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https://doi.org/10.1177/0964528419882941
Acupuncture in Medicine
 1 –8
DOI: 10.1177/0964528419882941
© The Author(s) 2020 
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Acupuncture in Medicine, 00(0)
acupuncture
IN MEDICINE
Post-needling soreness and trigger point 
dry needling for hemiplegic shoulder 
pain following stroke
Ana Mendigutía-Gómez1, María T Quintana-García1, Miriam 
Martín-Sevilla1, Diego de Lorenzo-Barrientos2, 
Jorge Rodríguez-Jiménez3,4, César Fernández-de-las-Peñas3,4,5 
and José L Arias-Buría3,4
Abstract
Objectives: To determine the presence of post-needling induced pain in subjects who had suffered a stroke and 
received trigger point (TrP) dry needling (DN), and to investigate the effects of including TrP-DN into a rehabilitation 
program for shoulder pain in this population.
Methods: A randomized clinical trial was conducted. Sixteen patients who had suffered a stroke and presented with 
shoulder pain were randomly assigned to receive rehabilitation alone or rehabilitation combined with DN. Both groups 
received a neurorehabilitation session including modulatory interventions targeting the central nervous system. Patients 
in the DN group also received a single session of DN over active TrPs in the shoulder musculature. A numerical pain 
rating scale (NPRS, 0–10) was used to asses post-needling induced pain at 1 min, 24 h, and 72 h after needling. Shoulder 
pain (NPRS, 0–10) was assessed at baseline, and 3 and 7 days after DN in both groups.
Results: Five (62%) patients receiving TrP-DN reported post-needling induced pain. Post hoc analysis found that post-
needling induced pain decreased significantly at 24 and 72 h (both p < 0.001) after DN. Patients receiving TrP-DN 
plus rehabilitation exhibited greater decreases in shoulder pain intensity at 3 days (Δ = –4.2, 95% confidence interval 
(CI) = –5.8 to −2.6) and 7 days (Δ = –4.3, 95% CI = –5.9 to −2.7) after the intervention compared with those receiving 
rehabilitation alone (all p < 0.001).
Conclusion: This trial found that 50% of stroke patients receiving DN experienced post-needling induced pain, a side 
effect that almost disappeared 72 h after the intervention without any additional therapeutic action. In addition, the inclu-
sion of TrP-DN into a rehabilitation session was effective at decreasing shoulder pain in these patients.
Keywords
dry needling, myofascial trigger point, rehabilitation, shoulder pain, stroke
Accepted: 21 September 2019
1 Department of Physical Therapy-Rehabilitation, Hospital Beata María 
Ana, Madrid, Spain
2 Instituto Nacional de Estadística, Madrid, Spain
3 Department of Physical Therapy, Occupational Therapy, Physical 
Medicine and Rehabilitation, Universidad Rey Juan Carlos, Alcorcón, 
Spain
4 Cátedra de Investigación y Docencia en Fisioterapia: Terapia Manual y 
Punción Seca, Universidad Rey Juan Carlos, Alcorcón, Spain
5 Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, 
Alcorcón, Spain
882941 AIM Acupuncture in MedicineMendigutía-Gómez et al.
Original paper
Corresponding author:
César Fernández de las Peñas, Facultad de Ciencias de la Salud, 
Universidad Rey Juan Carlos, Avenida de Atenas s/n, 28922 Alcorcón, 
Madrid, Spain. 
Email: cesar.fernandez@urjc.es
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2 Acupuncture in Medicine 
Acupuncture in Medicine, 00(0)
Introduction
Stroke is one of the major causes of permanent disability 
with an annual incidence ranging between 1.18% and 
1.44% per year.1,2 Although several advances have dropped 
stroke down to the fourth leading cause of death world-
wide,3 it represents a condition causing physical disability 
in up to 50% of sufferers.4
Stroke-associated disability is mainly related to the pres-
ence of spasticity and post-stroke pain. Post-stroke pain 
includes several painful conditions including central post-
stroke pain, painful shoulder, spinal pain, complex regional 
pain syndrome and spasticity-related pain. It seems that 
hemiplegic shoulder pain is probably one of the most com-
mon forms of post-stroke pain. In fact, hemiplegic shoulder 
pain has recently been associated with the burden of stroke.5 
The prevalence of hemiplegic shoulder pain is 30%,6 
although this rate has decreased in recent decades.7
A musculoskeletal origin of post-stroke shoulder pain is 
more likely than other causes, for example, spasticity-
related pain, in the early years after the event.8 Therefore, 
identification of a potential musculoskeletal source for 
hemiplegic shoulder pain may be important. Since subjects 
with hemiplegic shoulder pain usually exhibit not only pain 
symptoms in the shoulder but also pain referral to the elbow 
and hand, it is possible that myofascial trigger points (TrPs) 
can play a potential role in some stroke patients.9 There is 
preliminary evidence suggesting a role of myofascial pain 
in post-stroke pain.10 De Oliveira et al.10 found that 67.5% 
of individuals with post-stroke pain exhibited active TrPs, 
with the trapezius, supraspinatus, splenius capitis, infraspi-
natus and paraspinal muscles being most commonly 
affected. Therefore, it is possible that treatment of active 
TrPs in the shoulder muscles could be effective for the 
management of hemiplegic shoulder pain.
Dry needling (DN) is a common intervention used for 
the management of TrPs in non-neurological conditions.11 
In fact, there has been an increasing interest in the applica-
tion of DN to treat muscle spasticity;12 however, current 
evidence is mainly based on case reports.13–15 The only 
cross-over trial investigating the effects of DN on muscle 
spasticity in the upper extremity found that the inclusion of 
DN into a multimodal rehabilitation program was effective 
at improving pressure pain sensitivity and range of motion 
at the shoulder, but not muscle spasticity, in people who had 
experienced a stroke.16 Nevertheless, there is no mention of 
shoulder pain in previous papers. An old study reported that 
the inclusion of a needling intervention into an early reha-
bilitation program produced better outcomes in patients 
with hemiparetic shoulder pain; however, this study used 
an acupuncture approach, not a TrP-DN approach.11 
Similarly, a recent systematic review also observed that 
most studies investigating the effects of needling therapies 
for shoulder pain in stroke survivors used an acupuncture 
approach.17
A common minor adverse event observed after the appli-
cation of DN is the presence of post-needling induced pain 
or soreness.18 Post-needling induced pain or soreness is 
thought to be a consequence of the neuromuscular damage 
generated by repetitive needle insertions into the TrP area 
and several studies have documented this phenomenon in 
musculoskeletal pain conditions.19 Since post-needling 
soreness can be associated with a possible reluctance to 
receive further needling therapy and a reduction in treat-
ment adherence for some patients, it is important to investi-
gate its evolution in patients with neurological conditions. 
To the best of the authors’ knowledge, no study has previ-
ously investigated the presence of post-needling induced 
pain or soreness and the effects of TrP-DN on shoulder pain 
symptoms in patients who had suffered a stroke.
Therefore, the aims of this clinical trial were: (1) to 
investigate the presence of post-needling induced pain in 
subjects who had suffered a stroke receiving TrP needling 
in the shoulder area; and (2) to investigate effects on shoul-
der pain intensity of including a TrP-DN session into a 
rehabilitation program consisting of modulatory interven-
tions targeting the central nervous system following stroke. 
We hypothesized that all subjects receiving DN would 
exhibit post-needling induced pain, as this has previously 
been observed inmusculoskeletal pain, but for no longer 
than 72 h without the application of any post-needling inter-
vention. In addition, we also hypothesized that subjects 
receiving DN plus rehabilitation would exhibit a greater 
improvement in the intensity of shoulder pain than those 
receiving only rehabilitation.
Methods
Design
A randomized, controlled, clinical trial was conducted. The 
study was registered prospectively at ClinicalTrials.gov 
(ref. NCT03703193) and conducted in accordance with the 
Helsinki Declaration, and the study protocol was approved 
by the human research committee of the Universidad Rey 
Juan Carlos, Spain (ref. URJC 1512201600817). All par-
ticipants signed informed consent before their participation 
in the study.
Participants
Consecutive subjects who had experienced a stroke were 
screened according to the eligibility criteria from October to 
December 2018. Participants were recruited from Hospital 
Beata María Ana, Madrid (Spain). To be included, partici-
pants needed to have met the following criteria: (1) have 
experienced a first-ever unilateral stroke; (2) demonstrate 
hemiplegia resulting from the stroke; (3) be aged between 
30 and 60 years; (4) present hypertonicity in the upper 
extremity; (5) present pain symptoms in the hemiplegic 
Mendigutía-Gómez et al. 3
Acupuncture in Medicine, 00(0)
shoulder; and (6) exhibit active TrPs in the shoulder mus-
cles, for which pain referral reproduced the symptoms. 
Participants were excluded if they had: (1) experienced a 
recurrent stroke; (2) an absence of activeTrPs in the shoul-
der muscles reproducing shoulder symptoms; (3) undergone 
previous treatments with nerve blocks or motor point injec-
tions with neurolytic agents for spasticity at any time; (4) 
received previous treatment with botulinum toxin-A in the 
6 months prior to the trial; (5) severe cognitive deficits; (6) 
other neurologic diseases; (7) other medical conditions, for 
example, heart conditions, unstable hypertension, or frac-
ture; (8) a fear of needles; or (9) any contraindication to DN, 
for example, anticoagulant use, infections, bleeding, or 
psychosis.
All participants needed to exhibit at least one active TrP 
in the shoulder musculature reproducing their shoulder pain 
symptoms. TrP diagnosis was performed by a clinician with 
15 years of experience in TrP treatment in subjects who had 
experienced a stroke and following the criteria described by 
Simons et al.20 and confirmed in a recent Delphi study:21 (1) 
presence of a painful spot in a palpable taut band of a skel-
etal muscle; (2) local twitch response elicited by snapping 
palpation of the taut band; and (3) referred pain in response 
to compression. To be considered active, the pain referral 
elicited by the TrP needed to reproduce any symptom expe-
rienced by the subject in the hemiplegic shoulder and the 
subject needed to recognize the symptoms as a familiar 
experience. The muscles included in manual examination 
were the upper trapezius, pectoralis major, subscapularis, 
and infraspinatus. All these muscles are accessible to man-
ual palpation and treatment, and the referred pain elicited 
by their TrPs spreads to the shoulder or upper extremity.20
Interventions
Participants were randomly assigned to a DN group or a 
comparative control group. Concealed allocation was con-
ducted using a computer-generated random number table 
created by an external statistician.
All participants received a single session of a rehabilita-
tion program including modulatory interventions for spas-
ticity and pain control by a clinician with more than 20 years 
of experience in the management of stroke patients. Since 
there is no consensus on which rehabilitation approach is 
most effective for individuals who had experienced a 
stroke,22 different approaches (unilateral arm training, 
Bobath therapy, strength training, repetitive task training) 
have been proposed.23 Therefore, subjects received a single 
session of 45 min duration including unilateral arm training 
focusing on decreased muscle tone, passive positioning of 
the shoulder girdle, and repetitive task training exercises.16
Patients assigned to the DN group also received a single 
TrP-DN session over active TrPs by a physical therapist with 
15 years of experience with this procedure. Once an active 
TrP was located, the skin was properly cleaned with alcohol. 
Patients received TrP-DN using disposable stainless steel 
0.30 mm × 40 mm needles (Agupunt©, Barcelona, Spain) 
that were inserted into the skin over the TrP area and 
advanced into the muscle using the “fast-in and fast-out” 
technique24 until a first local twitch response was obtained. 
The depth of needle insertion ranged from 10 to 15 mm 
depending on the muscle thickness of the targeted muscle: 
upper trapezius (Figure 1a), infraspinatus (Figure 1c), sub-
scapularis (Figure 1c), or pectoralis mayor (Figure 1d). Once 
the first local twitch response was obtained, the needle was 
moved up and down (3–5 mm vertical motions, no rotations) 
for 60 s until no more local twitch responses were elicited. 
Upon removal of the needle, the area was compressed firmly 
with a cotton bud for approximately 1 min.
Outcome measures
The primary outcome included the intensity of post-nee-
dling induced pain and was assessed with an 11-point 
numerical pain rating scale (NPRS; 0 = no pain; 10 = maxi-
mum pain).25 It was defined as tenderness or pain perceived 
around the TrP area receiving the needling procedure. Post-
needling induced pain was assessed at 1 min, 24 h, and 72 h 
after DN.
Secondary outcomes including the intensity of shoul-
der pain and the presence of active TrPs were assessed 
before, and 3 and 7 days after the intervention. A separate 
11-point NPRS (0–10) was used to assess the mean level 
of shoulder pain at rest. There is no minimal clinically 
important difference (MCID) reported for shoulder pain 
in people who have experienced a stroke. Mintken et al.26 
reported that the MCID for the NPRS in individuals with 
shoulder pain is 1.1 points; therefore, we used this score 
in our study. Participants were asked to differentiate 
between their shoulder pain symptoms and TrP-DN-
induced pain.
Participants were also manually examined for the pres-
ence of active TrPs in the same muscles as at baseline, that 
is, upper trapezius, pectoralis major, subscapularis, and 
infraspinatus, by an assessor with 10 years of experience in 
the management of patients who had suffered a stroke who 
was blinded to each subject’s allocation.
Statistical analysis
Data were analyzed with SPSS version 22.0 (SPSS Inc., 
Chicago, IL, USA). Means, standard deviations (SDs) or 
95% confidence intervals (CIs) were calculated. The 
Kolmogorov–Smirnov test revealed a non-normal distribu-
tion of data; therefore, non-parametric tests were used in 
the main analysis. The non-parametric Mann–Whitney U 
test was used to examine for baseline differences between 
groups. For the main outcome, the non-parametric Friedman 
test with time (1 min, 24 h, and 72 h after intervention) as 
the main within-subjects factor was used to assess the 
4 Acupuncture in Medicine 
Acupuncture in Medicine, 00(0)
evolution of post-needling induced pain in the DN group. A 
second non-parametric Friedman test with time (baseline, 3 
and 7 days after intervention) as the main within-subjects 
and group (DN, comparative control) as the between- 
subjects factor was used to determine the effects of the 
interventions on shoulder pain intensity. Finally, a mixed 
chi-square test (McNemar–Bowker test) was applied to 
investigate the changes in the distribution of active TrPs 
between groups at baseline, and 3 and 7 days post-interven-
tion. The statistical analysis was conducted using a 95% CI 
and p ⩽ 0.05 was considered statistically significant. 
Consistent with the intention-to-treat principle, data from 
each subject were analyzed within the group to which the 
subject was assigned.
Results
Fifty patientswho had experienced a stroke were screened 
for eligibility criteria. Sixteen (mean ± SD age 47 ± 8 years; 
62% female) satisfied all the eligibility criteria, agreed to 
participate, and were included in the study. The reasons for 
ineligibility can be found in Figure 2, which provides a flow 
diagram of patient recruitment. Nine patients (56%) had the 
left side affected, whereas the remaining seven (44%) had 
the right side affected. The mean time from the stroke event 
was 9.0 ± 5.0 months. The baseline characteristics of both 
groups were similar for all variables (Table 1).
Post-needling induced pain
Five (62%) of the patients receiving DN reported post-
needling induced pain. The Friedman test revealed a sig-
nificant effect of time for the evolution of post-needling 
induced pain (p = 0.007). Post hoc analysis revealed that 
post-needling induced pain decreased significantly from 
baseline (mean ± SD = 5.4 ± 2.6) to 24 h (mean ± SD = 
 2.0 ± 1.5) and 72 h (mean ± SD = 0.5 ± 1.0; both, p < 0.001) 
after DN (Figure 3a).
Changes in shoulder pain
The Friedman test for repeated measures found a signifi-
cant group × time interaction for shoulder pain intensity 
(p < 0.001). Patients receiving TrP-DN plus the rehabilita-
tion program exhibited greater decreases in shoulder pain 
intensity at 3 (Δ = –4.2, 95% CI = –5.8 to −2.6) and 7 
(Δ = –4.3, 95% CI = –5.9 to −2.7) days after the interven-
tion, compared to those receiving the rehabilitation treat-
ment session alone (Table 2, Figure 3b).
Distribution of active TrPs
The distribution of active TrPs in the shoulder muscles was 
similar (all p > 0.5) in both groups before the interventions 
(Table 1). All active TrPs in the DN group underwent DN. 
After the needling session, only two patients exhibited 
Figure 1. Photographs of dry needling being applied over active trigger points within the upper trapezius (a), infraspinatus (b), 
subscapularis (c) and pectoralis major (d) muscles.
Mendigutía-Gómez et al. 5
Acupuncture in Medicine, 00(0)
active TrPs in the muscles within the DN group, whereas no 
changes were observed within the comparative control 
group (p < 0.001).
Discussion
This study demonstrated that application of TrP-DN pro-
voked post-needling induced pain in 50% of patients who 
had experienced a stroke and received DN, but this sore-
ness disappeared 72 h after the intervention without any 
additional therapeutic action. In addition, the inclusion of 
TrP-DN into a rehabilitation session was effective at 
decreasing shoulder pain intensity in this population.
Previous studies have found that the application of acu-
puncture is effective at reducing pain symptoms in the 
shoulder among people who had experience a stroke.17,27 To 
our knowledge, this trial is the first to use a TrP-DN 
approach for the management of hemiplegic shoulder pain. 
Our results showed that application of a single session of 
DN of the active TrPs reproducing the shoulder pain symp-
toms was effective at reducing the intensity of shoulder 
pain at a 1 week follow-up time point. The mechanisms 
underlying the observed changes in shoulder pain after the 
application of DN are unclear, but some hypotheses are 
proposed.28 It seems that DN exerts several mechanical 
effects on the TrP and the central nervous system, which 
may potentially initiate a cascade of neurophysiological 
mechanisms leading to anti-nociceptive effects. In fact, 
TrP-DN may reduce peripheral and central sensitization by 
removing the source of peripheral nociception (i.e. the 
TrP), by modulating spinal dorsal horn activity and by acti-
vating central inhibitory pain pathways.29 These effects 
could explain the observed changes in the intensity of 
shoulder pain. Nevertheless, it is important to consider that 
other factors may also be involved in hemiplegic shoulder 
pain at the same time as the active TrPs.
An important finding of this study was the presence of 
post-needling induced pain in just 50% of the patients who 
had experienced a stroke receiving the TrP-DN. This was 
an unexpected finding since previous studies conducted in 
people with musculoskeletal pain observed that all subjects 
receiving TrP-DN reported post-needling induced pain.19 
Similar to previous studies, post-needling induced pain 
almost disappeared 72 h after the TrP needling procedure 
without any post-needling intervention, supporting the con-
cept that post-needling induced pain could be a natural 
response, related to tissue healing, after the application of a 
needling intervention. To our knowledge, this study is the 
first to describe the presence of post-needling induced pain 
in patients with a neurological condition.
Figure 2. Flow diagram of patients throughout the course of the study.
6 Acupuncture in Medicine 
Acupuncture in Medicine, 00(0)
Figure 3. (a) Evolution of post-needling induced pain within 
the dry needling group and (b) evolution of shoulder pain 
intensity by treatment group. Data are expressed as mean 
and SEM. **Significant differences between groups (Friedman 
test, p < 0.001).
Ta
bl
e 
1.
 D
em
og
ra
ph
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 a
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ou
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 a
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lin
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 (
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 8
)
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ry
 n
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(n
 =
 8
)
A
ge
 (
ye
ar
s)
47
 ±
 7
48
 ±
 6
G
en
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r 
(m
al
e/
fe
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al
e)
3/
5
3/
5
T
im
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ke
 (
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±
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.0
9.
1 
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.5
A
ffe
ct
ed
 s
id
e 
(le
ft
/r
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ou
ld
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n 
(N
PR
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 0
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7.
0 
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U
pp
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m
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fr
as
pi
na
tu
s
A
ct
iv
e 
tr
ig
ge
r 
po
in
ts
 (
n,
 %
)
5 
(6
3%
)
3 
(3
8%
)
3 
(3
8%
)
6 
(7
5%
)
6 
(7
5%
)
2 
(2
5%
)
3 
(3
8%
)
7 
(8
8%
)
N
PR
S:
 n
um
er
ic
al
 p
ai
n 
ra
tin
g 
sc
al
e.
D
at
a 
ar
e 
ex
pr
es
se
d 
as
 m
ea
n 
±
 st
an
da
rd
 d
ev
ia
tio
n 
ex
ce
pt
 fo
r 
ge
nd
er
, a
ffe
ct
ed
 s
id
e 
an
d 
nu
m
be
r 
of
 a
ct
iv
e 
tr
ig
ge
r 
po
in
ts
.
Although the results of our trial are promising, potential 
limitations should be recognized. First, the sample size was 
small. This may be related to the inclusion and exclusion 
criteria, since patients needed to have hemiplegic shoulder 
pain related to active TrPs. In addition, since no previous 
study has investigated the presence of post-needling 
induced pain, a robust sample size calculation could not be 
performed. Second, as we only collected short-term out-
comes, we do not know if the observed changes lasted 
longer than 1 week. This is particularly relevant for stroke 
survivors since they are chronic patients. The fact that sig-
nificant changes were observed at 1 week follow-up sup-
ports future research in this area. Furthermore, only 
self-reported outcomes of pain intensity were collected. It 
would be interesting to determine changes in other out-
comes, for example, pressure pain thresholds, after applica-
tion of TrP-DN in patients with stroke. Third, we cannot 
determine the isolated effects of TrP-DN since it was 
applied integrated within a multimodal treatment session. 
Nevertheless, this represents a pragmatic clinical approach 
since people with hemiplegic shoulder pain are not treated 
Mendigutía-Gómez et al. 7
Acupuncture in Medicine, 00(0)
with just one technique. Fourth, we only applied a single 
DN session and the same clinician applied the intervention 
to all subjects within the DN group, which minimized het-
erogeneity but decreases the overall generalizability of the 
results. Future trials should include an increased number of 
treatment sessions, with a greater number of clinicians, 
larger ample size, and longer follow-up periods.
In conclusion, this study found that the application ofDN 
in patients who had suffered a stroke provoked post-nee-
dling induced pain in 50% of them, but soreness almost dis-
appeared 72 h after the intervention without any additional 
therapeutic action. Furthermore, the inclusion of a single 
session of TrP-DN into a multimodal rehabilitation session 
was effective at decreasing shoulder pain intensity in this 
population. Future studies with larger sample sizes and 
long-term periods of follow-up are needed to further con-
firm these results.
Contributors
All authors contributed to the study concept and design. CF-d-l-P 
and JLA-B performed the main statistical analysis. AM-G, MTQ-
G, and MM-S contributed to the literature review and interpreta-
tion of data. CF-d-l-P and JLA-B contributed to drafting of the 
report. DdL-B, JR-J, and JLA-B provided administrative, techni-
cal and material support. CF-d-l-P and JLA-B supervised the 
study. All authors revised the text for intellectual content and have 
read and approved the final version of the manuscript accepted for 
publication.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect 
to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, author-
ship, and/or publication of this article.
ORCID iDs
César Fernández-de-las-Peñas https://orcid.org/0000-0003 
-3772-9690
José L Arias-Buría https://orcid.org/0000-0001-8548-4427
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bl
e 
2.
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-in
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 p
os
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nc
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ok
e.
Sh
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(e
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.
https://orcid.org/0000-0003-3772-9690
https://orcid.org/0000-0003-3772-9690
https://orcid.org/0000-0001-8548-4427
8 Acupuncture in Medicine 
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