JOURNAL OF MANUAL & MANIPULATIVE THERAPY

2022, VOL. 30, NO. 3, 154–164

https://doi.org/10.1080/10669817.2021.1977069

Effect of dry needling on lumbar muscle stiffness in patients with low back
pain: A double blind, randomized controlled trial using shear wave
elastography
Shane L. Koppenhavera, Amelia M. Weaverb, Tyler L Randallb, Ryan J. Hollinsb, Brian A. Younga,
Jeffrey J. Hebertc, Laurel Proulxd,e and Cesar Fernández-de-las-Peñasf
a
Physical Therapy Department, Baylor University Doctoral Program in Physical Therapy, Waco, Texas, USA; bArmy Medical Center of
Excellence, U.S. Army-Baylor University Doctoral Program in Physical Therapy, San Antonio, Texas, USA; cUniversity of New Brunswick,
Faculty of Kinesiology, Fredericton, New Brunswick, CAN; dMurdoch University, Scholl of Psychology and Exercise Science, Murdoch,
Western Australia, Australia; eSchool of Physical Therapy, Regis University, Denver, CO, USA; fDepartment of Physical Therapy,
Occupational Therapy, Physical Medicine and Rehabilitation, Universidad Rey Juan Carlos (Urjc), Alcorcón, Madrid, Spain

ABSTRACT KEYWORDS
Background: Dry needling treatment focuses on restoring normal muscle function in patients Dry needling; ultrasound;
with musculoskeletal pain; however, little research has investigated this assertion. Shear wave elastography; muscle; low
elastography (SWE) allows quantification of individual muscle function by estimating both back pain
resting and contracted muscle stiffness.
Objective: To compare the effects of dry needling to sham dry needling on lumbar muscle
stiffness in individuals with low back pain (LBP) using SWE.
Methods: Sixty participants with LBP were randomly allocated to receive one session of dry
needling or sham dry needling treatment to the lumbar multifidus and erector spinae muscles
on the most painful side and spinal level. Stiffness (shear modulus) of the lumbar multifidus
and erector spinae muscles was assessed using SWE at rest and during submaximal contraction
before treatment, immediately after treatment, and 1 week later. Treatment effects were
estimated using linear mixed models.
Results: After 1 week, resting erector spinae muscle stiffness was lower in individuals who
received dry needling than those that received sham dry needling. All other between-groups
differences in muscle stiffness were similar, but non-significant.
Conclusion: Dry needling appears to reduce resting erector spinae muscle following treatment
of patients with LBP. Therefore, providers should consider the use of dry needling when
patients exhibit aberrant stiffness of the lumbar muscles.

1. Introduction function and reported no effect of dry needling on

muscle force [13]. Two of the studies used ultrasound
Dry needling is performed by inserting needles into
imaging to evaluate changes in muscle function after
painful areas of muscle that are perceived to have
dry needling and reported improved ability to contract
motor abnormalities in an attempt to restore normal
the lumbar multifidus muscle after dry needling
muscle function and relieve pain [1,2]. A growing body
[14,15]. Another study used electromyography (EMG)
of research supports the clinical effectiveness of dry
to measure lumbar multifidus muscle function in
needling for a variety of neuromusculoskeletal condi­
patients with LBP and found no post-needling changes
tions including low back pain (LBP) [3–10]. However,
in muscle activation [16].
specific evidence of physiologic effect, to include the
Ultrasound shear-wave elastography (SWE) is an
effect on muscle function, is more limited [11]. Normal
emerging technology that quantifies stiffness or elas­
muscle function includes both the absence of muscle
ticity of soft tissue by measuring the propagation
activation during rest and appropriate amount of mus­
speed of ultrasound-induced shear-waves within the
cle activation during contraction. Alternatively,
tissue. Since muscles consistently get stiffer when con­
impaired muscle function can include abnormal mus­
tracted, SWE has recently been advocated as being the
cle activation during rest and diminished muscle acti­
best method of estimating individual muscle function
vation during contraction [12].
and muscle stiffness can be used as a surrogate mea­
Multiple dry needling studies have included muscle
sure of muscle activation and muscle force [17]. The
function as a secondary outcome for a variety of neu­
single study to date that used SWE to measure changes
romusculoskeletal conditions. Most studies used some
after dry needling included a small sample (n = 7) of
sort of dynamometry to measure contracted muscle
patients with palpable trigger points in their upper

CONTACT Shane L. Koppenhaver shanekoppenhaver@mac.com Baylor University Doctoral Program in Physical Therapy, Waco, Texas, USA, 23508
E 3rd Ave. Liberty Lake, WA USA 99019
© 2021 Informa UK Limited, trading as Taylor & Francis Group

trapezius muscle and reported a significant reduction
of resting stiffness after dry needling [18]. No study to
date has used SWE to evaluate muscular changes after
dry needling in patients with LBP or included a large
sample of patients.
The primary purpose of this study was to compare
the effects of dry needling and sham dry needling, on
lumbar muscle stiffness in individuals with LBP using
SWE. We also compared the effects of dry needling and
sham dry needling on self-reported pain, disability,
overall self-perceived changes, and lumbopelvic
range of motion (RoM). We hypothesized that dry
needling would decrease resting stiffness in the para­
spinal musculature and increase stiffness during volun­
tary contraction of the lumbar multifidus when
compared to the sham dry needling. Additionally, we
expected that dry needling would improve self-
reported clinical outcomes and lumbopelvic RoM to
a greater extent than sham dry needling.
2. Methods
2.1 Study design
This study was a parallel arm randomized control trial
and was registered at ClinicalTrials.gov (NCT02352532).
The primary outcome was muscle stiffness which was
assessed as shear modulus using SWE. Secondary out­
comes were self-reported pain (assessed with numeric
pain rating scale – NPRS), LBP-related disability
(assessed with the Oswestry Disability Index – ODI),
self-reported overall change (assessed with the
Global Rating of Change – GRoC), and lumbopelvic
RoM (flexion, extension, and side-bending). Muscle
stiffness was assessed at baseline, immediately after
treatment, and approximately one week (5–7 days)
after treatment. Self-reported clinical outcomes and
RoM were assessed at baseline and approximately
one week later.
2.2 Participants
Participants with current LBP were recruited via adver­
tisements from the San Antonio Military Healthcare
System between June 2015 and March 2017. Current
LBP was defined as pain between the 12th rib and
buttocks causing at least a minimally important level
of physical disability (operationally defined as having
an ODI score of at least 10%) [19]. To participate,
volunteers were also required to be a Department of
Defense healthcare beneficiary (active duty military or
civilian dependent) and be between 18 and 65 years of
age. Individuals were excluded from participation if
they reported being pregnant, having a history of
surgery to the lumbosacral spine, or receiving manual
therapy, acupuncture, or dry needling interventions to
the lumbosacral spine within the previous 4 weeks.
JOURNAL OF MANUAL & MANIPULATIVE THERAPY 155
Volunteers who exhibited signs of lumbar radiculopa­
thy or non-musculoskeletal pathology (e.g. cancer,
cauda equina syndrome, infection) were also excluded.
The study protocol was approved by the Institutional
Review Board of Brooke Army Medical Center
(approval # C.2015.020d) and the rights of the partici­
pants were protected.
2.3 History and physical examination
After providing informed consent, medical history and
demographic information was collected via self-report
to include prior history of LBP, duration and location of
current symptoms, prior surgeries and treatments, age,
sex, height, and weight. Participants then underwent
a standardized clinical examination that was adminis­
tered by a trained examiner. This examination included
a brief clinical history, self-reported pain, disability, fear
avoidance behavior (as measured by the Fear
Avoidance Behavior Questionnaire), and a physical
examination. The most symptomatic side (right or
left) at the most symptomatic level (L3, L4, or L5) was
identified by the examiner based on a combination of
viewing the patient self-reported pain diagram and
tenderness during the palpatory examination. The pal­
patory exam included manual pressure on each lumbar
spinous and transverse processes at levels L3, L4, and
L5 in a posterior to anterior direction [20].
2.4 Shear wave elastography imaging
All SWE images were obtained using a Supersonic
Aixplorer ultrasound system (Supersonic Imagine, Aix-
en-Provence, France) with a 50 mm 10–2 MHz linear
transducer. Examiners trained on all imaging-related
procedures and practiced on colleagues until an
acceptable level of reliability (ICC3,3 > .70) was
obtained on 10 individuals before starting data collec­
tion. Since impaired contraction of the lumbar multi­
fidus has been previously reported in patients with LBP
[21,22], the lumbar multifidus was imaged both at rest
and during submaximal contraction. The lumbar erec­
tor spinae (iliocostalis and longissimus muscles) were
imaged at rest only. Imaging of both muscles was
performed only on the most symptomatic side at the
most symptomatic level for each participant. If the
most symptomatic side and/or level could not be
determined, imaging was performed on the right side
at the L4 spinous level.
To ensure consistency and maximal rest between
contractile conditions, the order of imaging for each
participant was (1) erector spinae at rest, (2) lumbar
multifidus at rest, (3) lumbar multifidus during contrac­
tion. This imaging sequence was completed three
times and the average value for each condition was
used for analyses, which has demonstrated acceptable
reliability in asymptomatic participants [23]. To image
156 S. L. KOPPENHAVER ET AL.
the erector spinae muscles, the transducer was placed
on the most prominent portion of the musculature
immediately above the iliac crest, centered on the
selected spinal level. The transducer was oriented in
the sagittal plane so it was parallel to the muscle fibers
[24], and then angled slightly medially to optimize
image clarity (Figure 1). The SWE box overlaying the
B-mode ultrasound image was then positioned so it
covered the largest region of muscle possible while
achieving complete fill and avoiding fascial planes
(Figure 2).
To image the lumbar multifidus muscles, the trans­
ducer was moved slightly medially from the location
used for the erector spinae, rotated approximately 20º
away from midline, and tilted approximately 10º medi­
ally toward the targeted level facet joint (Figure 1). The
depth of the image was adjusted for each participant
so that both the superficial fascia and facet joint were
visible during resting and contracted states. The SWE
box was then positioned over the lumbar multifidus
Figure 1. The erector spinae muscle bulk, the iliac crest, and
targeted level (e.g. L4 in photo) spinous process were all
marked on the must symptomatic side prior to imaging.
(Top) To image the erector spinae muscles, the transducer
was centered on the paraspinal muscle bulk with the transdu­
cer oriented parallel to the spine. (Bottom) To image the
lumbar multifidus, the transducer was rotated approximately
20º and tilted approximately 10º medially toward the targeted
level facet joint.
muscles, just superficial to the facet joint in order to
target the deepest fibers of the lumbar multifidus
(Figure 2). After imaging at rest, participants were
then instructed to lift their contralateral arm approxi­
mately 5 centimeters off the plinth while holding
a small weight normalized to approximately 1% of
the participant’s body weight and reimaged during
contraction. Additional details of these imaging proce­
dures have been reported elsewhere [25,26].
Image analysis was performed offline on a separate
computer with device-installed software. A circular
Q-Box was sized as large as possible (approximately
15 mm diameter) within the SWE image while ensuring
avoidance of any fascial planes, bony prominences,
and areas where the Aixplorer Multiwave failed to
determine the propagation speed. The Aixplorer
Multiwave provides the spatial-mean Young’s modulus
value in kilopascals based on the assumed isotropic
nature of soft tissues. Since skeletal muscle is unlikely
to be isotropic, we calculated shear modulus by divid­
ing the Young’s modulus by three [27].
2.5 Self-report measures and lumbopelvic range
of motion
An 11-point Numeric Pain Rating Scale (NPRS) was
used to quantify participants’ current back pain inten­
sity between 0 and 10. The NPRS is reliable and respon­
sive (minimally important difference = 2 points) in
patients with LBP [28,29]. Self-reported LBP-related
disability was quantified with the ODI. The ODI consists
of scores ranging from 0 to 100 (with higher scores
representing higher levels of disability) and has been
found to be both reliable and responsive to change
(minimally important difference = 10%) in patients
with LBP [19]. Subjective perception of overall change
was assessed using the GRoC with a 15-point Likert
type scale ranging from −7 (a very great deal worse) to
+7 (a very great deal better). The GRoC has been
shown to be highly reliable in patients with LBP, and
at least moderately responsive (minimally important
difference = 2.5 points) [30]. Active lumbosacral RoM
of flexion, extension, and side bending was measured
using a standard inclinometer centered on the spinous
process of the 12th thoracic vertebra. A single measure­
ment was taken for each motion as prior studies have
shown adequate reliability of single measures of lum­
bosacral RoM in patients with LBP [31].
2.6 Randomization
Following the baseline evaluation and outcome assess­
ment, participants were randomized to receive dry
needling or sham dry needling. Randomization was
performed by a computer-generated randomization
list with randomly varying block sizes of 2 and 4 pre­
pared prior to study initiation. Allocation was

Figure 2. The shear wave elastography (SWE) box, which overlays the B-mode ultrasound image, gives a visual color-coded image
based on regional tissue stiffness (Young’s modulus) within the box. Young’s modulus was later converted to shear modulus
(kilopascals- kPa).
concealed via opaque envelopes in order to blind all
outcome assessors to group assignment and was only
revealed to the treating provider immediately before
treatment.
2.7 Dry needling and sham dry needling
Treatment was performed by an experienced physical
therapist trained in dry needling and blinded to all
outcomes. The treating therapist was told by the base­
line examiner which side and spinal level were most
painful and then performed palpation to further loca­
lize the area for treatment to the most painful regions.
Treatment was applied to a total of four sites on the
most symptomatic side, to both the lumbar multifidi
and erector spinae muscles, at the two most sympto­
matic levels (between L3, L4, and L5). If the therapist
was unable to determine the most symptomatic levels
or areas, treatment was performed to the middle of the
muscle belly at the L4 and L5 levels.
Dry needling treatment included insertion of a sterile,
disposable, solid filament 0.30 × 50 mm stainless steel
Seirin J-Type or Myotech needle into the lumbar mus­
culature. ‘Clean technique’ was used throughout the
treatment procedure which included hand washing,
clean latex-free exam glove use, and participant skin
preparation with an alcohol swab prior to treatment
[32]. For the lumbar multifidus muscle, needles were
inserted approximately 1.5 cm lateral to the spinous
process at each segmental level in a posterior to anterior
direction (Figure 3- top). After piercing the skin, the
needles were directed into the muscle with a slight
inferior-medial angle (approximately 20º) to the depth
JOURNAL OF MANUAL & MANIPULATIVE THERAPY 157
of the lumbar lamina. For the erector spinae muscles,
the needle was inserted just lateral to the paraspinal
muscle bulk (approximately 5–10 cm lateral to the spi­
nous process) in a lateral to medial direction toward the
spinous process (Figure 3- bottom). Both segments of
each muscle were needled once with needle insertion
lasting approximately 5–10 seconds. During each inser­
tion a ‘pistoning’ (in and out motion) technique was
used in an attempt to elicit a local twitch response [33].
Sham dry needling was performed in a manner iden­
tical to dry needling treatment, with the exception of the
use of a Seirin J-Type or Myotech needle with the tip cut
off that did not pierce the skin. The needle was placed in
the guide tube to mimic insertion and then was rocked
and twisted against the skin so as to simulate dry need­
ling treatment without actually piercing the skin.
After treatment was administered, all participants
were verbally instructed in the performance of
a supine double knee-to-chest maneuver to be held
for 5–10 seconds and repeated 6 times in order to
alleviate residual soreness as needed. Subjects were
instructed not to initiate any new core exercises, but
to maintain their normal level of physical activity
throughout the next week. In addition to the described
outcome measures, participants were asked about
adverse events and side effects of treatment based
on previously documented findings [34].
2.8 Statistical analysis
A priori power analysis was performed using G*Power 3
[35]. A large effect size was expected based on the only
previous work investigating changes in shear modulus
158 S. L. KOPPENHAVER ET AL.

after dry needling treatment [18]. Two groups of 30

subjects provided 82% power to detect an effect size
of 0.80 while accounting for up to a 10% drop out rate.
All data were analyzed with IBM SPSS Version 26
software (Windows, Armonk, NY: IBM Corp) and STATA
version 16.1 software (StataCorp, College Station, Tx).
Baseline characteristics for the dry needling and sham
dry needling groups were summarized and compared
to ensure similar groups. Linear mixed modeling has
been advocated for longitudinal data analysis as it is
more flexible and does not rely on assumptions of
equal variance and correlations among repeated mea­
surements like analysis of variance (ANOVA) proce­
dures [36]. Therefore, treatment effects were
estimated using separate, random intercept linear
mixed models for each outcome (muscle shear mod­
ulus, NRPS, ODI, and lumbopelvic RoM). Time and
treatment group were modeled as fixed effects and
the baseline outcome score was included as
a covariate within each model. The hypothesis of inter­
est was the time-group interaction at each timepoint,
which was examined with pairwise comparisons of the
estimated marginal means. Since GRoC scores were
only obtained 1 week after treatment, they were com­
pared between groups using an independent t-test.
Consistent with intention-to-treat analysis, all missing Figure 3. Dry needling techniques. (Top) For the lumbar multi­
fidus muscle, needles were inserted approximately 1.5 cm
values were imputed using multiple imputation prior
lateral to the spinous process at the most symptomatic side
to other analyses. Significance for all statistical analyses and segmental level in a posterior to anterior direction with
was set a priori using 2-tailed α = 0.05. a slight inferior-medial angle (approximately 2º) to the depth
of the lumbar lamina. (Bottom) For the erector spinae muscles,
the needle was inserted just lateral to the paraspinal muscle
3. Results bulk (approximately 5–10 cm lateral to the spinous process) in
a lateral to medial direction toward the spinous process.
Participant recruitment and exclusion flow is outlined in
Figure 4. One participant in the dry needling group did not
return for the one-week follow-up assessment and did not those that received sham dry needling in all muscle con­
respond to attempts to reschedule. Descriptive statistics of ditions both immediately after treatment and one week
baseline demographic, clinical history, and examination later.
data are listed in Table 1. Sex and duration of symptoms Results of secondary outcome analyses of self-
were somewhat different between the groups and, there­ reported clinical improvement (NPRS, ODI, GRoC)
fore, were assessed for use as covariates for all analyses. and RoM are detailed in Table 3. Individuals that
However, since they were not statistically related to any received dry needling reported statistically larger
primary or secondary outcome measure they were not overall improvement (GRoC) (p = 0.016) and exhibited
included in the mixed models. statistically larger change in lumbopelvic flexion RoM
Results of primary outcome analyses of muscle stiffness (p = 0.008) than did individuals that received sham
are detailed in Table 2. Resting erector spinae muscle dry needling 1 week after treatment. There were no
stiffness was lower in individuals that received dry need­ other statistically significant between-groups differ­
ling than in those that received sham dry needling 1 week, ences in NPRS, ODI, or lumbopelvic extension or side-
after treatment after adjusting for baseline differences bending RoM (p = 0.182 to 0.716) 1 week after treat­
(p = 0.019). Specifically, resting erector spinae muscle ment. Both dry needling and sham dry needling
stiffness decreased by a mean of 13.5% in the dry needling groups reported statistically significant improve­
group compared to an increase of 6% in the sham dry ments in both pain (NPRS) and LBP-related disability
needling group 1 week after treatment (Figure 5). There (ODI). However, point estimates were smaller than
were no other statistically significant between-groups dif­ established minimally important differences indicat­
ferences in any muscle condition at any follow-up time­ ing changes might not be clinically important.
point (p = 0.089 to 0.551). However, point estimates of No serious adverse events were reported throughout
muscle stiffness consistently decreased in individuals that the course of this study. However, several participants
received dry needling and increased or did not change in reported mild side effects that had resolved before the
 JOURNAL OF MANUAL & MANIPULATIVE THERAPY 159

Table 1. Baseline characteristics for dry needling and sham dry needling groups.
Characteristics
Dry Needling (n=30) Sham Dry Needling (n = 30)
Age (years) 32.2 (8.2) 32.3 (6.6)
Sex (% women) 46.7% 33.3%
BMI 26.2 (3.5) 26.0 (3.0)
ODI 20.6 (7.6) 20.1 (6.6)
NPRS 2.0 (1.7) 1.7 (1.5)
Symptom duration (months)
Mean (SD) 84.6 (90.7) 68.7 (73.5)
Median (IQR) 55.0 (11.0–129.0) 36.5 (7.8–91.5)
FABQ-W 12.3 (5.9) 13.7 (7.5)
FABQ-PA 12.3 (5.1) 13.0 (5.4)
Previous episodes of back pain (%) 70.0% 56.7%
Flexion RoM (degrees) 95.7 (16.1) 100.3 (18.5)
Extension RoM (degrees) 24.0 (10.9) 26.1 (12.3)
Total side-bending RoM (degrees) 58.4 (12.9) 54.7 (14.5)
Side-bending asymmetry RoM (degrees) 5.2 (6.6) 4.9 (4.7)
Values are means (SD, standard deviation) unless stated otherwise.
Abbreviations: BMI, body mass index. ODI, Oswestry Disability Index. NPRS, numeric pain rating scale. SD, standard deviation. IQR, interquartile range.
FABQ-W, Fear Avoidance Behavior Questionnaire-Work subscale. FABQ-PA, Fear Avoidance Behavior Questionnaire-Physical Activity subscale. RoM, range
of motion.

1-week follow-up assessment. Two participants that
received dry needling and four participants that received
sham dry needling reported pain during treatment.
Additionally, two participants that received dry needling
reported dizziness and one reported an unspecified emo­
tional change after treatment. Statistically more partici­
pants (p = 0.030) in the dry needling group (83%) than
in the sham dry needling group (56%) thought that they
received true dry needling during treatment.
musculature and increase stiffness during voluntary
contraction of the lumbar multifidus when compared
to the sham dry needling. Additionally, we compared
the effect of dry needling and sham dry needling on
self-reported pain, disability, overall change, and lum­
bopelvic RoM. We expected dry needling to improve
self-reported clinical improvement measures and lum­
bopelvic RoM to a greater extent than the sham dry
needling.

4. Discussion 4.1 Muscle stiffness

The primary purpose of the current study was to com­
pare the effect of dry needling to sham dry needling on
lumbar muscle stiffness in individuals with LBP using
SWE. We hypothesized that dry needling would
decrease resting stiffness in the paraspinal
In support of our hypothesis, resting erector spinae
muscle stiffness was statistically lower in individuals
that received dry needling than in those that received
sham dry needling after adjusting for baseline differ­
ences. However, this was only true 1 week after, and

Table 2. Primary outcomes of muscle stiffness (shear modulus in kilopascals- kPa) of the erector spinae and lumbar multifidus
muscles before needling (baseline), immediately after needling (post-needle), and at 1-week follow-up. *Denotes statistical
significance (p < .05).
Dry Needling Sham Dry Needling Adjusted Between- P Value
Outcome/Visit
Group Difference
(Dry Needling –
Mean Change from Mean Change Sham)
Mean (SD) Baseline (95%CI) Mean from Baseline
Erector Spinae Muscle Stiffness (kPa) – Resting
Baseline 6.4 (3.6) 6.4 (3.2)
Post-needle 6.2 (3.7) −0.2 (−0.7, 0.4) 6.5 (3.4) 0.1 (−0.4, 0.7) −0.0 (−1.4, 0.7) 0.551
1-week 5.6 (3.7) −0.9 (−1.9, 0.1) 6.8 (3.2) 0.4 (−0.6, 1.4) −1.3 (−2.3, −0.2) 0.019*
Lumbar Multifidus Muscle Stiffness (kPa) – Resting
Baseline 6.2 (2.4) 7.4 (3.8)
Post-needle 6.0 (1.9) −0.2 (−1.1, 0.6) 7.4 (3.0) 0.0 (−0.8, 0.9) −0.7 (−2.0, 0.6) 0.279
1-week 5.9 (2.9) −0.3 (−1.5, 0.9) 7.4 (4.6) 0.0 (−1.2, 1.2) −0.8 (−2.1, 0.6) 0.254
Lumbar Multifidus Muscle Stiffness (kPa) – Contracted
Baseline 19.8 (10.5) 21.7 (11.3)
Post-needle 19.3 (10.4) −0.6 (−2.9, 1.8) 23.3 (13.0) 1.6 (−0.7, 3.9) −2.3 (−5.7, 1.0) 0.175
1-week 18.2 (10.5) −1.7 (−4.4, 1.1) 22.8 (12.7) 1.1 (−1.7, 3.8) −2.9 (−6.3, 0.4) 0.089
160 S. L. KOPPENHAVER ET AL.
Figure 4. Flow of participant recruitment and exclusion. Abbreviation: SLR, Straight Leg Raise Test; ODI, Oswestry Disability Index.
not immediately after treatment and was only signifi­
cant in the erector spinae and not the lumbar multi­
fidus muscle.
The finding that dry needling appears to reduce
resting erector spinae muscle stiffness is consistent
with the common application of dry needling to myo­
fascial trigger points which have been defined as
hypersensitive taut bands in skeletal muscle [37].
Myofascial trigger points have been have been found
to include and spontaneous electrical activity (SEA)
[38] and be characterized by localized stiff nodules
[39,40]. Limited evidence, at least in animal models,
suggests that dry needling into myofascial trigger
points can reduce abnormal SEA [38,41]. This reduction
of abnormal muscle activity at rest, may allow for more
normal coordination of agonist and antagonist mus­
cles and restoration of normal muscle function during
routine functional activities [2].
In the single study to date that has used SWE to
measure changes in resting muscle function after dry
needling, Maher et al. [18] found an immediate reduction
of resting upper trapezius muscle stiffness after dry need­
ling in a small sample of patients with palpable trigger
points. Our findings regarding resting muscle stiffness are
partially consistent with those observed by Maher et al.
(2013) as we found a delayed reduction in muscle stiffness
1 week after dry needling, but not immediately after
treatment. Additionally, our findings were only statistically
significant in the erector spinae and not the lumbar multi­
fidus muscles Figure 5. This muscle-dependent finding is
not surprising considering that the erector spinae muscle
commonly exhibits excessive contraction in patients with
LBP [12], just as the upper trapezius muscle commonly
exhibits excessive contraction in patients with neck
pain [42].
Contrary to our hypothesis, contracted lumbar
multifidus muscle stiffness was not statistically sig­
nificant different between groups after treatment.
Moreover, point estimates of contracted lumbar
multifidus muscle stiffness consistently decreased
after dry needling and increased after receiving
sham dry needling.
The lack of significant change in lumbar multifidus
stiffness during contraction is consistent with the majority
of studies in other body regions. A systematic review of
muscle force during contraction of the shoulder, thigh/
knee, ankle, elbow/hand/wrist musculature found no
effect of dry needling on muscle force as measured by
dynamometry or isometric hold [13]. Additionally, these
findings are consistent with a recent study [16] that used
EMG to measure contracted lumbar multifidus muscle
activation in adults with LBP before and after application
 JOURNAL OF MANUAL & MANIPULATIVE THERAPY 161

Figure 5. Comparisons in shear modulus (in kilopascals- kPa) of the erector spinae muscle between participants that received dry
needling and sham dry needling before treatment (baseline), immediately after treatment (post-needle), and at 1-week follow-up.
Error bars denote 95% confidence intervals. *Statistically significant difference at 1-week after adjusting for baseline values.

Table 3. Secondary outcomes of self-reported clinical improvement and lumbopelvic range of motion 1 week after treatment.
*Denotes statistical significance (p < .05).
Adjusted Between-
Group Difference
Outcome/Visit Dry Needling Sham Dry Needling (Dry Needing – Sham) P Value
Mean Change
Mean at 1-week Mean Change from Baseline Mean at 1-week from Baseline
Self-reported Clinical Improvement
Numeric Pain Rating 1.2 (1.8) −0.8 (−1.3, −0.2)* 1.1 (1.8) −0.6 (−1.1, −0.0)* −0.1 (−0.8, 0.6) 0.716
Scale
Oswestry Disability 13.7 (7.2) −7.0 (−9.7, −4.3)* 15.4 (7.1) −4.7 (−7.5, −2.1)* −1.9 (−5.1, 1.2) 0.228
Index
Global Rating of 2.2 (2.8) 2.2 (1.4, 3.0)* 0.8 (1.5) 0.8 (−0.01, 1.6) 1.4 (0.3, 2.6)* 0.016*
Change
Range of Motion
Flexion 90.3 (22.7) −5.5 (−11.4, 0.4) 103.6 (14.4) 3.3 (−2.6, 9.1) −10.3 (−17.8, −2.7)* 0.008*
Extension 26.4 (10.7) 2.4 (−1.1, 5.9) 25.7 (9.8) −0.4 (−3.9, 3.1) 1.8 (−2.2, 5.9) 0.373
Total side-bending 58.0 (13.2) −0.5 (−4.4, 3.5) 56.6 (13.9) 1.9 (−3.5, 4.4) −1.2 (−6.1, 3.8) 0.646
Side-bending 3.7 (3.9) −1.4 (−3.9, 1.0) 5.1 (4.2) 0.2 (−2.2, 2.6) −1.4 (−3.4, 0.6) 0.182
asymmetry

of two different dry needling techniques. Using the same
contraction strategy and time frames as the current study,
Wang-Price et al. [16] found no differences between dry
needling techniques and no main effect of time.
Contrary to the findings of the current study, some
research has reported variable changes in muscle con­
traction after dry needling. Nineteen of the 21 studies
included in the previously mentioned systematic review
demonstrated no effect of dry needling on muscle force
[13], however, two studies investigating the effects of dry
needling versus simple stretching found dry needling to
cause a greater improvement in maximal isometric neck
muscle strength that persisted up to six months after
intervention [43,44]. Two studies that investigated lumbar
paraspinal muscles (as was done in the current study)
using ultrasound imaging to measure percent change in
muscle thickness found mixed results. Koppenhaver et al.
[14], reported larger improvements in lumbar multifidus
muscle contraction after dry needling in patients with LBP
that responded clinically when compared to those that
162 S. L. KOPPENHAVER ET AL.
did not responded clinically one week after treatment.
Similarly Dar and Hicks [15], reported a larger improve­
ment in lumbar multifidus muscle contraction after dry
needling at one side and spinal level (right L4/5), but not
at the other side or spinal levels in asymptomatic
individuals.
4.2 Self-reported clinical improvement and range
of motion
Both dry needling and sham dry needling groups
reported significant improvements in pain (NPRS) and
LBP-related disability (ODI) one week after treatment.
Although point estimates of improvements in pain and
disability both favored dry needling group, the amount
of improvement was small and not significantly differ­
ent between intervention groups. Participants that
received dry needling reported statistically larger over­
all improvement on the GRoC than did those who
received sham dry needling. These results regarding
clinical outcomes appear to be consistent with sys­
tematic reviews of dry needling that report mixed
findings that usually, but not always, support the clin­
ical effectiveness of dry needling for a variety of mus­
culoskeletal conditions including LBP [3–10].
Participants that received dry needling exhibited
statistically larger change in lumbopelvic flexion RoM,
but not extension or side-bending RoM, than did indi­
viduals that received sham dry needling one week
after treatment. Flexion RoM decreased in participants
that received dry needling and slightly increased in
those that received sham dry needling. However,
point estimates of RoM changes in all directions were
very small and likely within measurement error for
both groups. Similar studies have reported improved
RoM after dry needling in studies in patients with neck
pain [45,46], and shoulder pain [47], but not in patients
after knee or shoulder surgery [48,49]. To our knowl­
edge, only one case report [50] has evaluated changes
in lumbopelvic RoM after dry needling. After treating
the lumbar multifidi and gluteal muscles with dry
needling, the author observed substantial clinical
improvement that was associated with a large increase
in lumbopelvic flexion RoM [50].
4.3 Limitations and future research
Various limitations of this study should be acknowledged
and may at least partially account for the results providing
mixed support for our initial study hypotheses. One poten­
tial explanation is large variability observed in stiffness
values. Many of the observed standard deviations of mus­
cle shear modulus were larger than 50% of the mean
values (Table 2). Such wide variability would decrease
the statistical power of our analyses.
Another limitation concerns the chronicity of the
study sample. The mean duration of LBP in study
participants was 84.6 and 68.7 months (approximately
6–7 years) in the dry needling and sham dry needling
groups, respectively. Prior evidence suggests that
patients with longer duration of LBP symptoms have
a worse clinical prognosis [51], worse outcomes after
dry needling treatment [52], and are less likely to exhi­
bit change in lumbopelvic muscle function with treat­
ment [53]. Therefore, the high chronicity of the
participants in the current study may have contributed
to the small changes in clinical outcomes (pain and
disability) after treatment, as well as adversely affected
the responsiveness of the paraspinal musculature to
a single session of dry needling treatment.
Additionally, it appears that our participant blinding
was only partially effective as a greater number of parti­
cipants in the dry needling group (83%) than in the sham
dry needling group (56%) thought that they received true
dry needling. Some participants likely had previously
received dry needling and/or acupuncture, which could
have been a contributing factor. While this is unlikely to
affect a physiologic outcome like muscle stiffness, it could
have affected the self-report measures such as pain, dis­
ability, and overall clinical improvement.
Finally, dry needling is mostly commonly used as
a part of a comprehensive multi-model treatment
approach that includes the application of other man­
ual therapies and exercise [2]. The fact that dry need­
ling was used in isolation in the current study could
have at least partially contributed to the lack of sig­
nificant differences between those that received sham
and true dry needling, especially in self-reported clin­
ical improvement and range of motion.
Future studies should assess for changes in muscle
stiffness after dry needling over longer periods of time
and when dry needling is combined with other common
treatments as is done in the context of clinical care. Future
studies should also evaluate for changes in muscle stiff­
ness after dry needling to other muscle groups (e.g. rotator
cuff muscles) and in other patient populations (e.g.
shoulder pain) and include whether any effect is modified
by treating directly into symptomatic trigger points and/or
the occurrence of a local twitch response.
5. Conclusions
Dry needling appears to reduce resting erector spinae
muscle stiffness following treatment of patients with
LBP. Dry needling did not significantly affect lumbar
multifidus muscle stiffness in this study, however,
point estimates consistently decreased after dry need­
ling and increased or did not change after sham dry
needling. Therefore, providers should consider the use
of dry needling when patients exhibit aberrant stiff­
ness of the lumbar muscles.

Disclosure statement
No potential conflict of interest was reported by the
author(s).
Funding
This work was funded by the Advanced Medical Technology
Initiative (AMTI), through the Telemedicine and Advanced
Technology Research Center (TATRC) at the U.S. Army
Medical Research and Development Command (USAMRDC).
Notes on contributor
The authors certify that they have no affiliations with or
financial involvement in any organization or entity with
a direct financial interest in the subject matter or materials
discussed in the article.
This study was approved by the Institutional Review
Board of Brooke Army Medical Center
The opinions or assertions contained herein are the pri­
vate views of the authors and are not to be construed as
official or as reflecting the views of the Departments of the
Army or Defense.
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