Original paper

Effectiveness of dry needling of

rectus abdominis trigger points for
the treatment of primary
dysmenorrhoea: a randomised
parallel-group trial
Alberto Gaubeca-Gilarranz,1 César Fernández-de-las-Peñas,2,3
José Raúl Medina-Torres,1 José M Seoane-Ruiz,4
Aurelio Company-Palonés,1 Joshua A Cleland,5,6,7 Jose L Arias-Buría2,3

For numbered affiliations see Abstract Introduction

end of article.
Objective  To compare the effectiveness of trigger point Primary dysmenorrhoea, defined as pain
dry needling (TrP-DN) versus placebo needling, relative to during menstruation, is one of the most
Correspondence to
Dr César Fernández-de-las- an untreated control group, on pain and quality of life in common gynaecological conditions
Peñas, Cátedra de Investigación primary dysmenorrhoea. and can occur during the normal ovula-
y Docencia en Fisioterapia: tory cycle in the absence of any pelvic
Terapia Manual y Punción Seca,
Methods  In this randomised, single blind, parallel-
Universidad Rey Juan Carlos, group trial, 56 females with primary dysmenorrhoea were pathology. It is extremely common in
Alcorcon 28922, Madrid, Spain; ​ randomly allocated to TrP-DN (n=19), placebo needling adolescent and young females and its
cesarfdlp@​yahoo.​es
(n=18) or no treatment (n=19). Patients in both groups prevalence ranges between 60 and 93%.1 2
Accepted 6 January 2018 were asked to undertake a stretching exercise of the
Primary dysmenorrhoea is characterised
Published Online First rectus abdominis daily. The needling group received
by a cramping pain in the lower-half of
2 May 2018 the abdominal area that can refer to the
a single session of TrP-DN to trigger points (TrPs) in
back, thigh and groin region and may
the rectus abdominis, and the placebo group received
also be accompanied by nausea, vomiting,
placebo needling. The primary outcome was pain intensity
diarrhoea, headache, fatigue and dizzi-
(visual analogue scale). Secondary outcomes were
ness.3 Burnett et al found that 60% of
quality of life, use of non-steroidal anti-inflammatory
females reported moderate to severe pain
drugs, the number of days with pain, and self-perceived
associated with primary dysmenorrhoea
improvement, measured using a Global Rate of Change. that resulted in numerous functional
Outcomes were assessed at baseline, and 1 and 2 months limitations.4 The severity of these symp-
after the treatment. toms often resulted in missed work or
Results  Females receiving TrP-DN exhibited greater school in at least 17% of females suffering
decreases (P<0.001) in pain than those receiving placebo from dysmenorrhoea.4 In fact, 30–50%
(1 month: Δ−19.8 mm, 25.9 to −13.7; 2 months: of females with primary dysmenorrhoea
Δ−26.0 mm, −33.1 to −18.9) or assigned to the missed school or work at least once per
untreated control group (1 month: Δ−26.0mm, −32.5 to cycle.1 Additionally, the burden of primary
−19.5; 2 months: Δ−20.1 mm, −26.4 to −13.8). Females dysmenorrhoea is greater than any other
in the TrP-DN group also exhibited a greater decrease in gynaecological complaint.5 For instance,
the amount of medications (P<0.001). No differences in in Japan, costs have been calculated to
the number of days with pain or quality of life were found be $4.2 billion (USD) a year, resulting in
(all P>0.1). substantial societal and economic burden.6
Conclusions  This trial suggests that a single session of Treatments for primary dysmenor-
TrP-DN of the rectus abdominis combined with stretching rhoea usually include surgical approaches
was more effective than placebo needling and stretching (nerve ablation), medication, acupunc-
To cite: Gaubeca-
Gilarranz A, Fernández-de- alone at reducing pain and the amount of medication ture, acupressure and physical therapy.7–9
las-Peñas C, Medina- used in primary dysmenorrhoea. While all of the aforementioned interven-
Torres JR, et al. Acupunct
Trial registration number  ACTRN12616000170426 .
tions may be of benefit, a recent system-
Med 2018;36:302–310. atic review reported that therapists should

302 Gaubeca-Gilarranz A, et al. Acupunct Med 2018;36:302–310. doi:10.1136/acupmed-2017-011566

 Original paper

consider using transcutaneous nerve stimulation, heat Trials) extension for pragmatic clinical trials.17 The
and yoga for the managment of primary dysmenor- protocol was approved by the Local Ethical Committee
rhoea.10 It seems that numerous treatment approaches of Universidad de Alcalá, Spain (CEIM/HU/2015/22)
could be used to manage this condition. An interven- and it was conducted according to the Declaration
tion commonly used in clinical practice, which has not of Helsinki. The trial was prospectively registered
been examined in primary dysmenorrhoea, is trigger in the Australian New Zealand Clinical Trials Registry
point dry needling (TrP-DN). Trigger points (TrPs) (ACTRN12616000170426) on 10th February 2016.
are defined as hypersensitive spots within taut bands
of skeletal muscle that are painful to palpation and Participants
usually elicit referred pain.11 TrPs are classified clini- Females with dysmenorrhoea attending different
cally as active or latent. If they are active, TrPs cause healthcare centres in Madrid (Spain) were recruited
spontaneous pain and the elicited referred pain repro- from February to April 2016 for this randomised
duces the patient’s symptoms. If they are latent, TrPs clinical trial. To be included, females had to be diag-
do not reproduce any of the patient’s symptoms.11 nosed with primary dysmenorrhoea by their gynaecol-
TrPs have been found to be involved in chronic pelvic ogist, be between 18 and 25 years of age, and have
pain syndrome including endometriosis.12 TrP-DN is pain >30 mm on a 100 mm VAS. In addition, females
widely used for a variety of musculoskeletal chronic also had to exhibit active TrPs in the rectus abdom-
pain conditions13 and it has been shown to be effec- inis reproducing their pain symptoms. They were
tive for neck-shoulder pain14 and low back pain,15 but excluded if they suffered from secondary dysmenor-
limited evidence exists to support its use for primary rhoea or any other conditions of the reproductive and
dysmenorrhea. Huang and Liu examined the effects urinary systems—for example, endometriosis. Addi-
of lidocaine injections for the treatment of primary tionally, females with children (previous pregnancy) or
dysmenorrhoea.16 In their study, patients received wet previous experiences of abortion were also excluded.
needling to TrPs in the abdominal muscles as well as Participants were counselled and signed an informed
stretching exercises, which were performed at home. consent form before their inclusion in the study.
This study reported that 63% of patients experi-
enced clinically meaningful improvements following Randomisation and masking
just one session of wet needling at 1 year follow-up. Females were randomly assigned to dry needling,
However, no control group was included and therefore placebo-needling or an untreated control group.
cause and effect relationships cannot be inferred.16 To Concealed allocation was conducted using a comput-
our knowledge, no study to date has investigated the er-generated randomised table of numbers created by
impact of TrP-DN of abdominal TrPs on symptoms an external statistician. Individual and sequentially
associated with primary dysmenorrhoea. The purpose numbered index cards with the random assignment
of the current randomised clinical trial was to compare were prepared. The index cards were folded and
the effects of TrP-DN  versus a placebo needling placed in sealed opaque envelopes. Another researcher
procedure, relative to an untreated control group, opened the envelope and proceeded with allocation.
on pain in females with primary dysmenorrhoea. We Treatment allocation was revealed to the partici-
hypothesised that females in the TrP-DN group would pants after collection of baseline outcomes. Clinicians
experience greater improvements in their symp- collecting outcomes were blind to group assignment.
toms than those assigned to the placebo needling or
untreated control groups. Interventions
The day of the intervention was scheduled 2 weeks
before the females began their menstrual period. All
Methods treatments were applied by two experienced physical
Study design therapists with more than 2 years of clinical experience
This randomised, parallel-group controlled clinical in the treatment of myofascial pain and the use of dry
trial compared the application of TrP-DN for primary needling for patients with primary dysmenorrhoea.
dysmenorrhoea to a placebo needling technique and Females allocated to the TrP-DN group received a
additionally included an untreated control group. The single session of dry needling into active TrPs of the
primary end point was the change in the intensity of rectus abdominis muscle. TrPs were diagnosed when
pain as assessed by a visual analogue scale (VAS) after 2 there was a palpable taut band, local pain on palpa-
months. Secondary outcomes included health-related tion of the spot and referred pain reproducing the
quality of life (SF-36 questionnaire), use of non-ste- symptoms of the patient (pain recognition).18Patients
roidal anti-inflammatory drugs (NSAIDs) to miti- received TrP-DN using disposable stainless needles
gate symptoms, the number of days with pain, and (0.25 mm×40 mm, Agupunt, Barcelona, Spain) that
self-perceived improvement with a 4-point Global were inserted into the skin over the TrP. In this study, the
Rate of Change (GROC). The current trial follows fast-in and fast-out technique described by Hong19 was
the CONSORT (Consolidated Standards of Reporting applied. Once the active TrP was located, the overlying

Gaubeca-Gilarranz A, et al. Acupunct Med 2018;36:302–310. doi:10.1136/acupmed-2017-011566 303

 Original paper

Figure 1  Dry needling applied to trigger points in the rectus abdominis

muscle.

skin was cleaned with alcohol. With the patient lying

supine, the needle was inserted through the skin and
advanced into the TrP horizontal to the lateral edge of
the rectus abdominis muscle (figure 1) until the first
local-twitch response was obtained. Hong suggested
that local twitch responses should be elicited during
TrP-DN to constitute a proper and successful tech-
nique19; however, it should be recognised that there
is controversy about the necessity of obtaining local
twitch responses in obtaining a positive outcome.20
Once the first local-twitch response was obtained, the
needle was moved in and out of the rectus abdominis
muscle (3–5 mm horizontal motions with no rotation)
for 25–30 s. This time period usually permits at least
2–3 local-twitch responses. In fact, a recent study has
reported that 2–3 local-twitch responses are enough Figure 2  Placebo needling procedure applied.
to obtain a positive outcome, at least in patients with
neck pain.21 maintaining the stretching position for 30–60 s every
No placebo for TrP-DN has been specifically day during the study period. Females were required to
designed. In this study, females assigned to the placebo complete a daily diary where they documented their
group received a sham needle procedure using a adherence to the stretching exercise regimen.
‘Dong Bang’ placebo needle, which is very similar
to the Streitberger needle22 (figure 2). These needles Outcomes
appear to represent an effective placebo technique for Outcomes were assessed at baseline and at 1 and
the majority of subjects in studies using acupuncture. 2 months after treatment, on the same days of the
The therapist performed the same procedure as was menstrual cycle. The primary outcome was the
done with a real needle in the TrP-DN group in order mean intensity of pain as assessed by VAS.23 Partici-
to blind the subjects. These placebo needles elicit a pants were asked to mark their intensity of pain on
mechanical stimulus over the tissue without perfo- a 100 mm horizontal line, with the ends of the line
rating the skin; the patients experienced a sensation of representing the extreme expressions of pain (no pain
pressure very similar to that of a normal needle. to maximum pain).24 The mean intensity of all days
Females assigned to the control group did not with menstrual pain was used for the analysis. There is
receive any needling intervention. In all groups, partic- no study determining the minimal clinically important
ipants were asked to perform self-stretching exer- difference (MCID) of pain for primary dysmenor-
cises of the external and internal obliques and rectus rhoea; therefore, we used data from other gynaecolog-
abdominis muscles (figure 3). They were instructed to ical problems such as endometriosis. In fact, it seems
perform these stretching exercises 3–5 times per day, that the VAS is the most frequently used scale for

304 Gaubeca-Gilarranz A, et al. Acupunct Med 2018;36:302–310. doi:10.1136/acupmed-2017-011566

 Original paper

Sample size determination

It was estimated that 15 individuals per group would
be required to detect a between-group difference of
10 mm in the primary outcome (MCID),26 assuming
an SD of 8 mm, at a two-tailed α level of 0.05 and
90% power. Group sizes were inflated to 17 to account
for an anticipated dropout rate of 10%.

Statistical analysis
Statistical analysis was performed using SPSS version
21.0 (Chicago, IL, USA) and it was conducted
according to the intention-to-treat principle with all
participants analysed in the group to which they were
originally allocated. When any data were missing, the
multiple imputation method was used.33 Mean, SD
Figure 3  Stretching exercise of the rectus abdominis and oblique
and 95% confidence intervals (95% CI) were calcu-
musculature.
lated for each variable. The Kolmogorov-Smirnov
test revealed a normal distribution of the quantitative
variables (P>0.05). Baseline demographic and clinical
assessing the intensity of pain in females with endome-
variables were compared among the groups using a
triosis.25 The MCID of the VAS for endometriosis has
one-way analysis of variance (ANOVA) for continuous
been found to be 10 mm.26 A recent study suggested
data and χ2 tests of independence for categorical data.
that in females with endometriosis who exhibit pain of
Our evaluation included several 3×3  mixed-model
at least 50 mm on a VAS scale at baseline, the suggested
repeated measured analysis of covariance (ANCOVA)
MCID should be a 50% decrease.27
with Time (baseline, 1 month and 2 months after) as
Secondary outcomes included health-related
the within-subjects factor, and Group (dry needling,
quality of life (SF-36 questionnaire), use of NSAIDs
placebo needling or control) as the between-subjects
to mitigate pain symptoms, the number of days with
factor, adjusted for baseline data to evaluate between-
menstrual pain, and self-perceived improvement
group differences in the outcomes. We used χ2 tests
with a 4-point Global Rate of Change (GROC). The
to compare self-perceived improvement at 2 months
Spanish version of the SF-36 questionnaire was used
between all groups. The hypothesis of interest was the
to determine changes in health-related quality of life.28
Group*Time interaction with a Bonferroni-corrected
This questionnaire includes eight domains evaluating
α level of  0.017 (three time points). To enable compar-
the repercussion of pain on quality of life. Scores
ison of between-group effect sizes, standardised mean
range from 0 (the lowest quality of life) to 100 (the
score differences (SMDs) were also calculated by
highest quality of life).29 In the current study, domains
dividing mean score differences by the pooled SD.
were combined into physical component scores (PCS)
and mental component scores (MCS).29 There are no
Results
specific data on the MCID for the PCS and MCS of
Between February and April 2016, 80 consecutive
the SF-36 questionnaire, but changes between 3 and 5
females with menstrual pain were screened for eligi-
points are accepted as clinically relevant30 31
bility. Fifty-six (70%) females satisfied all the eligibility
The number of NSAID tablets (ibuprofen 600 mg)
criteria, agreed to participate, and were randomly allo-
and the number of days with menstrual pain were
cated into the dry needling group (n=19), the placebo
monitored using a diary for the duration of the study.
needling group (n=18) or the control group (n=19).
Finally, at the 2-month follow-up stage, participants
Randomisation resulted in similar baseline features
were asked to rate their self-perceived improvement
(table 1). Four females were lost to follow-up at the
on a 4-point GROC scale with the following possible
end of the study. The reasons for ineligibility are found
answers: worse, equal, better, or much better.
in figure 4, which provides a flow diagram of patient
recruitment and retention. Five females assigned to
Treatment side effects the TrP-DN group (27%) experienced muscle sore-
Females were asked to report any adverse events they ness after dry needling, which resolved spontaneously
had experienced during the study. In the current study, within 24–36  hours. No other adverse event was
adverse events were defined as sequelae of 1 week’s reported by any participant during the study. The
duration with any symptom perceived as distressing percentage of adherence to the stretching exercise was
and unacceptable to the patient and requiring further 97% during the trial.
treatment.32 Particular attention was given to the pres- Adjusting for baseline outcomes, the mixed-model
ence of post-dry needling soreness within the group ANCOVA found significant Group*Time interactions
receiving TrP-DN. for the mean intensity of menstrual pain (F=8.162;

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 Original paper

Table 1  Baseline characteristics by treatment assignment

Placebo needling group
Dry needling group (n=19) (n=18) Control group (n=19)
Age (years) 21.4±1.8 21.7±2.1 21.3±2.3
Weight (kg) 56.4±7.5 57.0±9.6 58.8±7.7
Height (cm) 164.1±7.2 163.4±4.6 165.6±4.0
Body mass index (kg/cm2) 21.0±1.9 21.3±3.2 21.0±2.6
Mean pain intensity (VAS, 0–100) 65.4±19.4 65.5±13.1 62.1±14.3
Days with menstrual pain 2.3±1.1 2.3±1.5 2.5±0.8
Taking NSAIDs (yes/no) n (%) 16 (84%)/3 (16%) 14 (77.5)/4 (22.5%) 15 (78.9)/4 (21.1)
Number of NSAIDs taken 4.7±3.9 4.1±2.9 4.2±5.6
Use of contraceptive (yes/no) n (%) 6 (31.5%)/13 (69.5%) 4 (22.5%)/14 (77.5%) 6 (31.5%)/13 (69.5%)
PCS SF-36 (0–100) 50.7±6.9 52.0±4.5 51.5±6.2
MCS SF-36 (0–100) 51.5±6.0 53.3±4.1 48.1±8.3
MCS, Mental Component Score; NSAIDs, non-steroidal anti-inflammatory drugs; PCS, Physical Component Score; VAS, visual analogue scale.

P<0.001) and the number of NSAIDs (F=6.269; in the number of NSAIDs taken than those in the
P=0.004). Females receiving TrP-DN exhibited placebo  group (1 month: Δ −2.3 (-4.3 to −0.3);
a greater decrease in pain intensity than those receiving 2 months: Δ −2.5 (-4.3 to −0.7), P<0.001) or the
placebo needling (1 month: Δ −19.8 mm (−25.9 to control group (1 month: Δ −2.3 (-4.1 to −0.5); 2
−13.7); 2 months: Δ −26.0 mm (−33.1 to −18.9), months: Δ −2.5 (-3.7 to −1.3), P<0.001). Between-
P<0.001) or only stretching (1 month: Δ −26.0 mm groups effect sizes were large at all stages of follow-up
(−32.5 to −19.5); 2 months: Δ −20.1 mm (−26.4 (1.3>SMD>1.8) in favour of the TrP-DN group.
to −13.8), P<0.001, figure 5). Similarly females in The ANCOVA did not reveal significant Group*-
the dry needling group exhibited a greater decrease Time interaction for the number of days with

Figure 4  Flow diagram of patients throughout the course of the study. NSAIDs, non-steroidal anti-inflammatory drugs; TrP, trigger point.

306 Gaubeca-Gilarranz A, et al. Acupunct Med 2018;36:302–310. doi:10.1136/acupmed-2017-011566

 Original paper

Figure 5  Evolution of the intensity of menstrual pain intensity throughout the course of the study stratified by randomised treatment assignment. Data
are presented as mean (SE). VAS, visual analoque scale. ** indicates significant differences between groups (ANOVA, P<0.001).

menstrual pain (F=1.306, P=0.280), PCS (F=2.184; and their 95% CIs surpassed the MCID of 10 mm
P=0.124) and MCS (F=0.158; P=0.855). No signif- for the VAS26 in favour of the TrP-DN, supporting a
icant changes were observed at any stage of follow-up clinically relevant effect of this intervention. In addi-
in either group (P>0.32) (table 2). tion, within-group score changes of the TrP-DN group
No change was found in the distribution of females also surpassed the restrictive MCID of 50% of reduc-
using NSAIDs at any stage of follow-up (P>0.215). tion of baseline scores.27 Our results are similar to
A greater number of females receiving dry needling those previously reported by Huang and Liu, in their
described a self-reported improvement categorised as quasi-experimental study, who also demonstrated that
better (n=10, 55%) or much better (n=6, 33%) TrP injection of abdominal muscles was effective at
compared with those receiving placebo needling reducing menstrual pain.16
(better: n=2, 14%) or control (better: n=3, 16%) as Current literature supports the use of NSAIDs as
assessed by the GROC (χ2=28.277; P<0.001). first-line therapy, or oral contraceptive pills as second-
line, for pain relief in primary dysmenorrhoea.34 We
Discussion did not find changes in the number of females taking
This randomised clinical trial found that a single NSAIDs for pain relief; however, those females
session of dry needling directed at active TrPs of the receiving TrP-DN reduced the number of tablets
rectus abdominis muscle combined with a stretching taken for management of their pain. This would be
exercise was more effective than placebo needling expected since a reduction in pain intensity during
and stretching alone at reducing pain intensity and their menstrual cycles might lead to the need for fewer
the number of NSAID tablets used in females with NSAID tablets. Females receiving placebo needling or
primary dysmenorrhoea. No significant differences in stretching only did not experience significant change
health-related quality of life were observed. in the number of tablets. It should also be noted that
Current evidence suggests the use of medication, 30% of our females were taking contraceptive pills
acupuncture, acupressure, heat or nerve stimulation by medical prescription, and, obviously, no change in
for the management of females with primary dysmen- this proportion was observed after treatment. There
orrhoea.7–9 Previous trials have not identified TrP-DN were no differences in results in this small subgroup of
as a potentially effective intervention, not because females (data not shown).
there is scientific evidence against this approach but To determine the mechanisms of TrP treatment in
rather because there is a lack of studies investigating order to explain the results of this trial is beyond the
the effectiveness of this intervention in this population. scope of this paper; however, some hypotheses can be
To our knowledge, the current controlled trial is the proposed. Simons et al suggested that rectus abdom-
first to combine Tr-DN and stretching in females with inis muscle TrPs could refer pain to the hypogastrium,
primary dysmenorrhoea. We observed that females mimicking menstrual pain symptoms.11 We selected a
receiving TrP-DN exhibited better outcomes in terms sample of females with primary dysmenorrhoea where
of pain than those who received placebo needling or the referred pain elicited by active TrPs in the rectus
stretching only. In fact, between-group change scores abdominis reproduced their symptoms. The current

Gaubeca-Gilarranz A, et al. Acupunct Med 2018;36:302–310. doi:10.1136/acupmed-2017-011566 307

Original paper

Table 2  Primary and secondary outcomes at baseline, 1 month and 2 months after as well as within-group mean scores by randomised
treatment assignment
Timeline scores and within-group change scores: mean±SD (95% CI)
Outcomes Dry needling Placebo needling Control
Mean intensity of menstrual pain (VAS, 0–100)*
 Baseline 65.4±19.4 (57.9 to 72.9) 65.5±13.1 (57.2 to 73.8) 62.1±14.3 (54.5 to 69.7)
 One month after 28.8±21.9 (18.1 to 39.5 48.7±26.5 (37.1 to 60.3) 51.5±19.5 (40.8 to 62.2)
 Change baseline → 1 month −36.6±20.1 (-47.1 to 26.1) −16.8±22.3 (-29.1 to 4.4) −10.6±16.0 (−18.6 to –2.6)
 Two months after 29.4±22.5 (18.4 to 40.4) 55.5±22.6 (43.5 to 67.5) 46.2±24.1 (35.3 to 56.9)
 Change baseline → 2 months −36.0±14.2 (-43.2 to 28.8) −10.0±22.1 (-22.3 to 2.3) −15.9±22.1 (−26.9 to–4.9)
Number of days with menstrual pain
 Baseline 2.3±1.1 (1.7 to 2.9) 2.3±1.5 (1.7 to 2.9) 2.5±0.8 (2.0 to 3.0)
 One month after 1.8±0.7 (1.4 to 2.2) 2.0±3.0 (1.4 to 2.6) 2.2±0.9 (1.8 to 2.6)
 Change baseline → 1 month −0.5±0.7 (−0.7 to 0.3) −0.3±1.5 (-1.1 to 0.5) −0.3±0.8 (-0.6 to 0.0)
 Two months after 1.8±1.1 (1.2 to 2.4) 2.0±1.5 (1.6 to 2.4) 2.4±0.8 (1.8 to 3.0)
 Change baseline → 2 months −0.5±1.0 (−0.8 to 0.2) −0.3±0.9 (−0.9, 0.3) −0.1±0.7 (−0.2 to 0.0)
Number of non-steroidal anti-inflammatory drugs*
 Baseline 4.7±3.9 (3.0 to 6.5) 4.1±2.9 (2.6 to 5.6) 4.2±2.6 (3.1 to 5.1)
 One month after 1.4±1.8 (0.4 to 2.4) 3.1±1.8 (2.0 to 4.2) 3.2±3.3 (1.9 to 4.5)
 Change baseline → 1 month −3.3±1.5 (−4.1 to 2.5) −1.0±2.3 (−2.3 to 0.3) −1.0±2.0 (−2.5 to 0.5)
 Two months after 1.1±1.5 (0.2 to 2.0) 3.0±3.1 (1.5 to 4.5) 3.1±3.3 (1.8 to 4.4)
 Change baseline → 2 months −3.6±2.1 (−4.7 to 2.5) −1.1±1.5 (−2.5 to 0.3) −1.1±2.0 (−2.6 to 0.4)
Physical Component Score SF-36 (0–100)
 Baseline 50.7±6.9 (47.7 to 53.7) 52.0±4.5 (48.7 to 55.3) 51.5±6.2 (48.6 to 54.4)
 One month after 53.7±5.4 (51.0 to 56.4) 51.8±7.3 (48.8 to 54.8) 53.7±4.1 (51.1 to 56.3)
 Change baseline → 1 month 3.0±6.3 (−0.2 to 6.2) −0.2±5.2 (-3.3 to 2.9) 2.2±5.9 (−0.7 to 5,1)
 Two months after 54.9±4.6 (52.3 to 57.5) 51.5±8.2 (48.5 to 54.5) 54.6±2.6 (52.0 to 57.2)
 Change baseline → 2 months 4.2±5.8 (1.2 to 7.2) −0.5±5.2 (−3.6 to 2.6) 3.1±7.4 (−0.5 to 6.7)
Mental Component Score SF-36 (0–100)
 Baseline 51.5±6.0 (48.3 to 54.7) 53.3±4.1 (49.6 to 57.0) 48.1±8.3 (44.9 to 51.3)
 One month after 49.6±7.4 (46.0 to 53.2) 54.3±3.0 (50.2 to 58.4) 47.8±9.4 (44.3 to 51.3)
 Change baseline → 1 month −1.9±6.0 (−4.9 to 1.1) 1.0±4.0 (-1.3 to 3.3) −0.3±10.6 (−5.4 to 5.0)
 Two months after 51.1±7.6 (47.6 to 54.6) 54.2±4.6 (50.3 to 58.1) 47.8±7.8 (44.5 to 51.1)
 Change baseline → 2 months −0.4±7.1 (−4.0 to 3.2) 0.9±6.5 (−3.0 to 4.8) −0.3±6.5 (−3.6 to 3.0)
*Statistically significant differences among the groups (ANCOVA, P<0.001).

results are similar to those previously reported for might have increased symptoms; however, we do
females with chronic pelvic pain where active TrPs in not currently know what would happen if TrP-DN
the rectus abdominis muscle were the most prevalent.35 was performed at another time during the menstrual
It is interesting to note that, in females with primary cycle. Finally, it is also possible that needling thera-
dysmenorrhoea, pain appears only for a few days per pies—for example, acupuncture or dry needling—
month, usually the menstrual days, which does not regulate nitric oxide levels,36 which are elevated in
seem commensurate with TrP normal behaviour.11 females with primary dysmenorrhoea.37
Increased uterine prostaglandin F2α (PGF2α) produc- Another potential explanation could be related
tion in the weeks before menstruation could be trans- to somatovisceral convergence between the rectus
ported in the blood and settle in rectus abdominis abdominis muscle and the uterus. It seems that lamina
muscle taut bands, leading to irritation and activation, I of the spinal cord is the first site in the central
as Huang and Liu also suggested.16 After menstrua- nervous system where somatic and visceral pathways
tion, with the falling concentration of prostaglandins, converge onto individual projection and local circuit
the TrP could return to latency (asymptomatic), and neurons.38 Therefore, nociceptive stimulation of one
the symptoms may therefore decrease or disappear for structure, for example, somatic tissue, could refer to
a period of time. This is the reason why TrP-DN was the other, that is, the viscera, and vice versa. In such
conducted 2 weeks before menstruation in the current a way, the area of pain could be amplified by these
study. We believe that if dry needling was carried out mechanisms of convergence, overlapping visceral
during menstruation, post-needling induced soreness and somatic stimuli. Since the uterus and the rectus

308 Gaubeca-Gilarranz A, et al. Acupunct Med 2018;36:302–310. doi:10.1136/acupmed-2017-011566

 Original paper

abdominis muscle share common pain fibre pathways and stretching alone at reducing pain intensity and
and are both innervated by the lower thoracic nerves the number of NSAIDs used in females with primary
(T10 to T12), a nociceptive stimuli in either structure dysmenorrhoea. No changes in health-related quality
can stimulate the other. By reducing muscle nocicep- of life were observed in either group.
tion from active TrPs in the rectus abdominis with
TrP-DN, we may have been able to reduce nociceptive Author affiliations
1
Universidad de Alcalá de Henares, Alcalá de Henares, Spain
thresholds from the uterus, explaining our results. In 2
Cátedra de Investigación y Docencia en Fisioterapia: Terapia Manual y Punción
such a scenario, TrP-DN could act as a counter-irritant Seca, Universidad Rey Juan Carlos, Alcorcon, Spain
somatic stimulus to reduce visceral pain.38 3
Department of Physical Therapy, Occupational Therapy, Rehabilitation and
It is also important to consider that all the groups Physical Medicine, Universidad Rey Juan Carlos, Alcorcón, Spain
4
Hospital Universitario 12 de Octubre, Madrid, Spain
also received a stretching exercise of the rectus abdom- 5
Department of Physical Therapy, Franklin Pierce University, Manchester, New
inis muscle as described by Huang and Liu.16 In fact, Hampshire, USA
all the groups exhibited some decrease in the inten- 6
Physical Therapist, Rehabilitation Servicesv, Concord Hospital, Concord, New
sity of menstrual pain, probably associated with the Hampshire, USA
7
Faculty, Manual Therapy Fellowship Program, Regis University, Denver,
stretching of the rectus abdominis. These findings
Colorado, USA
are similar to Ortiz et al, who found that a general
stretching programme was effective at decreasing Contributors  All authors contributed to the study concept and
menstrual pain.39 It is possible that part of the decrease design. AGG, CFdlP and JLAB did the main statistical analysis.
in pain observed in our study could be related to the JRMT, JMSR and ACP contributed to the literature review and
interpretation of the data. CFdlP and JAC contributed to the
effects of the stretching exercise. We do not currently
drafting of the report. JAC and JAB provided administrative,
know the potential effects of the application of technical and material support. JAC and JLAB supervised the
TrP-DN combined with a general stretching and/or study. All authors revised the text for intellectual content, and
strengthening exercise programme. Future studies read and approved the final version of the manuscript accepted
should investigate which combination of therapeutic for publication.
programmes provides the best pain relief in females Funding  This research received no specific grant from any
funding agency in the public, commercial or not-for-profit
with primary dysmenorrhoea. sectors.
The results of this randomised controlled trial
Competing interests  None declared.
should be considered in light of some potential limita-
tions. First, we cannot be confident that our placebo Ethics approval  Universidad de Alcalá, Spain (CEIM/
HU/2015/22)
needling was truly inert, since the mechanical feeling
Provenance and peer review  Not commissioned; externally
of the needle entering into the tissue could also exert peer reviewed.
an analgesic effect. Second, only the rectus abdominis
© Article author(s) (or their employer(s) unless otherwise
muscle was needled; however, the referred pain elic- stated in the text of the article) 2018. All rights reserved.
ited by TrPs in other musculature could also be related No commercial use is permitted unless otherwise expressly
to symptoms in primary dysmenorrhoea. Third, granted.
we only included a follow-up period of two menstrual
cycles, so we are unable to comment on the longer-
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310 Gaubeca-Gilarranz A, et al. Acupunct Med 2018;36:302–310. doi:10.1136/acupmed-2017-011566