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Disability and Rehabilitation
ISSN: 0963-8288 (Print) 1464-5165 (Online) Journal homepage: http://www.tandfonline.com/loi/idre20
Improvement in clinical outcomes after dry
needling versus myofascial release on pain
pressure thresholds, quality of life, fatigue, pain
intensity, quality of sleep, anxiety, and depression
in patients with fibromyalgia syndrome
Adelaida M. Castro Sánchez, Hector García López, Manuel Fernández
Sánchez, José Manuel Pérez Mármol, María Encarnación Aguilar-Ferrándiz,
Alejandro Luque Suárez & Guillermo Adolfo Matarán Peñarrocha
To cite this article: Adelaida M. Castro Sánchez, Hector García López, Manuel Fernández
Sánchez, José Manuel Pérez Mármol, María Encarnación Aguilar-Ferrándiz, Alejandro Luque
Suárez & Guillermo Adolfo Matarán Peñarrocha (2018): Improvement in clinical outcomes after
dry needling versus myofascial release on pain pressure thresholds, quality of life, fatigue, pain
intensity, quality of sleep, anxiety, and depression in patients with fibromyalgia syndrome, Disability
and Rehabilitation, DOI: 10.1080/09638288.2018.1461259
To link to this article: https://doi.org/10.1080/09638288.2018.1461259
Published online: 23 Apr 2018.
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ORIGINAL ARTICLE
Improvement in clinical outcomes after dry needling versus myofascial release on
pain pressure thresholds, quality of life, fatigue, pain intensity, quality of sleep,
anxiety, and depression in patients with fibromyalgia syndrome
Adelaida M. Castro S�ancheza, Hector Garc�ıa L�opezb, Manuel Fern�andez S�ancheza, Jos�e Manuel P�erez M�armolc,
Mar�ıa Encarnaci�on Aguilar-Ferr�andizc, Alejandro Luque Su�arezd and Guillermo Adolfo Matar�an Pe~narrochae
aDepartment of Nursing, Physical Therapy and Medicine, University of Almeria (UAL), Almeria, Spain; bDepartment of Physical Therapy,
Andalusian Health Service, Primary Health Physical Therapy, Almeria, Spain; cResearch Institute – Biosanitaria Granada (IBS – Granada),
Department of Physical Therapy, Faculty of Health Science, University of Granada (UGR), Granada, Spain; dDepartment of Physical Therapy,
Faculty of Health Sciences, University of Malaga (UMA), Malaga, Spain; eMalaga Health District, Andalusian Health Service, Primary Health
Medical, Malaga, Spain
ABSTRACT
Purpose: To compare the effectiveness of dry needling versus myofascial release on myofascial trigger
points pain in cervical muscles, quality of life, impact of symptoms pain, quality of sleep, anxiety, depres-
sion, and fatigue in patients with fibromyalgia syndrome.
Method: A single-blind randomized controlled trial was conducted. Sixty-four subjects with fibromyalgia
were randomly assigned to a dry needling group or a myofascial release group. Pain pressure thresholds
of myofascial trigger points were evaluated in the cervical muscles. In addition, quality of life, impact of
fibromyalgia symptoms, quality of sleep, intensity of pain, anxiety and depression symptoms, impact of
fatigue at baseline and post treatment after four weeks of intervention were evaluated.
Results: Significant improvement was found in most pain pressure thresholds of the myofascial trigger
points in cervical muscles in the dry needling group compared to myofascial release (p< 0.05). Similarly,
these differences between groups were found for the components of quality of life of physical function
(F¼ 12.74, p¼ 0.001), physical role (F¼ 11.24, p¼ 0.001), body pain (F¼30.26, p< 0.001), general health
(F¼ 15.83, p< 0.001), vitality (F¼ 13.51, p¼ 0.001), social function (F¼ 4.73, p¼ 0.034), emotional role
(F¼ 8.01, p¼ 0.006), and mental health (F¼ 4.95, p¼ 0.030). Similar results were achieved for total impact
of FMS symptoms (F¼ 42.91, p< 0.001), quality of sleep (F¼ 11.96, p¼ 0.001), state anxiety (F¼ 7.40,
p¼ 0.009), and trait anxiety (F¼�14.63, p< 0.001), hospital anxiety and depression (F¼ 20.60, p< 0.001),
general pain intensity (F¼ 29.59, p< 0.001), and fatigue (F¼�25.73, p< 0.001).
Conclusion: The dry needling therapy showed higher improvements in comparison with myofascial
release therapy for pain pressure thresholds, the components of quality of life of physical role, body pain,
vitality and social function, as well as the total impact of FMS symptoms, quality of sleep, state and trait
anxiety, hospital anxiety-depression, general pain intensity and fatigue.
� IMPLICATIONS FOR REHABILITATION
� Dry needling therapy reduces myofascial trigger point pain in the short term in patients with fibro-
myalgia syndrome.
� This therapeutic approach improves anxiety, depression, fatigue symptoms, quality of life, and sleep
after treatment.
� Dry needling and myofascial release therapies decrease intensity of pain, and the impact of fibromyal-
gia symptoms in this population.
� These intervention approaches should be considered in an independent manner as complementary
therapies within a multidisciplinary setting.
ARTICLE HISTORY
Received 18 October 2017
Revised 27 February 2018
Accepted 2 April 2018
KEYWORDS
Chronic fatigue disorders;
physical therapy modalities;
musculoskeletal pain;
disability; mood disorders;
rehabilitation research
Introduction
Fibromyalgia syndrome (FMS) is characterized by chronic and dif-
fuse musculoskeletal pain. The prevalence has been estimated as
4.7% of inhabitants in Europe [1]. Although the exact cause
of fibromyalgia is unknown, abnormalities of the nervous
system regarding pain processing may explain the chronic pain.
Several studies have reported that subjects with FMS show
hyper-responsiveness and hyper-excitability of the central nervous
system (central sensitization) [2–4]. The relationship between cen-
tral sensitization and peripheral pain nociception can be sup-
ported because central hyper-excitability is influenced by
prolonged nociceptive peripheral inputs [5]. In fact, nociceptive
stimuli from muscle tissue seem to contribute to FMS [6,7].
Conditioned pain modulation has a specific role in pain gener-
ation, influencing pain perception and its prevention. Evidence
CONTACT Adelaida M. Castro S�anchez adelaid@ual.es Department of Nursing, Physical Therapy and Medicine, Faculty of Health Sciences, University of
Almer�ıa, Ctra. Sacramento s/n. La Ca~nada de San Urbano, Almer�ıa 04120, Spain
� 2018 Informa UK Limited, trading as Taylor & Francis Group
DISABILITY AND REHABILITATION, 2018
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has shown that dysfunctional conditioned pain modulation occurs
prior to the acquisition of pain and an improvement in condi-
tioned pain modulation reduces the levels of clinical pain [7].
Myofascial trigger point (MTrPs) pain is defined as pain caused
by one or more hyperirritable spots in the skeletal muscle that are
related to hypersensitivity palpable nodules in taut bands [8].
Alonso-Blanco et al. [9] reported that local and referred pain from
widespread active MTrPs fully reproduced the overall spontaneous
clinical pain area in patients with FMS. Simons et al. [10] sug-
gested that MTrPs can play an important role in the treatment of
pain in FMS. Patients with FMS usually present multiple active
trigger points,which are related to generalized pressure hyper-
algesia, and contribute to regional pain. In fact, trigger points
have been considered the main peripheral pain generator in this
population. Peripheral inputs from active MTrPs may lead to cen-
tral sensitization of FMS patients [9]. Staud et al. [11] concluded
that the overall spontaneous pain is located in certain body areas.
Local and referred pain has been induced from active trigger
points identified in the trapezius muscle, which reproduced neck-
shoulder pain patterns in FMS [12]. Previous studies have sug-
gested that the number of active MTrPs found in patients with
FMS is directly related to pain intensity [9,13–15]. Lucas et al. [13]
reported that latent MTrPs in the scapular rotator muscles change
the muscle activation pattern of this muscle group and of muscles
further distal in the shoulder girdle kinetic chain.
Low levels of quality of life and quality of sleep, and high lev-
els of fatigue, anxiety and depression symptoms have been
reported in FMS patients. It would be expected that the improve-
ment in MTrPs and pain after physical therapy interventions may
also have an influence on these health areas [16–18].
Dry needling is a minimally invasive technique in which an
acupuncture needle is inserted directly into MTrPs [8]. Previous
research has documented the immediate reduction in local and
referred pain after dry needling [19–21]. However, the effective-
ness of dry needling has been discussed in scientific literature. In
some studies, no beneficial effects have been observed [22] and
others have reported it to be effective on trigger points [23,24].
Dry needling seems to be effective on acute and chronic low back
pain, lumbar myofascial pain, headaches, chronic lumbar MTrPs,
and whiplash [25–30]. A systematic review concluded that direct
needling of MTrPs seems to be superior to no therapeutic inter-
vention, but the hypothesis that needling therapies have efficacy
beyond the placebo effect is neither supported nor refuted by the
evidence from clinical trials [22]. A previous study showed that
dry needling is effective on MTrPs for latissimus dorsi, quadratus
lumborum, and multifidus muscles [23]. These findings suggest
that needling techniques may be effective on the MTrPs in cer-
vical muscles in patients with the FMS.
Myofascial release is a therapeutic intervention defined as “a
rapidly spreading form of manual therapy aimed at providing pain
relief by restoring impaired functions of soft tissues” [31, p.2]. Its
effects are provided by the specific behavior of connective tissue
sheets, referred to as “fascia”. This tissue represents the main
element in the functioning of the musculoskeletal system and it
creates the fascial system that connects the whole body, from
head to feet. A source of tension in the fascial tissue, provoked by
tightening, stiffening, or restricted sliding capacity after micro-
trauma or acute injuries, can lead to pain and general dysfunction.
Inflammation of the fascial system may lead to peripheral nocicep-
tive input, provoking central sensitization in FMS patients. This
fascial dysfunction can be attributed to an imbalance of growth
hormone production and hypothalamic–pituitary–adrenal axis dys-
function. If we assume the relationship among inflammation,
fascial system dysfunction, and central sensitization in this
population, therapeutic approaches should include interventions
that target the fascia [31–33].
The purpose of the current randomized clinical trial was to
compare the effectiveness of dry needling versus myofascial
release on MTrPs in cervical muscles, quality of life, fatigue, anx-
iety and depression in patients with FMS.
Methods
Design and participants
A single-blind randomized controlled trial was conducted on
patients with FMS from fibromyalgia associations from AFIAL, AFIEL
and FIBROFAMUR (Almer�ıa-Murcia). FMS was diagnosed following
criteria for the diagnosis of fibromyalgia from the American College
of Rheumatology – ACR (modified 2010) [34]. Chronic widespread
musculoskeletal pain symptoms were assessed using the
Widespread Pain Index and the Symptoms Severity Scale [34].
Inclusion criteria were, (1) diagnosed with FMS, (2) manifesting
chronic widespread musculoskeletal pain symptoms, (3) aged
from 18 to 60 years, (4) limitation in activities of daily living due
to pain (at least one day in the previous month), and (5) agree-
ment to attend evening therapy sessions. Exclusion criteria were,
(1) change in the pharmacologic therapy during the period of the
study, (2) presence of cardiac, renal or hepatic insufficiency, (3)
severe physical disability, (4) comorbid condition (e.g., inflamma-
tory disease), (5) fever after infection, (6) hypotension, (7) skin
alterations, (8) psychiatric illness, or (9) previous history of surgery.
The selection and recruitment was conducted in accordance
with the declaration of Helsinki and all subjects signed a written
informed consent form prior to their inclusion in the study. This
study received ethics approval by the Research Committee of
University of Almeria (Almeria, Spain), with Approval Number:
UAL-428, Clinical Trials.gov ID: NCT03015662.
Randomization
Participants who met the inclusion-exclusion criteria were ran-
domly assigned to receive either dry needling therapy or myofas-
cial release therapy after a baseline examination. Both groups
received the intervention by a physical therapist with more than
12 years of experience with FMS patients and chronic pain. All
participants received a total of 4 sessions (once a week for four
weeks). Concealed allocation (ratio 1:1) was executed by a com-
puter-generated randomized table of numbers. This table was per-
formed at the beginning of the data collection process by an
investigator not involved in the recruitment or treatment phase.
The random assignment was included in individual and sequen-
tially numbered index cards. These index cards were folded and
placed in sealed opaque envelopes. A physiotherapist, blinded to
pre- and post-treatment evaluations, opened the envelope and
started with the assigned intervention for each participant.
Outcome measures
Outcome measures were assessed before the first treatment ses-
sion (baseline data), and 48 h after the four-week intervention
period by the physiotherapist blinded to the treatment allocation
of the patients. Evaluations were performed on two successive
days to avoid any related fatigue. Clinical and demographic infor-
mation including age, sex, height, weight, and education levels
were recorded.
Algometry was used to evaluate MTrPs in the following pairs
of cervical muscles: occipitofrontalis, splenius capitis, sternocleido-
mastoid, anterior scalene, middle scalene, posterior scalene, upper
2 A. M. CASTRO S�ANCHEZ ET AL.
trapezius, middle trapezius, lower trapezius, supraspinatus, infra-
spinatus, and multifidus level C6. The evaluation was performed
with a 2-min rest period between each muscle exploration. MTrPs
diagnosis was developed following the criteria described by
Gerwin et al. [35] and Simons et al. [10]: (1) presence of a palpable
taut band within a skeletal muscle, (2) presence of a hyperirritable
spot in the taut band, and (3) presence of referred pain in
response to MTrPs compression [35]. Measure outcomes were reg-
istered three times for each muscle, with a 30-s resting period
between each trial. The total scores, used for the main analysis,
were the mean of the three trials, increasing the intra-examiner
reliability. Inter-rater reliability analyses of this assessment method
have shown a substantial agreement among examiners for the
MTrPs diagnosis [35].
In addition, patients completed the following self-
report measures:
The SF-36 quality of life questionnaire assesses eight domains,
including physical functioning, physical role, bodily pain, general
health, vitality, social functioning, role-emotional and mental
health. This instrument has a total score ranging from 0 (poorest
level of qualityof life) to 100 (highest level of quality of life). The
SF-36 questionnaire has been shown to be able to discriminate
between subjects with health problems and healthy controls. The
Spanish version of the SF-36 showed good levels of reliability and
validity. Reliability of SF-36 was high for all subscales from the
questionnaire, with Cronbach’s alpha indices ranging from 0.84 to
0.95 [36–38].
The Spanish version of the fibromyalgia impact questionnaire
was used to assess the impact of FMS symptoms on the physical
and mental health of patients. This questionnaire consists of 10
subscales assessing physical function, number of days feeling
good (well-being), work missed, ability to do work, pain, fatigue,
rest, stiffness, anxiety, and depression. The scores range from 0 to
100, with higher scores reflecting a more negative impact. This
questionnaire has shown a total interclass correlation coefficient
of 0.81 [39].
The Pittsburgh Quality of Sleep Questionnaire Index was used
to assess the quality of sleep. It comprises of 24 items, where
patients respond to 19 of these items, and a person living in the
same dwelling (or hospital room) responds to the remaining five.
This questionnaire has 7 dimensions: subjective quality, sleep
latency, sleep duration, habitual sleep efficacy, sleep perturbations,
use of hypnotic medication, and daily dysfunction. Each dimen-
sion is scored from 0 (no problems) to 3 (severe problems), where
the total score varies in a range from 0 to 21 points. Psychometric
analysis of the Pittsburgh Quality of Sleep Questionnaire Index
showed a high reliability with a coefficient of 0.78 [40].
The Visual Analog Scale was used to assess pain intensity and
degree of relief experienced by patients, scored from 0 points (no
pain) to 10 points (unbearable pain). The test-retest reliability ana-
lysis showed a correlation of 0.64 for the visual numeric version in
Spanish [41].
Anxiety levels were evaluated using the 40-item State-Trait
Anxiety Inventory, which measures anxiety as a stable dimension
of personality (trait or tendency to anxiety) and state anxiety. The
trait anxiety subscale reports the frequency with which anxiety is
experienced. However, the state anxiety subscale indicates the
feelings or sensations of anxiety at a specific moment in time (at
evaluation time). Factorial analyses identified four factors related
to the presence or absence of anxiety on each scale: presence of
state anxiety, absence of state anxiety, presence of trait anxiety,
and absence of trait anxiety. Cronbach’s alpha for total score of
State-Trait Anxiety Inventory was 0.93, showing a high reliability
for this inventory [42,43].
The Beck Depression Inventory was used to evaluate a wide
spectrum of depressive symptoms by a self-applied 21-item ques-
tionnaire. The total questionnaire score ranges from 0 to 63
points. The result is interpreted by the usual classifications as fol-
lows: no depression (0–9 points), mild depression (10–18 points),
moderate depression (19–29 points) and severe depression (�30
points). Internal consistency was high, with Cronbach’s alpha at
0.87 [44,45].
Fatigue Impact Scale assesses the impact of fatigue. It is a
questionnaire-based inventory, which requires patients to rate the
perceived functional limitations in the psychosocial, cognitive, and
physical domains due to fatigue over the previous month. This
questionnaire is scored from 0 (no problem) to 4 (extreme prob-
lem), with a maximum score in the three sub-scales of 80, 40, and
40 points, respectively. The total score of impact is 160 points,
representing the highest level of perceived fatigue. Internal con-
sistency for the Fatigue Impact Scale and its three subscales was
high, with Cronbach’s alpha higher than 0.87. Fatigue Impact
Scale also showed a good test-retest reliability with coefficients
ranging from 0.68 to 0.85 [46,47].
The Hospital Anxiety Depression scale was designed to detect
significant anxiety and depression in general medical patients.
This scale contains 7 items in each of its two subscales, anxiety
and depression. The total score ranges from 0 to 21 points on
each subscale, which have shown to provide independent meas-
ures of these mood disorders in medical populations. The test-
retest reliability of Hospital Anxiety Depression scale showed cor-
relation coefficients higher than 0.85. The internal consistency was
high, with Cronbach’s alpha at 0.86 for anxiety and 0.86 for
depression [48].
Interventions
Dry needling therapy
Active or latent MTrPs were highlighted in black or red, respect-
ively. Active or latent MTrPs were needled in the same position
employed by the blinded examiner for diagnosis. All dry needling
procedures were performed by the same investigator individually,
and the technique used was similar to the Hong method [49,50],
using sterile Ener-Qi needles (EQ 1661) for the puncture of MTrPs
(trigger points). After cleansing the skin (2% chlorhexidine), the
needle (0.25� 25) (diameter� length) was inserted to a depth of
5–15mm depending on the depth of active or latent trigger point.
The insertions of the needle in each MTrPs were performed using
Hong’s fast-in, fast-out technique until a local twitch response was
obtained. Hypoxia was produced by compression (for 15 s) in
every active or latent MTrPs needled [50]. All patients received
four sessions (once-weekly). This technique was applied to the fol-
lowing pairs of muscles, selected according to Simons et al. [10]:
occipitofrontalis, splenius capitis, sternocleidomastoid (clavicular
branch MTrPs 1, 2, and 3; sternal branch MTrPs 1, 2, 3, and 4), sca-
lene (anterior MTrPs 1 and 2; middle MTrP 1; posterior MTrP 1),
trapezius (upper MTrPs 1 and 2; middle MTrPs 5, 6, and 7; lower
MTrPs 3 and 4), supraspinatus (central point; myotendinous inser-
tion; tendon), infraspinatus (upper middle area; upper lateral area;
lateral scapular side; middle scapular side), and multifidus
(level C6).
Myofascial release therapy
Patients received a myofascial therapy standardized protocol indi-
vidually [32,33,51], following the procedure described in the
appendix published by Castro-S�anchez et al. [32] termed as
“Description of the Techniques Applied in the Myofascial Therapy
DRY NEEDLING AND MYOFASCIAL RELEASE ON FIBROMYALGIA 3
Protocol”. This protocol was performed in the following order:
deep fascia release in the temporal region, suboccipital release,
compression-decompression of the temporomandibular joint, glo-
bal release of cervicodorsal fascia, release of pectoral region, dia-
phragm release (transverse slide), and transverse diaphragmatic
plane [32,33,51].
Statistical analyses
An assessor blinded to the treatment allocation conducted the
statistical analyses using SPSS statistical software (SPSS Inc.,
Chicago, IL, USA), version 22.0. Firstly, the normal distribution of
variables was verified by the Kolgomorov-Smirnov test, after a
descriptive analysis. The homogeneity of variances was observed
using Levene’s test. Linearity was evaluated by bivariate scatter
plots of observed residual values against the expected values.
Comparisons between groups were conducted among demo-
graphic and clinical data at baseline, using the Student t-test for
continuous data and the chi-square test for categorical data. The
time �groups effects between both groups (dry needling versus
myofascial release therapy) and time points (baseline versus post-
treatment evaluation for the primary outcome (active and latent
myofascial trigger points: number of trigger points) were calcu-
lated using repeated measures analysis of variance ANOVA. All
analyses followed the intention to treat principle. Changes in vari-
able scores within and between groups were measured by means
of t-tests for paired or independent samples as appropriate (95%
confidence interval). Effect sizes were calculated using Cohen’s d
coefficient. An effect size <0.2 reflects a negligible difference,
between �0.2 and <0.5 a small difference, between �0.5 and
<0.8 a moderate difference,and �0.8 a large difference. p Values
<0.05 was considered statistically significant. Sample size calcula-
tion was performed by using G�power software (http://www.gpo-
wer.hhu.de/en.html).
Results
Participants
In total, 82 FMS patients were recruited for the clinical trial and
64 patients, 58 women and 6 men, aged 27–58 years (mean:
48.71 ± 7 years), met the inclusion criteria. They were randomly
assigned to the dry needling group (n¼ 32) or myofascial release
group (n¼ 32). The M± SD for demographic characteristics and
differences between groups at baseline are shown in Table 1.
Both groups had similar characteristics since no significant differ-
ence was found when comparing them. A flowchart of the recruit-
ment and follow-up of participants is depicted in Figure 1.
Changes in pain pressure thresholds: MTrPs algometry
Significant time � groups interaction were achieved for the follow-
ing pain pressure thresholds in MTrPs: Occipitofrontalis (right:
F¼ 14.14, p< 0.001, CI¼ 0.26, 0.99; left: F¼ 4.41, p¼ 0.040,
CI¼ 0.14, 1.06), splenius capitis (right: F¼ 4.25, p¼ 0.044, CI¼ 0.12,
0.69; left: F¼ 8.50, p¼ 0.005, CI¼ 0.09, 0.70), anterior scalene 1
(right: F¼ 4.11, p¼ 0.047, CI¼�0.11, 0.15; left: F¼ 4.79, p¼ 0.033,
CI¼�0.06, 0.26), anterior scalene 2 (right: F¼ 4.55, p¼ 0.038,
CI¼ 0.03, 0.04; left: F¼ 7.09, p¼ 0.010, CI¼ 0.04, 0.43), middle sca-
lene (left: F¼ 4.17, p¼ 0.046, CI¼ 0.08, 0.50), upper trapezius 2
(right: F¼ 10.33, p¼ 0.002, CI¼ 0.06, 1.09), lower trapezius 3 (right:
F¼ 4.46, p¼ 0.039, CI¼ 0.39, 1.41), middle trapezius 5 (right:
F¼ 7.96, p¼ 0.007, CI¼ 0.10, 0.99), middle trapezius 7 (right:
F¼ 9.43, p¼ 0.003, CI¼ 0.16, 0.42), myotendinous insertion of
supraspinatus (right: F¼ 8.35, p¼ 0.005, CI¼ 0.11, 1.06), upper
middle area of the infraspinatus (right: F¼ 6.59, p¼ 0.013,
CI¼ 0.074, 0.58). Infraspinatus lateral scapular side (left: F¼ 4.16,
p¼ 0.046, CI¼ 0.21, 0.84) and multifidus level C6 (right: F¼ 13.51,
p¼ 0.001, CI¼ 0.09, 0.78). Within group analysis demonstrated a
significant pre-post-treatment improvement for most MTrPs (at
least on one side) in the dry needling group, however, myofascial
release group only showed changes over time for sternal sterno-
cleidomastoid 2 and 4, anterior scalene 2, central and myotendi-
nous insertion of supraspinatus and infraspinatus middle scapular
side. Table 2 shows pre-post-intervention values and within and
between-group changes scores with associated 95% CI for MTrPs
algometry. The effects sizes ranged from small to large for the dry
needling group (minimum d¼ 0.22, maximum d¼ 1.13) and from
negligible to small for the myofascial release group (minimum
d¼ 0.16 maximum d¼ 0.23).
Changes in quality of life, impact of FMS symptoms and quality
of sleep
Regarding quality of life, the ANOVA analysis showed significant
time � groups interaction for physical function (F¼ 12.74,
p¼ 0.001, CI¼�6.31, 16.65), physical role (F¼ 11.24, p¼ 0.001,
CI¼ 8.34, 41.65), body pain (F¼ 30.26, p< 0.001, CI¼ 11.73,
33.93), general health (F¼ 15.83, p< 0.001, CI¼�5.20, 13.03),
vitality (F¼ 13.51, p¼ 0.001, CI¼ 0.76, 23.23), social function
(F¼ 4.73, p¼ 0.034, CI¼�0.46, 26.63), emotional role (F¼ 8.01,
p¼ 0.006, CI¼�13.05, 33.05), mental health subscales (F¼ 4.95,
p¼ 0.030, CI¼�1.22, 20.42) and after four week post-treatment.
Between-groups analysis showed significant differences at post-
treatment evaluation for physical role (t¼ 3.161, p¼ 0.003), body
pain (t¼ 4.338, p< 0.001), vitality (t¼ 2.007, p¼ 0.049), and social
function (t¼ 2.195, p¼ 0.032). Figure 2 shows between-group dif-
ferences for fibromyalgia symptoms. Within group analysis
showed a significant improvement from baseline values for all
subscales in the dry needling group (p< 0.05). The myofascial
release group only experienced pre-post-treatment changes for
physical function (t¼�5.043, p¼ 0.009) and body pain
(t¼�6.212, p¼ 0.011). The effect sizes for quality of life in the
dry needling group were small to large (minimum d¼ 0.44, max-
imum d¼ 0.86), and in the myofascial release were negligible/
small (d� 0.20).
Regarding the impact on FMS symptoms, similar results were
achieved for the Fibromyalgia Impact Questionnaire, showing sig-
nificant time �groups interaction for physical impairment
Table 1. M± SD and absolute frequency of patients’ characteristics at baseline.
Dry needling
group
N¼32
Myofascial
release group
N¼ 32 p
Age (years) 47.37 ± 4.98 46.79 ± 7.23 0.225
Age range 29–59 26–57
Weight (kg) 69.73 ± 15.32 67.70 ± 15.17 0.527
Height (cm) 158.91 ± 7.63 161.07 ± 6.86 0.100
Sex 0.641
Female 30 28
Male 2 4
Educational level 0.081
No studies 5 3
School level 10 14
Bachelor level 12 13
University level 5 2
Values are expressed as absolute frequency for categorical variables and as
means ± standard deviations for continuous variables (N¼ 64). P associated with
student t-test for independent samples in continuous variables and chi-square in
categorical variables.
4 A. M. CASTRO S�ANCHEZ ET AL.
http://www.gpower.hhu.de/en.html
http://www.gpower.hhu.de/en.html
(F¼ 29.14, p< 0.001, CI¼�2.90, �0.18), number of days feeling
good (F¼ 20.69, p< 0.001, CI¼�4.40, �1.87), work missed
(F¼ 18.46, p< 0.001, CI¼�4.46, �1.90), ability to do work
(F¼ 28.80, p< 0.001, CI¼�3.96, �1.83), pain (F¼ 29.59, p< 0.001,
CI¼�3.87, �1.92), fatigue (F¼ 32.01, p< 0.001, CI¼�3.44,
�1.48), rested (F¼ 28.54, p< 0.001, CI¼�3.57, �1.62), stiffness
(F¼ 31.09, p< 0.001, CI¼�3.52, �1.40), anxiety (F¼ 9.53,
p¼ 0.002, CI¼�2.85, -0.34), depression (F¼ 9.17, p¼ 0.004,
CI¼�2.12, 0.72) and total score of Fibromyalgia Impact
Questionnaire (F¼ 42.91, p< 0.001, CI¼�33.14, 14.27). Between-
groups analysis showed significant differences at post-treatment
evaluation for physical impairment (t¼�2.359, p¼ 0.021), number
of days feeling good (t¼�5.285, p< 0.001), work missed
(t¼ 5.278, p< 0.001), ability to do work (t¼�5.882, p<0.001), pain
(t¼�6.508, p< 0.001), fatigue (t¼�5.549, p< 0.001), rested
(t¼�5.822, p< 0.001), stiffness (t¼�5.062, p< 0.001), anxiety
(t¼�2.877, p¼ 0.006), and total score of Fibromyalgia Impact
Questionnaire (t¼�5.450, p< 0.001). Figure 3 shows between-
group differences for fibromyalgia symptoms. Within group ana-
lysis showed significant changes from baseline values for all sub-
scales in the dry needling group (p< 0.05). The myofascial release
group only experienced pre-post-treatment improvement for num-
ber of days feeling good (t¼ 7.289, p¼ 0.001), work missed
(t¼ 6.813, p¼ 0.004), ability to do work (t¼ 6.975, p¼ 0.012), pain
(t¼ 6.796, p¼ 0.015) and stiffness (t¼ 6.780, p¼ 0.008) subscales.
The effects size was large (d¼ 1.67) in the dry needling group for
the total score of Fibromyalgia Impact Questionnaire and small in
the myofascial release group (d¼ 0.27).
Regarding quality of sleep, time � groups interactions were also
found for quality of sleep (F¼ 8.07, p¼ 0.006, CI¼�0.98, -0.28),
sleep latency (F¼ 9.91, p¼ 0.003, CI¼�0.59, 0.33), daily dysfunc-
tion (F¼ 11.96, p¼ 0.001, CI¼�1.05, 0.12) and total score of
Pittsburgh Quality of Sleep Questionnaire Index (F¼ 11.96,
p¼ 0.001, CI¼�5.54, 0.85). Between-groups analysis showed sig-
nificant differences at post-treatment evaluation for quality of
sleep (t¼�4.139, p< 0.001), and total score of Pittsburgh Quality
of Sleep Questionnaire Index (t¼�3.150, p¼ 0.003). Figure 4
shows between-group differences for fibromyalgia symptoms.
Within-group analysis showed only significant changes from base-
line values in the dry needling group for these outcomes
(p< 0.05). The effects size was moderate in the dry needling
group for the total score of PSQ (d¼ 0.45).
Changes in anxiety, depression, pain intensity, and fatigue
For anxiety, the 2� 2 ANOVA repeated measures demonstrated
time � groups interaction for state anxiety (F¼ 8.82, p¼ 0.004,
CI¼�0.45, 0.12), trait anxiety (F¼�10.25, p¼ 0.002, CI¼�0.54,
0.14), total state anxiety (F¼ 7.40, p¼ 0.009, CI¼�6.74, 3.249),
total trait anxiety (F¼�14.63, p< 0.001, CI¼�9.85, 1.19).
However, between-groups analysis showedno significant
differences at post-treatment evaluation (p> 0.05). For depression,
time � groups interaction was found for Beck Depression Inventory
(F¼ 24.360, p< 0.05, CI¼ 19.34, 27.28) and significant differences
at post-treatment evaluation were achieved (t¼�2.115,
p¼ 0.038). Regarding Hospital Anxiety-Depression Scale, similar
Figure 1. Design and flow of participants through the trial following CONSORT 2010 guidelines.
DRY NEEDLING AND MYOFASCIAL RELEASE ON FIBROMYALGIA 5
Table 2. Baseline, post-treatment, pre-post-treatment differences and change scores in each group (95% confidence interval) for MTrPs Algometry.
Outcome/group Side Baseline One month post-treatment Paired t-test p Within-group score Changes Between-group score Changes
Occipitofrontalis (kg/cm2)
Dry needling Right 2.23 ± 0.68 2.86 ± 0.79 0.001� �0.63 (�0.88, �0.38) 0.63 (0.26, 0.99)
Left 2.41 ± 0.74 2.98 ± 0.89 0.001� �0.57 (�0.83, �0.30)
Myofascial Right 2.12 ± 0.56 2.24 ± 0.62 0.078 �0.12 (�0.24, 0.02) 0.61 (0.14, 1.06)
Left 2.17 ± 0.60 2.39 ± 0.83 0.120 �0.21 (�0.45, 0.05)
Splenius capitis (kg/cm2)
Dry needling Right 2.45 ± 0.67 2.88 ± 0.44 0.001� �0.43 (�0.65, �0.21) 0.40 (0.12, 0.69)
Left 2.60 ± 0.62 2.91 ± 0.34 0.003� �0.31 (�0.51, �0.11)
Myofascial Right 2.32 ± 0.69 2.47 ± 0.63 0.053 �0.16 (�0.32, 0.002) 0.40 (0.09, 0.70)
Left 2.48 ± 0.73 2.49 ± 0.74 0.228 �0.03 (�0.07, 0.02)
Clavicular sternocleidomastoid 1 (kg/cm2)
Dry needling Right 2.25 ± 0.13 2.28 ± 0.13 0.088 �0.03 (�0.05, 0.004) �0.15 (�0.23, �0.06)
Left 2.32 ± 0.08 2.33 ± 0.07 0.536 �0.006 (�0.03, 0.01)
Myofascial Right 2.43 ± 0.19 2.44 ± 0.20 0.857 �0.004 (�0.02, 0.01) �0.07 (�0.13, �0.02)
Left 2.40 ± 0.15 2.42 ± 0.16 0.324 �0.005 (�0.01, 0.001)
Clavicular sternocleidomastoid 2 (kg/cm2)
Dry needling Right 2.22 ± 0.22 2.28 ± 0.17 0.068 �0.06 (�0.12, 0.004) �0.13 (�0.24, �0.02)
Left 2.33 ± 0.07 2.35 ± 0.07 0.023� �0.016 (�0.04, 0.01)
Myofascial Right 2.41 ± 0.24 2.42 ± 0.26 0.658 �0.002 (�0.03, 0.02) �0.04 (�0.13, 0.03)
Left 2.41 ± 0.17 2.41 ± 0.23 0.891 0.012 (�0.03, 0.06)
Clavicular sternocleidomastoid 3 (kg/cm2)
Dry needling Right 2.29 ± 0.14 2.31 ± 0.14 0.110 �0.02 (�0.04, 0.004) �0.15 (�0.23, �0.07)
Left 2.33 ± 0.08 2.35 ± 0.09 0.202 �0.016 (�0.04, 0.01)
Myofascial Right 2.45 ± 0.17 2.47 ± 0.18 0.736 �0.007 (�0.02, 0.16) �0.06 (�0.13, 0.02)
Left 2.41 ± 0.18 2.44 ± 0.20 0.063 �0.02 (�0.02, 0.02)
Sternal sternocleidomastoid 1 (kg/cm2)
Dry needling Right 2.25 ± 0.17 2.27 ± 0.18 0.402 �0.02 (�0.08, �0.03) �0.13 (�0.26, 0.003)
Left 2.34 ± 0.14 2.35 ± 0.14 0.264 �0.01 (�0.03, 0.01)
Myofascial Right 2.39 ± 0.30 2.41 ± 0.32 0.267 �0.02 (�0.04, 0.02) �0.06 (�0.15, 0.04)
Left 2.44 ± 0.19 2.43 ± 0.24 0.785 0.01 (�0.01, 0.07)
Sternal sternocleidomastoid 2 (kg/cm2)
Dry needling Right 2.18 ± 0.28 2.26 ± 0.23 0.108 �0.07 (�0.17, 0.01) �0.12 (�0.26, 0.03)
Left 2.27 ± 0.22 2.41 ± 0.12 0.019� �0.14 (�0.25, �0.02)
Myofascial Right 2.32 ± 0.33 2.36 ± 0.34 0.066 �0.04 (�0.11, 0.02) 0.05 (�0.06, 0.17)
Left 2.31 ± 0.31 2.37 ± 0.28 0.049� �0.05 (�0.01, 0.001)
Sternal sternocleidomastoid 3 (kg/cm2)
Experimental Right 2.24 ± 0.24 2.31 ± 0.15 0.141 �0.07 (�0.17, 0.02) �0.08 (�0.20, 0.04)
Left 2.32 ± 0.18 2.36 ± 0.12 0.130 �0.04 (�0.09, 0.01)
Myofascial Right 2.36 ± 0.32 2.38 ± 0.29 0.344 �0.02 (�0.07, 0.16) 0.03 (�0.06, 0.16)
Left 2.33 ± 0.27 2.31 ± 0.25 0.303 0.012 (�0.00, 0.03)
Sternal sternocleidomastoid 4 (kg/cm2)
Dry needling Right 2.31 ± 0.15 2.30 ± 0.12 0.861 0.003 (�0.35, 0.04) �0.18 (�0.27, 0.08)
Left 2.38 ± 0.08 2.40 ± 0.10 0.009� �0.02 (�0.05, �0.01)
Myofascial Right 2.48 ± 0.23 2.47 ± 0.23 0.429 0.009 (�0.39, 0.05) �0.06 (�0.13, 0.02)
Left 2.43 ± 0.18 2.46 ± 0.20 0.031� �0.02 (�0.05, 0.001)
Anterior scalene 1 (kg/cm2)
Dry needling Right 2.36 ± 0.31 2.44 ± 0.26 0.083 �0.08 (�0.17, 0.01) 0.02 (�0.11, 0.15)
Left 2.48 ± 0.39 2.54 ± 0.38 0.057 �0.06 (�0.12, 0.00)
Myofascial Right 2.46 ± 0.20 2.42 ± 0.26 0.321 0.04 (�0.03, 0.11) 0.09 (�0.06, 0.26)
Left 2.46 ± 0.22 2.45 ± 0.23 0.326 0.01 (�0.010, 0.03)
Anterior scalene 2 (kg/cm2)
Dry needling Right 2.18 ± 0.45 2.42 ± 0.35 0.012� �0.23 (�0.41, �0.05) 0.24 (0.03, 0.04)
Left 2.43 ± 0.51 2.57 ± 0.37 0.024� �0.14 (�0.26, �0.02)
Myofascial Right 2.15 ± 0.44 2.18 ± 0.41 0.541 �0.03 (�0.11, 0.06) 0.23 (0.04, 0.43)
Left Left 2.30 ± 0.36 2.34 ± 0.37 0.039� �0.03 (�0.06, �0.001)
Middle scalene (kg/cm2)
Dry needling Right 2.12 ± 0.50 2.38 ± 0.41 0.016� �0.26 (�0.47, �0.05) 0.11 (�0.12, 0.34)
Left 2.35 ± 0.56 2.53 ± 0.39 0.009� �0.18 (�0.31, �0.04)
Myofascial Right 2.23 ± 0.52 2.27 ± 0.49 0.619 �0.03 (�0.16, 0.10) 0.29 (0.08, 0.50)
Left Left 2.23 ± 0.47 2.24 ± 0.43 0.906 �0.001 (�0.12, 0.10)
Posterior scalene (kg/cm2)
Dry needling Right 2.84 ± 0.43 2.88 ± 0.49 0.086 �0.03 (�0.07, 0.00) 0.25 (0.08, 0.43)
Left 2.84 ± 0.37 2.90 ± 0.40 0.059� �0.06 (�0.12, 0.00)
Myofascial Right 2.60 ± 0.19 2.62 ± 0.19 0.109 �0.02 (�0.05, 0.00) 0.23 (0.04, 0.41)
Left Left 2.63 ± 0.29 2.67 ± 0.30 0.062 �0.04 (�0.07, 0.00)
Upper trapezius 1 (kg/cm2)
Dry needling Right 3.33 ± 1.12 3.63 ± 0.88 0.082 �0.30 (�0.65, 0.04) 0.36 (�0.14, 0.87)
Left 3.33 ± 1.11 3.53 ± 0.96 0.043� �0.19 (�0.38, �0.006)
Myofascial Right 3.23 ± 1.08 3.27 ± 1.06 0.063 �0.004 (�0.08, 0.002) 0.31 (�0.19, 0.82)
Left 3.08 ± 1.09 3.22 ± 1.01 0.195 �0.13 (�0.33, 0.07)
Upper trapezius 2 (kg/cm2)
Dry needling Right 2.32 ± 0.95 3.37 ± 0.90 0.001� �1.05 (�1.45, �0.65) 0.57 (0.06, 1.09)
Left 2.61 ± 1.05 3.31 ± 0.94 0.001� �0.70 (�1.06, �033)
(continued)
6 A. M. CASTRO S�ANCHEZ ET AL.
Table 2. Continued
Outcome/group Side Baseline One month post-treatment Paired t-test p Within-group score Changes Between-group score Changes
Myofascial Right 2.53 ± 1.06 2.80 ± 1.08 0.089 �0.26 (�0.56, 0.004) 0.78 (0.27, 1.28)
Left 2.40 ± 0.95 2.53 ± 0.99 0.316 �0.12 (�0.37, 0.12)
Lower trapezius 3 (kg/cm2)
Dry needling Right 2.82 ± 1.14 3.35 ± 1.01 0.030� �0.54 (�1.02, �0.05) 0.91 (0.39, 1.41)
Left 3.37 ± 1.06 3.49 ± 1.00 0.355 �0.12 (�0.38, 0.14)
Myofascial Right 2.49 ± 0.96 2.45 ± 0.94 0.748 0.05 (�0.24, 0.34) 0.63 (0.08, 1.19)
Left 2.80 ± 1.12 2.85 ± 1.13 0.490 �0.05 (�0.20, 0.10)
Lower trapezius 4 (Kg/cm2)
Dry needling Right 3.90 ± 0.70 3.93 ± 0.69 0.009� �0.02 (�0.05, �0.001) 0.32 (�0.08, 0.72)
Left 3.72 ± 0.89 3.75 ± 0.82 0.758 �0.03 (�0.22, 0.16)
Myofascial Right 3.51 ± 0.94 3.61 ± 0.86 0.165 �0.10 (�0.25, 0.04) �0.00 (�0.38, 0.38)
Left 3.75 ± 0.64 3.75 ± 0.65 1.000 �
Middle trapezius 5 (kg/cm2)
Dry needling Right 3.63 ± 1.08 4.01 ± 0.64 0.020� �0.38 (�0.069, �0.06) 0.54 (0.10, 0.99)
Left 3.99 ± 0.62 4.05 ± 0.65 0.656 �0.05 (�0.31, 0.20)
Myofascial Right 3.47 ± 1.03 3.87 ± 0.72 0.177 0.11 (�0.05, 0.27) 0.01 (�0.26, 0.29)
Left 4.03 ± 0.37 4.04 ± 0.40 0.763 0.006 (�0.05, 0.03)
Middle trapezius 6 (Kg/cm2)
Dry needling Right 4.23 ± 0.18 4.27 ± 0.18 0.039� �0.03 (�0.06, �0.001) 0.38 (0.09, 0.66)
Left 4.06 ± 0.64 4.09 ± 0.60 0.365 �0.03 (�0.09, 0.03)
Myofascial Right 3.87 ± 0.72 3.89 ± 0.75 0.415 �0.02 (�0.06, 0.02) 0.04 (�0.23, 0.32)
Left 4.07 ± 0.45 4.05 ± 0.47 0.475 0.02 (�0.03, 0.06)
Middle trapezius 7 (kg/cm2)
Dry needling Right 4.42 ± 0.21 4.49 ± 0.20 0.001� �0.07 (�0.09, �0.04) 0.29 (0.16, 0.42)
Left 4.35 ± 0.16 4.34 ± 0.19 0.798 0.01 (�0.07, 0.08)
Myofascial Right 4.22 ± 0.27 4.19 ± 0.29 0.348 0.02 (�0.03, 0.08) 0.09 (�0.04, 0.21)
Left 4.25 ± 0.27 4.25 ± 0.29 0.882 �0.003 (�0.05, 0.04)
Central supraspinatus (kg/cm2)
Dry needling Right 3.03 ± 0.93 3.60 ± 0.60 0.001� �0.57 (�0.87, 0.27) 0.49 (0.07, 0.91)
Left 3.43 ± 0.80 3.54 ± 0.76 0.291 �0.11 (�0.32, 0.10)
Myofascial Right 2.87 ± 1.03 3.11 ± 0.97 0.042� �0.23 (�0.46, �0.01) 0.20 (�0.22, 0.63)
Left 3.25 ± 0.93 3.34 ± 0.88 0.133 �0.09 (�0.20, 0.02)
Myotendinous insertion of supraspinatus (kg/cm2)
Dry needling Right 2.92 ± 1.00 3.65 ± 0.78 0.002� �0.66 (�1.01, �0.25) 0.59 (0.11, 1.06)
Left 3.58 ± 0.77 3.88 ± 0.34 0.026� �0.30 (�0.56, �0.04)
Myofascial Right 3.02 ± 1.04 2.96 ± 1.04 0.701 0.06 (�0.25, 0.37) 0.91 (0.51, 1.31)
Left 2.91 ± 1.00 2.96 ± 1.04 0.596 �0.05 (�0.24, 0.14)
Supraspinatus tendon (kg/cm2)
Dryneedling Right 3.80 ± 0.60 3.93 ± 0.41 0.288 �0.13 (�0.39, 0.12) 0.10 (�0.15, 0.35)
Left 4.01 ± 0.11 4.04 ± 0.12 0.078 �0.03 (�0.07, 0.004)
Myofascial Right 3.78 ± 0.59 3.83 ± 0.57 0.007� �0.05 (�0.09, �0.01) 0.10 (�0.06, 0.25)
Left 3.87 ± 0.40 3.94 ± 0.41 0.001� �0.07 (�0.11, �0.03)
Upper middle area of the infraspinatus (kg/cm2)
Dry needling Right 3.39 ± 0.82 3.73 ± 0.48 0.014� �0.34 (�0.61, �0.07) 0.25 (�0.07, 0.58)
Left 3.45 ± 0.83 3.61 ± 0.72 0.084 �0.16 (�0.35, 0.02)
Myofascial Right 3.47 ± 0.78 3.48 ± 0.76 0.861 �0.003 (�0.04, 0.03) 0.13 (�0.25, 0.42)
Left 3.44 ± 0.81 3.48 ± 0.78 0.057 �0.03 (�0.07, 0.001)
Upper lateral area of the infraspinatus (kg/cm2)
Dry needling Right 3.27 ± 0.93 3.67 ± 0.67 0.039� �0.40 (�0.79, �0.02) 0.34 (�0.06, 0.75)
Left 3.75 ± 0.65 3.89 ± 0.37 0.111 �0.13 (�0.30, 0.03)
Myofascial Right 3.23 ± 0.88 3.33 ± 0.86 0.134 �0.10 (�0.24, 0.03) 0.48 (0.14, 0.86)
Left 3.45 ± 0.84 3.41 ± 0.85 0.591 0.04 (�0.11, 0.19)
Infraspinatus lateral scapular side (kg/cm2)
Dry needling Right 3.65 ± 0.73 3.82 ± 0.48 0.259 �0.17 (�0.49, 0.13) 0.42 (0.05, 0.80)
Left 3.74 ± 0.71 4.01 ± 0.17 0.020� �0.27 (�0.50, �0.05)
Myofascial Right 3.32 ± 0.94 3.40 ± 0.90 0.227 �0.08 (�0.21, 0.05) 0.52 (0.21, 0.84)
Left 3.44 ± 0.84 3.49 ± 0.68 0.068 �0.04 (�0.09, 0.003)
Infraspinatus medial scapular side (kg/cm2)
Dry needling Right 3.77 ± 0.68 3.91 ± 0.41 0.049� �0.14 (�0.27, �0.001) 0.10 (�0.18, 0.40)
Left 33.98 ± 0.39 4.09 ± 0.13 0.064 �0.11 (�0.24, 0.001)
Myofascial Right 3.75 ± 0.65 3.81 ± 0.63 0.040� �0.05 (�0.10, �0.002) 0.26 (0.05, 0.45)
Left 3.77 ± 0.68 3.84 ± 0.53 0.252 �0.07 (�0.19, 0.05)
Multifidus level C6 (kg/cm2)
Dry needling Right 2.62 ± 0.66 3.18 ± 0.51 0.001� �0.56 (�0.83, �0.28) 0.44 (0.09, 0.78)
Left 3.12 ± 0.51 3.28 ± 0.40 0.158 �0.15 (�0.37, 0.06)
Myofascial Right 2.76 ± 0.75 2.74 ± 0.79 0.163 0.02 (�0.14, 0.18) 0.09 (�0.18, 0.38)
Left 3.16 ± 0.65 3.18 ± 0.67 0.763 �0.02 (�0.13, 0.08)
�p< 05.
Values are expressed as means ± standard deviation for baseline and 1month post-treatment and as mean score change (95% confidence interval) for within- and
between-group values.
DRY NEEDLING AND MYOFASCIAL RELEASE ON FIBROMYALGIA 7
findings were found for the anxiety subscale (F¼ 11.98, p¼ 0.001,
CI¼�5.66, �1.53), depression subscale (F¼ 19.62, p< 0.001,
CI¼�4.06, 0.72), total score of Hospital Anxiety Depression Scale
(F¼ 20.60, p< 0.001, CI¼�9.51, �1.02). Between-groups analysis
only showed significant differences at post-treatment evaluation
for the anxiety subscale (t¼�3.247, p¼ 0.002).
Regarding pain intensity and fatigue, time �groups interaction
was observed for pain intensity (F¼ 29.59, p< 0.001, CI¼�3.87,
�1.89), physical fatigue (F¼�21.17, p< 0.001, CI¼�11.08,
�3.18), psychosocial fatigue (F¼�24.62, p< 0.001, CI¼�19.91,
�2.28), cognitive fatigue (F¼�18.26, p< 0.001, CI¼�11.06,
�2.40) and total scores of Fatigue Impact Scale (F¼�25.73,
Figure 2. Differences between-group (at 1-month post-treatment) for quality of life.
Figure 3. Differences between-group (at 1-month post-treatment) for fibromyalgia symptoms.
8 A. M. CASTRO S�ANCHEZ ET AL.
p< 0.001, CI¼�41.19, -8.73). Between-groups analysis showed
significant differences at post-treatment evaluation for pain inten-
sity (t¼�6.508, p< 0.001), physical fatigue (t¼�3.771, p< 0.001),
psychosocial fatigue (t¼�2.712, p¼ 0.09), cognitive fatigue
(t¼�3–338, p¼ 0.001) and total scores of Fatigue Impact Scale
(t¼�3.279, p¼ 0.002). Figure 5 shows between-group differences
for fibromyalgia symptoms.
Within-group comparisons showed significant differences
between baseline and post-treatment for all these outcomes (anx-
iety, depression, pain intensity and fatigue) in the dry needling
Figure 4. Differences between-group (at 1-month post-treatment) for quality of sleep.
Figure 5. Differences between-group (at 1-month post-treatment) for total anxiety, depression, pain intensity and fatigue.
DRY NEEDLING AND MYOFASCIAL RELEASE ON FIBROMYALGIA 9
group; however, the myofascial release group showed no changes
over time for these variables, except for pain intensity. The effect
sizes in the dry needling group were moderate for state and trait
anxiety, total Hospital Anxiety Depression scale (d¼ 0.63, d¼ 0.57,
d¼ 0.61, respectively), and large for pain and fatigue (d¼ 1.93,
d¼ 1.07, respectively). The effect in the myofascial release group
for pain intensity was negligible (d� 0.02).
Discussion
The main results of the present study have shown that the bene-
fits obtained through dry needling seem to be higher than those
achieved through myofascial therapy in the short term. The results
show that a four-week dry needling therapy significantly reduced
the sensitivity to MTrPs pressure as measured by algometry in
most of the trigger points evaluated, and improved the quality of
life, quality of sleep, anxiety, depression, fatigue and intensity of
pain, in comparison with myofascial release therapy; whereas, this
type of manual therapy showed significant improvements in
intensity of pain and impact of fibromyalgia symptoms. Previous
studies had already shown the effectiveness obtained after this
therapeutic approach by executing a protocol with a large num-
ber of treatment sessions [32,33].
A reduction was found in the number of trigger points after
dry needling therapy in a similar manner to a previous study on
MTrPs in spinal muscles [22]. Research has also reported that
intramuscular anesthetic injection into the upper trapezius muscle
and local anesthetic epidural blockade decreased hyperalgesia in
FMS [23]. Shah et al. [14] observed that inserting a needle into
the tissues and its entry into the trigger point may increase the
tissue blood circulation of this part of the muscle. Hence, dry nee-
dling seems to produce a desensitizing effect in patients with
MTrPs, supporting the present findings related to the differences
between groups on MTrPs pain.
Regarding intensity of pain, both therapies reduced it.
Scientific literature suggests that the therapeutic mechanism of
pain relief following dry needling might be associated with per-
ipheral and central pathways, including segmental inhibition and
biochemical activity by means of endogenous opioids and adren-
ergic mediators [15,52–54]. Dry needling stimulation on MTrPs
induces short-term segmental antinociceptive effects by a modu-
lating effect on hyperalgesia, alleviating symptoms of central
hyperexcitability. Inactivation of MTrPs using dry needling and the
reduction of referred pain can be the result of desensitizing
effects of the treatment [54]. On the other hand, although evi-
dence of muscle disease in FMS patients is scarce, researchers
agree that these patients may show an intramuscular connective
tissue or fascial system dysfunction. In fact, most of the symptoms
are manifested at the musculoskeletal level. Hence, myofascial
release interventions can normalize the length and the sliding
characteristics of myofascial tissues by stretching restricted fascia,
releasing pressure from the pain-sensitive structures and returning
the mobility to the joints. Effective and readily available protocols
of myofascial release interventions could redound in multiple ben-
efits to FMS patients [31–33]. A study including 10 myofascial
release modalities in FMS patients concluded that this therapeutic
approach was effective in reducing pain as measured by pressure
algometry and the McGill Pain Questionnaire, as well as improving
clinical global impression severity and disease impact compared
to a placebo group at post-treatment [31,32]. Specifically,
improvements were achieved at the second left rib and left glu-
teal muscle after a 20-week weekly intervention and one-year
post-intervention follow-up; however, the reduction of pain in our
clinical trial was produced in cervical muscles. Another similar
study, including a massage-myofascial release therapy in patients
with FMS, showed a reduction of sensitivity to pain at MTrPs at
the lower cervical and gluteal muscles, aswell as the right greater
trochanter just after the intervention and at one-month follow-up,
in comparison with a placebo group [31,33].
At the end of the treatment period, both groups differed sig-
nificantly in quality of sleep, anxiety, depression and fatigue symp-
toms and in the total score for the impact of fibromyalgia
symptoms. Ouyang et al. [54], after a needle stimulation on tender
points in FMS, showed short-term improvements in the intensity
of pain, depression, quality of life, pressure pain threshold, phys-
ical symptoms, impact of disease and general health; however,
the reasons for an improvement mediated by dry needling stimu-
lation in FMS were not totally justified. Dry needling at myofascial
trigger spots in rabbit skeletal muscles seems to modulate the
biochemical responses associated with pain, inflammation, and
hypoxia. This treatment reduces substance P, enhances the sz-
endorphin levels in the serum and rabbit skeletal muscles. These
effects can be associated with the benefits of acupuncture in
decreasing mediators of inflammation such as TNF-a, IL-1, IL-6,
and pro-inflammatory cytokines in blood and joints; which con-
tribute to reducing allodynia, hyperalgesia, fatigue, and depres-
sion, respectively [55]. Dry needling of trigger points can also
generate a local twitch response with changes to muscle length
and tension through regulation of spontaneous electrical activity
and a change in blood flow within the ischemic and hypoxic tis-
sues of the trigger points [55]. On the other hand, regarding the
effectiveness of myofascial release treatment, two randomized
clinical trials have shown improvements in quality of life, anxiety
levels, quality of sleep and pain at post-treatment and follow-up
periods [24,32]. After three months of intervention, FMS patients
improved in painful tender points, McGill Pain Score, physical
function and clinical severity. At six months post-intervention,
FMS patients receiving myofascial release treatment showed a
reduction in the mean number of painful points and pain score,
but with improved physical function. At one year post-interven-
tion, there were improvements in painful points at the second left
rib and left gluteal muscle and affective dimension [32].
The current study has some limitations, including the type of
therapeutic groups and lack of follow-up assessments. Firstly, dry
needling therapy or myofascial release therapy were applied inde-
pendently; nevertheless, physical therapists in the clinical setting
usually treat their FMS patients with multi-modal approaches.
Future studies should examine the effectiveness of multimodal
approaches including dry needling on MTrPs in combination with
other accepted interventions. Secondly, a placebo control group
was not included and this could be an appropriate comparator.
Thirdly, there was no evaluation at a follow-up period after the
intervention; however, the current findings may provide relevant
preliminary data that could guide future interventions in
FMS patients.
Conclusion
This study has shown that dry needling therapy reduced MTrPs
pain in patients with FMS. This dry needling protocol also seems
to decrease anxiety, depression and fatigue symptoms, and
improve quality of life and sleep in a short term. Dry needling
and myofascial release therapy reduced the intensity of pain and
the impact of fibromyalgia symptoms after four sessions. Dry nee-
dling therapy should be strongly considered as a physiotherapy
technique inside the multidisciplinary approach implemented on
these patients in the rehabilitation context.
10 A. M. CASTRO S�ANCHEZ ET AL.
Acknowledgements
The authors acknowledge the collaboration of patients and associ-
ations involved in this study.
Disclosure statement
No potential conflict of interest was reported by the authors.
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12 A. M. CASTRO S�ANCHEZ ET AL.
	Abstract
	Introduction
	Methods
	Design and participants
	Randomization
	Outcome measures
	Interventions
	Dry needling therapy
	Myofascial release therapy
	Statistical analyses
	Results
	Participants
	Changes in pain pressure thresholds: MTrPs algometry
	Changes in quality of life, impact of FMS symptoms and quality of sleep
	Changes in anxiety, depression, pain intensity, and fatigue
	Discussion
	Conclusion
	Acknowledgements
	Disclosure statement
	References