)
 Baseline 21.7 ± 2.2 (15.6, 27.8) 20.0 ± 2.1 (14.0, 26.0)
  One week after 17.9 ± 1.1 (12.4, 23.4) 19.1 ± 1.9 (14.1, 24.1)
  Change baseline → 1 week –3.8 ± 2.1 (–6.1, –1.5) –0.9 ± 1.1 (–1.8, 0.0)
  One month after 16.0 ± 2.0 (11.4, 20.6) 16.0 ± 1.9 (11.8, 20.2)
  Change baseline → 1 month –5.7 ± 2.8 (–9.6, –1.8) –4.0 ± 3.0 (–6.2, –1.8)
a
Inspiratory vital capacity (mL)
 Baseline 3502.0 ± 661.0 (3169.5, 3834.5) 3438.0 ± 595.0 (3105.0, 3771.0)
  One day after 3658.0 ± 522.5 (3358.0, 3958.0) 3313.0 ± 607.9 (3013.5, 3612.5)
  Change baseline → 1 day 156.0 ± 126.0 (52.0, 260.0) –125.0 ± 116.0 (–191.0, –59.0)
  One week after 3762.0 ± 446.8 (3455.5, 4068.5) 3340.0 ± 688.5 (3033.0, 3647.0)
  Change baseline → 1 week 260.0 ± 222.0 (131.0, 389.0) –98.0 ± 112.0 (–209.0, 13.0)
  One month after 3729.0 ± 496.5 (3411.5, 4046.5) 3355.0 ± 688.0 (3038.0, 3673.0)
  Change baseline → 1 month 227.0 ± 180.0 (105.0, 349.0) –83.0 ± 121.0 (–213.0, 47.0)

CI: confidence interval; NPRS: numerical pain rating scale; NDI: neck disability index; ANCOVA: analysis of covariance.
a
Statistically significant differences between groups (ANCOVA, p < 0.01).

decreases in neck pain, as measured by the NPRS, particu-
larly 1 month after the intervention with large between-
group effect sizes when compared to the application of TrP
pressure release over the same muscle; however, it should
be recognized that this difference was lower than the estab-
lished MCID for this outcome measure.23 In addition, no
significant changes in related disability were found, sug-
gesting a small clinical effect. These findings may be
related to the fact that we applied only one session. Previous
studies supporting the positive effects of TrP-DN for the
management of neck pain have used more than one
session.28,29 It is possible that a greater number of sessions
of DN over scalene TrPs could have led to greater between-
group changes. Furthermore, we only treated one muscle.
Therefore, clinicians should consider applying DN (or
pressure release) to all muscles in which TrPs reproduce the
symptoms of a patient with mechanical neck pain. Most
studies have only treated one muscle, namely, the upper
trapezius.13,28,29
An interesting finding of this trial was the inclusion of
respiratory outcomes; to our knowledge, no previous
study has investigated this. We observed that patients who

Acupuncture in Medicine, 00(0)

Arias-Buría et al. 7
received DN showed larger improvements in inspiratory
vital capacity than those receiving pressure release. These
findings may be related to the fact that we applied the
needling intervention over the scalene muscles, which are
involved in maintenance of not only cervical spine but
also respiratory function.11 Since superficial neck flexors,
such as the scaleni, usually exhibit overactivity in patients
with neck pain symptoms,4 it is possible that the presence
of TrPs in these muscles could be related to the presence
of respiratory dysfunction previously found in this
population.8–10 In line with this hypothesis, TrPs are not
just associated with sensory symptoms but also with
motor disturbances including altered muscle activation
patterns,30 accelerated fatigability,31 and increased co-
antagonist activation.32 Since DN is able to decrease mus-
cle taut band-related stiffness33 and to restore sarcomere
length,34 these changes could lead to better respiratory
dynamics, explaining the findings observed in the current
clinical trial. The presence of respiratory dysfunction and
the potential for it to improve with musculoskeletal treat-
ment may lead to incorporation of assessment or treat-
ment of respiratory outcomes into physical therapy
practice of individuals with mechanical neck pain. Future
trials should investigate the association between changes
in clinical and respiratory outcomes.
The results of this randomized controlled trial should
be considered according to its potential limitations. First,
we could not exclude a potential placebo effect of the nee-
dling procedure, since no placebo or sham needling was
used.35 Second, we did not assess the expectations of the
patients in relation to the treatment, which could have
influenced the results.36 Third, only the anterior scalene
muscle was needled; this procedure does not represent
common clinical practice, since other muscles are often
treated in patients with neck pain. Fourth, we included a
follow-up period of just 1 month, so we do not know
whether long-term evolution of the condition would
exhibit the same tendency. Fifth, we just applied a single
session of each intervention. It is possible that a greater
number of sessions would lead to different outcomes. In
addition, we did not control for other potential treatments
that the patients had received. It is plausible that combin-
ing DN with other interventions, for example, spinal
manipulation and exercise, would potentiate the out-
comes. Finally, the sample size was relatively small and
some secondary outcomes are likely underpowered; how-
ever, the fact that statistically and clinically significant
results were observed in some outcomes suggests that a
larger sample may not alter the direction of the results.
Future studies should include large sample sizes, multiple
and multimodal treatment sessions, a greater number of
clinicians, and long-term follow-up to confirm the results
of the current trial.
Conclusion
The results of this randomized clinical trial found that a
single session of DN of active TrPs in the anterior scalene
muscle was more effective than a single session of manual
pressure release over the same muscle in terms of reducing
pain intensity and increasing inspiratory vital capacity in
individuals with mechanical neck pain. Future trials are
required to further confirm these results.
Contributors
All authors contributed to the study concept and design. JLAB,
AMA, and CFdlP did the main statistical analysis. JLAB, GMGS,
and ROS contributed to literature review and interpretation of data.
CFdlP and GPM contributed to draft the report. CFdlP, GMGS,
ROS, and GPM provided administrative, technical, and material
support. CFdlP and GPM supervised the study. All authors revised
the text for intellectual content, and read and approved the final
version of the manuscript accepted for publication.
Declaration of conflicting interests
The authors declared the following potential conflicts of interest
with respect to the research, authorship, and/or publication of this
article: Dr Fernandez-de-las-Penas is an instructor in Trigger
Point Therapy and receive royalties from published books.
Funding
The authors received no financial support for the research, author-
ship, and/or publication of this article.
ORCID iDs
José L Arias-Buría https://orcid.org/0000-0001-8548-4427
César Fernández-de-las-Peñas https://orcid.org/0000-0003-
3772-9690
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