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EffectivenessofDryNeedlingforMyofascial

TriggerPointsAssociatedWithNeckand

ShoulderPain:ASystematicReviewandMeta-

Analysis

ArticleinArchivesofPhysicalMedicineandRehabilitation·January2015

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

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REVIEW ARTICLE (META-ANALYSIS)

Effectiveness of Dry Needling for Myofascial TriggerPoints Associated With Neck and Shoulder Pain: ASystematic Review and Meta-Analysis

Q18 Lin Liu, MSc,a Qiang-Min Huang, MD, PhD,a,b Qing-Guang Liu, MSc,a Gang Ye, MCh,c

Cheng-Zhi Bo, BSc,a Meng-Jin Chen, BSc,a Ping Li, PTbQ1

Q2 From the aDepartment of Sport Medicine and the Center of Rehabilitation, School of Sport Science, Shanghai University of Sport, Shanghai;bDepartment of Pain Rehabilitation, Shanghai Hudong Zhonghua Shipbuilding Group Staff-worker Hospital, Shanghai; and cDepartment ofPain Rehabilitation, Tongji Hospital, Tongji University, Shanghai, China.

AbstractObjective: To evaluate current evidence of the effectiveness of dry needling of myofascial trigger points (MTrPs) associated with neck andshoulder pain.Data Sources: PubMed, EBSCO, Physiotherapy Evidence Database, ScienceDirect, The Cochrane Library, ClinicalKey, Wangfang DataQ4 , ChinaKnowledge Resource Integrated Database, Chinese VIP InformationQ5 , and SpringerLink databases were searched from database inception toJanuary 2014.Study Selection: Randomized controlled trials were performed to determine whether dry needling was used as the main treatment and whetherpain intensity was included as an outcome. Participants were diagnosed with MTrPs associated with neck and shoulder pain.Data Extraction: Two reviewers independently screened the articles, scored methodological quality, and extracted data. The results of the study ofpain intensity were extracted in the form of mean and SD data. Twenty randomized controlled trials involving 839 patients were identified formeta-analysis.Data Synthesis: Meta-analyses were performed using RevMan version 5.2 and Stata version 12.0. The results suggested that compared withcontrol/sham, dry needling of MTrPs was effective in the short term (standardized mean difference [SMD]Z!1.91; 95% confidence interval [CI],!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) wassuperior to dry needling in relieving MTrP pain in the medium term (SMDZ1.69; 95% CI, 0.40e2.98; PZ.01). Other therapies (includingphysiotherapy) were more effective than dry needling in treating MTrP pain in the medium term (SMDZ.62; 95% CI, 0.02e1.21; PZ.04).Conclusions: Dry needling can be recommended for relieving MTrP pain in neck and shoulders in the short and medium term, but wet needling isfound to be more effective than dry needling in relieving MTrP pain in neck and shoulders in the medium term (9e28dQ6 ).Archives of Physical Medicine and Rehabilitation 2015;-:-------

ª 2015 by the American Congress of Rehabilitation Medicine

Myofascial trigger points (MTrPs) are localized, hyperirritablespots in the skeletal muscles associated with palpable nodules inmuscle fibers.1,2 These spots can be classified into active MTrPsand latent MTrPs with referred pain and local twitch re-sponses.1,3,4 Epidemiological surveys have shown that 30% to85% of the population in the United States and 18.7% to 85.1% inGermany has MTrP pain.5,6

Numerous studies have shown that MTrPs are prevalent inpatients with chronic nontraumatic neck and shoulder pain.7-11 Arecent survey of 72 patients with shoulder pain showed that activeMTrPs were prevalent in the infraspinatus (77%) and the uppertrapezius muscles (58%), whereas latent MTrPs were prevalent inthe teres major (49%) and anterior deltoid muscles (38%).12

Persistence of MTrPs in neck and shoulder muscles for long pe-riods will result in headache, neck and shoulder pain, dizziness orvertigo, limited neck and shoulder range of motion, abnormalsensation, autonomic dysfunction, and disability.10,13-16

Supported by the National Natural Science Foundation of China (grant no. 81470105).

Disclosures: none.Q3

0003-9993/15/$36 - see front matter ª 2015 by the American Congress of Rehabilitation Medicinehttp://dx.doi.org/10.1016/j.apmr.2014.12.015

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Conservative interventions for MTrPs include dry needling,wet needling (eg, lidocaine injection and some local anestheticinjections), ischemic compression, physiotherapy, laser, and oraldrugs.17 Of these therapies, dry needling has been widely used inclinical practice because of its simple operation and good effi-cacy.18,19 In 2001, a systematic review conducted by Cummingsand White18 found that direct needling of MTrPs seems to be aneffective treatment, but evidence of the good efficacyQ9 of needlingtherapies beyond placebo from clinical trials was lacking at thattime. A systematic review with meta-analysis20 found that dryneedling, compared with sham/placeboQ10 , can decrease painimmediately after the treatment and in 4 weeks in patients withupper quarter myofascial pain syndrome. Nonetheless, the numberof high-quality randomized controlled trials (RCTs) was limited,and evidence of the long-term efficacy of dry needling for myo-fascial pain syndrome associated with neck and shoulder pain waslacking in this meta-analysis; thus, large-scale, multiple-termRCTs are necessary to support this recommendation. Morerecently, another systematic review21 found no significant differ-ence between dry needling and lidocaine injection for MTrPs inneck and shoulders immediately after the treatment, at 1 month,and at 3 to 6 months; however, some errors affecting the meta-analysis results were identified; there was no difference betweendry needling and physical therapy for MTrPs in neckand shoulders.

Therefore, this systematic review and meta-analysis aimed todetermine the short-, medium-, and long-term effectiveness of dryneedling in relieving pain in patients with MTrPs in neck andshoulders compared with placebo/sham dry needling, wetneedling, and other treatments (including physical therapy, botu-linum toxin injection, and miniscalpel-needle release).

Methods

Search strategy

A systematic review and meta-analysis was conducted accordingto the Preferred Reporting Items for Systematic Reviews andMeta-Analyses statement.22 We searched sequentially electronicdatabases (PubMed, EBSCO, Physiotherapy Evidence Database[PEDro], ScienceDirect, The Cochrane Library, ClinicalKey,Wangfang Data, China Knowledge Resource Integrated Database,Chinese VIP Information, SpringerLink) from database inceptionto January 2014. The searches were limited (where database fa-cilities allowed) to RCTs or clinical trials, but without languagerestriction. The search terms were (acupu* OR needl*) AND(myofascial pain OR trigger point* OR trigger area* OR tautband*) AND random*. Moreover, supplementary searches wereconducted online (eg, http://www.google.cn and http://www.clinicaltrials.gov) to obtain articles that could not be found in

the databases via the university library website and to check forany omitted trials.

Inclusion and exclusion criteria

Studies were included if they (1) had RCT design; (2) includedpatients with MTrPs associated with neck and shoulder pain; (3)used acupuncture or dry needling as an intervention; and (4) had atleast 1 outcome measure of either visual analog scale (VAS) ornumerical rating scale (NRS) to assess pain intensity. Meanwhile,studies were excluded if (1) MTrPs were not defined according tothe criteria of Simons et al1; (2) MTrPs in patients with neck andshoulder pain were latent MTrPs; (3) different types of dryneedling were compared with each other; (4) RCT subjects wereanimals; and (5) RCT reported no data results Q11.

Study selection and data extraction

Two authors scanned the titles and abstracts independently, andstudies that satisfied the inclusion and exclusion criteria wereretrieved for full-text assessment. We extracted data on the samplesize of the population, number of male and female patients, meanage of the population, duration of symptoms, diagnosis, locationand interventions adopted for MTrPs, outcome measures, the timeto achieve the outcome, and PEDro scores. The results of the studyof pain intensity (VAS/NRS) were extracted in the form of meanand SD data.

Outcome measures were classified as short term if the measurewas applied immediately to 3 days after the final reported treat-ment, medium term if applied 9 days to 4 weeks after the finalreported treatment, and long term if applied 2 to 6 months after thefinal reported treatment.

The remaining discrepancies in data extraction were resolvedafter a discussion between the 2 reviewers. A third revieweradjudicated when necessary.

Quality assessment

Two reviewers independently assessed the validity of the studiesincluded by using the PEDro quality scale. Any disagreementswere resolved with a discussion between the 2 reviewers. A thirdreviewer adjudicated when necessary. The PEDro scale rates thequality of RCTs that evaluate the therapeutic interventions on thebasis of the presence or absence of key methodological compo-nents.23,24 Q12Studies with scores "6/10 were considered as high-quality evidence, and studies with scores #5/10 were consideredas low-quality evidence.

Data synthesis and statistical analysis

Nine separate meta-analyses were performed with pain on VAS/NRS as the outcome measure. The 9 meta-analyses are as follows:dry needling compared with control/sham in the short, medium,and long term; dry needling compared with wet needling in theshort, medium, and long term; and dry needling compared withother treatments in the short, medium, and long term.

Meta-analyses were performed using RevMan version 5.2a

with a continuous variable random-effects model to account forthe additional uncertainty associated with interstudy variability ineffect of the intervention.23 Heterogeneity was assessed using theCochran Q test, which had statistical significance (P<.1), and thechi-square test (I2), which indicated inconsistency by a quantita-tive number.25 An I2 value of 25%, 50%, and 75% representedsmall, moderate, and large degrees of heterogeneity,

List of abbreviations:CI confidence interval

MCID minimum clinically important differenceMTrP myofascial trigger pointNRS numerical rating scale

PEDro Physiotherapy Evidence DatabaseRCT randomized controlled trialSMD standardized mean differenceVAS visualQ8 analog scale

2 L. Liu et al

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respectively.24,26 Effect sizes were measured using the standard-ized mean difference (SMD) and 95% confidence interval (CI).

To explore the heterogeneity between studies, we performedstepwise meta-regression using Stata version 12.0b and sensitivityanalysis. By using random-effects univariate meta-regressionmodels, we assessed the clinical and methodological variablesthat affected the association between dry needling and changes inpain intensity. On the basis of univariate meta-regression, weconducted sensitivity analyses to assess the subgroups of studiesthat are most likely to yield valid estimates of the intervention.Funnel plots were constructed to verify the existence of publica-tion bias (outcome level).

Results

Study selection

The initial search resulted in 1489 hits (fig 1). After applying theinclusion and exclusion criteria, 20 RCTs were eligible andincluded in the review.

Study characteristics

Table 1 summarizes the sample size of the population, number ofmale and female patients, mean age of the population, country orregion of the population, diagnosis, inclusion criteria, interventiongroups (independent variables), outcome measurements (depen-dent variables), time to achieve the outcomes, and PEDro scores.

Risk of bias within studies

Table 1 lists the PEDro scores of 20 RCTs, in which 19 are ratedas high-quality evidence ("6/10) and only 1 as low-quality evi-dence (#5/10). However, most RCTs did not commonly scorepoints for concealed random allocation and blinding of therapists.

Effect of dry needling versus control/sham

By comparing dry needling with control/sham, we found thatstudies including 6,29,30,35,37,43,45 6,31,36,38,41,43,44 and 2 RCTs36,38

in the short, medium, and long term, respectively, assessed thepain effects Q13.

Fig 1 Flow diagram of search strategy and results. Abbreviations: CNKI, China National Knowledge Infrastructure Database; VIP, ChineseChongqing VIP Information database.

Dry needling for myofascial trigger points 3

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Table 1 Characteristics of the participants included in this systematic review

Study (Design andCountry) n (M/F) Mean Age (y)* Diagnosis (Duration*) Inclusion Criteria

InterventionGroup Outcome Measure

Time to Achieve theOutcome (BaselinePain*)

PEDroScores

Ay et al,27 2010(RCT, Turkey)

80 (28/52) 38.08$9.81,y

37.20$10.10zMPS(34.27$40.95mo,y

30.63$37.25moz)

Regional pain, taut band,referred pain and sensorychange, extremesensitivity in taut band,ROM; at least 1 activeMTrP in the uppertrapezius muscle ("1mo)

DN; lidocaineinjection

Pain (VAS); AROM ofthe CS; depression(BDI)

Pretreatment(5.55$1.33cm,y

5.82$1.25cmz);4wk; 12wk

6/10

Byeon et al,28 2003(RCT, Korea)

30 (18/12) 50.9$9.7,y

50.2$9.9,x

51.2$9.9jj

MPS MTrPs in the uppertrapezius muscles;palpable taut band in themuscle

DN; IMS; IMES Pain (VAS); MPQ;PROM of the CS

Pretreatment(6.2$1.1cm,y

6.4$1.6cm,x 6.2$1.4cmjj); 3d; 1wk;2wk

6/10

Chou et al,29 2009(RCT, China)

20 (8/12) 37.7$11.3,y

33.3$7.7{Active MTrPs(5.9$3.3mo,y

5.8$2.8mo{)

MTrPs in the unilateralupper trapezius muscle;no treatment withacupuncture; poorresponse to conservativeand noninvasivetreatments

Acupuncture;shamacupuncture

Pain (NRS); EPNamplitude

Pretreatment(7.4$0.8cm,y

7.4$0.8cm{);immediately

6/10

Chou et al,30 2011(RCT, China)

45 (22/23) 34.1$10.7,y

33.9$8.3{Unilateral MTrPs(6.1$2.2mo,y

6.2$2.2mo{)

"5/10 VAS score on theunilateral shoulder due toMTrPs in the uppertrapezius muscle; noacupuncture treatment;poor response toconservative andnoninvasive treatments

Modifiedacupuncture;placebo

Pain (NRS); PPT(algometry); ROM ofthe CS; EPNamplitude

Pretreatment(7.7$1.0cm,y

7.6$1.1cm{);immediately

6/10

DiLorenzo et al,31

2004 (RCT, Italy)101 (28/73) 69.56$6.21,y

67.43$9.05{Shoulder pain due toactivation of MTrPs(3.53wk)

Patients 4e8 wk postecerebrovascularaccident who hadundergone at least 3wk ofphysical therapy;shoulder pain ("6/10score on VAS)

DN; placebo Pain (VAS); disability(RMI); quality ofdaytime rest andsleep

Pretreatment(7.93$0.87cm,y

8.02$0.83cm{);10d; 16d; 22d

6/10

Ga et al,32 2007(RCT, Korea)

39 (3/36) 79.22$6.80,y

75.90$8.69zChronic shoulder orneck pain due toMPS

"6mo; aged >60y;complaining of chronicshoulder or neck pain

Acupuncture;lidocaineinjection

Pain (VAS and FACES);PPI; PROM of the CS;depression (GDS-SF)

Pretreatment(6.98$1.32cm,y

6.43$2.08cmz);1wk; 2wk; 4wk

7/10

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Table 1 (continued )

Study (Design andCountry) n (M/F) Mean Age (y)* Diagnosis (Duration*) Inclusion Criteria

InterventionGroup Outcome Measure

Time to Achieve theOutcome (BaselinePain*)

PEDroScores

Ga et al,33 2007(RCT, Korea)

40 (4/36) 79.22$6.80,y

76.27$8.63xChronic MPS Chronic MPS of the upper

trapezius muscles basedon physical examinationand interview

DN; IMS Pain (VAS and FACES);PPT; PROM of theCS; depression(GDS-SF)

Pretreatment(6.98$1.32cm,y

6.71$1.84cmx);1wk; 2wk; 4wk

9/10

Hong,34 1994(RCT, USA)

58 (16/42) 41.7$14.4,y

42.2$14.4zMPS (7.6$4.7mo,y

10.2$5.6moz)Tender spots in taut bands,referred pain, LTR withpalpation of MTrP, ROM ofthe CS for lateral bendingto opposite side; at least1 MTrP in the uppertrapezius muscle

DN; lidocaineinjection

Pain (VAS); PPT; ROMof the CS(goniometer)

Pretreatment(7.80$0.83cm,y

7.88$0.93cmz);immediately; 2wk

8/10

Hsieh et al,35 2007(within-subject RCT,China)

14 (8/6) 60.2$13.2 Bilateral shoulder painwith active MTrPs

No treatment for at least3mo; MTrPs in thebilateral infraspinatusmuscles; nocontraindication for dryneedling; no conditionfor substance abuse; nosurgery to the neck/upper limb; nodifferences in clinicalpresentation

DN; placebo Pain (VAS); PPT; AROMand PROM ofshoulder(goniometer)

Pretreatment(7.8$1.2 cm,y

7.7$1.4cm{);immediately

7/10

Ilbuldu et al,36 2004(RCT, Turkey)

60 (0/60) 35.29$9.18,y

32.35$6.88,{

33.90$10.36#

MTrPs(38.48$31.94mo,y

36.95$33.65mo,{

32.95$28.61mo#)

MTrPs in the uppertrapezius muscles; localpain, pain and sensorychanges referred fromMTrP, palpable taut band,extreme sensitivity in 1point in band, limitedROM

DN; placebo;laser

Pain (VAS); ROM of theCS (goniometer);functional status(NHP)

Pretreatment(5.10$1.97cm,y

5.70$1.81cm,{

5.50$1.96cm#);4wk; 24wk

7/10

Irnich et al,37 2002(crossover RCT,Germany)

34 (9/25) 51.9 y MPS (36.7mo) "2mo; ROM in CS; cervicalMPS or “irritationsyndrome” (diffuseintense pain and irritatedsoft tissues withprolonged aggravationafter motion andpressure)

DN; sham laseracupuncture;nonlocalacupuncture

Pain (VAS); ROM of theCS; repeatability ofmobility change

Pretreatment(3.34$1.941cm,y

3.04$1.862cm,{

3.50$2.264cm**);immediately(15e30min)

9/10

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559560561562563564565566567568569570571572573574575576577578579580581582583584585586587588589590591592593594595596597598599600601602603604605606607608609610611612613614615616617618619620

Table 1 (continued )

Study (Design andCountry) n (M/F) Mean Age (y)* Diagnosis (Duration*) Inclusion Criteria

InterventionGroup Outcome Measure

Time to Achieve theOutcome (BaselinePain*)

PEDroScores

Itoh et al,38 2007(RCT, Japan)

40 (11/29) 62.3$10.1,y

65.0$10.5{Neck pain due toMTrPs (2.9$2.7y,y

2.3$1.5y{)

"6mo with no radiation;normal CS nerve function;aged "45y

Acupuncture;shamacupuncture

Pain (VAS); neckdisability (NDI)

Pretreatment(6.70$1.32cm,y

6.41$2.07cm{);weekly; over 12wk

8/10

Kamanli et al,39 2005(RCT, Turkey)

29 (6/23) 37.20$8.08,y

37.30$9.76,z

38.3$5.26yy

MTrPs(32.50$21.99mo,y

49.20$34.96mo,z

50.66$19.92moyy)

At least 1 MTrP on CS, back,or shoulder muscles withdisease of at least 6mo induration

DN; lidocaineinjection; BTI

Pain (VAS); PPT;functional status;anxiety anddepression; painscore

Pretreatment(7.03$2.68cm,y

6.90$1.43cm,z

6.09$1.95cmyy);4 wk

5/10

Krishnan et al,40 2000(crossover RCT,USA)

30 (20/10) 38.5$10.28 MPS Presence of trigger points,which are discrete tenderareas in the uppertrapezius muscles

Needle only;bupivacaineinjection;ropivacaineinjection; BDinjection; RDinjection

Pain (VAS) Pretreatment;immediately

7/10

Ma et al,41 2010(RCT, China)

43 (21/22) 42.2$5.3,y

42.3$5.1,{

42.6$4.9zz

MPS (22.5$15.3y,y

20.8$16.5y,{

21.8$15.9yzz)

MTrPs in the unilateralupper trapezius muscles;ROM; no acupuncture orMSN treatmentpreviously; followinstructions andcomplete a home-basedstretching program

Acupunctureneedling;placebo; MSNrelease

Pain (VAS); PPT; ROMof the CS(goniometer)

Pretreatment(6.2$1.9cm,y

6.3$1.7cm,{

6.3$1.8cmzz);2wk; 12wk

6/10

Rayegani et al,42 2014(RCT, Iran)

28 32$10,y

38.6$4.2xxMPS (9.6$8.4y,y

9.8$9.6yxx)"2mo; MPS in the uppertrapezius muscles; painarea that might radiateto neck, arm, and upperback and not confined to1 dermatome ormyotome; taut bandspressing pain;neurological test resultwas normal

DN;physiotherapy

Pain (VAS); PPT;quality of life(SF-36)

Pretreatment(2.9$2.8cm,y

3.6$2.6cmxx);1wk; 4wk

6/10

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683684685686687688689690691692693694695696697698699700701702703704705706707708709710711712713714715716717718719720721722723724725726727728729730731732733734735736737738739740741742743744

Table 1 (continued )

Study (Design andCountry) n (M/F) Mean Age (y)* Diagnosis (Duration*) Inclusion Criteria

InterventionGroup Outcome Measure

Time to Achieve theOutcome (BaselinePain*)

PEDroScores

Tekin et al,43 2013(RCT, Turkey)

39 (8/31) 42.9$10.9,y

42.0$12.0{MPS (63.5$50.7mo,y

57.9$48.3mo{)"6mo; local spontaneouspain, referred pain orsensory changes fromMTrP, palpable taut band,localized tenderness, ROM;at least 1 active MTrP

DN; shamintervention

Pain (VAS); quality oflife (SF-36)

Pretreatment(6.6$1.3cm,y

6.4$1.6cm{);3d; 4wk

8/10

Tough et al,44 2010(RCT, UK)

41 (17/24) 34.2$10.8,y

36.9$10.9{MTrPs pain due towhiplash injury(6.8$4.3wk,y

7.3$4.7wk{)

Two to 16 wk duration andfulfilling the Grade IIQuebec Task Forceclassification of WAD;"18y and making fullyinformed consent

Acupuncture;shamacupuncture

Pain (VAS); neckdisability (NDI);anxiety anddepression

Pretreatment(4.9$1.6cm,y

5.0$1.6cm{);3wk; 6wk

7/10

Tsai et al,45 2010(RCT, China)

35 (14/21) 46.4$12.2,y

41.5$10.4{Unilateral shoulderpain due to MTrPs(7.5$3.9mo,y

6.8$4.5mo{)

Unilateral shoulder paincaused by digitalcompression of MTrP inthe upper trapeziusmuscle (tenderness andpain reproduction withpalpation of a tight band)

DN; shamneedling

Pain (NRS); PPT; ROMof the CS(goniometer)

Pretreatment(7.3$1.4cm,y

7.2$1.4cm{);immediately

6/10

Ziaeifar et al,16 2014(RCT, Iran)

33 30.06$9.87,y

26.5$8.57kkMTrPs MTrPs in the upper trapezius

muscles; taut band,tender spot, referred pain;"30mm on a VAS rangingfrom 0 to 100 mm

DN; compressiontechnique

Pain (VAS); PPT;disability of arm,hand, and shoulder

Pretreatment(6.56$1.63cm,y

6.23$1.26cmkk); 9d

7/10

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-platenoise; F, female; FACES, Wong-Baker Faces Pain Rating Scale; GDS-SF, Geriatric Depression ScaleeShort Form; IMES, intramuscular electrical stimulation; IMS, intramuscular stimulation; LTR, local twitchresponse; 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.

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Figure 2 shows that there is a high heterogeneity between thetrials in the short term (c2Z62.09; I2Z92%; P<.00001), mediumterm (c2Z38.75; I2Z87%; P<.00001), and long term (c2Z8.12;I2Z88%; PZ.004). Therefore, random-effect models were used,and caution should be exercised while drawing the conclusion. Weused univariate meta-regression models to explore the source ofheterogeneity between trials. Initial pain intensity was the onlycovariate associated with the heterogeneity between studies in themedium term (PZ.024). The decrement in pain intensity inducedby dry needling increased as the initial pain intensity increased

(fig 3). Hence, we performed a sensitivity analysis by excludingthe 2 studies36,44 with the lowest value of the initial pain intensity.In the pooled analysis of the remaining 4 studies,31,38,41,43 theheterogeneity was significantly low between the individual effi-cacy estimates (I2Z0%; PZ.86).

The meta-analysis revealed statistically significant effects ofdry needling compared with control/sham in the short term(SMDZ!1.91; 95% CI, !3.10 to !0.73; PZ.002) and mediumterm (SMDZ!1.07; 95% CI, !1.87 to !0.27; PZ.009), but themeta-analysis revealed no statistically significant effects of dry

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Fig 2 Forest plot for dry needling compared with control/sham in different terms. CI, confidence interval.

Fig 3 Meta-regression bubble plots: (A) association between initial pain intensity and SMD pain intensity when dry needling was comparedwith control/sham in the medium term; (B) association between publication year and SMD pain intensity when dry needling was compared withother treatments in the medium term. Each circle corresponds to a study, and reference number is shown.

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needling compared with control/sham in the long term(SMDZ!1.15; 95% CI, !3.34 to 1.04; PZ.30).

Effect of dry needling versus wet needling

By comparing dry needling with wet needling, we found that 6studies including 2,34,40 4,27,32,34,39 and 1 RCTs27 in the short,medium, and long term, respectively, assessed the pain effects.

Figure 4 shows low (c2Z7.74; I2Z35%; PZ.01) and high(c2Z35.70; I2Z92%; P<.00001) heterogeneities between thetrials in the short and medium term, respectively, and no hetero-geneity in the long term. Although we observed low heterogeneityin the short term, the choice of the effects model will not have asignificant effect on the pooled effect sizes; hence, we could userandom-effects models to conduct the meta-analysis in all terms.The high heterogeneity (I2Z92%) in the medium term remindedus to exercise caution while interpreting the results. Data availablefrom 6 pooled studies presented in fig 4 favored dry needling overwet needling. No statistically significant differences wereobserved in the short term (SMDZ!.01; 95% CI, !0.41 to 0.40;PZ.98) and long term (SMDZ.33; 95% CI, !0.11 to 0.78;PZ.14); however, significant effects of wet needling comparedwith dry needling were observed in the medium term(SMDZ1.69; 95% CI, 0.40e2.98; PZ.01).

Effect of dry needling versus other treatments

By comparing dry needling with other treatments, we found that 3studies including 2 RCTs28,37 in the short term and 7 studiesincluding 6 RCTs16,28,33,36,39,41 in the medium term and 2RCTs36,41 in the long term assessed the pain effects.

Figure 5 shows low (c2Z2.45; I2Z18%; PZ.29), high(c2Z23.80; I2Z75%; PZ.0006), and moderate (c2Z2.39;I2Z58%; PZ.12) heterogeneities between the trials in the short,medium, and long term, respectively. The choice of the effectsmodelwill not have a significant effect on the pooled effect sizes; hence, weused random-effects model to conduct the meta-analysis in thesubgroup. We further used univariate meta-regression models toexplore the source of heterogeneity between trials. Publication yearwas the only covariate associated with the heterogeneity betweenstudies in the medium term (PZ.007). The decrement in pain in-tensity due to other treatments decreased as the publication yearincreased (see fig 3B). Hence, we further performed a sensitivityanalysis by excluding 1 study16 with the highest publication year. Inthe pooled analysis of the remaining 4 studies,28,33,36,39,41,46 theheterogeneity was significantly low between the individual efficacyestimates (I2Z44%; PZ.11).

Data available from the 3 pooled studies presented in fig 5favored other treatments over dry needling; no statistically sig-nificant differences were observed in the short term (SMDZ.33;95% CI, !0.12 to 0.78; PZ.15) and long term (SMDZ.58; 95%CI, !0.18 to 1.34; PZ.13); however, significant effects of othertreatments compared with dry needling were observed in themedium term (SMDZ.62; 95% CI, 0.02e1.21; PZ.04).

Publication Bias

Three funnel plots were constructed to assess the presence ofpublication bias (fig 6). The results indicated that 2 funnel plotswere generally symmetrical, whereas 1 funnel plot from thecomparison between dry needling and wet needling in the medium

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Fig 4 Forest plot for dry needling compared with wet needling in different terms. aDry needling vs lidocaine injection without local twitchresponses elicited. bDry needling vs lidocaine injection with local twitch responses elicited. cDry needling vs bupivacaine þ dexamethasoneinjection. dDry needling vs ropivacaine injection. eDry needling vs bupivacaine injection. fDry needling vs ropivacaine þ dexamethasone in-jection. CI Z confidence interval.

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term was asymmetrical, which indicates that potential publicationbias occurred. Publication bias may be attributed to the absence ofa substantial number of studies or unpublished studies excluded.

DiscussionTwenty RCTs comparing dry needling with placebo or othertreatments for MTrPs associated with neck and shoulder pain indifferent terms were identified for this review. Compared withcontrol/sham, dry needling resulted in significant improvement,specifically in the short and medium term. However, wet needlingof MTrPs associated with neck and shoulder pain was moreeffective than dry needling in the medium and long term.Furthermore, compared with dry needling, other treatments

showed significant clinical effects in different terms. To date, dataremain insufficient to draw conclusions about the long-term ef-fects of wet needling compared with dry needling on MTrPsassociated with neck and shoulder pain.

By comparing dry needling with control/sham, we found that theSMD in the short term was 1.91cm,29,30,35,37,43,45 which was greaterthan the 1.3-cm/1.4-cm minimum clinically important difference(MCID) reported by Bijur et al.46 Moreover, a statistically signifi-cant difference in the short term was found when dry needling wascompared with control/sham. Therefore, this review found sufficientevidence to support the claim that dry needling has significantclinical effects on MTrPs associated with neck and shoulder pain inthe short term as compared with control/sham. In addition, the SMDin the medium term was 1.07cm,31,36,38,41,43,44 which was lower

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Fig 5 Forest plot for dry needling compared with other treatments in different terms. Abbreviations: BTI, botulinum toxin injection; CI,confidence interval; IMES, intramusclar electrical stimulation; IMS, intramusclar stimulation; MSN, miniscalpel-needle release; NLA, nonlocalacupuncture. aDry needling vs compression.

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Fig 6 Funnel plots for all meta-analyses: (A) dry needling compared with sham/control; (B) dry needling compared with wet needling; and (C)dry needling compared with other treatments. Q19

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than the reported 1.3-cm/1.4-cm MCID46; hence, a statisticallysignificant difference in the medium term was found when dryneedling was compared with control/sham. However, no statisticallysignificant difference in the long term was found when dry needlingwas compared with control/sham. This effect may be worthexploring by using large-scale RCTs.

By comparing dry needling with wet needling, we found thatthe 1.69-cm SMD in the medium term27,33,34,39 was greater thanthe reported 1.3-cm/1.4-cm MCID.46 A statistically significantdifference was also found in this subgroup. On the basis of thecurrent evidence, wet needling is found to be a better treatmentthan dry needling in the medium term. We found no statistical andclinical significance in the short34,40 and long27 term when dryneedling was compared with wet needling, because different in-terventions were included in wet needling in the short termwhereas only 1 study was included in the long termQ14 . Future studieswill require sufficient sample sizes to adequately determinewhether wet needling was an optimal treatment for MTrPs asso-ciated with neck and shoulder pain in the short and long term.

By comparing dry needling with other treatments, we foundthat the SMD in the short, medium, and long term was .33,28,37

.62,16,28,33,36,39,41 and .58cm,36,41 respectively, and all meanswere lower than the reported 1.3-cm/1.4-cm MCID.46 Neverthe-less, a statistically significant difference in the medium term wasobserved when dry needling was compared with other treatments.Therefore, none of the studies in this review was adequatelypowered to determine a significant change in pain when othertreatments were compared with dry needling. This result was dueto the pooled effects from different treatments. Hence, a largedifference was observed among the included studies aftermeta-analysis.

Study limitations

In this systematic review, high heterogeneity was observed formost meta-analyses in the forest plots. High heterogeneity forthese meta-analyses may be explained by clinical diversity(including some differences in subjects, different inclusion criteriabetween these studies, variance in the comparison treatments, andvariance in the outcome measures) and methodological diversity(such as the design of random trial, use of blinding, andconcealment of allocation). We tried using meta-regression toexplore the sources of heterogeneity; however, ideal results werenot obtained because of the absence of a substantial number ofstudies when dry needling was compared with control/sham in theshort term. Therefore, the random-effects model addressed theheterogeneity of studies by considering the interstudy variation.47

Heterogeneity is almost inevitable among studies conductedindependently by different investigators at different geographicalregions. Therefore, using the random-effects model rather than thefixed-effects model was a conservative strategy when apparentstatistical heterogeneity was observed in the data.25 Meta-analysisperformed using the random-effects model in the present reviewyielded results that were unbiased and provided an accurate esti-mate of the effects concerned; thus, the results were internallyvalid. The results were generalized to regular clinical practicewhen different studies of different population groups were com-bined; thus, the results were also externally valid.24,25

Another limitation of the review is that the data results reportedby Rayegani et al42 were not included in the meta-analysis,although the inclusion and exclusion criteria of the systematicreview and meta-analysis were met, because the data results were

not within the scope of the time definition of the short, medium,and long term. Therefore, large-scale, multiple-term, high-qualityRCTs would be necessary to prove or exclude the significantadvantages or disadvantages.

ConclusionsOn the basis of the available evidence to date, dry needling can becautiously recommended for relieving MTrP pain in neck andshoulders in the short and medium term than control/sham, butwet needling is found to be more effective than dry needling inrelieving MTrP pain in neck and shoulders in the medium term(9e28d). On the basis of the results of 6 individualRCTs16,28,33,36,39,41 included in the meta-analysis of 7 studies,other treatments can be cautiously recommended for relievingMTrP pain in neck and shoulders in the medium term than dryneedling. However, scientific evidence proving the effectivenessof dry needling for MTrPs associated with neck and shoulder paincompared with wet needling and other treatments in the short andlong term is insufficient. Accordingly, further research shouldinclude more large-scale, multiple-center, high-quality RCTs andadequate follow-up to provide the best evidence that can suggestthe best therapeutic method in the clinic.

Suppliers

a. RevMan version 5.2; The Nordic Cochrane Centre.b. Stata version 12.0; StataCorp LP.

Keywords

Dry needling; Meta-analysis; Myofascial trigger points; Neck-shoulder pain; Randomized controlled trial; Rehabilitation Q7

Corresponding author

Qiang-Min Huang, MD, PhD, Department of Sport Medicine andthe Center of Rehabilitation, School of Sport Science, ShanghaiUniversity of Sport, Keyanlou 4-408, Hengren Rd No. 188,Shanghai 200438, China. E-mail address: huaqia404@aliyun.com.

Acknowledgment

We thank Tian-Song Zhang, PhD, for assistance with manu-script revision.

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