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An Sist Sanit Navar. 2015 Jan-Apr;38(1):105-15.

[Cervical myofascial pain syndrome. Narrative review of physiotherapeutic

[Article in Spanish]
Cap-Juan MA1.

Author information
Pain is a complex and multifactorial phenomenon that depends on the interaction of biopsychosocial
factors. Between 15-25% of adults suffer from chronic pain at some point in their lives. Cervical chronic
pain is considered a public health problem affecting 9.6% men and 21.9% women, according to the latest
National Health Survey 2011-12. A high percentage of medical consultations due to muscle pain turn out
to be myofascialpain syndrome (MPS). Its existence implies the presence of myofascial trigger points
which can be latent or active throughout the whole population. The aim of this review is to update
knowledge in the various therapies applied by the physiotherapist in the treatment of
this syndrome at cervicallevel. From the review it appears that some of the most used techniques that
may be useful in the short or medium term are: ischemic compression and/or trigger point pressure
release and dry needling. Furthermore, various combinations of treatment modalities are used to treat
this syndrome, taking other aspects into account, such as education.
25963463[PubMed - in process]

2. Am J Phys Med Rehabil. 2010 Feb;89(2):133-40. doi: 10.1097/PHM.0b013e3181a5b1bc.

Remote effects of dry needling on the irritability of

the myofascial trigger point in the upper trapezius muscle.
Tsai CT1, Hsieh LF, Kuan TS, Kao MJ, Chou LW, Hong CZ.
Author information
To investigate the remote effect of dry needling on the irritability of a myofascial trigger point in the upper
trapezius muscle.
Thirty-five patients with active myofascial trigger points in upper trapezius muscles were randomly divided
into two groups: 18 patients in the control group received sham needling, and 17 patients in the dryneedling group received dry needling into the myofascial trigger point in the extensor carpi radialis longus
muscle. The subjective pain intensity, pressure pain threshold, and range of motion of the neck were
assessed before and immediately after the treatment.
Immediately after dry needling in the experimental group, the mean pain intensity was significantly
reduced, but the mean pressure threshold and the mean range of motion of cervical spine were
significantly increased. There were significantly larger changes in all three parameters of measurement in
the dry-needling group than that in the control group.

This study demonstrated the remote effectiveness of dry needling. Dry needling of a
distal myofascial trigger point can provide a remote effect to reduce the irritability of a
proximal myofascial trigger point.
PMID: 19404189
[PubMed - indexed for MEDLINE]


Evid Based Complement Alternat Med. 2012;2012:705327. doi: 10.1155/2012/705327. Epub 2012 Dec 31.

Probable mechanisms of needling therapies for myofascial pain control.

Chou LW1, Kao MJ, Lin JG.

Author information
Myofascial pain syndrome (MPS) has been defined as a regional pain syndrome characterized by muscle
pain caused by myofascial trigger points (MTrPs) clinically. MTrP is defined as the hyperirritable spot in a
palpable taut band of skeletal muscle fibers. Appropriate treatment to MTrPs can effectively relieve the
clinical pain of MPS. Needling therapies, such as MTrP injection, dry needling, or acupuncture (AcP) can
effectively eliminate pain immediately. AcP is probably the first reported technique in treating MPS
patients with dry needling based on the Traditional Chinese Medicine (TCM) theory. The possible
mechanism of AcP analgesia were studied and published in recent decades. The analgesic effect of AcP
is hypothesized to be related to immune, hormonal, and nervous systems. Compared to slow-acting
hormonal system, nervous system acts in a faster manner. Given these complexities, AcP analgesia
cannot be explained by any single mechanism. There are several principles for selection of acupoints
based on the TCM principles: "Ah-Shi" point, proximal or remote acupoints on the meridian, and extrameridian acupoints. Correlations between acupoints and MTrPs are discussed. Some clinical and animal
studies of remote AcP for MTrPs and the possible mechanisms of remote effectiveness are reviewed and


Curr Pain Headache Rep. 2006 Oct;10(5):345-9.

Treatment of myofascial pain syndrome.

Hong CZ1.

Author information
Myofascial pain syndrome (MPS) is caused by myofascial trigger points (MTrPs) located within taut bands
of skeletal muscle fibers. Treating the underlying etiologic lesion responsible for MTrP activation is the
most important strategy in MPS therapy. If the underlying pathology is not given the appropriate
treatment, the MTrP cannot be completely and permanently inactivated. Treatment of active MTrPs may
be necessary in situations in which active MTrPs persist even after the underlying etiologic lesion has
been treated appropriately. When treating the active MTrPs or their underlying pathology, conservative
treatment should be given before aggressive therapy. Effective MTrP therapies include manual therapies,
physical therapy modalities, dry needling, or MTrP injection. It is also important to eliminate any

perpetuating factors and provide adequate education and home programs to patients so that recurrent or
chronic pain can be avoided.

[PubMed - indexed for MEDLINE]


AbstractZhonghua Yi Xue Za Zhi (Taipei). 2002 Nov;65(11):501-12.

New trends in myofascial pain syndrome.

Hong CZ1.

Author information
This review article summarizes recent studies on myofascial trigger point (MTrP) to further clarify the
mechanism of MTrP. MTrP is the major cause of muscle pain (myofascial pain) in clinical practice. There
are multiple MTrP loci in an MTrP region. An MTrP locus contains a sensory component (sensitive locus)
and a motor component (active locus). A sensitive locus is the site from which pain, referred pain (ReP),
and local twitch response (LTR) can be elicited by needle stimulation. Sensitive loci are probably
sensitized nociceptors based on a histological study. They are widely distributed in the whole muscle, but
are concentrated in the endplate zone. An active locus is the site from which spontaneous electrical
activity (SEA) can be recorded. Active loci are dysfunctional endplates since SEA is essentially the same
as endplate noise (EPN) recorded from an abnormal endplate as reported by neurophysiologists. Both
ReP and LTRs are mediated through spinal cord mechanisms, demonstrated in both human and animal
studies. The pathogenesis of MTrPs appears to be related to the integration in the spinal cord (formation
of MTrP circuits) in response to the disturbance of the nerve endings and abnormal contractile
mechanism at multiple dysfunctional endplates. Methods usually applied to treat MTrPs include stretch,
massage, thermotherapy, electrotherapy, laser therapy, MTrP injection, dry needling, and acupuncture.
The mechanism of acupuncture is similar to dry needling or MTrP injection. The new technique of MTrP
injection can also be used to treat neurogenic spasticity.

[PubMed - indexed for MEDLINE]


Biomedicine (Taipei). 2014;4:13. Epub 2014 Aug 2.

Needling therapy for myofascial pain: recommended technique with multiple

rapid needle insertion.
Chou LW1, Hsieh YL2, Kuan TS3, Hong CZ4.

Author information
Myofascial trigger point (MTrP) is a major cause of muscle pain, characterized with a hyperirritable spot
due to accumulation of sensitized nociceptors in skeletal muscle fibers. Many needling therapy
techniques for MTrP inactivation exist. Based on prior human and animal studies, multiple insertions can
almost completely eliminate the MTrP pain forthwith. It is an attempt to stimulate many sensitive loci

(nociceptors) in the MTrP region to induce sharp pain, referred pain or local twitch response. Suggested
mechanisms of needling analgesia include effects related to immune, hormonal or nervous system.
Compared to slow-acting biochemical effects involving immune or hormonal system, neurological effects
can act faster to provide immediate and complete pain relief. Most likely mechanism of multiple needle
insertion therapy for MTrP inactivation is to encounter sensitive nociceptors with the high-pressure
stimulation of a sharp needle tip to activate a descending pain inhibitory system. This technique is
strongly recommended for myofasical pain therapy in order to resume patient's normal life rapidly, thus
saving medical and social resources.
Acupuncture; Analgesia; Mechanism; Myofascial trigger point; Needling


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Clin J Pain. 2010 Mar-Apr;26(3):251-7. doi: 10.1097/AJP.0b013e3181b8cdc8.

Comparison of miniscalpel-needle release, acupuncture needling, and

stretching exercise to trigger point inmyofascial pain syndrome.
Ma C1, Wu S, Li G, Xiao X, Mai M, Yan T.

Author information
Myofascial pain syndrome (MPS) is one of the most common causes of chronic musculoskeletal pain.
Several methods have been recommended for the inactivation of trigger points (TrPs). We carried out this
study to investigate the effectiveness of miniscalpel-needle (MSN) release and acupuncture needling and
self neck-stretching exercises on myofascial TrPs of the upper trapezius muscle.
Eighty-three TrPs in 43 patients with MPS were treated and randomly assigned to 3 groups: group 1
received MSN release in conjunction with self neck-stretching exercises; group 2 received acupuncture
needling treatment and performed self neck-stretching exercises; and group 3, the control group, was
assigned self neck-stretching exercises only. The therapeutic effectiveness was evaluated using
subjective pain intensity (PI) with a visual analog scale, pressure pain threshold (PPT), and contralateral
bending range of motion (ROM) of cervical spine at pretreatment, 2 weeks, and 3 months after treatment.
The improvement of PI, PPT, and contralateral bending ROM of cervical spine was significantly greater in
group 1 and 2 than that in control group at 2 weeks and 3 months follow-up. Compared with group 2,
patients in group 1 had a statistically significant reduction in PI, an increase in PPT, contralateral bending
ROM of cervical spine at 3 months follow-up.
The effectiveness of MSN release for MPS is superior to that of acupuncture needling treatment or
self neck-stretching exercises alone. The MSN release is also safe, without severe side effects in
treatment of MPS.


[PubMed - indexed for MEDLINE]

8. J Orthop Sports Phys Ther. 2013 Sep;43(9):620-34. doi: 10.2519/jospt.2013.4668.

Effectiveness of dry needling for upper-quarter myofascial pain:

a systematic review and meta-analysis.
Kietrys DM1, Palombaro KM, Azzaretto E, Hubler R, Schaller B, Schlussel JM, Tucker M.
Author information
Systematic review and meta-analysis.

Myofascial pain syndrome (MPS) is associated with hyperalgesic zones in muscle

called myofascial trigger points. When palpated, active myofascial trigger points cause local or referred
symptoms, including pain. Dry needling involves inserting an acupuncture-like needle into
amyofascial trigger point, with the goal of reducing pain and restoring range of motion.
To explore the evidence regarding the effectiveness of dry needling to reduce pain in patients with MPS of
the upper quarter.
An electronic literature search was performed using the key word dry needling. Articles identified with the
search were screened for the following inclusion criteria: human subjects, randomized controlled trial
(RCT), dry needling intervention group, and MPS involving the upper quarter. The RCTs that met these
criteria were assessed and scored for internal validity using the MacDermid Quality Checklist. Four
separate meta-analyses were performed: (1) dry needling compared to sham or control immediately after
treatment, (2) dry needling compared to sham or control at 4 weeks, (3) dry needling compared to other
treatments immediately after treatment, and (4) dry needling compared to other treatments at 4 weeks.
The initial search yielded 246 articles. Twelve RCTs were ultimately selected. The methodological quality
scores ranged from 23 to 40 points, with a mean of 34 points (scale range, 0-48; best possible score, 48).
The findings of 3 studies that compared dry needling to sham or placebo treatment provided evidence
that dry needling can immediately decrease pain in patients with upper-quarter MPS, with an overall effect
favoring dry needling. The findings of 2 studies that compared dry needling to sham or placebo treatment
provided evidence that dry needling can decrease pain after 4 weeks in patients with upper-quarter MPS,
although a wide confidence interval for the overall effect limits the impact of the effect. Findings of studies
that compared dry needling to other treatments were highly heterogeneous, most likely due to variance in
the comparison treatments. There was evidence from 2 studies that lidocaine injection may be more
effective in reducing pain than dry needling at 4 weeks.
Based on the best current available evidence (grade A), we recommend dry needling, compared to sham
or placebo, for decreasing pain immediately after treatment and at 4 weeks in patients with upper-quarter
MPS. Due to the small number of high-quality RCTs published to date, additional well-designed studies
are needed to support this recommendation.
Therapy, level 1a-.

Comment in

Painful and tender muscles: dry needling can reduce myofascial pain related to trigger points
muscles. [J Orthop Sports Phys Ther. 2013]

[PubMed - indexed for MEDLINE]


Curr Pain Headache Rep. 2014;18(8):437. doi: 10.1007/s11916-014-0437-0.

Dry needling for management of pain in the upper quarter and craniofacial
Kietrys DM1, Palombaro KM, Mannheimer JS.

Author information
Dry needling is a therapeutic intervention that has been growing in popularity. It is primarily used with
patients that have pain of myofascial origin. This review provides background about dry
needling, myofascial pain, and craniofacial pain. We summarize the evidence regarding the effectiveness
of dry needling. For patients with upper quarter myofascial pain, a 2013 systematic review and metaanalysis of 12 randomized controlled studies reported that dry needling is effective in reducing pain
(especially immediately after treatment) in patients with upper quarter pain. There have been fewer
studies of patients with craniofacial pain and myofascial pain in other regions, but most of these studies
report findings to suggest the dry needling may be helpful in reducing pain and improving other pain
related variables such as the pain pressure threshold. More rigorous randomized controlled trials are
clearly needed to more fully elucidate the effectiveness of dry needling.


[PubMed - indexed for MEDLINE]

10. J Bodyw Mov Ther. 2014 Jul;18(3):390-8. doi: 10.1016/j.jbmt.2013.11.009. Epub 2013 Nov 9.

The effect of dry needling for myofascial trigger points in

the neck and shoulders: a systematic review and meta-analysis.
Ong J1, Claydon LS2.
Author information
and purpose: The aim of this systematic review with meta-analysis is to determine the effect of dry
needling in the treatment of MTrPs.
Searches were performed using the electronic databases AMED, EBM reviews, Embase, and Ovid
MEDLINE (all from database inception-February 2012).
Randomized controlled trials (RCTs) were included if they compared dry needling with another form of
treatment or placebo and included pain intensity as an outcome.
Two blinded reviewers independently screened the articles, scored their methodological quality and
extracted data.
Physiotherapy Evidence Database (PEDro) quality scale and the Cochrane risk of bias tool were used.

Four RCTs compared dry needling to lidocaine and one RCT compared dry needling to placebo. Metaanalyses of dry needling revealed no significant difference between dry needling and lidocaine
immediately after treatment standardized mean difference (SMD) 0.41 (95%CI -0.15 to 0.97), at one
month (SMD -1.46; 95% CI -2.04 to 4.96) and three to six months (SMD -0.28; 95% CI -0.63 to 0.07).
Although not significant in the meta-analyses, there were interesting patterns favoring lidocaine
immediately after treatment and dry needling at three to six months.
Copyright 2013 Elsevier Ltd. All rights reserved.

Dry needling; Lidocaine; Myofascial trigger points; Randomised controlled trial

Comment inWhether lidocaine or dry needling should be the favored treatment after meta
analysis. [J Bodyw Mov Ther. 2014]
[PubMed - indexed for MEDLINE]

11. Clin Rheumatol. 2013 Mar;32(3):309-15. doi: 10.1007/s10067-012-2112-3. Epub 2012 Nov 9.

The effect of dry needling in the treatment of myofascial pain syndrome: a

randomized double-blinded placebo-controlled trial.
Tekin L1, Akarsu S, Durmu O, Cakar E, Diner U, Kralp MZ.

Author information
The objective of this study was to test the hypothesis that dry needling is more effective than sham dry
needling in the treatment of myofascial painsyndrome (MPS). This was a prospective, double-blinded,
randomized-controlled study conducted in an outpatient clinic. Thirty-nine subjects with
established myofascial trigger points were randomized into two groups: study group (N =22) and placebo
group (N=17). Dry needling was applied using acupuncture needles, and sham dry needling was applied
in the placebo group. The treatment was composed of six sessions which were performed in 4 weeks; the
first four sessions were performed twice a week (for 2 weeks) and the last two, once a week (for 2
weeks). The visual analog scale (VAS) and Short Form-36 (SF-36) were used. When compared with the
initial values, VAS scores of the dry needling group following the first and sixth sessions were significantly
lower (p=0.000 and p<0.000, respectively). When VAS scores were compared between the groups, the
first assessment scores were found to be similar, but the second and third assessment scores were found
to be significantly lower in the dry needling group (p =0.034 and p < 0.001, respectively). When SF-36
scores of the groups were compared, both the physical and mental component scores were found to be
significantly increased in the dry needling group, whereas only those of vitality scores were found to be
increased significantly in the placebo (sham needling) group. The present study shows that the dry
needling treatment is effective in relieving the pain and in improving the quality of life of patients with
[PubMed - indexed for MEDLINE]