ARTICLE

Percutaneous Electrical Nerve Stimulation Versus Dry

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Needling: Effectiveness in the Treatment of Chronic Low

Back Pain
S. Pérez-Palomares
B. Oliván-Blázquez
R. Magallón-Botaya
Ma L. De-la-Torre-Beldarraı́n
E. Gaspar-Calvo
L. Romo-Calvo
R. Garcı́a-Lázaro
For personal use only.

B. Serrano-Aparicio

ABSTRACT. Objective: The aim of this study was to evaluate the effectiveness of treating
myofascial trigger points [TrPs] with dry needling [DN] compared to percutaneous electrical
nerve stimulation [PENS].
Method: In this clinical trial, 122 subjects suffering from non-specific chronic low back pain
[CLBP] were treated. They were randomly distributed into two treatment groups: one taking
PENS and the other taking DN of TrPs on the deep lumbar paraspinal muscles [lumbar multifidi],
quadratus lumborum, and gluteus medius. Four variables were measured: perceived pain and sleep
quality using a visual analog scale [VAS], pressure-pain tolerance threshold on TrPs with an
algometer, and quality of life assessed with the Oswestry Disability Index.

S. Pérez-Palomares, Aragonese Health Service, Spain and Investigator of the IAPP Network.
B. Oliván-Blázquez, Investigator of the Aragonese Health Science Institute and Investigator of the IAPP
Network.
R. Magallón-Botaya, Aragonese Health Service, Spain and Coordinator of the IAPP Network in Aragón. Health
Institute Carlos III. Spain.
Ma L. De-la-Torre-Beldarraı́n, E. Gaspar-Calvo, and L. Romo-Calvo, Aragonese Health Service. Spain and
Investigator of the IAPP Network.
R Garcı́a-Lázaro1, Investigator of the IAPP Network.
B. Serrano-Aparicio, Aragonese Health Service. Spain and Investigator of the IAPP Network.
Address correspondence to: Bárbara Oliván Blázquez, Primary Care Research Unit, C.S. Arrabal. C/Andador
Aragüés del Puerto S/N. 50.015. Zaragoza (Spain), Phone: 0034 976 731500/0034 636 441315, Fax: 0034 976
733324. E-mail: [email protected]
Journal of Musculoskeletal Pain, Vol. 18(1), 2010
Available online at www.informaworld.com/WJMP


C 2010 by Informa Healthcare USA, Inc. All rights reserved.
doi: 10.3109/10582450903496047 23
 24 JOURNAL OF MUSCULOSKELETAL PAIN

Results: At least one TrP was found in all patients, most commonly situated in the quadratus
lumborum muscle [97.6 percent]. The improvement achieved for both treatment groups was similar
in all the measured variables, although the DN group carried out fewer sessions than the PENS
group.
Conclusions: It could be concluded that the effectiveness of DN is comparable to that of PENS
and, therefore, it may be considered as another useful tool with limited adverse effects within the
multidisciplinary approach required in the management of non-specific CLBP.

KEYWORDS. Chronic low back pain, Trigger points, PENS, Dry-needling, Myofascial pain
syndrome
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INTRODUCTION found in a taut, palpable band of skeletal mus-

cle, producing focal pain on compression. Seen
The incidence of chronic low backpain from a microscopic perspective, it is made up
[CLBP] is reported to be very high. Between of multiple contraction knots, representing a se-
60 and 80 percent of the population have lumbar vere, localized shortening of select sarcomeres.
pain in the course of their lives (1, 2). Treatment The most accepted and developed hypothesis ex-
for CLBP is mainly pharmacological, given that plaining the etiology of TrP, suggests that TrPs
it provides a temporary relief. However, it is as- are the result of dysfunctional motor endplates
sociated with side effects, thus the current trend of extrafusal skeletal muscle fiber, characterized
is to seek alternative, non-pharmacological treat- by an excessive release of acetylcholine. There-
ments (3, 4). For this reason, clinical practice fore this could be conceived as a neuromuscular
guidelines recommend using a multidisciplinary dysfunction. Besides pain, TrPs are the cause
For personal use only.

approach (2, 5), through applying different tech- of functional limitation, weakness, and motor
niques to CLBP, in which percutaneous electri- ataxia (12).
cal nerve stimulation [PENS] is included and There are many techniques for TrP treatment,
considered as a highly effective analgesic tech- but DN has shown to be effective in inactivating
nique (3, 6). them (13). The injection onto the TrP of sub-
Another effective treatment for muscular stances such as local anaesthetics, nonsteroidal
pain, and the object of the ongoing study, is antinflamatory drugs [NSAID], or botulinum
dry needling [DN] of myofascial trigger points toxin has not shown greater effectiveness than
[TrPs] which gets performed on selected mus- DN, which does not add any substance and uses
cles of the lower spine and pelvis (7–9). The only the mechanical effects as a therapy, with the
comparison of the effectiveness of DN to that of condition of obtaining the local twitch response
PENS is of interest due to the lower costs that (14, 15).
its use and practice entail. Previous comparative studies on these two
Percutaneous electrical nerve stimulation is techniques have never been carried out. Both
an analgesic treatment in which low frequency of them have been separately tested and proved
electrical currents are applied through needles highly effective, PENS as a treatment for CLBP
inserted into the affected areas. It consists in (3, 4, 6), and DN as a technique of choice in
nerve stimulation at the level of the dermatomes the treatment of myofascial pain (14). Given the
corresponding to the area affected by pain. The similarities between chronic muscular pain and
analgesic effect is based on Melzack and Wall’s myofascial pain and the involvement of TrPs
Gate Control theory (10). The effectiveness of in the circuits of hyperalgesia and chronic pain
PENS in the treatment of CLBP has been demon- [peripheral sensitization, spinal segmental sen-
strated in comparison with other commonly used sitization with involvement in myotome, sclero-
therapies (3, 4). tome and dermatome, central sensitization, and
At present, a consistent theory attributes the dysfunctional inhibition], we propose a com-
cause of musculoskeletal pain to the existence of parison of the two techniques, one of them
an active TrP, the myofascial pain syndrome the- with the treatment focused on the “target organ”
ory (9, 11, 12). A TrP is a hyperirritable nodule [the DN], and the other with the stimulation of
 Pérez-Palomares et al. 25

peripheral sensory nerves at the level of the der- circumstances that, in the researcher’s judgment,
matomes involved in low back pain, also known might have interfered in the results.
as PENS. Neither advanced age, nor the possible exis-
Therefore, the main objective of this study tence of facetary and/or ligament problems with
is to assess the effectiveness of DN therapy for normal radiology that might be modifier factors
CLBP by comparing it to PENS. Furthermore, of the effect, were considered as exclusion crite-
we aim to establish a link between non-specific ria. It is also possible that degenerative problems
CLBP and the presence of TrPs in order to ex- of different ranges may coexist, or any other al-
plain its clinical background and justify its treat- terations of the statics with overload of capsu-
ment. loligamentary structures that may also partici-
pate in the pain and play an important role in the
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perpetuation of the active TrPs.

MATERIALS AND METHODS In brief, the patients diagnosed with non-
specific CLBP were included according to an
A pragmatic clinical trial was carried out by exclusively medical criterion, without regarding
randomizing two parallel groups in order to com- alterations in any other complementary test, but
pare the effectiveness of DN to that of PENS without discriminating the origin of the low back
in the non-pharmacological treatment of non- pain.
specific CLBP. The trial was based on previ- The independent variable was the therapeutic
ous studies (3, 16, 17) in which patients were method assigned: PENS or DN. The dependent
recruited from four primary health care cen- variables were: 1. Perceived pain measured us-
ters belonging to the Health Service in the ing a visual analog scale [VAS: 0 as absence of
city of Zaragoza between July 2004 and 2005. pain and 10 as maximum pain in a total of 10 cm,
For personal use only.

These patients were randomly allocated into two 1 cm per level]; 2. Pain tolerance measured by
groups and each one was given a treatment, ei- algometer on selected TrPs [pain-pressure toler-
ther PENS or DN. Both methods were applied ance threshold, PPT]; the more active the TrP
in all health centers participating in the study. is, the less pressure it can tolerate (18); 3. Sleep
A third-party investigator carried out the ran- quality [also measured using VAS], and 4. Qual-
domized distribution of both the sequence and ity of life measured in terms of ability to function
the assignment, by using a random numbers ta- using the Oswestry Disability Index.
ble applied in order of inclusion of each patient Other variables were registered including sex,
into the study. age, pain background, medication, previous ther-
The study was done on patients over 18 years apies [pharmacological treatment, type of medi-
of age who had been referred to the physiother- cation, duration of treatment, and development],
apy consultation by their primary physician, and trauma or surgical events, and other concurrent
whose CLBP had been evolving for four months conditions. At the time of the study, 65.3 percent
or more, or fewer duration if it has had been a of the subjects in the study were taking some
recidivate. All of them expressed their consent to kind of medication for CLBP, either on a regular
participate in this research after being informed. basis [40 percent] or as required depending on
All the subjects had previously received pharma- the occurrence of pain [60 percent]. The dura-
cological treatment [NSAIDs and/or analgesics] tion of medication ranged from three weeks [for
and had reported little or modest improvement, cases of exacerbated occurrence of CLBP] to
to the extent that at the time of inclusion in the several years. The limited improvement of non-
study, 65.3 percent of the subjects, equally dis- specific CLBP symptoms with pharmacological
tributed into both treatment groups, were taking treatment is the reason that led us to seek an
medication, either when needed or on a regular alternative, non-pharmacological therapy (9).
basis. Exclusion criteria were suspected or diag- Once the patients were included in the study,
nosed fibromyalgia syndrome and suspected or an initial measurement of the dependent vari-
diagnosed structural lesions in the lumbar col- ables was made and a diagnosis of active TrPs
umn, either at the disc level or on any other struc- present in the previously selected muscles was
ture. Concomitant non-pharmacological treat- carried out, no matter what the therapy they
ments [acupuncture, homeopathy] were also ex- were to receive. Those muscles were: deep lum-
cluded, as well as any medical conditions or bar paraspinal muscles, right and left quadratus
 26 JOURNAL OF MUSCULOSKELETAL PAIN

IMAGE 1. IMAGE 2.
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lumborum [superficial TrPs] (19, 20), and right In successive sessions, only those TrPs that re-
and left gluteus medius [TrP 3] according to mained active were treated.
Travell and Simons’ nomenclature (12). The cri- In order to minimize variability from hav-
teria for diagnosis of the active TrPs were the ex- ing to involve professionals from different fields
istence of a painful nodule in taut band and the for each therapy, researchers were previously
pain recognized by the patient when pressure is trained to perform both therapies (19, 20). Vari-
exerted on it (12). able measurement criteria were also unified. In
For personal use only.

Percutaneous electrical nerve stimulation our study we have tried to minimize these short-
therapy consisted of the application of a low- comings through consensus in TrP diagnosis cri-
frequency [4 Hz] electric current through eight teria and training for all study physiotherapists,
0.3 × 25 mm acupuncture needles, which were regardless of the fact whether they have an ex-
introduced at a depth of 2 to 2.5 cms. They were pertise in TrP management or lack thereof. Per-
positioned at the level of dermatomes from L2 manent telephone contact was maintained with
to L5, as shown in Image 1. The duration of the the coordinating researcher in order to solve
impulse was 0.3 milliseconds and it was applied any kind of doubts or problems that might have
with a portable device normally used in primary risen.
care facilities [Carin TNS 190 portable]. Each Additionally, peripheral noxious stimulation
patient was subjected to a total of nine PENS would be produced by the actual insertion of
sessions spread over three weeks, three sessions the needle, whether superficial or deep, which
per week on alternate days. Every session lasted would activate pain control mechanisms at the
for 30 minutes. level of the posterior horn of the spinal cord
Dry needling therapy consisted of three ses- (21, 22). For this reason no placebo group was
sions during three weeks, once per week, leav- used for either of the compared therapies [in
ing at least an eight-day latent period between their study on PENS, Ghoname et al. (3) did use
sessions (12). The treatment was registered and one].
consisted of the DN technique performed us- With regard to the dependent variables, VAS
ing needles with plastic guide tubes, measuring pain and quality of sleep were measured on three
0.30 × 40 mm. It was applied according to the occasions: at the beginning, at an intermediate
fast-in and fast-out Hong’s technique [Image 2], point [before the second DN session and the sixth
which is based on the search for local twitch re- PENS session], and at the end of the therapy.
sponse (15), followed by the spray and stretch The algometry on TrPs was performed at the
technique for each treated muscle. Each muscle beginning and at the end, and likewise for quality
was passively stretched in three sequences and of life/functioning with the Oswestry Disability
vapocoolant spray was applied to the pain ref- Index.
erence zone in three sweeps for each sequence. All dependent variable measurements were
In the first session, treatment was carried out on made by a blinded evaluator. The variables that
the TrPs diagnosed during the initial assessment. showed a normal distribution were contrasted
 Pérez-Palomares et al. 27

using Student’s t-test. These were VAS pain and as the difference between initial and final mea-
algometry on the deep paraspinal muscles. A surements. The following sections were stud-
Mann–Whitney U test was used for the variables ied: personal care, lifting weight, walking, sit-
that did not follow a normal distribution: These ting, standing, and social life. As can be seen in
were sleep quality, algometry on the quadratus Table 4, there were no significant differences in
lumborum and gluteus medius, and the Oswestry the results of both therapies with regard to qual-
Disability Index. ity of life in any sections [personal care P = 0,94,
walking P = 0,86, sitting P = 0, 51, standing P
= 0, 26, social life P = 0, 18], except in “lifting
RESULTS weight” [P = 0.03], where the improvement was
greater for the DN technique.
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There was a recruitment of 91 women and In terms of clinical relevance, a lessening of

31 men, for a total of 122 patients. The average VAS pain of 40 percent or more was considered
age was 45.85 years, with a standard deviation as an improvement. In Table 5 the improvement
of 14.4. PENS therapy was given to 67 patients results for both groups are shown.
and DN therapy to 68. The study was abandoned
by 10 patients, 3 from PENS and 7 from DN
therapy. DISCUSSION
Being a pragmatic clinical trial, the statistical
analysis of this study was based on the actual Similar levels of effectiveness for the treat-
data. At the end of the study, the data analyzed ment of non-specific CLBP in both the tech-
were those from the patients who had completed niques were compared. Differences in the re-
the treatment. The confidence interval used was sults of both interventions were not relevant. We
For personal use only.

of about 95 percent. obtained changes in all the variables of mea-

As shown in Table 1, both groups gave sim- surement for both treatment groups. However,
ilar measurements at the start of the study. All the most relevant result was the drop of local
patients [100 percent] presented at least one TrP, sensitivity to compression on existing TrPs
the most common location being the quadratus [measured with algometry] for both PENS
lumborum muscle [97.6 percent]. treated group and DN treated group.
Table 2 shows results for the variables VAS The clinical recovery obtained along with the
pain and sleep quality. The difference between changes in local sensitivity to compression ob-
initial and final measurements for each treatment tained in TrPs confirmed previous studies, from
was calculated to obtain the degree of improve- those of Dr. Travell in the second half of the
ment. As observed, there were no significant 20th century to the most recent publications
differences in the results of both therapies [P (23), which back up a close relationship between
= 0.94 for VAS pain, P = 0.68 for quality of CLBP and the TrPs. Although the pathophysi-
sleep]. ology of the TrPs is not completely known, it
Table 3 gives the results of algometry on deep has been demonstrated the high concentration
paraspinal muscles, quadratus lumborum, and of nociceptive substances inside active TrPs and
gluteus medius muscles. If less pain is found its link with central sensitiveness circuits in the
at the TrP, the values measured by the algome- present concept of chronic pain (24). The drop
ter become higher. The improvement was cal- in the concentration of nociceptive substances
culated from the difference between initial and after the local twitch response elicited would
final measurements. As we could see, there were explain the inactivation of the active TrP with
no significant differences in the results of both DN, through a specific local technique on the
therapies [P = 0.93 for right deep paraspinal, sensitized tissue which is the active TrP (25).
P = 0.83 for left deep paraspinal, P = 0.33 We have also found certain significant dif-
for right quadratus lumborum, P = 0.12 for left ferences in the PPT algometric measurements of
quadratus lumborun, P = 0.32 for right gluteus the active TrPs in the subjects treated with PENS,
medius, and P = 0.14 for left gluteus medius]. who were not given any local treatment on the
Regarding the quality of life in terms of abil- TrPs. At this point, analgesia in the mechanism
ity to function measured using the Oswestry of myofascial pain could be explained in terms
Disability Index, improvement was considered of central desensitization. The involvement
 28 JOURNAL OF MUSCULOSKELETAL PAIN

TABLE 1. Initial Values for Both Groups

Variables PENS DN P-value

GENDER:
Male 18.8% 32.8% 0.08
Female 81.3% 67.2%
AGE:
<40 years old 34.4% 50.0% 0.18
40–60 years old 45.3% 31.0%
>60 years old 20.3% 19.0%
OCCUPATION:
Sedentary 23.4% 20.0% 0.89
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Standing position 25.0% 25.9%

Physical activity 48.5% 53.5%
DEVELOPMENT PERIOD:
0–3 months 15.6% 25.8% 0.52
3–6 months 25% 25.8%
6–12 months 15.6% 10.3%
Over one year 43.7% 36.2%
PREVIOUS OCCURRENCES:
Yes 87.5% 89.7% 0.71
No 12.5% 10.3%
MEDICATION:
Yes 60.32% 70.69% 0.23
No 39.68% 29.31%
INITIAL VAS PAIN 6.27[±1.68] point 6.04[±1.68] point 0.45
For personal use only.

INITIAL QUALITY OF SLEEP [median 3.75[±2.95] point 3.89[±3.04] point 0.81

VAS values]
PAIN MEASURED BY ALGOMETRY
[median initial values]
Right deep paraspinal 6.38[±2.17] g/cm2 6.83[±3.10] g/cm2 0.59
Left deep paraspinal 5.97[±2.37] g/cm2 6.33[±2.64] g/cm2 0.68
Right quadratus lumbor 5.26[±2.39] g/cm2 5.28[±2.64] g/cm2 0.96
Left quadratus lumbor 5.54[2.60]± g/cm2 5.19[±2.71] g/cm2 0.55
Right gluteus medius 5.71[±2.79] g/cm2 5.48[±2.65] g/cm2 0.69
Left gluteus medius 5.63[±2.97] g/cm2 5.50[±2.55] g/cm2 0.84

TABLE 2. Median Difference Values in VAS Measurements of Pain and Sleep Quality at the
Beginning and the End of the Treatment According to Therapy

PENS DN P-value

Initial–final VAS difference in pain 2.38[±2.27] 2.35[±2.58] 0.94

Initial–final VAS difference in sleep quality 1.72[±2.67] 1.85[±2.66] 0.68

Statistical analyses used: Student’s t-test for pain perception and Mann–Whitney U test for sleep quality.

TABLE 3 Median Difference Values for Initial and Final Algometry Readings According to Therapy

PENS DN P-value

Right deep paraspinal 0.91[±4.39] 1.04[±4.45] 0.93

Left deep paraspinal 1.75[±4.6] 2.06[±3.35] 0.83
Right quadratus lumborum 0.89[±3.10] 1.73[±3.47] 0.33
Left quadratus lumborun 0.76[±2.77] 1.64[±2.91] 0.12
Right gluteus medius 0.77[±3.27] 0.87[±2.76] 0.32
Left gluteus medius 0.58[±2.46] 1.77[±3.44] 0.14

Statistical analyses used: Student’s t-test for deep paraspinal muscles and Mann–Whitney U test for quadratus lumborum and gluteus
medius muscles.
 Pérez-Palomares et al. 29

TABLE 4. Median Difference Values between Initial and Final Measurements of Oswestry
Disability Index Variables

PENS DN P-value

Personal care 0.38[±0.97] 0.34[±0.82] 0.94

Lifting weight 0.59[±1.42] 0.06[±0.96] 0.03
Walking 0.17[±0.98] 0.15[±0.57] 0.86
Sitting 0.21[±0.89] 0.33[±1.05] 0.51
Standing 0.25[±0.84] 0.41[±0.82] 0.26
Social life 0.72[±1.10] 0.72[±3.03] 0.178

Statistical analysis used: Mann–Whitney U test.

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TABLE 5. Clinical Relevance effective, but postreatment soreness associated

to it can cause a higher rate of abandonment with
No of patients with Percentage of patients regard to PENS. Therefore, we have two useful
more than 40% with more than 40% tools to deal with chronic muscular pain the ac-
reduction in VAS pain reduction in VAS pain
tion of which have been confirmed in different
PENS 28 53.85% ways in the context of neuromuscular chronic
DN 24 46.15% pain matrix.

ACKNOWLEDGEMENTS
of central desensitization in TrPs related pain
For personal use only.

syndromes can be discussed in terms of bilat- The authors would like to thank Eva Andrés
eral decrease in PPT, central changes following for her expert advice on statistics, and Jesús
dermatomal electrical stimulation, and temporal Magdalena, J.M. Vergara, and Orlando Mayoral
summation of pain in the myofascial pain syn- for their scientific and methodological commen-
dromes (18, 24, 25). taries. The work was supported by the Aragonese
Percutaneous electrical nerve stimulation Health Service (Spain) and Research Network
proved to be a simpler technique to apply than on Preventive Activities and Health Promo-
DN because it raised less problems or doubts tion (Health Institute Carlos III) and Aragonese
among professionals in the field. DN needs a Health Science Institute.
previous process of standardization before it can
be applied. However, as we required a larger Declaration of interest: The author reports no
number of PENS sessions in order to obtain the conflict of interest. The author alone is respon-
same results, we can state that DN is more cost- sible for the content and writing of this paper.
effective.
Postreatment soreness could justify the higher
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