Musculoskeletal Science and Practice 68 (2023) 102872

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Musculoskeletal Science and Practice

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

Original article

Effectiveness of different percutaneous electrolysis protocols in the

endogenous modulation of pain: A Double-Blinded Randomized
Clinical Trial
Juan L. Sánchez-González a, Víctor Navarro-López b, c, Laura Calderón-Díez a,
Sergio Varela-Rodríguez a, César Fernández-de-las-Peñas c, d, *, José L. Sánchez-Sánchez a
a
Department of Nursery and Physiotherapy, Faculty of Nursery and Physiotherapy, University of Salamanca, 37007, Salamanca, Spain
b
International Doctoral School, Faculty of Health Sciences, Rey Juan Carlos University, 28922, Madrid, Spain
c
Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Rey Juan Carlos University, Madrid, Spain
d
Cátedra de Investigación y Docencia en Fisioterapia: Terapia Manual y Punción Seca, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain

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

Keywords: Objective: This randomized clinical trial investigated if the application of percutaneous electrolysis (PE) enhances
Pain endogenous pain mechanisms (EPM) when compared with a simple needle application (acting as sham).
Electrolysis percutaneous Methods: Forty-six asymptomatic subjects, aged 18–40 years, were randomized into three groups receiving a
Endogenous pain
single ultrasound-guided PE intervention consisting of a needle insertion on the lateral epicondyle: sham
Randomized controlled trial
(without electrical current), low-intensity (0.3 mA, 90s), or high-intensity (three pulses of 3 mA, 3s) PE.
Widespread pressure pain thresholds (PPT), conditioned pain modulation (CPM), and temporal summation (TS)
were bilaterally assessed in the lateral epicondyle, bicipital groove, transverse process of C5 and tibialis anterior
muscle. Outcomes were obtained by an assessor blinded to the treatment allocation of the subjects.
Results: No significant changes in CPM were observed in either group (omnibus ANOVA all, P > .05). A signif­
icant bilateral increase in PPT in the lateral epicondyle in the high intensity group as compared with the sham
group was observed (P < .01). A significant decrease of TS in both low (P = .002) and high (P = .049) intensity
groups on the right, but not on the left, tibialis anterior was also observed when compared with the sham group.
Conclusions: One session of PE is able to slightly stimulate modulatory pathways related to nociceptive gain,
particularly pressure pain sensitivity and temporal summation but not conditioning pain modulation, when
compared with a sham needle intervention, with changes even contralaterally. No significant differences were
found between low- and high-intensity doses of percutaneous electrolysis.

1. Introduction Scientific evidence concerning PE has increased in the last decade.

Percutaneous electrolysis (PE) is an ultrasound-guided needling
intervention that involves the application of a galvanic electrical current
through a solid filament needle (de la Cruz Torres et al., 2016; García
Bermejo et al., 2018; Valera-Garrido and Minaya-Muñoz, 2016). This
technique combines the mechanical stimulation produced by the needle
and the electrical/biochemical stimulation by the electrical current (de
la Cruz Torres et al., 2016; Valera-Garrido and Minaya-Muñoz, 2016).
PE is mainly used for treating musculoskeletal disorders with the aim of
reactivating a local inflammatory response and generating an analgesic
effect (Abat et al., 2014a,b; Valera-Garrido and Minaya-Muñoz, 2016).
The clinical effects of PE have been evaluated when applied to different
tissues such as tendons (Moreno et al., 2017), muscles (Arias-Buría et al.,
2015), or nerves (Margalef et al., 2020), and some musculoskeletal pain
conditions such as patellar tendinopathy, lateral epicondylalgia, shoul­
der pain, temporomandibular pain or chronic whiplash syndrome have
shown clinical improvement with PE treatment. A recent meta-analysis
has found moderate-quality evidence supporting a positive effect of
ultrasound-guided PE for decreasing pain and related-disability in
musculoskeletal pain (Arias-Buría et al., 2015; Gómez-Chiguano et al.,
2021).
Nevertheless, the underlying mechanisms of this technique are not

* Corresponding author. Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Avenida de Atenas s/n, 28922, Alcorcón, Madrid, Spain.
E-mail address: cesar.fernandez@urjc.es (C. Fernández-de-las-Peñas).

https://doi.org/10.1016/j.msksp.2023.102872
Received 29 May 2023; Received in revised form 28 September 2023; Accepted 10 October 2023
Available online 11 October 2023
2468-7812/© 2023 Elsevier Ltd. All rights reserved.
J.L. Sánchez-González et al.
still completely defined and both mechanical and biochemical effects
are currently proposed. In fact, PE is considered a non-thermal inter­
vention [9] inducing cell necrosis throughout the electrolytic reaction
produced by the electrical current flow through the needle. Using the
cathode as an active electrode in a saline solution, PE would be able to
generate a controlled inflammatory response, to create a change in pH
allowing phagocytosis of degenerated tissue and permit a specific pos­
terior repair (Abat et al., 2014a,b; Mattiussi and Moreno, 2019; Rodrí­
guez-Huguet et al., 2020a,b; Zhao, 2009). Basic research papers have
investigated the histologic and molecular response produced by the
application of PE in collagenase-induced tendinopathy in rats and have
reported an increase in the expression of some genes associated with
collagen regeneration and remodeling of extracellular matrix (Abat
et al., 2014a,b; Sánchez-Sánchez et al., 2020).
Another potential mechanism of action of PE is a neurophysiological
effect. This hypothetical effect is integrated into a pain neuroscience
paradigm and has also been suggested for other needling techniques
such as dry needling, acupuncture, or electro-acupuncture (Cagnie et al.,
2013; Chou et al., 2012; Fernández-de-Las-Peñas & Nijs, 2019; Leung,
2012). Pain is a complex phenomenon that can be modulated by several
and dynamic factors. Based on the results from experimental and clinical
studies, it is accepted that endogenous pain modulatory mechanisms
(EPM) can increase or inhibit the experience of pain (Yarnitsky et al.,
2015; Kennedy et al., 2016). Pain modulation starts in the peripheral
nervous system at the level of free nerve endings, however, the main
modulation capacity to inhibit or facilitate the nociceptive stimulus and
response is found in the central nervous system (Moana-Filho et al.,
2018). Today, conditioned pain modulation (CPM) and temporal sum­
mation (TS) are considered potential indicators of EPM (Kennedy et al.,
2016; Moana-Filho et al., 2018; Yarnitsky et al., 2015). It has been
proposed that EPM efficacy may predict the analgesic effect in response
to treatment and that even some therapies are able to potentiate the EPM
(Yarnitsky, 2015). The role of neurophysiological effect of some thera­
pies, such as exercise, in EPM has been extensively studied (Meeus et al.,
2015a; Vaegter et al., 2020). In fact, just one study has investigated the
short-term effects of PE on EPM, however, this study only analyzed
changes in the same side of the intervention (Varela-Rodríguez et al.,
2022). Hence, investigating bilateral changes would further support an
effect of PE on EPM.
The primary aim of this randomized clinical trial is to investigate if
the application of percutaneous electrolysis enhances EPM by inducing
bilateral generalized changes when compared with a simple needle
application. The secondary aim is to determine if the effects on EPM are
different between the application of two different protocols (i.e., low
intensity or high intensity of the electrical current) of PE.
2. Methods
2.1. Study design
A double-blind randomized controlled trial was conducted to
compare to compare the effects of different PE protocols on EPM in a
sample of healthy individuals. The development of this project took
place at the Faculty of Nursing and Physiotherapy of the University of
Salamanca (Spain). The study was approved by the Ethics Committee of
University of Salamanca (number 550/2021) and was conducted in
accordance with the Declaration of Helsinki. The reporting of this study
is presented according to the Consolidated Standards of Reporting Trials
(CONSORT) 2010 Statement (Zwarenstein et al., 2008). The trial was
registered in ClinicalTrials.gov with the registration number
NCT04710992.
2.2. Participants
A sample of asymptomatic student volunteers from the University of
Salamanca were recruited via email and social networks between
2
Musculoskeletal Science and Practice 68 (2023) 102872
October 2022 and December 2022. Inclusion criteria consisted of: (a)
age between 18 and 30 years and (b) both sexes. Exclusion criteria
included: (a) previous or current history of lateral epicondylalgia; (b)
any pathology or process causing pain (acute/subacute or chronic pain
condition); (c) potential skin alterations; (d) any underlying medical
condition affecting pain processing (e.g., rheumatoid arthritis, fibro­
myalgia); (e) medical or physiotherapeutic treatment in the previous
week; (f) caffeine intake in the 2 h prior to measurement; (g) belone­
phobia or fear of needles; (h) cognitive and sensory disorders; (i) intense
physical activity the day of test; (j) neurological, cardiovascular or
metabolic diseases; or (k) pregnancy. All participants who met the in­
clusion criteria received an explanation of the procedure and those who
chose to participate signed a written informed consent form before any
data were collected.
2.3. Allocation and randomization
Randomized concealed assignment was performed with GraphPad
Software Inc, San Diego, CA, USA, generating a random table of
numbers. Subjects were randomly assigned to one of the following three
groups: 1, sham group; 2, low-intensity group; or 3, high-intensity
group. The randomization procedure was conducted by a researcher
not involved in any other aspect of the experiment. Individual,
sequentially numbered cards with the random assignment were folded
into sealed opaque envelopes. The therapist opened the corresponding
envelope after baseline data collection.
2.4. Blinding
Both the evaluator and study participants were unaware of the group
assignment. The person in charge of conducting the intervention was the
only person who was aware of the group assignment and was not
involved in any other aspect of the research such as data analysis or data
collection. Statistical analysis was performed by an independent
researcher who was also blinded to group allocation and was not either
involved in other aspects of the study.
2.5. Interventions
In this randomized clinical trial, all groups (sham, low-intensity,
high-intensity) received a single session of an ultrasound-guided nee­
dle intervention on the common extensor tendon of the lateral epi­
condyle on the dominant (right) side. The intervention was performed
by a physiotherapist with more than 15 years of experience in PE. The
participants were lying comfortably in the supine position with the right
elbow on the stretcher in a 15◦ -20◦ flexion position and the forearm in
pronation. The same protocol described by Rodríguez-Huguet et al.
(2020) was followed, by inserting a 0.3 × 25 mm acupuncture needle at
45◦ to the skin in the direction of the lateral epicondyle to reach the deep
surface of the common extensor tendon under ultrasound guidance
(Fig. 1). The sham group did not receive any electrical current, just the
needle insertion; the low-intensity group received an electrical galvanic
current at an intensity of 0.3 mA for 90s; whereas the high-intensity
groups received three pulses of 3 mA for 3s each of electrical galvanic
current.
2.6. Outcome measures
All outcomes were evaluated before (3min) and immediately after
(2min) each intervention by an assessor blinded to the treatment allo­
cation group. The trial was always performed in the same room at the
same time hour and at the same temperature, due to the influence of the
circadian rhythm on pain system, specifically on the descending pain
modulatory system (Bumgarner et al., 2021).
Outcomes included widespread pressure pain thresholds (PPT),
conditioned pain modulation (CPM), and temporal summation (TS). A
J.L. Sánchez-González et al. Musculoskeletal Science and Practice 68 (2023) 102872

the difference between the score of the last (10th) and the first (1st)
pressure stimuli.
All measurements were performed first on the left side and then on
the right side before and after the intervention. The pressure cuff for the
calculation of CPM was always located on the left side.

2.7. Intervention side effects

Participants were asked to report any adverse events they experi­

enced during the study. Adverse event was defined as any symptom
potentially perceived as distressing and unacceptable to the patient
immediately or later during the following 7 days after the intervention
(Carlesso et al., 2010).

2.8. Sample size determination

We calculated the sample size based on the results of Varela-Ro­

dríguez et al. (2022), estimating an effect size of 0.25 (Cohen’s d) for
Fig. 1. Ultrasound-guided percutaneous electrolysis on the lateral epiconydle.
between-group differences in CPM using a two-way ANOVA model, with
The needle reached the deep surface of the common extensor tendon.
a statistical power of 80% and an alpha error of 0.05, for 3 groups, and 2
measurements. The estimated sample size was 42 subjects, considering
digital pressure algometer (Force One FDIX, Wagner Instruments,
10% due to possible dropouts, a sample of 46 subjects was obtained. The
Greenwich, CT, USA) with a 1 cm2 round rubber surface was used in all
GPower 3.1 program (Düsseldorf, Germany) was used to calculate the
procedures. Outcomes were always evaluated in the same order both at
sample size (Faul and Lang, 2009).
baseline and after the intervention. Each outcome variable was bilat­
erally assessed by algometry at the common extensor tendon of the
2.9. Statistical analysis
lateral epicondyle (treatment area), bicipital groove (proximal-related
segmental area), transverse process of C5 vertebra (remote-segmental
Data were analyzed by an independent statistician using IBM-SPSS
related area) and tibialis anterior muscle (distal unrelated area). All
software (IBM Corp. Published 2019. IBM SPSS Statistics for Windows,
locations were marked with a pen to evaluate all measurements at the
version 29.0. Armonk, NY, USA: IBM Corp.). The significance level was
same points.
set at 0.05 and 95% confidence interval limits for all analyses. Changes
The primary outcome was CPM and it was assessed following com­
in outcomes were analyzed according to the intention-to-treat principle.
mon test recommendations (Yarnitsky et al., 2015). The conditioned
The assumption of normality of all variables was evaluated with the
stimulus was achieved by means of an ischemic pain provoked by a
Shapiro-Wilk test and by plotting the data distributions. A descriptive
pressure cuff placed on the left arm. Insufflations with the pressure cuff
analysis of the demographic and baseline characteristics of the sample
of about 10–20 mmHg were performed until the subject felt the first
was performed, calculating mean and standard deviation for continuous
sensation of pain following previous studies (Tobbackx et al., 2013).
variables that followed a normal distribution, the median and inter­
Subsequently, the pressure exerted by the cuff was maintained for
quartile range for continuous variables that did not follow a normal
approximately 30 s and then adjusted to evoke a subject-perceived pain
distribution, and the absolute number and relative frequency percentage
intensity of 4/10 (Nir and Yarnitsky, 2015). When the subject perceived
for categorical variables. All variables followed normal distribution;
that intensity of pain, PPTs were repeated again at the 8 marked points
accordingly, parametric tests were used in the analyses.
(conditioned PPTs). The CPM score was calculated as the difference
A one-way repeated measure analysis of variance (ANOVA) was used
between conditioned and unconditioned PPT scores. A positive score
to identify possible baseline differences among the three groups. A 3-
(conditioned PPT>unconditioned PPT) suggests activation of CPM,
way omnibus mixed analysis of variance (ANOVA), with group (sham,
whereas a negative score (conditioned PPT<unconditioned PPT) sug­
high intensity, or low intensity) as the inter-subject factor, and time
gests impaired CPM.
(pre-intervention, or post-intervention) and site (dominant side, or non-
Secondary outcomes included widespread PPTs and TS of mechani­
dominant side) as the intra-subject factors and all baseline data as
cal stimuli. Pressure was applied perpendicularly over the eight points
covariates was used to determine the effect of each intervention. An
described above at a rate of approximately 1 kg/cm2 per second until the
alpha index of 0.05 was adopted for the analysis. Tukey’s Honestly-
subject reported the slightest perception of pain. At that time, the
significant-difference test was used for post hoc comparison. Mean dif­
algometer was removed and the pressure was recorded. Two measure­
ferences and 95% confidence intervals (CI) are presented to demonstrate
ments were taken at each point assessed with a 30 s interval to avoid
the magnitude and significance of any pairwise differences. The effect
temporal summation (Nie et al., 2005), and the mean was used for
size (Cohen’s d) was calculated for the significant variables, being
analysis. If there was a difference of more than 1 kg/cm2 between the
considered as small (0.20–0.49), medium (0.50–0.79) or large.
two measurements at the same point, a third measurement was ob­
tained. If needed, the final PPT value was determined after excluding the
3. Results
most extreme measurement and calculating the mean of the other two.
Widespread PPT was assessed before CPM to obtain baseline (uncondi­
3.1. Sample characteristics
tioned) values.
One minute after CPM, TS was calculated. Ten mechanical pressure
From 53 volunteers, a total of 46 were finally included and randomly
stimuli were exerted sequentially with 1sec-interval between stimuli on
allocated into three groups: sham, low-intensity, high-intensity (Fig. 2).
each of the evaluated areas. The stimuli were performed with the
All randomized subjects received the intervention to which they were
algometer at the unconditioned PPT level (Meeus et al., 2015b). Subjects
assigned, and completed the outcome assessments, complying with the
were asked to rate the intensity of pain evoked by the first and last
intention-to-treat protocol. There were no dropouts during the study,
pressure on a verbal numerical pain rating scale (NPRS; 0: no pain/10:
nor were adverse effects observed during the interventions (Fig. 2).
maximum tolerable pain). The score obtained for the TS was the result of
Demographic features and baseline outcomes are summarized in

3
J.L. Sánchez-González et al.
Fig. 2. Consort flow diagram.
Table 1. Significant between-group differences at baseline in PPT at the
bicipital groove and C5 vertebra and on TS on the tibialis anterior and
C5 vertebra were found at the beginning of the trial.
3.2. Conditioned pain modulation
The Omnibus ANOVA revealed no significant group x time x side
interaction for CPM at any location: lateral epicondyle (F = 1.02; P =
.368), tibialis anterior (F = 3.08; P = .056), bicipital groove (F=.097; P
= .908), and C5 vertebra (F = 1.49; P = .235).
No significant group x time interaction was either found at any
location: lateral epicondyle (F = 2.86; P = .068), tibialis anterior (F =
1.61; P = .211); bicipital groove (F=.122; P = .885), C5 vertebra
(F=.762; P = .473). Overall, changes were small in all groups (Table 2)
3.3. Widespread pressure pain sensitivity
The Omnibus ANOVA showed no significant 3-way interaction effect
(group x time x side) for PPT in lateral epicondyle (F=.687; P = .509),
tibialis anterior (F = 1.100; P = .342), bicipital groove (F=.18; P =
.836), and neck (F=.837; P = .44). A significant group x time interaction
was observed for PPT in the lateral epicondyle (F = 6.167; P = .004):
post hoc analyses revealed a significant bilateral increase in PPT in the
lateral epicondyle in the high intensity group when compared with the
4
Musculoskeletal Science and Practice 68 (2023) 102872
sham group (Table 3). No significant group x time interaction was found
in tibialis anterior (F = 2.87; P = .067), bicipital groove (F = 1.45; P =
.246), or cervical spine (F = 1.816; P = .175).
3.4. Temporal summation
The Omnibus ANOVA showed a significant group x time x side
interaction effect for TS within the tibialis anterior (F = 3.52; P = .038):
post hoc analysis revealed significant decrease of TS in both low and
high intensity groups on the right, but not on the left, tibialis anterior
when compared with the sham group (Table 4). No significant group x
time x side interaction was seen for TS in lateral epicondyle (F = 1.147;
P = .327), bicipital groove (F=.828; P = .444), and cervical spine (F =
1.06; P = .355).
No significant interaction effect (group x time) was observed in
lateral epicondyle (F= .93; P = .403), tibialis anterior (F = 2.61; P =
.085), bicipital groove (F= .697; P = .503). although a significant
interaction in effect (group x time) was observed in the cervical point (F
= 3.362; P = .044) with the Omnibus ANOVA, the pos hoc analysis did
not observe any significant difference (Table 4)
4. Discussion
This study revealed that the application of a single session of
J.L. Sánchez-González et al. Musculoskeletal Science and Practice 68 (2023) 102872

Table 1 Table 1 (continued )

Baseline demographic and outcome measures. Sham (n Low High P F
Sham (n Low High P F = 16) Intensity (n Intensity (n value
= 16) Intensity (n Intensity (n value = 15) = 15)
= 15) = 15)
TS left tibialis 1.38 1.53 (1.24) 1.27 (1.75) .877 .131
Age (years) 23.25 25.25 (8.3) 25.0 (8.5) 7.43 .299 anterior (0–10) (1.26)
(6.6) TS right tibialis .13 1.33 (.82) 1.2 (1.32) .005 5.967
Weight (kg) 65.55 68.1 (15.2) 63.5 (12.6) .637 .455 anterior (0–10) (1.02)
(11.7) TS left bicipital .94 1.33 (1.35) 1.13 (1.59) .793 .233
Height (m) 169.7 169.1 (11.3) 166.9 (11.7) .745 .285 groove (0–10) (1.81)
(9.0) TS right bicipital .63 (1.2) 1.07 (1.1) 1.07 (1.34) .508 .688
BMI (Kg/m2) 22.6 23.6 (3.3) 22.6 (2.6) .541 .573 groove (0–10)
(2.4) TS left C5 vertebra .44 1.8 (1.26) 1.47 (1.77) .048 3.255
Dominance (% 93.8% 93.3% 100% .619 .485 (0–10) (1.59)
right) TS right C5 .94 (.85) 1.33 (.82) 1.6 (1.5) .25 1.432
Male; female (%) 31.2%; 33.3%; 33.3%; .99 .01 vertebra (0–10)
68.8% 66.7% 66.7%
CPM: Conditioned pain modulation; PPT: Pressure pain threshold; TS: temporals
Smoking (%) 25% 20% 13.3% .729 .319
Conditioned Pain Modulation (CPM) summation; kg: kilogram; Data are expressed as mean (standard deviation).
CPM left − .22 − .02 (.73) .2 (.58) .097 2.47
epicondyle (.41) percutaneous electrolysis with a high dose (three pulses of 3 mA for 3s
tendon (kg/
each) on the lateral epicondyle was able to increase PPT (peripheral
cm2)
CPM right .03 (.28) − .08 (.26) .03 (.4) .515 .675 effect) on the elbow (local area) and also to reduce temporal summation
epicondyle (central modulatory effect) on the tibialis anterior (distant area), but did
tendon (kg/ not exert any effect on CPM. No other changes in PPTs or TS were either
cm2) found. The application of PE with low intensity (0.3 mA for 90s) did not
CPM left tibialis − .01 − .17 (.47) .1 (.55) .249 1.438
anterior (kg/ (.28)
exert any effect on pain processing outcomes.
cm2) We did not find any effect on CPM (primary outcome) after the
CPM right tibialis − .03 − .09 (.33) − .16 (.38) .637 .456 application of either sham, low or high intensity PE in healthy subjects.
anterior (kg/ (.42) Our results disagree with a previous meta-analysis showing that physical
2
cm )
therapy interventions have a small effect in central sensitization-
CPM left bicipital .02 (.29) .03 (.36) − .08 (.36) .585 .542
groove (kg/ associated variables by increasing CPM in people with chronic muscu­
cm2) loskeletal pain (Varela-Rodríguez et al., 2022). The heterogeneity
CPM right .07 (.27) .01 (.15) .06 (.24) .668 .408 among measurement locations and the lack of differences favoring PE
bicipital groove suggest limited impact on the CPM, in agreement with a previous study
(kg/cm2)
CPM left C5 − .03 .16 (.36) .1 (.51) .396 1.02
in PE in healthy subjects (Varela-Rodríguez et al., 2022) and in other
vertebra (kg/ (.33) studies investigating other needling interventions such as acupuncture
2
cm ) (Schliessbach et al., 2012; Tobbackx et al., 2013). It is possible that the
CPM right C5 .01 (.31) .06 (.35) .15 (.45) .573 .564 fact that healthy individuals do not exhibit impaired CPM, or they
vertebra (kg/
exhibit smaller deficits in CPM as compared with pain population
cm2)
Pressure Pain Threshold (PPT) (Huynh et al., 2022), could explain the lack of differences in this pop­
PPT left 1.8 (.56) 1.97 (.58) 1.77 (.57) .639 .452 ulation suggesting that improvements of CPM after the application of
epicondyle (Kg/ any therapeutic intervention is observed in individuals or conditions
2
cm ) with impaired CPM.
PPT right 1.58 1.71 (.57) 1.94 (.57) .215 1.594
epicondyle (Kg/ (.56)
The current study also observed that high intensity dose of PE eli­
cm2) cited a bilateral increase of PPTs (mechanical hypoalgesia) at the
PPT left tibialis 2.39 (.9) 2.52 (.78) 2.6 (.94) .725 .324 treatment site (right elbow) and at the corresponding site on the
anterior (Kg/ contralateral side (left elbow) just compared to the sham group. A
2
cm )
generalized increase of PPTs was also observed all measurement loca­
PPT right tibialis 2.12 (73) 2.3 (76) 2.92 (1.4) .079 2.698
anterior (Kg/ tions of the same side to the intervention in the high-intensity group, but
cm2) differences did not reach significant significance. An hypoalgesic effect
PPT left bicipital 1.6 (.49) 2.02 (.42) 2.47 (.78) .002 7.119 of PE at a point segmentally related to the treatment area (e.g., cervical
groove (Kg/ spine for the elbow) has been previously found (Varela-Rodríguez et al.,
2
cm )
PPT right bicipital 1.59 1.98 (.56) 2.33 (.96) .014 4.75
2022), but the novelty of the current study is that changes were detected
groove (Kg/ (.36) bilaterally (mirror effect). Bilateral effects have been reported previ­
cm2) ously in studies involving other needle techniques such as dry needling,
PPT left C5 1.67 2.02 (.65) 2.17 (.51) .04 3.483 electro-acupuncture or percutaneous electrical nerve stimulation
vertebra (Kg/ (.44)
(Audette et al., 2004; De-la-Cruz-Torres et al., 2021; Hsieh et al., 2011;
cm2)
PPT right C5 1.54 1.81 (.56) 2.04 (.58) .038 3.526 Koo et al., 2002) suggesting that these procedures generate spinal cord
vertebra (Kg/ (.43) mechanisms.
2
cm ) In relation to TS assessment, small changes were found in the
Temporal Summation homolateral tibialis anterior with both applications, low- and high-
TS left epicondyle .5 (1.26) 1.47 (1.85) 1.47 (1.86) .2 1.671
tendon (0–10)
intensity, of PE when compared to sham. Our results would agree with
TS right 1.19 2 (1.81) 1.8 (1.66) .306 1.218 those reported by Arribas-Romano et al. (2020) in their meta-analysis
epicondyle (.98) showing that physical therapy interventions are able to decrease TS
tendon (0–10) with a small effect size in people with chronic musculoskeletal pain. On
the contrary, current results disagree with those previously reported by
Valera-Rodríguez et al. (2022) who did not find significant differences in

5
J.L. Sánchez-González et al. Musculoskeletal Science and Practice 68 (2023) 102872

Table 2 Table 3
Within- and between-groups differences in Conditioned Pain Modulation (CPM). Within- and between-groups differences in Pressure Pain Thresholds (PPT).
Measure Group Before After Within-group Between-Group Group Before After Within-group Between-Group
Differences Differences Differences Differences

Right Sham .03 .06 .03 (− .18 to Sham vs Low Right Sham 1.58 1.47 − .11 (− .28 to Sham vs Low
epicondyle (.28) (.19) .25); p = .775 .15 (− .23 to epicondyle (.56) (.49) .06); p = .213 .08 (− .21 to
tendon (Kg/ .52); p = .620 tendon (Kg/ .38); p = .779
cm2) Low − .08 .09 .18 (− .05 to Sham vs High cm2) Low 1.71 1.69 − .02 (− .20 to Sham vs High
(.26) (.35) .40); p = .121 .07 (− .45 to (.57) (.53) .15); p = .779 .31 (.02–.61); p
.30); p = .887 = .004 *
High .03 (.4) .006 − .04 (− .26 to Low vs High .22 High 1.94 2.15 .21 (.03–.38); Low vs High .23
(.35) .18); p = .711 (− .6 to .16); p (.57) (.60) p = .024 (− .07 to .53); p
= .358 = .164
Left Sham − .22 .11 .34 (.08–.59); Sham vs Low Left Sham 1.8 1.45 − .41 (− .64 to Sham vs Low
epicondyle (.41) (.29) p = .011 .15 (− .59 to epicondyle (.56) (.44) − .17); p < .22 (− .18 to
tendon (Kg/ .28); p = .681 tendon (Kg/ .001 .63); p = .379
cm2) Low − .02 .16 .18 (− .08 to Sham vs High .4 cm2) Low 1.97 1.78 − .18 (− .42 to Sham vs High
(.73) (.47) .45); p = .169 (− .84 to .04); p (.58) (.61) .06); p = .136 .51 (.11–.92); p
= .084 = .011 *
High .2 (.58) .18 − .06 (− .33 to Low vs High .25 High 1.77 1.87 .10 (− .14 to Low vs High .29
(.28) .20); p = .727 (− .7 to .2); p = (.57) (.54) .35); p = .392 (− .13 to .70); p
.386 = .222
Right tibialis Sham − .03 .05 .08 (− .19 to Sham vs Low Right tibialis Sham 2.12 2.11 − .007 (− .28 Sham vs Low
anterior (.42) (.3) .35); p = .546 .06 (− .52 to anterior (73) (1.06) to .26); p = .23 (− .24 to
(Kg/cm2) .41); p = .952 (Kg/cm2) .96 .70); p = .462
Low − .09 − .06 − .02 (− .30 to Sham vs High Low 2.3 2.53 .23 (− .05 to Sham vs High
(.33) (.35) .25); p = .862 .03 (− .49 to (76) (1.06) .51); p = .113 .37 (− .10 to
.44); p = .990 .84); p = .151
High − .16 − .10 − .05 (− .33 to Low vs High .03 High 2.92 3.29 .36 (.08–.64); Low vs High .14
(.38) (.29) .22); p = .692 (− .44 to .50); p (1.4) (1.72) p = .013 (− .34 to .61); p
= .986 = .768
Left tibialis Sham − .003 − .14 − .14 (− .23 to Sham vs Low Left tibialis Sham 2.39 2.12 − .27 (− .61 to Sham vs Low
anterior (.28) (.44) .50); p = .453 .63 (.00–1.26); anterior (.9) (1) .069); p = .16 (− .42 to
(Kg/cm2) p = .05 (Kg/cm2) .116 .75); p = .775
Low − .17 .32 .49 (.12–.86); Sham vs High Low 2.52 2.42 − .11 (− .46 to Sham vs High
(.47) (.89) p = .01 .08 (− .54 to (.78) (.93) .25); p = .549 .58 (− .10 to
.71); p = .941 1.16); p = .056
High .1 (.55) .05 − .05 (− .42 to Low vs High .54 High 2.6 2.96 .31 (− .04 to Low vs High .41
(.29) .31); p = .775 (− 1.45 to .87); (.94) (1.48) .66); p = .086 (− .18 to 1.01);
p = .100 p = .229
Right bicipital Sham .07 .004 − .07 (− .23 to Sham vs Low Right bicipital Sham 1.59 1.68 .09 (− .15 to Sham vs Low
groove (Kg/ (.27) (.15) .08); p = .348 .01 (− .27 to groove (Kg/ (.36) (.46) .33); p = .444 .14 (− .27 to
cm2) .25); p = .995 cm2) .55); p = .685
Low .01 − .07 − .08 (− .24 to Sham vs High .9 Low 1.98 2.21 .23 (− .01 to Sham vs High
(.15) (.22) .07); p = .300 (− .29 to .23); p (.56) (.84) .48); p = .063 .20 (− .20 to
= .963 .61); p = .461
High .06 − .04 − .1 (− .26 to Low vs High .02 High 2.33 2.6 − .29 (− .54 to Low vs High .06
(.24) (.34) .06); p = .206 (− .28 to .25); p (.96) (1.32) − .05); p = .02 (− .36 to .48); p
= .985 = .932
Left bicipital Sham .02 − .03 − .05 (− .33 to Sham vs Low Left bicipital Sham 1.6 1.6 .07 (− .13 to Sham vs Low
groove (Kg/ (.29) (.25) .23); p = .727 .04 (− .5 to .44); groove (Kg/ (.49) (.40) .27); p = .479 .08 (− .61 to
cm2) p = .971 cm2) .34); p = .831
Low .03 .03 − .01 (− .29 to Sham vs High Low 2.02 2.03 .01 (− .19 to Sham vs High
(.36) (.19) .28); p = .984 .06 (− .42 to (.42) (.49) .21); p = .907 .24 (− .10 to
.54); p = .971 .56); p = .208
High − .08 − .18 − .11 (− .39 to Low vs High .1 High 2.47 2.6 .18 (− .03 to Low vs High .16
(.36) (.19) .17); p = .454 (− .38 to .59); p (.78) (1.19) .38); p = .095 (− .19 to .52); p
= .862 = .504
Right C5 Sham .01 .03 .02 (− .22 to Sham vs Low Right C5 Sham 1.54 1.49 − .05 (− .30 to Sham vs Low
vertebra (.31) (.23) .25); p = .896 .04 (− .37 to vertebra (.43) (.47) .21); p = .715 .29 (− .14 to
(Kg/cm2) .46); p = .961 (Kg/cm2) .73); p = .239
Low .06 .03 − .03 (− .27 to Sham vs High Low 1.81 2.06 .25 (− .01 to Sham vs High
(.35) (.32) .22); p = .808 .16 (− 25 to (.56) (.93) .51); p = .06 .36 (− .07 to
.57); p = .622 .79); p = .117
High .15 .01 − .14 (− .39 to Low vs High .11 High 2.04 2.35 .32 (.06–.58); Low vs High .07
(.45) (.32) .10); p = .248 (− .30 to .53); p (.58) (.86) p = .017 (− .37 to .51); p
= .790 = .922
Left C5 Sham − .03 − .04 − .001 (− .20 Sham vs Low Left C5 Sham 1.67 1.6 .05 (− .18 to Sham vs Low
vertebra (.33) (.27) to .19); p = .25 (− .08 to .6); vertebra (.44) (.49) .28); p = .661 .19 (− .21 to
(Kg/cm2) .975 p = .182 (Kg/cm2) .59); p = .489
Low .16 − .09 .26 (.05–.46); Sham vs High Low 2.02 2.16 .14 (− .10 to Sham vs High
(.36) (.23) p = .015 .03 (− .31 to (.65) (.78) .38); p = .247 .17 (− .23 to
.38); p = .283 .57); p = .571
High .1 (.51) .07 − .04 (− .24 to Low vs High .22 High 2.17 2.28 .12 (− .12 to Low vs High .02
(.21) .17); p = .721 (− .13 to .57); p (.51) (.68) .36); p = .330 (− .43 to .39); p
= .283 = .990

Data are expressed as mean (standard deviation) for main values and as mean
(95% confidence interval) for within-group and between-group changes.

6
J.L. Sánchez-González et al. Musculoskeletal Science and Practice 68 (2023) 102872

Data are expressed as mean (standard deviation) for main values and as mean Table 4
(95% confidence interval) for within-group and between-group changes. * Sta­ Within- and between-groups differences in Temporal Summation (TS).
tistically significant differences (post hoc analysis, P < .05).
Measure Group Before After Within-group Between-Group
Differences Differences
TS between PE groups and sham. Similarly, PE had no significant effect Right Sham 1.19 1.56 .38 (− .22 to Sham vs Low
on most TS measurements, in line with those results observed when epicondyle (.98) (1.21) .97); p = .210 .31 (− .72 to
applying acupuncture and electroacupuncture in patients with whiplash tendon 1.33); p = .748
and chronic low back pain (Leite et al., 2018; Tobbackx et al., 2013). (0–10) Low 2.00 2.07 .07 (− .55 to Sham vs High
(1.81) (1.39) .68); p = .827 .31 (− .72 to
Thus, although the results of the present study suggest a potential effect
1.33); p = .748
on TS, the effect of PE and other needling techniques on this pain pro­ High 1.8 1.87 .07 (− .55 to Low vs High .00
cessing variable is still uncertain and further investigation is warranted. (1.66) (1.92) .68); p = .827 (− 1.04 to 1.04);
An important finding from the current study is that no significant p = .989
differences between the low intensity and high intensity groups were Left Sham .50 .69 .19 (− .41 to Sham vs Low
epicondyle (1.26) (1.35) .78); p = .527 .14 (− .88 to
observed. These results are consistent with those observed in those tendon 1.17); p = .936
previous studies comparing two PE protocols. Varela-Rodríguez et al. (0–10) Low 1.47 1.80 .33 (− .28 to Sham vs High
(2022) investigated the effects of PE on CPM in healthy subjects but just (1.85) (1.61) .95); p = .278 .59 (− .044 to
in one side of the body whereas Valera-Calero et al. (2021) explored the 1.6); p = .354
High 1.47 1.07 − .40 (− 1.01 Low vs High .73
effects on sensitivity in patellofemoral pain syndrome. By analyzing the
(1.86) (1.79) to .21); p = (− .88 to 1.77);
comparisons between each of the PE protocols with the sham group, the .194 p = .213
high-intensity group was the only one to obtain significant differences in Right tibialis Sham .13 .88 .75 Sham vs Low
two PPT measurement sites in relation to the sham group. This could anterior (1.02) (1.02) (.28–1.22); p 1.22 (.4–2.03);
indicate a greater activation of central endogenous analgesia mecha­ (0–10) = .003 p = .002 *
Low 1.33 .87 − .47 (− .95 to Sham vs High
nisms when high-intensity electrical current is applied, in accordance (.82) (.83) .02); p = .06 .82 (.01–1.63);
with findings from previous animal studies in which higher intensities p = .049 *
were related to a greater inflammatory response and a faster reversal of High 1.20 1.13 − .07 (− .55 to Low vs High .4
signs of myofascial trigger points (Abat et al., 2014a,b; Margalef et al., (1.32) (1.06) .42); p = .784 (− .43 to 1.22);
p = .477
2020). On the other hand, a recent meta-analysis found small evidence
Left tibialis Sham 1.38 1.06 − .31 (− .87 to Sham vs Low
suggesting that low-intensity PE could be more effective for reducing anterior (1.26) (1.29) .25); p = .265 .15 (− .81 to
musculoskeletal pain than high-intensity (Sánchez-González et al., (0–10) 1.12); p = .921
2023). Therefore, further research is needed to explore which galvanic Low 1.53 1.07 − .47 (− 1.04 Sham vs High
current dosage is more effective in both subjective relief of patients’ (1.24) (.88) to .11); p = .09 (− .88 to
.110 1.05); p = 974
symptoms and activation of analgesic mechanisms.
High 1.27 .87 − .40 (− .98 to Low vs High .07
Finally, several limitations must be recognized before drawing any (1.75) (1.19) .18); p = .169 (− .91 to 1.05);
conclusion. First, the lack of comparability between groups at baseline p = .985
for some of the outcome variables should be considered, although this Right bicipital Sham .63 1.00 .37 (− .08 to Sham vs Low
groove (1.2) (1.41) .83); p = .101 .51 (− .27 to
was corrected by including all baseline data as covariates. Second, the
(0–10) 1.29); p = .265
participants were healthy subjects, thus future clinical trials should be Low 1.07 .93 − .13 (− .60 to Sham vs High
conducted to confirm these results in individuals with pain conditions. (1.1) (1.1) .33); p = .567 .31 (− .47 to
Third, although pain sensory testing provides information on the 1.09); p = .606
neurophysiological effects of PE, the exact mechanisms of action High 1.07 1.13 .07 (− .39 to Low vs High .2
(1.34) (1.55) .53); p = .774 (− .59 to .99); p
involved cannot be known with certainty. Additionally, the clinician
= .814
who conducted the intervention could not be blinded due to the diffi­ Left bicipital Sham .94 .44 − .50 (− 1.42 Sham vs Low
culty in proper masking with needling techniques. Similarly, we did not groove (1.81) (1.55) to .42); p = .03 (− 1.23 to
assess blinding of participants which could be a potential bias, partic­ (0–10) .280 1.56); p = .999
Low 1.33 .80 − .53 (− 1.48 Sham vs High
ularly within the placebo group. Finally, the effects of PE on nociceptive
(1.35) (1.15) to .42); p = .63 (− .96 to
pain processing outcomes were only studied immediately after and the .264 2.22); p = .603
results could be different if the follow-up time is extended. High 1.13 1.27 .13 (− .82 to Low vs High .67
(1.59) (1.39) 1.08); p = (− .95 to 2.28);
5. Conclusions .779 p = .581
Right C5 Sham .94 1.00 .06 (− .37 to Sham vs Low
vertebra (.85) (.89) .49); p = .772 .13 (− .62 to
One session of percutaneous electrolysis seems to be able to slightly (0–10) .87); p = .908
stimulate modulatory pain pathways related to nociceptive processing, Low 1.33 1.27 − .07 (− .51 to Sham vs High
particularly pressure pain sensitivity and temporal summation but not (.82) (1.16) .38); p = .764 .46 (− .28 to
1.21); p = .299
conditioning pain modulation, compared with a sham intervention, with
High 1.60 1.20 − .40 (− .85 to Low vs High .33
changes even contralaterally. No significant differences were found (1.5) (1.08) .04); p = .077 (− .42 to 1.09);
between low- and high-intensity doses of percutaneous electrolysis. p = .539
Further research to clarify the effects of percutaneous electrolysis on Left C5 Sham .44 .88 .44 (− .22 to Sham vs Low
endogenous modulation is needed. vertebra (1.59) (.89) 1.09); p = .97 (− .17 to
(0–10) .187 2.11); p = .108
Low 1.80 1.27 − .53 (− 1.21 Sham vs High
Authors’Contributions (1.26) (.96) to .15); p = .84 (− .3 to 1.9);
.121 p = .1.87
All authors contributed to the study concept and design. Methodol­ High 1.47 1.07 .40 (− .28 to Low vs High .13
(1.77) (1.49) 1.08); p = (− 1.29 to 1.02);
ogy, J.L.S.-G., L.C.-D., J.L.S.-S. V.N.-L. and S.V.-R. did the main statis­ .242 p = .958
tical analysis and interpretation of data. J.L.S.-G., L.C.-D., J.L.S.-S.
contributed to drafting the report. J.L.S.-G., L.C.-D., J.L.S.-S. and C.F.-d.-
l.-P. supervised the study. All authors revised the text for content and

7
J.L. Sánchez-González et al.
Data are expressed as mean (standard deviation) for main values and as mean
(95% confidence interval) for within-group and between-group changes. * Sta­
tistically significant differences (post hoc analysis, P < .05).
have read and approved the final version of the manuscript.
Disclosure and conflicts of interest
Financial disclosure statements have been obtained, and no conflicts
of interest have been reported by the authors or by any individuals in
control of the content of this article. No conflicts of interest are declared.
Trial registration
ClinicalTrials.gov, NCT04710992 (http://www.clinicaltrials.gov)
References
Abat, F., Diesel, W.J., Gelber, P.E., Polidori, F., Monllau, J.C., Sanchez-Ibañez, J.M.,
2014a. Effectiveness of the Intratissue Percutaneous Electrolysis (EPI®) technique
and isoinertial eccentric exercise in the treatment of patellar tendinopathy at two
years follow-up. Muscles, Ligaments and Tendons Journal 4 (2), 188–193. https://
doi.org/10.11138/mltj/2014.4.2.188.
Abat, F., Valles, S.L., Gelber, P.E., Polidori, F., Stitik, T.P., García-Herreros, S.,
Monllau, J.C., Sanchez-Ibánez, J.M., 2014b. Mecanismos moleculares de reparación
mediante la técnica Electrólisis Percutánea Intratisular en la tendinosis rotuliana.
Rev. Española Cirugía Ortopédica Traumatol. 58 (4), 201–205. https://doi.org/
10.1016/j.recot.2014.01.002.
Arias-Buría, J.L., Truyols-Domínguez, S., Valero-Alcaide, R., Salom-Moreno, J., Atín-
Arratibel, M.A., Fernández-de-las-Peñas, C., 2015. Ultrasound-guided percutaneous
electrolysis and eccentric exercises for subacromial pain syndrome: a randomized
clinical trial. Evid. base Compl. Alternative Med. 2015, 1–9. https://doi.org/
10.1155/2015/315219.
Arribas-Romano, A., Fernández-Carnero, J., Molina-Rueda, F., Angulo-Diaz-Parreño, S.,
Navarro-Santana, M.J., 2020. Efficacy of physical therapy on nociceptive pain
processing alterations in patients with chronic musculoskeletal pain: a systematic
review and meta-analysis. Pain Med. 21 (10), 2502–2517. https://doi.org/10.1093/
pm/pnz366.
Audette, J.F., Wang, F., Smith, H., 2004. Bilateral activation of motor unit potentials
with unilateral needle stimulation of active myofascial trigger points. Am. J. Phys.
Med. Rehabil. 83 (5), 368–374. https://doi.org/10.1097/01.
PHM.0000118037.61143.7C.
Bumgarner, J.R., Walker, W.H., Nelson, R.J., 2021. Circadian rhythms and pain.
Neurosci. Biobehav. Rev. 129, 296–306. https://doi.org/10.1016/j.
neubiorev.2021.08.004.
Cagnie, B., Dewitte, V., Barbe, T., Timmermans, F., Delrue, N., Meeus, M., 2013.
Physiologic effects of dry needling. Curr. Pain Headache Rep. 17 (8), 348. https://
doi.org/10.1007/s11916-013-0348-5.
Carlesso, L.C., MacDermid, J.C., Santaguida, L.P., 2010. Standardization of adverse event
terminology and reporting in orthopaedic physical therapy: application to the
cervical spine. J. Orthop. Sports Phys. Ther. 40 (8), 455–463. https://doi.org/
10.2519/jospt.2010.3229.
Chou, L.-W., Kao, M.-J., Lin, J.-G., 2012. Probable mechanisms of needling therapies for
myofascial pain control. Evid. base Compl. Alternative Med. 2012, 1–11. https://doi.
org/10.1155/2012/705327.
de la Cruz Torres, B., Albornoz Cabello, M., García Bermejo, P., Naranjo Orellana, J.,
2016. Autonomic responses to ultrasound-guided percutaneous needle electrolysis of
the patellar tendon in healthy male footballers. Acupunct. Med. 34 (4), 275–279.
https://doi.org/10.1136/acupmed-2015-010993.
De-la-Cruz-Torres, B., Carrasco-Iglesias, C., Minaya-Muñoz, F., Romero-Morales, C.,
2021. Crossover effects of ultrasound-guided percutaneous neuromodulation on
contralateral hamstring flexibility. Acupunct. Med. 39 (5), 512–521. https://doi.
org/10.1177/0964528420920283.
Faul, A., Lang, 2009. Statistical power analyses using G*Power 3.1: tests for correlation
and regression analyses. Behav. Res. Methods 41, 1149–1160.
Fernández-de-Las-Peñas, C., Nijs, J., 2019. <p>Trigger point dry needling for the
treatment of myofascial pain syndrome: current perspectives within a pain
neuroscience paradigm</p&gt. J. Pain Res. 12, 1899–1911. https://doi.org/
10.2147/JPR.S154728.
García Bermejo, P., de La Cruz Torres, B., Naranjo Orellana, J., Albornoz Cabello, M.,
2018. Autonomic responses to ultrasound-guided percutaneous needle electrolysis:
effect of needle puncture or electrical current? J. Alternative Compl. Med. 24 (1),
69–75. https://doi.org/10.1089/acm.2016.0339.
Gómez-Chiguano, G.F., Navarro-Santana, M.J., Cleland, J.A., Arias-Buría, J.L.,
Fernández-de-las-Peñas, C., Ortega-Santiago, R., Plaza-Manzano, G., 2021.
Effectiveness of ultrasound-guided percutaneous electrolysis for musculoskeletal
pain: a systematic review and meta-analysis. Pain Med. 22 (5), 1055–1071. https://
doi.org/10.1093/pm/pnaa342.
Hsieh, Y.-L., Chou, L.-W., Joe, Y.-S., Hong, C.-Z., 2011. Spinal cord mechanism involving
the remote effects of dry needling on the irritability of myofascial trigger spots in
8
Musculoskeletal Science and Practice 68 (2023) 102872
rabbit skeletal muscle. Arch. Phys. Med. Rehabil. 92 (7), 1098–1105. https://doi.
org/10.1016/j.apmr.2010.11.018.
Huynh, V., Lütolf, R., Rosner, J., Luechinger, R., Curt, A., Kollias, S., Michels, L.,
Hubli, M., 2022. Descending pain modulatory efficiency in healthy subjects is related
to structure and resting connectivity of brain regions. Neuroimage 247, 118742.
https://doi.org/10.1016/j.neuroimage.2021.118742.
Kennedy, D.L., Kemp, H.I., Ridout, D., Yarnitsky, D., Rice, A.S.C., 2016. Reliability of
conditioned pain modulation: a systematic review. Pain 157 (11), 2410–2419.
https://doi.org/10.1097/j.pain.0000000000000689.
Koo, S.T., Park, Y. il, Lim, K.S., Chung, K., Chung, J.M., 2002. Acupuncture analgesia in a
new rat model of ankle sprain pain. Pain 99 (3), 423–431. https://doi.org/10.1016/
S0304-3959(02)00164-1.
Leite, P.M.S., Mendonça, A.R.C., Maciel, L.Y.S., Poderoso-Neto, M.L., Araujo, C.C.A.,
Góis, H.C.J., Souza, J.H.S., DeSantana, J.M., 2018. Does electroacupuncture
treatment reduce pain and change quantitative sensory testing responses in patients
with chronic nonspecific low back pain? A randomized controlled clinical trial. Evid.
base Compl. Alternative Med. 2018, 1–8. https://doi.org/10.1155/2018/8586746.
Leung, L., 2012. Neurophysiological basis of acupuncture-induced analgesia—an
updated review. J. Acupunct. Meridian Stud. 5 (6), 261–270. https://doi.org/
10.1016/j.jams.2012.07.017.
Margalef, R., Valera-Garrido, F., Minaya-Muñoz, F., Bosque, M., Ortiz, N., Santafe, M.M.,
2020. Percutaneous needle electrolysis reverses neurographic signs of nerve
entrapment by induced fibrosis in mice. Evid. base Compl. Alternative Med. 2020,
1–7. https://doi.org/10.1155/2020/6615563.
Mattiussi, G., Moreno, C., 2019. Treatment of proximal hamstring tendinopathy-related
sciatic nerve entrapment: presentation of an ultrasound-guided “Intratissue
Percutaneous Electrolysis” application. Muscle Ligaments and Tendons Journal 248.
https://doi.org/10.32098/mltj.02.2016.13, 06(02).
Meeus, M., Hermans, L., Ickmans, K., Struyf, F., van Cauwenbergh, D., Bronckaerts, L., de
Clerck, L.S., Moorken, G., Hans, G., Grosemans, S., Nijs, J., 2015a. Endogenous pain
modulation in response to exercise in patients with rheumatoid arthritis, patients
with chronic fatigue syndrome and comorbid fibromyalgia, and healthy controls: a
double-blind randomized controlled trial. Pain Pract. 15 (2), 98–106. https://doi.
org/10.1111/papr.12181.
Meeus, M., Hermans, L., Ickmans, K., Struyf, F., van Cauwenbergh, D., Bronckaerts, L., de
Clerck, L.S., Moorken, G., Hans, G., Grosemans, S., Nijs, J., 2015b. Endogenous pain
modulation in response to exercise in patients with rheumatoid arthritis, patients
with chronic fatigue syndrome and comorbid fibromyalgia, and healthy controls: a
double-blind randomized controlled trial. Pain Pract. 15 (2), 98–106. https://doi.
org/10.1111/papr.12181.
Moana-Filho, E.J., Herrero Babiloni, A., Theis-Mahon, N.R., 2018. Endogenous pain
modulation in chronic orofacial pain: a systematic review and meta-analysis. Pain
159 (8), 1441–1455. https://doi.org/10.1097/j.pain.0000000000001263.
Moreno, C., Mattiussi, G., Núñez, F.J., Messina, G., Rejc, E., 2017. Intratissue
percutaneous electolysis combined with active physical therapy for the treatment of
adductor longus enthesopathy-related groin pain: a randomized trial. J. Sports Med.
Phys. Fit. 57 (10), 1318–1329. https://doi.org/10.23736/S0022-4707.16.06466-5.
Nie, H., Arendt-Nielsen, L., Andersen, H., Graven-Nielsen, T., 2005. Temporal summation
of pain evoked by mechanical stimulation in deep and superficial tissue. J. Pain 6
(6), 348–355. https://doi.org/10.1016/j.jpain.2005.01.352.
Nir, R.-R., Yarnitsky, D., 2015. Conditioned pain modulation. Curr. Opin. Support.
Palliat. Care 9 (2), 131–137. https://doi.org/10.1097/SPC.0000000000000126.
Rodríguez-Huguet, M., Góngora-Rodríguez, J., Lomas-Vega, R., Martín-Valero, R., Díaz-
Fernández, Á., Obrero-Gaitán, E., Ibáñez-Vera, A.J., Rodríguez-Almagro, D., 2020a.
Percutaneous electrolysis in the treatment of lateral epicondylalgia: a single-blind
randomized controlled trial. J. Clin. Med. 9 (7), 2068. https://doi.org/10.3390/
jcm9072068.
Rodríguez-Huguet, M., Góngora-Rodríguez, J., Rodríguez-Huguet, P., Ibañez-Vera, A.J.,
Rodríguez-Almagro, D., Martín-Valero, R., Díaz-Fernández, Á., Lomas-Vega, R.,
2020b. Effectiveness of percutaneous electrolysis in supraspinatus tendinopathy: a
single-blinded randomized controlled trial. J. Clin. Med. 9 (6), 1837. https://doi.
org/10.3390/jcm9061837.
Sánchez-González, J.L., Navarro-López, V., Cañada-Sánchez, P., Juárez-Vela, R.,
Viñaspre-Hernández, R. R. de, Varela-Rodríguez, S., 2023. Efficacy of different
intensities of percutaneous electrolysis for musculoskeletal pain: a systematic review
and meta-analysis. Front. Med. 10 https://doi.org/10.3389/fmed.2023.1101447.
Sánchez-Sánchez, J.L., Calderón-Díez, L., Herrero-Turrión, J., Méndez-Sánchez, R., Arias-
Buría, J.L., Fernández-de-las-Peñas, C., 2020. Changes in gene expression associated
with collagen regeneration and remodeling of extracellular matrix after
percutaneous electrolysis on collagenase-induced achilles tendinopathy in an
experimental animal model: a pilot study. J. Clin. Med. 9 (10), 3316. https://doi.
org/10.3390/jcm9103316.
Schliessbach, J., van der Klift, E., Siegenthaler, A., Arendt-Nielsen, L., Curatolo, M.,
Streitberger, K., 2012. Does acupuncture needling induce analgesic effects
comparable to diffuse noxious inhibitory controls? Evid. base Compl. Alternative
Med. 2012, 1–5. https://doi.org/10.1155/2012/785613.
Tobbackx, Y., Meeus, M., Wauters, L., de Vilder, P., Roose, J., Tom Verhaeghe, J., Nijs,
2013. Does acupuncture activate endogenous analgesia in chronic whiplash-
associated disorders? A randomized crossover trial. Eur. J. Pain 17 (2), 279–289.
https://doi.org/10.1002/j.1532-2149.2012.00215.x.
Vaegter, H.B., Fehrmann, E., Gajsar, H., Kreddig, N., 2020. Endogenous modulation of
pain. Clin. J. Pain 36 (3), 150–161. https://doi.org/10.1097/
AJP.0000000000000788.
Valera-Calero, J.A., Sánchez-Mayoral-Martín, A., Varol, U., 2021. Short-term
effectiveness of high- and low-intensity percutaneous electrolysis in patients with
J.L. Sánchez-González et al.
patellofemoral pain syndrome: a pilot study. World J. Orthoped. 12 (10), 781–790.
https://doi.org/10.5312/wjo.v12.i10.781.
Valera-Garrido, F., Minaya-Muñoz, F., 2016. Invasive Physiotherapy, second ed. Elsevier.
Varela-Rodríguez, S., Sánchez-Sánchez, J.L., Velasco, E., Delicado-Miralles, M., Sánchez-
González, J.L., 2022. Endogenous pain modulation in response to a single session of
percutaneous electrolysis in healthy population: a double-blinded randomized
clinical trial. J. Clin. Med. 11 (10), 2889. https://doi.org/10.3390/jcm11102889.
Yarnitsky, D., 2015. Role of endogenous pain modulation in chronic pain mechanisms
and treatment. Pain 156 (Suppl. 1), S24–S31. https://doi.org/10.1097/01.j.
pain.0000460343.46847.58.
Musculoskeletal Science and Practice 68 (2023) 102872
Yarnitsky, D., Bouhassira, D., Drewes, A.M., Fillingim, R.B., Granot, M., Hansson, P.,
Landau, R., Marchand, S., Matre, D., Nilsen, K.B., Stubhaug, A., Treede, R.D., Wilder-
Smith, O.H.G., 2015. Recommendations on practice of conditioned pain modulation
(CPM) testing. Eur. J. Pain 19 (6), 805–806. https://doi.org/10.1002/ejp.605.
Zhao, M., 2009. Electrical fields in wound healing—an overriding signal that directs cell
migration. Semin. Cell Dev. Biol. 20 (6), 674–682. https://doi.org/10.1016/j.
semcdb.2008.12.009.
Zwarenstein, M., Treweek, S., Gagnier, J.J., Altman, D.G., Tunis, S., Haynes, B.,
Oxman, A.D., Moher, D., 2008. Improving the reporting of pragmatic trials: an
extension of the CONSORT statement. BMJ 337, a2390. https://doi.org/10.1136/
bmj.a2390 a2390.