Archives of Physical Medicine and Rehabilitation

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Archives of Physical Medicine and Rehabilitation 2015;-:-------

ORIGINAL ARTICLE

Effectiveness of Dry Needling on the Lower Trapezius

in Patients With Mechanical Neck Pain: A Randomized
Controlled Trial
Daniel Pecos-Martı́n, PhD,a F. Javier Montañez-Aguilera, PhD,b
Tomás Gallego-Izquierdo, PhD,a Alicia Urraca-Gesto, PhD,c Antonia Gómez-Conesa, PhD,d
Natalia Romero-Franco, PhD,a Gustavo Plaza-Manzano, PhDe
From the aPhysical Therapy Department, Alcalá University, Madrid; bPhysical Therapy Department, Center for University Studies Cardenal
Herrera University, Valencia; cRehabilitation and Physical Therapy Department, University Hospital Alcorcón Foundation, Madrid; dDepartment
of Physical Therapy, Faculty of Medicine, Murcia University, Murcia; and ePhysical Medicine and Rehabilitation Department, Medical Hydrology,
Faculty of Medicine, Complutense University Madrid, Madrid, Spain.

Abstract
Objective: To evaluate the effect of dry needling into a myofascial trigger point (MTrP) in the lower trapezius muscle of patients with mechanical
idiopathic neck pain.
Design: A single-center, randomized, double-blinded controlled study.
Setting: Patients were recruited from the student population of a local hospital by advertisement in the university clinic from January 2010 to
December 2011.
Participants: Patients (NZ72) with unilateral neck pain, neck pain for
3 months, and active trigger points in the lower trapezius muscle were
randomly assigned to 1 of 2 treatment groups. All the patients completed the study.
Interventions: Dry needling in an MTrP in the lower trapezius muscle, or dry needling in the lower trapezius muscle but not at an MTrP.
Main Outcome Measures: The visual analog scale (VAS), Neck Pain Questionnaire (NPQ), and pressure-pain threshold (PPT) were assessed
before the intervention and 1 week and 1 month postintervention.
Results: Treatment with dry needling of the lower trapezius muscle close to the MTrP showed decreases in pain and PPT as well as an
improvement in the degree of disability (P<.001) compared with the baseline and control group measurements (P<.001). The dry-needling
technique performed in the MTrP showed more significant therapeutic effects (P<.001).
Conclusions: The application of dry needling into an active MTrP of the lower trapezius muscle induces significant changes in the VAS, NPQ,
and PPT levels compared with the application of dry needling in other locations of the same muscle in patients with mechanical neck pain.
Archives of Physical Medicine and Rehabilitation 2015;-:-------
ª 2015 by the American Congress of Rehabilitation Medicine

Physiotherapists use trigger point dry needling (TrP-DN) as an Investigators have found TrP-DN to be an effective technique to
invasive treatment where a solid filament needle is inserted into a release pain in temporomandibular disorders,8 for preventing pain
myofascial trigger point (MTrP)da hyperirritable nodule or spot after total knee arthroplasty,9 and for treating supraspinatus le-
of exquisite tenderness to palpation that refers pain at a distance sions.10 Additionally, recent studies6,11,12 reported that TrP-DN
and can cause distant motor and autonomic effectsdto reduce increased the cervical range of motion as well as decreased pain
pain symptoms.1-6 MTrPs are classified as active, symptom- immediately after treatment and at a 4-week follow-up point in
producing or latent and are not spontaneously symptomatic.1,7 patients with upper-quarter myofascial pain syndromes, particu-
larly neck pain.
Clinical Trial Registration No.: ISRCTN68233026.
Moreover, imbalances of the scapulothoracic muscles have
Disclosures: none. been found in patients with neck pain and cervicogenic headache,

0003-9993/15/$36 - see front matter ª 2015 by the American Congress of Rehabilitation Medicine
http://dx.doi.org/10.1016/j.apmr.2014.12.016
2 D. Pecos-Martı́n et al

where trigger points in the lower trapezius muscle produced Interventions

muscle dysfunction and local and referred pain.13-15 Although
many studies16-19 reported that patients with neck pain had trigger The patients were randomly assigned to the treatment group
points in the cervical and shoulder muscles, such as the upper (nZ36) (TrP-DN: on the trigger point of the lower trapezius) or
trapezius muscle, few authors have studied trigger points as the the control group (nZ36) (non-TrP-DN: 1.5cm medially from the
main cause of neck pain. trigger point of the lower trapezius). An external clinical assistant
Despite the already beneficial effects of TrP-DN, we might be randomly assigned the intervention to each participant using the
able to maximize these effects by performing TrP-DN on the Epidat software version 4.021,a computerized randomization pro-
active trigger point instead of other sites of the same muscle.20 gram to generate the intervention allocation. Hence, for each
However, to our knowledge, no studies have analyzed the site- intervention, both the subjects and investigators were blinded: the
specific effects of TrP-DN therapy. dry-needling procedure was performed by the same physiothera-
We aimed to analyze the effects of TrP-DN on active trigger pist expert in this treatment, and the evaluation process was per-
points in the lower trapezius muscle in patients with neck pain formed by another physiotherapist who was blinded to the
compared with TrP-DN in another site of the same muscle. patients’ group assignments. Additionally, subjects were blinded
Additionally, we evaluated the role of the lower trapezius muscle to the group to which they belonged because the treatment out of
in the pain and disability of patients with neck pain. We hypoth- the TrP-DN (non-TrP-DN) was performed very close to the
esized that TrP-DN is more effective on the active trigger points trigger point.
than other points in the same muscle. In the treatment group, participants were placed on their side
for treatment (this position reduces the risk of producing a
Methods pneumothorax) while the physiotherapist firmly held the lower
trapezius muscle in a pincer grasp to precisely locate the trigger
The present research refers to a single-center, randomized, double- point for TrP-DN. Then a monofilament needle was directed up-
blinded control study. The study was guided by the Consolidated ward across the muscle mass as it was held by the fingers to avoid
Standards of Reporting Trials (CONSORT) statement and any possibility of penetrating the lung and causing a pneumo-
included the CONSORT checklist. thorax.22 The needle was moved up and down within the muscle,
using a “fast-in and fast-out” technique.23 Needle insertions were
Participants repeated 8 to 10 times. The procedure of TrP-DN was similar to
that used by Hong23,24 (fig 1).
Seventy-two participants (14 men, 58 women) aged 18 to 42 years
The control group received the same protocol in the lower
(mean age  SD, 235y) with mechanical idiopathic neck pain
trapezius muscle, but the needle tip was inserted in other points
participated in the study. Participants were randomly recruited
close to, but outside of, the trigger point location (non-TrP-DN)
from the student population by advertisement in the university
(1.5cm medially from the trigger point) (see fig 1).
clinic from January 2010 to December of 2011.
We used the same dry stainless steel needlesb (.2525mm) for
Criteria for inclusion in this study were (1) unilateral neck
both interventions. The area was always first disinfected with a
pain, (2) neck pain for
3 months, and (3) active trigger points in
skin antiseptic. On needle removal, pressure was immediately
the lower trapezius (performed by a physiotherapist with 12y of
applied to the skin using a cotton bud to prevent excessive
experience in trigger point diagnosis). The diagnosis of active
bleeding.25
MTrPs in the lower trapezius muscle was based on the major
The treatment group (TrP-DN) and the control group (non-TrP-
criteria proposed by Simons et al1,7: (1) presence of a palpable taut
DN) were treated by a physiotherapist who had 12 years of clin-
band in the skeletal muscle; (2) presence of an exquisitely tender
ical experience in the management of trigger points using this
spot in the taut band; (3) recognition of the elicited pain as the
technique. The TrP-DN was applied to the ipsilateral side of the
patient’s pain; and (4) a painful limit induced by the full-stretch
neck pain, which was 63.9% on the right side and 36.1% on the
range of motion. When 3 of the 4 criteria were met, a positive
left side.
MTrP was diagnosed.
All the participants were contacted to schedule follow-up ap-
Participants were excluded from this study if they had (1) a
pointments at Principe de Asturias Hospital.
history of neck trauma; (2) cervical radiculopathy; (3) previously
had surgery in the neck or shoulder area; (4) a history of diag-
Outcome measures
nosed primary headache; (5) trigger point therapy or TrP-DN in
the neck within the previous 6 months; (6) evidence of cognitive
deficits; or (7) needle phobia. This study was performed in Prin- Subjective pain intensity
cipe de Asturias Hospital in Alcalá de Henares (Madrid). All Pain intensity was assessed using a visual analog scale (VAS). The
subjects signed an informed consent before data collection. The VAS for pain measures the amount of pain experienced by a
study was approved by the Ethical Committee of Principe de subject, with a continuous range from 0 for no pain and 10 for
Asturias Hospital in Alcalá de Henares. maximum pain. It has been validated as a reliable, generalizable,
and an internally consistent measure of clinical and experi-
mental pain.26
The subjects were asked to indicate the pain levels that they
List of abbreviations: experienced before treatment and 1 week and 1 month
MTrP myofascial trigger point after treatment.
NPQ Neck Pain Questionnaire
PPT pressure-pain threshold
Disability measures
TrP-DN trigger point dry needling
The Neck Pain Questionnaire (NPQ)27 was used to assess self-
VAS visual analog scale
perceived levels of disability as a result of neck pain. The NPQ

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Dry needling on the lower trapezius 3

Fig 1 (A) Position of patient during dry needling. (B) Dry needling on the lower trapezius, near but outside the trigger point (1.5cm away from
the trigger point). (C) Dry needling on the lower trapezius on the trigger point.

includes 9 parameters for monitoring symptoms over time and The PPT was assessed before, immediately posttreatment, and
understanding how the neck pain affects the ability to manage 1 week and 1 month posttreatment.
everyday life: neck pain intensity, sleeping, numbness in the arm
at night, carrying objects, duration, when reading/watching tele- Statistical analysis
vision, when working, during social activities, and when driving.
The last item is optional. The answers for each question are on a The sample size calculation was based on results reported by a
scale from 0 to 4. The sum of all responses is calculated and previous pilot study with 40 subjects: 20 experimental and 20
converted into a score percentage. The percentage score provides control subjects. In this study, the main dependent variable was
information about the patient’s level of functionality (0% for the pain (assessed by the VAS), and after 1 month of treatment, the
least disabled, 100% for the most severely disabled). In addition, mean VAS scores  SD were 3.901.63 in the control group and
the NPQ presents an item (question 10) that evaluates the patient’s 2.742.05 in the experimental group.
assessment of change in pain after follow-up. The NPQ has been We used this result to determine the size effect (Cohen’s dif-
shown to have validity, reliability, and internal consistency,27 and ference between 2 means). The size effect was .63. Furthermore,
it is an instrument with sensitivity to changes in both short-term we assumed an alpha level of .05 and a desired power (b) of 80%
and long-term periods.27,28 The minimal clinically important dif- with a ratio of the sample sizes of the 2 groups being 1 (N2/N1)
ference for the NPQ has been determined to be a 25% score and with a 1-tailed hypothesis test. These assumptions generated a
reduction from the baseline.29 sample size of at least 32 participants per group. G*Power 3.1.3
Disability was assessed before and 1 month after treatment.

Pressure-pain threshold
The trigger point of the lower trapezius muscle was identified
while participants were lying on their side for treatment, by using
a pincer grasp of the hyperirritable spots in the taut bands of the
same muscle. To locate the trigger point, the point was marked
with indelible ink, and the distance between this mark and the
medial border of the scapula was measured with a caliper.30 This
mark established the site for all testing. Because of the criteria
proposed by Simons,7 the location for the follow-up measures
was stable.
A pressure algometerc was used to assess the pressure-pain
threshold (PPT),31 which has been proven to be both reliable and
valid.32 The algometer was applied to the marked site with the
rubber rod perpendicular to the surface of the skin. Pressure was
increased at a rate of approximately 1kg/cm2 every second until
the subject reported “pain,” and then compression was stopped.
Three repetitive measurements at an interval of 30 seconds were
performed at each site. The average value of the 3 measures was Fig 2 Consolidated Standards of Reporting Trials flow diagram of
then used for data analysis. subject recruitment throughout the course of the study.

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4 D. Pecos-Martı́n et al

Table 1 Sex, age, and preintervention pain intensity measurements

Sex Neck Pain
Group n Age (y) M W Duration (mo) Northwick VAS (cm) PPT (kg/cm2)
Intervention 36 235 6 30 5.72.6 19.77.9 5.31.5 2.80.5
Placebo 36 236 8 28 7.02.8 22.111.4 5.61.6 2.80.6
Total 72 235 14 58 6.42.7 20.99.8 5.41.6 2.80.6
NOTE. Values are mean  SD or as otherwise indicated. Pain intensity measured using the Northwick questionnaire (Northwick).
Abbreviations: M, men; W, women.

for Windows33,d and David Walker’s effect size calculator34 were The mixed-model linear analysis revealed a significant group-
used. The final sample was 72 subjects. by-time interaction (FZ75.913, P<.001) for subjective pain in-
To assess the influence of the different types of interventions tensity, with patients treated by TrP-DN showing a 40.9% and
(TrP-DN on the trigger point vs TrP-DN 1.5cm from the trigger 60.9% reduction between the baseline measurements and the 1
point) and the time of measurement on the results of the ques- week and 1 month posttreatment measurements (P<.001). The
tionnaires and the PPT, a mixed model with linear procedures was between-group differences showed that the treatment group had a
conducted because we designed a repeated-measures study with greater reduction in the subjective intensity of neck pain than the
unequal intervals between measurements. Our analysis included control group 1 week and 1 month posttreatment (2.4 and 2.7
within-subject variables (the time of measurement with 4 levels: points less pain in the treatment group 1wk and 1mo later,
before, immediately after, 1wk and 1mo after the intervention) and respectively; P<.001) (table 2).
between-subjects variables (the intervention with 2 levels: placebo The mixed-model linear analysis revealed a significant group-
and treatment). by-time interaction (FZ17.881, P<.001) for NPQ, in which pa-
We performed a post hoc paired t test with a Bonferroni tients treated with TrP-DN experienced a reduction of 50.5% in
adjustment for alpha inflation to explore the effects of the inter- neck pain and a lower level of disability from neck pain compared
action between the time of the measurements and the type of the with baseline measurements (P<.001), and achieved 5.6 times
intervention. We investigated the relationship between the type of more reduction in neck pain than those in the control group by the
the intervention and the subjective rating of improvement on a 5- 1-month follow-up time point (P<.001) (table 3).
point scale using a contingency table and a chi-square test, which On the tenth question on the NPQ, the contingency table
was calculated by the exact method. The intensity of the associ- analysis showed a significant correlation between being in the
ation was assessed using a contingency coefficient. SPSS for treatment or control group and the change in the patient’s condi-
Windows (version 18.0e) was used for all statistical analyses. tion. This association was measured by the chi-square test
Significance was accepted at an alpha level of .05. (P<.001). In the treatment group, 14 subjects were “much better,”
20 subjects were “slightly better,” and 2 subjects were “the same
as before” at the 1-month follow-up. In the control group, 1
Results
subject was “slightly better,” 19 subjects were “the same as
One hundred thirty-four subjects were screened for eligibility. before,” 8 subjects were “slightly worse,” and 8 subjects were
Sixty-two were excluded: 35 were excluded because they did not “much worse” at the 1-month follow-up (fig 3).
meet the inclusion criteria, and 27 refused to participate because of The mixed-model linear analysis revealed a significant group-
personal issues unrelated to the intervention (such as a lack of time) by-time interaction (FZ116.273, P<.001) for the PPT in which
(fig 2). Finally, 72 subjects were treated, and 36 were assigned to the patients treated with TrP-DN showed a significant increase of
experimental group and 36 to the control group. No significant 54.9%, 53.8%, and 57.4% compared with baseline measurements
difference was found between the 2 groups in terms of the de- immediately after treatment and 1 week and 1 month later,
mographic and clinical characteristics at baseline (table 1). respectively (P<.001). However, patients in the control group also

Table 2 Subjective pain intensity outcome data Table 3 NPQ outcome data
1wk Post- 1mo Post- 1mo Post-
Variable Pretreatment treatment treatment Variable Pretreatment treatment
Control* 5.61.6 5.31.6 5.11.5 Control* 22.111.4 20.48.1
Treatment* 5.31.5 2.61.8 2.11.6 Treatment* 19.77.9 9.97.4
Within-group Within-group change
differences score from pretreatment
Control group 0.3 (0.0 to 0.6) 0.5 (0.1e0.9) Control group 1.7 (0.1 to 3.6)
Treatment group 2.7 (2.0e3.3)y 3.2 (2.6e3.8)y Treatment group 9.7 (7.3e12.2)y
Between-group 2.4 (1.6e3.2)y 2.7 (2.0e3.4)y Between-group difference 8.0 (5.0e11.0)y
difference change score
NOTE. Values are mean  SD or mean (95% confidence interval). NOTE. Values are mean  SD or mean (95% confidence interval).
* 0e10 scale. * 0e36 questionnaire.
y y
Statistically significant (P<.001). Statistically significant (P<.001).

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Dry needling on the lower trapezius 5

Fig 3 Number of subjects classified according to rates of subjective change in pain after 1 month of follow-up compared with baseline.

showed a significant reduction of 22.6% and 9.2% immediately improvement after treatment in the active trigger points but not in
after the treatment and 1 week later, respectively, compared with the sham-needling group in short-term follow-up assessments.
their baseline measurements by the PPT (P<.001), and the Although the pathophysiology of trigger points remains un-
between-group differences showed that the treatment group had clear, muscle overload associated with repetitive and prolonged
higher values of PPT compared with the control group throughout activities and low-level muscle contractions may produce changes
the follow-up period (1.2 times higher immediately after TrP-DN, in the fiber structure, localized tissue stiffness, and the blood flow
1.4 times higher 1wk after treatment, and 1.4 times higher 1mo properties of the biochemical milieu.38,39 Additionally, many au-
after treatment; P<.001) (table 4). thors have reported more acidic biochemical environments in
active trigger points as well as elevated levels of inflammatory
mediators, neuropeptides, and proinflammatory cytokines, which
Discussion are typically associated with persistent pain and tenderness.40,41
In the present study, we found that in patients with mechanical The mechanical effect of the needle may improve the fiber
idiopathic neck pain, TrP-DN produced greater effects on the VAS structure, the localized tissue stiffness, and the local circulation of
and PPT assessments, as well as the degree of disability, when the the biochemical milieu associated with the trigger point.39 The
technique was performed on the site of the trigger point compared change of local blood flow and the induction of local twitch re-
with 1.5cm medially from the trigger point. A recent study20 that sponses through TrP-DN at the trigger points may improve
used dry needling on the active trigger points in the trapezius, ischemia, hypoxia, and the presence of algesic substances such as
which is associated with cervical pain, increased the size and substance P and the calcitonin gene-related peptide.20,40,42 This
blood flow to the site of the active trigger point, and decreased the corresponds with the decrease in pain and local tenderness after
VAS scores and increased the PPT scores of the subjects. the TrP-DN of a trigger point, which persisted at least 1 month
Although many studies6,12,35 reported decreased pain and after therapy in our study.
increased motion in patients with neck pain after TrP-DN, to our Additionally, in this study, we reported that TrP-DN treatment
knowledge this is the first study reporting the importance of site- of the lower trapezius improved the perceived level of disability
specific TrP-DN in the treatment of muscle trigger points in caused by neck pain, and thus the lower trapezius was shown to be
patients with myofascial cervical pain. Srbely et al36 reported associated with neck pain as Simons1 first reported. In agreement,
similar results in the supraspinatus muscle. However, these differ- Arendt-Nielsen and Graven-Nielsen43 suggested that trigger
ences were unclear in studies by Tsai37 and Fernández-Carnero4 and points in the lower trapezius muscle may induce motor alterations
colleagues when they used a sham TrP-DN intervention above the (such as restricted range of motion, weak regions, and reduced co-
trigger point into the subcutaneous layer but not reaching the muscle coordination) and sensory alterations (such as pain and tender-
layer. Additionally, other studies4,37 have shown a significant ness).44 This is the first study investigating the effect of treating

Table 4 PPT outcome data

Variable Pretreatment Posttreatment 1wk Posttreatment 1mo Posttreatment
Control (kPa) 2.80.6 3.50.7 3.10.6 3.00.6
Treatment (kPa) 2.80.5 4.30.6 4.30.6 4.40.5
Within-group differences*
Control group 0.6 (0.8 to 0.5)y 0.3 (0.4 to 0.3)y 0.4 (0.3 to 0.6)
Treatment group 1.5 (1.6 to 1.4)y 1.5 (1.63 to 1.4)y 1.6 (1.7 to 1.4)y
Between-group difference 0.9 (1.1 to 0.6)y 1.2 (1.41 to 1.1)y 1.4 (1.6 to 1.2)y
NOTE. Values are mean  SD or mean (95% confidence interval).
* Within-group differences are given as change from preintervention measure.
y
Statistically significant (P<.001).

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6 D. Pecos-Martı́n et al

the lower trapezius for cervical myofascial pain. Many authors Corresponding author
reported altered function of the axioscapular muscles in me-
chanical neck pain and greater upper trapezius activity and a weak Gustavo Plaza-Manzano, PhD, Associate Professor, Physical
lower trapezius on the side of pain in patients with cervical Medicine and Rehabilitation Department, Medical Hydrology,
pain.16-19,45-47 Faculty of Medicine, Complutense University, Street Ciudad
Because we reported increased effects (changes in the PPT Universitaria, E-28040, Madrid, Spain. E-mail address: gusplaza@
value and pain sensitivity in patients with mechanical idiopathic ucm.es.
neck pain) after the TrP-DN treatment of trigger points in the lower
trapezius muscle, this increase could affect the spinal and supra-
spinal mechanisms as well as both peripheral and central mecha-
nisms.36,48 The high-pressure stimulation of nociceptors during References
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