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Effectiveness of Dry Needling for Myofascial

Trigger Points Associated With Neck and
Shoulder Pain: A Systematic Review and Meta-
Analysis

Article in Archives of Physical Medicine and Rehabilitation · January 2015

Impact Factor: 2.57 · DOI: 10.1016/j.apmr.2014.12.015 · Source: PubMed

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 1
Archives of Physical Medicine and Rehabilitation 63
2 journal homepage: www.archives-pmr.org 64
3 Archives of Physical Medicine and Rehabilitation 2015;-:------- 65
4 66
5 67
6 68
7 69
8 REVIEW ARTICLE (META-ANALYSIS) 70
9 71
10 72
11 Effectiveness of Dry Needling for Myofascial Trigger 73
12 74
13 Points Associated With Neck and Shoulder Pain: A 75
14 76
15 Systematic Review and Meta-Analysis 77
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17 79
18
Q18
Lin Liu, MSc,a Qiang-Min Huang, MD, PhD,a,b Qing-Guang Liu, MSc,a Gang Ye, MCh,c 80
19 Q1 Cheng-Zhi Bo, BSc,a Meng-Jin Chen, BSc,a Ping Li, PTb 81
20 82
21 Q2 From the aDepartment of Sport Medicine and the Center of Rehabilitation, School of Sport Science, Shanghai University of Sport, Shanghai; 83
22 b
Department of Pain Rehabilitation, Shanghai Hudong Zhonghua Shipbuilding Group Staff-worker Hospital, Shanghai; and cDepartment of 84
23 Pain Rehabilitation, Tongji Hospital, Tongji University, Shanghai, China. 85
24 86
25 87
26 Abstract 88
27 Objective: To evaluate current evidence of the effectiveness of dry needling of myofascial trigger points (MTrPs) associated with neck and 89
28 shoulder pain. 90
29 Q4 Data Sources: PubMed, EBSCO, Physiotherapy Evidence Database, ScienceDirect, The Cochrane Library, ClinicalKey, Wangfang Data, China 91
30 Q5 Knowledge Resource Integrated Database, Chinese VIP Information, and SpringerLink databases were searched from database inception to 92
31 January 2014. 93
32 Study Selection: Randomized controlled trials were performed to determine whether dry needling was used as the main treatment and whether 94
33 pain intensity was included as an outcome. Participants were diagnosed with MTrPs associated with neck and shoulder pain. 95
34 Data Extraction: Two reviewers independently screened the articles, scored methodological quality, and extracted data. The results of the study of 96
35 pain intensity were extracted in the form of mean and SD data. Twenty randomized controlled trials involving 839 patients were identified for 97
36 meta-analysis. 98
37 Data Synthesis: Meta-analyses were performed using RevMan version 5.2 and Stata version 12.0. The results suggested that compared with 99
38 control/sham, dry needling of MTrPs was effective in the short term (standardized mean difference [SMD]Z!1.91; 95% confidence interval [CI], 100
39 !3.10 to !0.73; PZ.002) and medium term (SMDZ!1.07; 95% CI, !1.87 to !0.27; PZ.009); however, wet needling (including lidocaine) was 101
40 superior to dry needling in relieving MTrP pain in the medium term (SMDZ1.69; 95% CI, 0.40e2.98; PZ.01). Other therapies (including 102
41 physiotherapy) were more effective than dry needling in treating MTrP pain in the medium term (SMDZ.62; 95% CI, 0.02e1.21; PZ.04). 103
42 Conclusions: Dry needling can be recommended for relieving MTrP pain in neck and shoulders in the short and medium term, but wet needling is 104
43 Q6 found to be more effective than dry needling in relieving MTrP pain in neck and shoulders in the medium term (9e28d). 105
44 Archives of Physical Medicine and Rehabilitation 2015;-:------- 106
45 107
ª 2015 by the American Congress of Rehabilitation Medicine
46 108
47 109
48 110
49 111
50 Myofascial trigger points (MTrPs) are localized, hyperirritable Numerous studies have shown that MTrPs are prevalent in 112
51 spots in the skeletal muscles associated with palpable nodules in patients with chronic nontraumatic neck and shoulder pain.7-11 A 113
52 muscle fibers.1,2 These spots can be classified into active MTrPs recent survey of 72 patients with shoulder pain showed that active 114
53 and latent MTrPs with referred pain and local twitch re- MTrPs were prevalent in the infraspinatus (77%) and the upper 115
54 sponses.1,3,4 Epidemiological surveys have shown that 30% to trapezius muscles (58%), whereas latent MTrPs were prevalent in 116
55 85% of the population in the United States and 18.7% to 85.1% in the teres major (49%) and anterior deltoid muscles (38%).12 117
56 Germany has MTrP pain.5,6 Persistence of MTrPs in neck and shoulder muscles for long pe- 118
57 riods will result in headache, neck and shoulder pain, dizziness or 119
58 Supported by the National Natural Science Foundation of China (grant no. 81470105).
vertigo, limited neck and shoulder range of motion, abnormal 120
59 Q3 Disclosures: none. sensation, autonomic dysfunction, and disability.10,13-16 121
60 122
61 0003-9993/15/$36 - see front matter ª 2015 by the American Congress of Rehabilitation Medicine 123
62 http://dx.doi.org/10.1016/j.apmr.2014.12.015 124

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125 Conservative interventions for MTrPs include dry needling, the databases via the university library website and to check for 187
126 wet needling (eg, lidocaine injection and some local anesthetic any omitted trials. 188
127 injections), ischemic compression, physiotherapy, laser, and oral 189
128 drugs.17 Of these therapies, dry needling has been widely used in Inclusion and exclusion criteria 190
129 clinical practice because of its simple operation and good effi- 191
Studies were included if they (1) had RCT design; (2) included
130 cacy.18,19 In 2001, a systematic review conducted by Cummings 192
patients with MTrPs associated with neck and shoulder pain; (3)
131 and White18 found that direct needling of MTrPs seems to be an 193
Q9
used acupuncture or dry needling as an intervention; and (4) had at
132 effective treatment, but evidence of the good efficacy of needling 194
least 1 outcome measure of either visual analog scale (VAS) or
133 therapies beyond placebo from clinical trials was lacking at that 195
numerical rating scale (NRS) to assess pain intensity. Meanwhile,
134 time. A systematic review with meta-analysis20 found that dry 196
studies were excluded if (1) MTrPs were not defined according to
135 Q10 needling, compared with sham/placebo, can decrease pain 197
the criteria of Simons et al1; (2) MTrPs in patients with neck and
136 immediately after the treatment and in 4 weeks in patients with 198
shoulder pain were latent MTrPs; (3) different types of dry
137 upper quarter myofascial pain syndrome. Nonetheless, the number 199
needling were compared with each other; (4) RCT subjects were
138 of high-quality randomized controlled trials (RCTs) was limited, 200
animals; and (5) RCT reported no data results. Q11
139 and evidence of the long-term efficacy of dry needling for myo- 201
140 fascial pain syndrome associated with neck and shoulder pain was Study selection and data extraction 202
141 lacking in this meta-analysis; thus, large-scale, multiple-term 203
142 RCTs are necessary to support this recommendation. More Two authors scanned the titles and abstracts independently, and 204
143 recently, another systematic review21 found no significant differ- studies that satisfied the inclusion and exclusion criteria were 205
144 ence between dry needling and lidocaine injection for MTrPs in retrieved for full-text assessment. We extracted data on the sample 206
145 neck and shoulders immediately after the treatment, at 1 month, size of the population, number of male and female patients, mean 207
146 and at 3 to 6 months; however, some errors affecting the meta- age of the population, duration of symptoms, diagnosis, location 208
147 analysis results were identified; there was no difference between and interventions adopted for MTrPs, outcome measures, the time 209
148 dry needling and physical therapy for MTrPs in neck to achieve the outcome, and PEDro scores. The results of the study 210
149 and shoulders. of pain intensity (VAS/NRS) were extracted in the form of mean 211
150 Therefore, this systematic review and meta-analysis aimed to and SD data. 212
151 determine the short-, medium-, and long-term effectiveness of dry Outcome measures were classified as short term if the measure 213
152 needling in relieving pain in patients with MTrPs in neck and was applied immediately to 3 days after the final reported treat- 214
153 shoulders compared with placebo/sham dry needling, wet ment, medium term if applied 9 days to 4 weeks after the final 215
154 needling, and other treatments (including physical therapy, botu- reported treatment, and long term if applied 2 to 6 months after the 216
155 linum toxin injection, and miniscalpel-needle release). final reported treatment. 217
156 The remaining discrepancies in data extraction were resolved 218
157 Methods after a discussion between the 2 reviewers. A third reviewer 219
158 adjudicated when necessary. 220
159 Search strategy 221
160 Quality assessment 222
161 A systematic review and meta-analysis was conducted according 223
Two reviewers independently assessed the validity of the studies
162 to the Preferred Reporting Items for Systematic Reviews and 224
included by using the PEDro quality scale. Any disagreements
163 Meta-Analyses statement.22 We searched sequentially electronic 225
were resolved with a discussion between the 2 reviewers. A third
164 databases (PubMed, EBSCO, Physiotherapy Evidence Database 226
reviewer adjudicated when necessary. The PEDro scale rates the
165 [PEDro], ScienceDirect, The Cochrane Library, ClinicalKey, 227
quality of RCTs that evaluate the therapeutic interventions on the
166 Wangfang Data, China Knowledge Resource Integrated Database, 228
basis of the presence or absence of key methodological compo-
167 Chinese VIP Information, SpringerLink) from database inception 229
nents.23,24 Studies with scores "6/10 were considered as high- Q12
168 to January 2014. The searches were limited (where database fa- 230
quality evidence, and studies with scores #5/10 were considered
169 cilities allowed) to RCTs or clinical trials, but without language 231
as low-quality evidence.
170 restriction. The search terms were (acupu* OR needl*) AND 232
171 (myofascial pain OR trigger point* OR trigger area* OR taut Data synthesis and statistical analysis 233
172 band*) AND random*. Moreover, supplementary searches were 234
173 conducted online (eg, http://www.google.cn and http://www. Nine separate meta-analyses were performed with pain on VAS/ 235
174 clinicaltrials.gov) to obtain articles that could not be found in NRS as the outcome measure. The 9 meta-analyses are as follows: 236
175 dry needling compared with control/sham in the short, medium, 237
176 and long term; dry needling compared with wet needling in the 238
177 short, medium, and long term; and dry needling compared with 239
178 List of abbreviations: other treatments in the short, medium, and long term. 240
179 CI confidence interval Meta-analyses were performed using RevMan version 5.2a 241
180 MCID minimum clinically important difference with a continuous variable random-effects model to account for 242
181 MTrP myofascial trigger point the additional uncertainty associated with interstudy variability in 243
182 NRS numerical rating scale effect of the intervention.23 Heterogeneity was assessed using the 244
183 PEDro Physiotherapy Evidence Database Cochran Q test, which had statistical significance (P<.1), and the 245
RCT randomized controlled trial
184 chi-square test (I2), which indicated inconsistency by a quantita- 246
SMD standardized mean difference
185 Q8 tive number.25 An I2 value of 25%, 50%, and 75% represented 247
VAS visual analog scale
186 small, moderate, and large degrees of heterogeneity, 248

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287 Fig 1 Flow diagram of search strategy and results. Abbreviations: CNKI, China National Knowledge Infrastructure Database; VIP, Chinese 349
288 Chongqing VIP Information database. 350
289 351
290 352
291 respectively.24,26 Effect sizes were measured using the standard- Study characteristics 353
292 ized mean difference (SMD) and 95% confidence interval (CI). 354
293 To explore the heterogeneity between studies, we performed Table 1 summarizes the sample size of the population, number of 355
294 stepwise meta-regression using Stata version 12.0b and sensitivity male and female patients, mean age of the population, country or 356
295 analysis. By using random-effects univariate meta-regression region of the population, diagnosis, inclusion criteria, intervention 357
296 models, we assessed the clinical and methodological variables groups (independent variables), outcome measurements (depen- 358
297 that affected the association between dry needling and changes in dent variables), time to achieve the outcomes, and PEDro scores. 359
298 pain intensity. On the basis of univariate meta-regression, we 360
299 conducted sensitivity analyses to assess the subgroups of studies Risk of bias within studies 361
300 that are most likely to yield valid estimates of the intervention. 362
Table 1 lists the PEDro scores of 20 RCTs, in which 19 are rated
301 Funnel plots were constructed to verify the existence of publica- 363
as high-quality evidence ("6/10) and only 1 as low-quality evi-
302 tion bias (outcome level). 364
dence (#5/10). However, most RCTs did not commonly score
303 points for concealed random allocation and blinding of therapists. 365
304 Results 366
305 Effect of dry needling versus control/sham 367
306 Study selection 368
307 By comparing dry needling with control/sham, we found that 369
308 The initial search resulted in 1489 hits (fig 1). After applying the studies including 6,29,30,35,37,43,45 6,31,36,38,41,43,44 and 2 RCTs36,38 370
309 inclusion and exclusion criteria, 20 RCTs were eligible and in the short, medium, and long term, respectively, assessed the 371
310 included in the review. pain effects. Q13 372

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Table 1 Characteristics of the participants included in this systematic review
Time to Achieve the
Study (Design and Intervention Outcome (Baseline PEDro
Country) n (M/F) Mean Age (y)* Diagnosis (Duration*) Inclusion Criteria Group Outcome Measure Pain*) Scores
Ay et al,27 2010 80 (28/52) 38.08$9.81,y MPS Regional pain, taut band, DN; lidocaine Pain (VAS); AROM of Pretreatment 6/10
(RCT, Turkey) 37.20$10.10z (34.27$40.95mo,y referred pain and sensory injection the CS; depression (5.55$1.33cm,y
30.63$37.25moz) change, extreme (BDI) 5.82$1.25cmz);
sensitivity in taut band, 4wk; 12wk
ROM; at least 1 active
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MTrP in the upper

trapezius muscle ("1mo)
Byeon et al,28 2003 30 (18/12) 50.9$9.7,y MPS MTrPs in the upper DN; IMS; IMES Pain (VAS); MPQ; Pretreatment 6/10
(RCT, Korea) 50.2$9.9,x trapezius muscles; PROM of the CS (6.2$1.1cm,y
51.2$9.9jj palpable taut band in the 6.4$1.6cm,x 6.2$
muscle 1.4cmjj); 3d; 1wk;
2wk
Chou et al,29 2009 20 (8/12) 37.7$11.3,y Active MTrPs MTrPs in the unilateral Acupuncture; Pain (NRS); EPN Pretreatment 6/10
(RCT, China) 33.3$7.7{ (5.9$3.3mo,y upper trapezius muscle; sham amplitude (7.4$0.8cm,y
5.8$2.8mo{) no treatment with acupuncture 7.4$0.8cm{);
acupuncture; poor immediately
response to conservative
and noninvasive
treatments
Chou et al,30 2011 45 (22/23) 34.1$10.7,y Unilateral MTrPs "5/10 VAS score on the Modified Pain (NRS); PPT Pretreatment 6/10
(RCT, China) 33.9$8.3{ (6.1$2.2mo,y unilateral shoulder due to acupuncture; (algometry); ROM of (7.7$1.0cm,y
6.2$2.2mo{) MTrPs in the upper placebo the CS; EPN 7.6$1.1cm{);
trapezius muscle; no amplitude immediately
acupuncture treatment;
poor response to
conservative and
noninvasive treatments
DiLorenzo et al,31 101 (28/73) 69.56$6.21,y Shoulder pain due to Patients 4e8 wk post DN; placebo Pain (VAS); disability Pretreatment 6/10
2004 (RCT, Italy) 67.43$9.05{ activation of MTrPs ecerebrovascular (RMI); quality of (7.93$0.87cm,y
(3.53wk) accident who had daytime rest and 8.02$0.83cm{);
undergone at least 3wk of sleep 10d; 16d; 22d
physical therapy;
shoulder pain ("6/10
www.archives-pmr.org

score on VAS)
Ga et al,32 2007 39 (3/36) 79.22$6.80,y Chronic shoulder or "6mo; aged >60y; Acupuncture; Pain (VAS and FACES); Pretreatment 7/10
(RCT, Korea) 75.90$8.69z neck pain due to complaining of chronic lidocaine PPI; PROM of the CS; (6.98$1.32cm,y
MPS shoulder or neck pain injection depression (GDS-SF) 6.43$2.08cmz);

L. Liu et al
1wk; 2wk; 4wk
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Dry needling for myofascial trigger points

Table 1 (continued )
Time to Achieve the
Study (Design and Intervention Outcome (Baseline PEDro
Country) n (M/F) Mean Age (y)* Diagnosis (Duration*) Inclusion Criteria Group Outcome Measure Pain*) Scores
Ga et al,33 2007 40 (4/36) 79.22$6.80,y Chronic MPS Chronic MPS of the upper DN; IMS Pain (VAS and FACES); Pretreatment 9/10
(RCT, Korea) 76.27$8.63x trapezius muscles based PPT; PROM of the (6.98$1.32cm,y
on physical examination CS; depression 6.71$1.84cmx);
and interview (GDS-SF) 1wk; 2wk; 4wk
Hong,34 1994 58 (16/42) 41.7$14.4,y MPS (7.6$4.7mo,y Tender spots in taut bands, DN; lidocaine Pain (VAS); PPT; ROM Pretreatment 8/10
(RCT, USA) 42.2$14.4z 10.2$5.6moz) referred pain, LTR with injection of the CS (7.80$0.83cm,y
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palpation of MTrP, ROM of (goniometer) 7.88$0.93cmz);

the CS for lateral bending immediately; 2wk
to opposite side; at least
1 MTrP in the upper
trapezius muscle
Hsieh et al,35 2007 14 (8/6) 60.2$13.2 Bilateral shoulder pain No treatment for at least DN; placebo Pain (VAS); PPT; AROM Pretreatment 7/10
(within-subject RCT, with active MTrPs 3mo; MTrPs in the and PROM of (7.8$1.2 cm,y
China) bilateral infraspinatus shoulder 7.7$1.4cm{);
muscles; no (goniometer) immediately
contraindication for dry
needling; no condition
for substance abuse; no
surgery to the neck/
upper limb; no
differences in clinical
presentation
Ilbuldu et al,36 2004 60 (0/60) 35.29$9.18,y MTrPs MTrPs in the upper DN; placebo; Pain (VAS); ROM of the Pretreatment 7/10
(RCT, Turkey) 32.35$6.88,{ (38.48$31.94mo,y trapezius muscles; local laser CS (goniometer); (5.10$1.97cm,y
33.90$10.36# 36.95$33.65mo,{ pain, pain and sensory functional status 5.70$1.81cm,{
32.95$28.61mo#) changes referred from (NHP) 5.50$1.96cm#);
MTrP, palpable taut band, 4wk; 24wk
extreme sensitivity in 1
point in band, limited
ROM
Irnich et al,37 2002 34 (9/25) 51.9 y MPS (36.7mo) "2mo; ROM in CS; cervical DN; sham laser Pain (VAS); ROM of the Pretreatment 9/10
(crossover RCT, MPS or “irritation acupuncture; CS; repeatability of (3.34$1.941cm,y
Germany) syndrome” (diffuse nonlocal mobility change 3.04$1.862cm,{
intense pain and irritated acupuncture 3.50$2.264cm**);
soft tissues with immediately
prolonged aggravation (15e30min)
after motion and
pressure)
(continued on next page)

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Table 1 (continued )
Time to Achieve the
Study (Design and Intervention Outcome (Baseline PEDro
Country) n (M/F) Mean Age (y)* Diagnosis (Duration*) Inclusion Criteria Group Outcome Measure Pain*) Scores
Itoh et al,38 2007 40 (11/29) 62.3$10.1,y Neck pain due to "6mo with no radiation; Acupuncture; Pain (VAS); neck Pretreatment 8/10
(RCT, Japan) 65.0$10.5{ MTrPs (2.9$2.7y,y normal CS nerve function; sham disability (NDI) (6.70$1.32cm,y
2.3$1.5y{) aged "45y acupuncture 6.41$2.07cm{);
weekly; over 12wk
Kamanli et al,39 2005 29 (6/23) 37.20$8.08,y MTrPs At least 1 MTrP on CS, back, DN; lidocaine Pain (VAS); PPT; Pretreatment 5/10
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(RCT, Turkey) 37.30$9.76,z (32.50$21.99mo,y or shoulder muscles with injection; BTI functional status; (7.03$2.68cm,y
38.3$5.26yy 49.20$34.96mo,z disease of at least 6mo in anxiety and 6.90$1.43cm,z
50.66$19.92moyy) duration depression; pain 6.09$1.95cmyy);
score 4 wk
Krishnan et al,40 2000 30 (20/10) 38.5$10.28 MPS Presence of trigger points, Needle only; Pain (VAS) Pretreatment; 7/10
(crossover RCT, which are discrete tender bupivacaine immediately
USA) areas in the upper injection;
trapezius muscles ropivacaine
injection; BD
injection; RD
injection
Ma et al,41 2010 43 (21/22) 42.2$5.3,y MPS (22.5$15.3y,y MTrPs in the unilateral Acupuncture Pain (VAS); PPT; ROM Pretreatment 6/10
(RCT, China) 42.3$5.1,{ 20.8$16.5y,{ upper trapezius muscles; needling; of the CS (6.2$1.9cm,y
42.6$4.9zz 21.8$15.9yzz) ROM; no acupuncture or placebo; MSN (goniometer) 6.3$1.7cm,{
MSN treatment release 6.3$1.8cmzz);
previously; follow 2wk; 12wk
instructions and
complete a home-based
stretching program
Rayegani et al,42 2014 28 32$10,y MPS (9.6$8.4y,y "2mo; MPS in the upper DN; Pain (VAS); PPT; Pretreatment 6/10
(RCT, Iran) 38.6$4.2xx 9.8$9.6yxx) trapezius muscles; pain physiotherapy quality of life (2.9$2.8cm,y
area that might radiate (SF-36) 3.6$2.6cmxx);
to neck, arm, and upper 1wk; 4wk
back and not confined to
1 dermatome or
myotome; taut bands
pressing pain;
neurological test result
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was normal
(continued on next page)

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Dry needling for myofascial trigger points

Table 1 (continued )
Time to Achieve the
Study (Design and Intervention Outcome (Baseline PEDro
Country) n (M/F) Mean Age (y)* Diagnosis (Duration*) Inclusion Criteria Group Outcome Measure Pain*) Scores
Tekin et al,43 2013 39 (8/31) 42.9$10.9,y MPS (63.5$50.7mo,y "6mo; local spontaneous DN; sham Pain (VAS); quality of Pretreatment 8/10
(RCT, Turkey) 42.0$12.0{ 57.9$48.3mo{) pain, referred pain or intervention life (SF-36) (6.6$1.3cm,y
sensory changes from 6.4$1.6cm{);
MTrP, palpable taut band, 3d; 4wk
localized tenderness, ROM;
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at least 1 active MTrP

Tough et al,44 2010 41 (17/24) 34.2$10.8,y MTrPs pain due to Two to 16 wk duration and Acupuncture; Pain (VAS); neck Pretreatment 7/10
(RCT, UK) 36.9$10.9{ whiplash injury fulfilling the Grade II sham disability (NDI); (4.9$1.6cm,y
(6.8$4.3wk,y Quebec Task Force acupuncture anxiety and 5.0$1.6cm{);
7.3$4.7wk{) classification of WAD; depression 3wk; 6wk
"18y and making fully
informed consent
Tsai et al,45 2010 35 (14/21) 46.4$12.2,y Unilateral shoulder Unilateral shoulder pain DN; sham Pain (NRS); PPT; ROM Pretreatment 6/10
(RCT, China) 41.5$10.4{ pain due to MTrPs caused by digital needling of the CS (7.3$1.4cm,y
(7.5$3.9mo,y compression of MTrP in (goniometer) 7.2$1.4cm{);
6.8$4.5mo{) the upper trapezius immediately
muscle (tenderness and
pain reproduction with
palpation of a tight band)
Ziaeifar et al,16 2014 33 30.06$9.87,y MTrPs MTrPs in the upper trapezius DN; compression Pain (VAS); PPT; Pretreatment 7/10
(RCT, Iran) 26.5$8.57kk muscles; taut band, technique disability of arm, (6.56$1.63cm,y
tender spot, referred pain; hand, and shoulder 6.23$1.26cmkk); 9d
"30mm on a VAS ranging
from 0 to 100 mm
Abbreviations: AROM, active range of motion; BD, bupivacaine þ dexamethasone; BDI, Beck Depression Inventory; BTI, botulinum toxin injection; CS, cervical spine; DN, dry needling; EPN, the end-plate
noise; F, female; FACES, Wong-Baker Faces Pain Rating Scale; GDS-SF, Geriatric Depression ScaleeShort Form; IMES, intramuscular electrical stimulation; IMS, intramuscular stimulation; LTR, local twitch
response; M, male; MPQ, McGill Pain Questionnaire; MPS, myofascial pain syndrome; MSN, miniscalpel needle; NDI, Neck Disability Index; NHP, Nottingham Health Profile; PPI, pressure pain intensity; PPT,
pressure pain threshold; PROM, passive range of motion; RD, ropivacaine þ dexamethasone; RMI, Rivermead Mobility Index; ROM, range of motion; SF-36, 36-Item Short Form Health Survey; WAD Z ---. Q17

* Values are mean $ SD.

y
DN group.
z
Lidocaine injection group.
x
IMS group.
jj
IMES group.
{
Placebo/sham group.
#
Laser group.
** Nonlocal acupuncture group.
yy
BTI group.
zz
MSN group.
xx
Physiotherapy group.
kk
Compression technique group.

7
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867
866
865
864
863
862
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857
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855
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848
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846
845
844
843
842
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840
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838
837
836
835
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833
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831
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829
828
827
826
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820
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812
811
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809
808
807
 8 L. Liu et al

869 931
870 932
871 933
872 934
873 935
874 936
875 937
876 938
877 939
878 940
879 941
880 942
881 943
882 944
883 945
884 946
885 947
886 948
887 949
888 950
889 951
890 952
891 953
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892 954
893 955
894 956
895 957
896 958
897 959
Fig 2 Forest plot for dry needling compared with control/sham in different terms. CI, confidence interval.
898 960
899 961
900 962
901 Figure 2 shows that there is a high heterogeneity between the (fig 3). Hence, we performed a sensitivity analysis by excluding 963
902 trials in the short term (c2Z62.09; I2Z92%; P<.00001), medium the 2 studies36,44 with the lowest value of the initial pain intensity. 964
903 term (c2Z38.75; I2Z87%; P<.00001), and long term (c2Z8.12; In the pooled analysis of the remaining 4 studies,31,38,41,43 the 965
904 I2Z88%; PZ.004). Therefore, random-effect models were used, heterogeneity was significantly low between the individual effi- 966
905 and caution should be exercised while drawing the conclusion. We cacy estimates (I2Z0%; PZ.86). 967
906 used univariate meta-regression models to explore the source of The meta-analysis revealed statistically significant effects of 968
907 heterogeneity between trials. Initial pain intensity was the only dry needling compared with control/sham in the short term 969
908 covariate associated with the heterogeneity between studies in the (SMDZ!1.91; 95% CI, !3.10 to !0.73; PZ.002) and medium 970
909 medium term (PZ.024). The decrement in pain intensity induced term (SMDZ!1.07; 95% CI, !1.87 to !0.27; PZ.009), but the 971
910 by dry needling increased as the initial pain intensity increased meta-analysis revealed no statistically significant effects of dry 972
911 973
912 974
913 975
914 976
915 977
916 978
917 979
918 980
919 981
920 982
921 983
922 984
923 985
924 986
925 987
926 988
927 989
928 Fig 3 Meta-regression bubble plots: (A) association between initial pain intensity and SMD pain intensity when dry needling was compared 990
929 with control/sham in the medium term; (B) association between publication year and SMD pain intensity when dry needling was compared with 991
930 other treatments in the medium term. Each circle corresponds to a study, and reference number is shown. 992

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 Dry needling for myofascial trigger points 9

993 1055
994 1056
995 1057
996 1058
997 1059
998 1060
999 1061
1000 1062
1001 1063
1002 1064
1003 1065
1004 1066
1005 1067
1006 1068
1007 1069
1008 1070
1009 1071
1010 1072
1011 1073
1012 1074
1013 1075
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1014 1076
1015 1077
1016 1078
1017 1079
1018 1080
1019 1081
Fig 4 Forest plot for dry needling compared with wet needling in different terms. aDry needling vs lidocaine injection without local twitch
1020 1082
responses elicited. bDry needling vs lidocaine injection with local twitch responses elicited. cDry needling vs bupivacaine þ dexamethasone
1021 1083
injection. dDry needling vs ropivacaine injection. eDry needling vs bupivacaine injection. fDry needling vs ropivacaine þ dexamethasone in-
1022 1084
jection. CI Z confidence interval.
1023 1085
1024 1086
1025 needling compared with control/sham in the long term Figure 5 shows low (c2Z2.45; I2Z18%; PZ.29), high 1087
1026 (SMDZ!1.15; 95% CI, !3.34 to 1.04; PZ.30). (c Z23.80; I2Z75%; PZ.0006), and moderate (c2Z2.39;
2 1088
1027 I2Z58%; PZ.12) heterogeneities between the trials in the short, 1089
1028 Effect of dry needling versus wet needling medium, and long term, respectively. The choice of the effects model 1090
1029 will not have a significant effect on the pooled effect sizes; hence, we 1091
By comparing dry needling with wet needling, we found that 6
1030 used random-effects model to conduct the meta-analysis in the 1092
studies including 2,34,40 4,27,32,34,39 and 1 RCTs27 in the short,
1031 subgroup. We further used univariate meta-regression models to 1093
medium, and long term, respectively, assessed the pain effects.
1032 explore the source of heterogeneity between trials. Publication year 1094
Figure 4 shows low (c2Z7.74; I2Z35%; PZ.01) and high
1033 was the only covariate associated with the heterogeneity between 1095
(c2Z35.70; I2Z92%; P<.00001) heterogeneities between the
1034 studies in the medium term (PZ.007). The decrement in pain in- 1096
trials in the short and medium term, respectively, and no hetero-
1035 tensity due to other treatments decreased as the publication year 1097
geneity in the long term. Although we observed low heterogeneity
1036 increased (see fig 3B). Hence, we further performed a sensitivity 1098
in the short term, the choice of the effects model will not have a
1037 analysis by excluding 1 study16 with the highest publication year. In 1099
significant effect on the pooled effect sizes; hence, we could use
1038 the pooled analysis of the remaining 4 studies,28,33,36,39,41,46 the 1100
random-effects models to conduct the meta-analysis in all terms.
1039 heterogeneity was significantly low between the individual efficacy 1101
The high heterogeneity (I2Z92%) in the medium term reminded
1040 estimates (I2Z44%; PZ.11). 1102
us to exercise caution while interpreting the results. Data available
1041 Data available from the 3 pooled studies presented in fig 5 1103
from 6 pooled studies presented in fig 4 favored dry needling over
1042 favored other treatments over dry needling; no statistically sig- 1104
wet needling. No statistically significant differences were
1043 nificant differences were observed in the short term (SMDZ.33; 1105
observed in the short term (SMDZ!.01; 95% CI, !0.41 to 0.40;
1044 95% CI, !0.12 to 0.78; PZ.15) and long term (SMDZ.58; 95% 1106
PZ.98) and long term (SMDZ.33; 95% CI, !0.11 to 0.78;
1045 CI, !0.18 to 1.34; PZ.13); however, significant effects of other 1107
PZ.14); however, significant effects of wet needling compared
1046 treatments compared with dry needling were observed in the 1108
with dry needling were observed in the medium term
1047 medium term (SMDZ.62; 95% CI, 0.02e1.21; PZ.04). 1109
(SMDZ1.69; 95% CI, 0.40e2.98; PZ.01).
1048 1110
1049 Effect of dry needling versus other treatments Publication Bias 1111
1050 1112
1051 By comparing dry needling with other treatments, we found that 3 Three funnel plots were constructed to assess the presence of 1113
1052 studies including 2 RCTs28,37 in the short term and 7 studies publication bias (fig 6). The results indicated that 2 funnel plots 1114
1053 including 6 RCTs16,28,33,36,39,41 in the medium term and 2 were generally symmetrical, whereas 1 funnel plot from the 1115
1054 RCTs36,41 in the long term assessed the pain effects. comparison between dry needling and wet needling in the medium 1116

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 10 L. Liu et al

1117 1179
1118 1180
1119 1181
1120 1182
1121 1183
1122 1184
1123 1185
1124 1186
1125 1187
1126 1188
1127 1189
1128 1190
1129 1191
1130 1192
1131 1193
1132 1194
1133 1195
1134 1196
1135 1197
1136 1198
1137 1199
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1138 1200
1139 1201
1140 1202
1141 1203
1142 1204
1143 Fig 5 Forest plot for dry needling compared with other treatments in different terms. Abbreviations: BTI, botulinum toxin injection; CI, 1205
1144 confidence interval; IMES, intramusclar electrical stimulation; IMS, intramusclar stimulation; MSN, miniscalpel-needle release; NLA, nonlocal 1206
1145 acupuncture. aDry needling vs compression. 1207
1146 1208
1147 1209
1148 term was asymmetrical, which indicates that potential publication showed significant clinical effects in different terms. To date, data 1210
1149 bias occurred. Publication bias may be attributed to the absence of remain insufficient to draw conclusions about the long-term ef- 1211
1150 a substantial number of studies or unpublished studies excluded. fects of wet needling compared with dry needling on MTrPs 1212
1151 associated with neck and shoulder pain. 1213
1152 By comparing dry needling with control/sham, we found that the 1214
1153 Discussion SMD in the short term was 1.91cm,29,30,35,37,43,45 which was greater 1215
1154 Twenty RCTs comparing dry needling with placebo or other than the 1.3-cm/1.4-cm minimum clinically important difference 1216
1155 treatments for MTrPs associated with neck and shoulder pain in (MCID) reported by Bijur et al.46 Moreover, a statistically signifi- 1217
1156 different terms were identified for this review. Compared with cant difference in the short term was found when dry needling was 1218
1157 control/sham, dry needling resulted in significant improvement, compared with control/sham. Therefore, this review found sufficient 1219
1158 specifically in the short and medium term. However, wet needling evidence to support the claim that dry needling has significant 1220
1159 of MTrPs associated with neck and shoulder pain was more clinical effects on MTrPs associated with neck and shoulder pain in 1221
1160 effective than dry needling in the medium and long term. the short term as compared with control/sham. In addition, the SMD 1222
1161 Furthermore, compared with dry needling, other treatments in the medium term was 1.07cm,31,36,38,41,43,44 which was lower 1223
1162 1224
1163 1225
1164 1226
1165 1227
1166 1228
1167 1229
1168 1230
1169 1231
1170 1232
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1171 1233
1172 1234
1173 1235
1174 1236
1175 1237
1176 1238
1177 Fig 6 Funnel plots for all meta-analyses: (A) dry needling compared with sham/control; (B) dry needling compared with wet needling; and (C) 1239
1178 dry needling compared with other treatments. Q19 1240

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 Dry needling for myofascial trigger points 11

1241 than the reported 1.3-cm/1.4-cm MCID46; hence, a statistically not within the scope of the time definition of the short, medium, 1303
1242 significant difference in the medium term was found when dry and long term. Therefore, large-scale, multiple-term, high-quality 1304
1243 needling was compared with control/sham. However, no statistically RCTs would be necessary to prove or exclude the significant 1305
1244 significant difference in the long term was found when dry needling advantages or disadvantages. 1306
1245 was compared with control/sham. This effect may be worth 1307
1246 exploring by using large-scale RCTs. Conclusions 1308
1247 By comparing dry needling with wet needling, we found that 1309
1248 the 1.69-cm SMD in the medium term27,33,34,39 was greater than On the basis of the available evidence to date, dry needling can be 1310
1249 the reported 1.3-cm/1.4-cm MCID.46 A statistically significant cautiously recommended for relieving MTrP pain in neck and 1311
1250 difference was also found in this subgroup. On the basis of the shoulders in the short and medium term than control/sham, but 1312
1251 current evidence, wet needling is found to be a better treatment wet needling is found to be more effective than dry needling in 1313
1252 than dry needling in the medium term. We found no statistical and relieving MTrP pain in neck and shoulders in the medium term 1314
1253 clinical significance in the short34,40 and long27 term when dry (9e28d). On the basis of the results of 6 individual 1315
1254 needling was compared with wet needling, because different in- RCTs16,28,33,36,39,41 included in the meta-analysis of 7 studies, 1316
1255 terventions were included in wet needling in the short term other treatments can be cautiously recommended for relieving 1317
1256 Q14 whereas only 1 study was included in the long term. Future studies MTrP pain in neck and shoulders in the medium term than dry 1318
1257 will require sufficient sample sizes to adequately determine needling. However, scientific evidence proving the effectiveness 1319
1258 whether wet needling was an optimal treatment for MTrPs asso- of dry needling for MTrPs associated with neck and shoulder pain 1320
1259 ciated with neck and shoulder pain in the short and long term. compared with wet needling and other treatments in the short and 1321
1260 By comparing dry needling with other treatments, we found long term is insufficient. Accordingly, further research should 1322
1261 that the SMD in the short, medium, and long term was .33,28,37 include more large-scale, multiple-center, high-quality RCTs and 1323
1262 .62,16,28,33,36,39,41 and .58cm,36,41 respectively, and all means adequate follow-up to provide the best evidence that can suggest 1324
1263 were lower than the reported 1.3-cm/1.4-cm MCID.46 Neverthe- the best therapeutic method in the clinic. 1325
1264 less, a statistically significant difference in the medium term was 1326
1265 observed when dry needling was compared with other treatments. 1327
1266 Therefore, none of the studies in this review was adequately Suppliers 1328
1267 powered to determine a significant change in pain when other 1329
1268 treatments were compared with dry needling. This result was due a. RevMan version 5.2; The Nordic Cochrane Centre. 1330
1269 to the pooled effects from different treatments. Hence, a large b. Stata version 12.0; StataCorp LP. 1331
1270 difference was observed among the included studies after 1332
1271 meta-analysis. 1333
1272 Keywords 1334
1273 Study limitations 1335
Dry needling; Meta-analysis; Myofascial trigger points; Neck-
1274 Q7
1336
In this systematic review, high heterogeneity was observed for shoulder pain; Randomized controlled trial; Rehabilitation
1275 1337
1276 most meta-analyses in the forest plots. High heterogeneity for 1338
1277 these meta-analyses may be explained by clinical diversity 1339
1278 (including some differences in subjects, different inclusion criteria Corresponding author 1340
1279 between these studies, variance in the comparison treatments, and 1341
1280 variance in the outcome measures) and methodological diversity Qiang-Min Huang, MD, PhD, Department of Sport Medicine and 1342
1281 (such as the design of random trial, use of blinding, and the Center of Rehabilitation, School of Sport Science, Shanghai 1343
1282 concealment of allocation). We tried using meta-regression to University of Sport, Keyanlou 4-408, Hengren Rd No. 188, 1344
1283 explore the sources of heterogeneity; however, ideal results were Shanghai 200438, China. E-mail address: huaqia404@aliyun. 1345
1284 not obtained because of the absence of a substantial number of com. 1346
1285 studies when dry needling was compared with control/sham in the 1347
1286 short term. Therefore, the random-effects model addressed the Acknowledgment 1348
1287 heterogeneity of studies by considering the interstudy variation.47 1349
1288 Heterogeneity is almost inevitable among studies conducted We thank Tian-Song Zhang, PhD, for assistance with manu- 1350
1289 independently by different investigators at different geographical script revision. 1351
1290 regions. Therefore, using the random-effects model rather than the 1352
1291 fixed-effects model was a conservative strategy when apparent 1353
1292 statistical heterogeneity was observed in the data.25 Meta-analysis References 1354
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1294 yielded results that were unbiased and provided an accurate esti- 1. Simons DG, Travell JG, Simons LS. Travell and Simons’ myofascial 1356
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1296 1358
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