Accepted Manuscript

Postneedling soreness after myofascial trigger point dry needling: Current status and
future research

Aitor Martín-Pintado-Zugasti, Orlando Mayoral del Moral, Robert D. Gerwin, Josue

Fernández-Carnero

PII: S1360-8592(18)30051-2
DOI: 10.1016/j.jbmt.2018.01.003
Reference: YJBMT 1659

To appear in: Journal of Bodywork & Movement Therapies

Received Date: 21 September 2017

Revised Date: 27 December 2017
Accepted Date: 8 January 2018

Please cite this article as: Martín-Pintado-Zugasti, A., Mayoral del Moral, O., Gerwin, R.D., Fernández-
Carnero, J., Postneedling soreness after myofascial trigger point dry needling: Current status and future
research, Journal of Bodywork & Movement Therapies (2018), doi: 10.1016/j.jbmt.2018.01.003.

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1 TITLE PAGE
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3 • TITLE
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5 POSTNEEDLING SORENESS AFTER MYOFASCIAL TRIGGER POINT DRY
6 NEEDLING: CURRENT STATUS AND FUTURE RESEARCH
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8 AUTHORS
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10 • Aitor Martín-Pintado-Zugasti1, PhD; Orlando Mayoral del Moral2, PhD;

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11 Robert D. Gerwin3, MD; Josue Fernández-Carnero, PhD4,5,6

12 • Affiliations

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13 1. Department of Physical Therapy, Faculty of Medicine, CEU-San Pablo University,
14 Madrid, Spain.

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15 2. Physical Therapy Department. Hospital Provincial. Toledo, Spain.
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16 3. Department of Neurology, Johns Hopkins University School of Medicine,
17 Baltimore, MD, USA.

4. Department of Physical Therapy, Occupational Therapy, Rehabilitation and

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19 Physical Medicine. Rey Juan Carlos University, Madrid, Spain.
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20 5. Hospital La Paz Institute for Health Research, IdiPAZ, Madrid, Spain.

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21 6. Grupo Multidisciplinar de Investigación y Tratamiento del Dolor. Grupo de

22 Excelencia Investigadora URJC-Banco de Santander. Madrid, Spain.

•
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23 ADDRESS FOR REPRINT REQUESTS / CORRESPONDING AUTHOR.

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25 Aitor Martín-Pintado Zugasti,
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26 Department of Nursing and Physiotherapy, CEU-San Pablo University, Carretera

27 Boadilla del Monte, Km 5,300, Urbanización Montepríncipe, 28668 Boadilla del Monte,
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28 Madrid, Spain.

29 • Telephone: 0034-913724700 Email: martinpintado.a@gmail.com.

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38 • AUTHOR DISCLOSURES
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40 This research did not receive any specific grant from funding agencies in the

41 public, commercial, or not-for-profit sectors.

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43 Conflict of interests: none.

44

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45 All authors have seen and approved the final version of the manuscript being

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46 submitted. We warrant that the article is the authors' original work, hasn't

47 received prior publication and isn't under consideration for publication

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48 elsewhere.
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64 POSTNEEDLING SORENESS AFTER MYOFASCIAL TRIGGER POINT DRY

65 NEEDLING: CURRENT STATUS AND FUTURE RESEARCH

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67 ABSTRACT

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69 Post-dry needling soreness is a common complication of myofascial trigger

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70 point (MTrP) dry needling treatment. The prevention, management and relevance of

71 this complication remain uncertain. This paper examines the current state of

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72 knowledge and suggests directions for further studies in this area. MTrPs are

73 hypersensitive nodules in skeletal muscles’ taut bands, present in several pain

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conditions. Dry needling has been recommended for relieving MTrP pain. MTrP dry
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75 needling procedures have shown to be associated with postneedling soreness,
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76 which is thought to be a consequence of the neuromuscular damage, and

77 hemorrhagic and inflammatory reaction generated by the needle. Postneedling

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78 soreness is a very frequent effect after deep dry needling, usually lasting less than
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79 72 hours. It may not be especially distressing for most patients. However, patients

80 presenting with higher levels of postneedling soreness, not perceiving dry needling
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81 effectiveness in the first session, or not having high myofascial pain intensity before

82 treatment, could be the most likely to find postneedling soreness more distressing,
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83 functionally limiting and to abandon treatment. Future research should assess the

84 clinical relevance of postneedling soreness. Postneedling soreness should be

85 considered when investigating dry needling effectiveness since it could overlie the

86 original myofascial pain and influence the patients’ pain ratings.

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88 Keywords: needles; pain; trigger points; adverse effects; physical therapy modalities

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89 INTRODUCTION

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91 The presence of soreness is a frequent complication of myofascial trigger

92 point (MTrP) dry needling treatment (Ga et al., 2007a; Hong, 1994; Martín-Pintado-

93 Zugasti et al., 2015; Torres et al., 2004). The prevention, management and

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94 relevance of postneedling soreness remain uncertain. This paper examines the

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95 current state of knowledge and suggests directions for further studies in this area.

96

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97 MTrPs are hypersensitive nodules in taut bands present in skeletal muscles.

98 MTrPs are classified either as active MTrPs, which are symptom-producing by

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triggering local or referred spontaneous pain, or as latent MTrPs, which upon
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100 stimulation do not reproduce any symptom experienced by the patient. (Simons et
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101 al., 1999). Moreover, MTrPs contribute to autonomic phenomena, motor dysfunction

102 and impaired range of motion (Ge et al., 2012, 2014; Simons et al., 1999). Active
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103 MTrPs have been found in subjects presenting with several pain conditions,
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104 including tension type headache (Fernández-de-Las-Peñas et al., 2010), migraine

105 (Giamberardino et al., 2007), temporomandibular disorders (Fernández-de-las-

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106 Peñas et al., 2010), nonspecific shoulder pain (Bron et al., 2011), subacromial
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107 impingement (Alburquerque-Sendín et al., 2013; Hidalgo-Lozano et al., 2010), lateral

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108 epicondylalgia (Fernandez-Carnero et al., 2007), or knee osteoarthritis (Henry et al.,

109 2012). Direct trauma or overuse are thought to lead to the development or

110 perpetuation of MTrPs, when muscle capacity is exceeded and normal recovery is

111 delayed (Bron and Dommerholt, 2012).

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113 The treatment of MTrPs includes dry needling therapies frequently used by

114 different health care providers. MTrP dry needling consists of inserting solid filament

115 needles into the muscle in the location of the MTrP (Dommerholt et al., 2006). Local

116 twitch responses, transient contractions of the taut band elicited by dry needling,

117 have been associated with better outcomes in pain reduction and range of motion

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118 (Hong, 1994), and with a decrease in nociceptive and inflammatory mediators

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119 present at the MTrP (Shah and Gilliams, 2008).

120

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121 Recent reviews and meta-analysis on the effectiveness of dry needling have

122 suggested or recommended dry needling over control non-needling treatments, or

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placebo treatment, for the treatment of MTrP pain in short and medium term studies
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124 (Kietrys et al., 2013; Liu et al., 2015). Very low quality to moderate quality evidence
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125 suggested that dry needling performed by physical therapists was more effective

126 than no treatment, sham dry needling and other treatments (Gattie et al., 2017).
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127
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128 Adverse effects of dry needling

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130 There are few reports detailing significant adverse effects following MTrPs dry
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131 needling. Cummings et al (2014) reported the presence of a pneumothorax

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132 complication after dry needling in the iliocostalis muscle. Acute cervical subdural (Ji

133 et al., 2015) or epidural (Lee and Jo, 2011) hematoma have been reported following

134 cervical muscle dry needling. In addition, Callan et al (Callan et al., 2016) reported a

135 deep spine infection and Steentjes et al (Steentjes et al., 2016) reported an infection

136 of a hip prosthesis.

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137 Brady et al (2014) assessed the incidence of adverse effects after 7629 dry

138 needling interventions. The authors did not observe significant adverse effects,

139 whereas mild adverse effects were very common, since they were presented in

140 19.18 percent of cases. Common adverse effects included bruising (7.55%),

141 bleeding (4.65%), pain during treatment (3.01%), and pain after treatment (2.19%).

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142 Guidelines that provide recommendations for improving the safety of deep dry

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143 needling, such as correct technique, proper hygiene and anatomical knowledge of

144 the location of organs, vessels and nerves, have been developed in some countries

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145 in response to the recognition that there are risks associated with the procedure

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146 (Dommerholt and Fernandez-de-las-Peñas, 2013).
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147

148 POSTNEEDLING SORENESS

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150 Simons et al (Simons et al., 1999) initially described soreness as a

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151 consequence of MTrP injection procedures. They considered postinjection and

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152 postneedling soreness as being a result of the tissue injury produced by the needle
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153 and the following inflammatory reaction, fundamentally different from the

154 pathophysiology of the MTrP itself. Domingo et al (Domingo et al., 2013) reported
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155 damage to mice muscle fibers and intramuscular nerves associated with a transient
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156 inflammatory response that showed healing beginning in 3 days post dry needling

157 and complete healing in 6 days. Hsieh et al (Hsieh et al., 2012) reported that

158 nociceptive and inflammatory mediators such as substance P, increased in rabbit

159 muscle after 5 days of consecutive needling, due to an excessive muscle damage.

160 This response was the opposite when dry needling was applied once, so it was only

161 associated to an increased dosage of dry needling. The local increase in such

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162 neurotransmitters and proinflammatory mediators could be hypothesized to

163 predispose some individuals to experience postneedling soreness, but further

164 research is needed.

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166 Simons et al (Simons et al., 1999) and Hong (Hong, 1994) associated

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167 soreness with capillary hemorrhage and the consequent irritation of muscle and

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168 observed that patients presenting with visible ecchymosis or swelling after needling

169 presented with greater postinjection or postneedling soreness. Based on that,

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170 Simons et al (Simons et al., 1999) highlighted the importance of hemostasis during

171 and after MTrP injection. Domingo et al (2013) observed that dry needling in mice

172
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occasionally induced bleeding, as observed in humans. A recent study did not find
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173 significant correlations between the presence of blood in the cotton swab after
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174 hemostasis and the intensity of postneedling soreness after deep dry needling of

175 latent MTrPs (Martín-Pintado-Zugasti et al., 2015). However, the presence of blood
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176 in the cotton swab may not detect possible deep tissue hemorrhage.
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178 The number of needle insertions and the pain perceived during needling is
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179 positively correlated with the intensity of postneedling soreness in healthy subjects
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180 (Martín-Pintado-Zugasti et al., 2015), thus confirming the relationship between the
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181 amount of tissue damage produced during needling and the intensity of postneedling

182 soreness. Other variables are thought to influence postneedling soreness

183 perception, such as psychosocial factors (Martín-Pintado-Zugasti et al., 2014) or

184 gender (Martín-Pintado-Zugasti et al., 2015). The characteristics of the muscle being

185 needled, such as the presence of active or latent MTrPs, could lead to a different

186 postneedling soreness response. The number of LTRs elicited during needling could

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187 also influence postneedling soreness. However, it has not been found significant

188 associations between postneedling soreness intensity and the number of LTRs

189 elicited (Martinez Merinero et al., 2009).

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191 Factors associated with the therapists’ dry needling technique, or MTrP

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192 diagnostic skills and experience, may influence postneedling soreness presence or

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193 intensity. Accurate localization of the MTrP may minimize the number of needle

194 insertions, while adequate hemostasis during and after MTrP dry needling could

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195 reduce bleeding.

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Postneedling soreness after deep dry needling has been considered to be of
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198 greater intensity and duration than postinjection soreness (Hong, 1994; Simons et
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199 al., 1999). However, beveled hypodermic needles of 0.4 mm diameter were used for

200 dry needling rather than the filiform needles now used (Dommerholt et al., 2006). Dry
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201 needling applied with solid filament needles of 0.30 mm in diameter did not provoke
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202 significantly higher postneedling soreness compared to postinjection soreness in Ga

203 et al´s study (Ga et al., 2007b). Further research is needed to investigate whether
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204 postinjection soreness is less painful compared to postneedling soreness performed

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205 with filiform needles.

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207 Frequency, intensity and duration

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209 Various studies have evaluated the presence or characteristics of

210 postneedling soreness or postneedling tenderness (Arias-Buría et al., 2015; Brady et

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211 al., 2014; Fernández-Carnero et al., 2017; Ga et al., 2007a, 2007b; Hong, 1994;

212 Llamas-Ramos et al., 2014; Martín-Pintado-Zugasti et al., 2014, 2015; Martinez

213 Merinero et al., 2009; Mejuto-Vázquez et al., 2014; Myburgh et al., 2012; Salom-

214 Moreno et al., 2017; Téllez-García et al., 2014; Torres et al., 2004). In most cases,

215 postneedling soreness was assessed secondary to the main objectives of evaluating

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216 the effectiveness of dry needling procedures on reducing MTrPs pain (Arias-Buría et

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217 al., 2015; Ga et al., 2007a, 2007b; Hong, 1994; Llamas-Ramos et al., 2014; Mejuto-

218 Vázquez et al., 2014; Myburgh et al., 2012; Téllez-García et al., 2014). The results

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219 are summarized in Table 1. The small number of published studies, as well as

220 important differences in study design, make it impossible to draw definitive

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conclusions about the mean frequency, intensity or duration of postneedling
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222 soreness. Additional research is needed to delineate the postneedling soreness
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223 characteristics that may be expected after dry needling, considering specific muscles

224 or pain conditions receiving the treatment, the needling technique performed, the
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225 needle size, the presence or type of MTrPs needled or the number of needle
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226 insertions or LTRs elicited during needling.

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228 Patients who report postneedling soreness describe it as quite different from
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229 the pain caused by MTrPs. The quality of soreness is described as constant
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230 pressure or dull aching, which is distinguishable from the sharp and tight aching that

231 they experience before needling (Hong, 1994).

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233 Dry needling of latent trigger points in healthy subjects resulted in higher

234 levels of postneedling soreness frequency than seen in patients with dry needling of

235 active MTrPs. It may be that those patients presenting with myofascial pain find

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236 postneedling soreness harder to perceive, since the two pains may overlap (Irnich et

237 al., 2002). Hong’s finding (Hong, 1994) that hypodermic needles with cutting edges

238 produced more frequent and longer lasting post-needling soreness may be explained

239 by the greater degree of tissue damage produced by the needle.

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241 Post-needling soreness was reported to range between 50 and 100% in most

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242 of the studies (Table 1). Myburgh et al (2012) and Brady et al (2014) reported lower

243 percentages of post-needling soreness. The specific design of these studies could

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244 have led to different reports of postneedling soreness. In Myburgh et al´s study

245 (Myburgh et al., 2012), postneedling soreness was present in 29.4% of symptomatic

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patients and not at all in asymptomatic subjects receiving deep dry needling.
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247 However, postneedling soreness overlapped with delayed onset muscle soreness
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248 from a contraction testing and no LTR was elicited while needling asymptomatic

249 subjects. Brady et al (2014) reported the presence of pain after treatment, which
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250 could be attributed to postneedling soreness, in 2.19% of cases after needling

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251 procedures. Notably, the postneedling soreness presence was recorded by

252 therapists by completing a questionnaire that included mild adverse events observed
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253 after needling and not from the patients. In addition, 30% of needling treatments
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254 were superficial dry needling and there was no further information about the protocol
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255 used for the remaining deep dry needling techniques.

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257 The duration of post-needling soreness was less than 72 hours in most of

258 studies in which filiform needles were used (Arias-Buría et al., 2015; Ga et al.,

259 2007a; Llamas-Ramos et al., 2014; Martín-Pintado-Zugasti et al., 2015; Mejuto-

260 Vázquez et al., 2014; Téllez-García et al., 2014; Torres et al., 2004). However,

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261 Salom-Moreno et al (2017) reported that it did not completely disappear 72h after the

262 needling procedure, although pain levels were relatively small. In the case of dry

263 needling with syringe beveled needles, the postneedling soreness duration seems to

264 be longer, with a reported mean duration of five days (Hong, 1994).

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266 Post-injection soreness lasted a mean of 13.7 days with a maximum intensity

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267 of 8.3 points on a 0-10 Likert subjective pain scale in fibromyalgia patients whose

268 tender points were injected (Hong and Hsueh, 1996). These values were significantly

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269 higher than the postinjection soreness mean duration (1.2 days) and intensity (2.3

270 points) present in those with chronic neck pain who received lidocaine injections in

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active MTrPs. The authors suggested that central sensitization present in patients
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272 with fibromyalgia led to augmented pain responses (Hong and Hsueh, 1996). This
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273 could be a generalized phenomenon in all patients with central pain sensitization.

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275 There is little data about postneedling soreness intensity. The mean maximal
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276 intensity was reported to be between 3.5 and 5.6 on a 0 to 10-point scale (Hong,

277 1994; Martín-Pintado-Zugasti et al., 2014, 2015; Salom-Moreno et al., 2017), but
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278 further research is needed.

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279
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280 Postneedling tenderness after dry needling of latent trigger points in healthy

281 subjects has been previously observed. The pressure pain threshold significantly

282 decreased at the needle site immediately after needling and during 48 hours (Martín-

283 Pintado-Zugasti et al., 2014, 2015; Torres et al., 2004). However, immediately after

284 dry needling, the pressure pain threshold of active MTrPs in myofascial pain patients

285 increases, showing an hypoalgesic effect of dry needling (Cagnie et al., 2012;

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286 Cerezo-Tellez et al., 2016; Fernández-Carnero et al., 2010; Koppenhaver et al.,

287 2015; Ziaeifar et al., 2013).

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289 PLACE TABLE 1 HERE

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291 Clinical relevance of postneedling soreness

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293 Further research is needed to determine the importance that postneedling

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294 soreness has for patients receiving dry needling procedures, as well as the possible

295 alterations in function caused by postneedling soreness, and whether it could lead to

296 reduced treatment adherence.

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297
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298 Previous research has reported reduced treatment adherence as a direct

299 consequence of postinjection soreness. Fifty-one percent of subjects receiving

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300 lidocaine MTrP injections were reluctant to have further injections (Lai and Hong,
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301 1998). However, the authors discussed that postinjection soreness was greater

302 compared with previous research, probably due to the larger 23 gauge needle size
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303 used that could cause “more microtrauma, hematoma and inflammatory reaction”. In
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304 addition, higher rates of withdrawal from treatment have been attributed to
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305 postneedling soreness after dry needling with filiform needles, when compared with

306 other invasive procedures, such as percutaneous electrical nerve stimulation (Pérez

307 Palomares et al., 2010).

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309 To our knowledge, there are no studies that investigated functional limitations

310 possibly related to postneedling soreness. Simons et al (Simons et al., 1999)

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311 recommended avoiding any demanding muscular activity for 24 hours and placing

312 muscles in a fixed, shortened position for a prolonged length of time, as well as

313 avoiding strenuous activities, such as playing tennis, moving furniture or traveling to

314 conventions for at least the two or three-day period of postinjection soreness, and

315 preferably for about one week. However, they encouraged patients to use their

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316 muscles in a gentle, normal way through their full range of motion. There have been

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317 no studies to support such recommendations. The American Physical Therapy

318 Association (APTA, 2012) recommends warning patients about the occurrence of

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319 soreness and considers postneedling soreness capable of influencing patients’

320 functionality since it suggests scheduling the needling treatment to take into account

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the patient’s lifestyle, social or work commitments.
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323 Simons et al (1999) considered that postinjection soreness was not

324 unfavorable if the patient's myofascial pain from MTrPs was relieved. However, they
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325 commented that sometimes considerable postinjection soreness and distressing

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326 referred autonomic and proprioceptive phenomena could occur after injection. They

327 recommended not injecting again until soreness was gone. Additionally, Hong
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328 (Hong, 1994) observed that most patients presenting with postneedling soreness
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329 found it tolerable compared with the original MTrP pain.

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331 In clinical practice, most patients receiving dry needling associated with

332 improvements in myofascial pain levels do not find postneedling soreness so

333 distressing in comparison with the original myofascial pain and may not consider it

334 relevant. However, those patients presenting with high levels of postneedling

335 soreness, not perceiving dry needling effectiveness in the first session or not having

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336 high MTrP pain intensity before treatment, could be the most likely to find

337 postneedling soreness more distressing and functionally limiting or to be reluctant to

338 undergo further needling treatments. The pain level perceived during dry needling

339 could also be associated with reduced treatment adherence. Previous research has

340 shown this clinical perception. Perez-Palomares et al (2010) observed that patients

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341 presenting with high levels of baseline pain showed higher tolerance to the treatment

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342 and higher pain improvements after dry needling in patients with low back pain.

343 However, those patients with low baseline myofascial pain, showed reduced

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344 tolerance and augmented abandonment rate attributed to postneedling soreness.

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346
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Other authors have considered the pain perceived after dry needling as a mild
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347 adverse event, defined as short-term and non-serious, with no change in function
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348 (Brady et al., 2014). It reflects conflicting opinions between authors about the impact

349 and clinical relevance of postneedling soreness.

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350
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351 Dommerholt et al (2015) questioned whether, in the most usual case in which

352 postneedling soreness is not associated with severe debilitating pain, postneedling
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353 soreness could be presented to the patient as a positive sign rather than a negative
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354 experience. Future studies could investigate the importance of the information
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355 provided to the patient or the patients’ beliefs about postneedling soreness.

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357 Previous research has investigated the effectiveness of additional therapies

358 applied after needling for treating postneedling (León-hernández et al., 2016; Martín-

359 Pintado-Zugasti et al., 2014, 2015; Salom-Moreno et al., 2017) or postinjection (Lai

360 and Hong, 1998) soreness. Percutaneous electrical nerve stimulation reduced post-

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361 dry needling soreness intensity after needling of the trapezius MTrP in chronic neck

362 pain patients (León-hernández et al., 2016). Low load exercise also improved

363 postneedling soreness intensity after dry needling of MTrPs in the infraspinatus

364 muscle in subacromial pain syndrome patients (Salom-Moreno et al., 2017) and

365 ultrasound reduced tenderness and improved the cervical range of motion after

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366 trigger point injection of MTrPs in the upper trapezius in neck pain patients (Lai and

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367 Hong, 1998). Spray and stretch immediately improved postneedling soreness

368 (Martín-Pintado-Zugasti et al., 2014) and ischemic compression reduced both pain

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369 intensity and duration (Martín-Pintado-Zugasti et al., 2015) after dry needling of

370 latent MTrPs. Moreover, Simons et al (1999) recommended various treatments

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intended to reduce postinjection soreness, including a moist heating pack, stretches
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372 or nonsteroidal anti-inflammatory drugs. Further research is needed to determine the
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373 effects of other additional therapies that are thought to be clinically effective in

374 reducing or preventing postneedling soreness, such as transcutaneous electrical

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375 nerve stimulation, kinesiotape or moderate physical activity.

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377 Research implications of postneedling soreness

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379 To the authors’ knowledge, there are no studies that have assessed the
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380 influence that postneedling soreness or postneedling tenderness may have on the

381 outcomes of studies investigating the effectiveness of dry needling on myofascial

382 pain associated with MTrPs. Postneedling soreness could mask the original

383 myofascial pain and influence myofascial pain ratings. Further studies have been

384 recommended to take this situation into account (Irnich et al., 2002). Patients may

385 rate levels of myofascial pain and sensitivity higher or range of motion and muscle

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386 function lower, mainly when evaluating immediate or short-term dry needling effects

387 (Fernández-Carnero et al., 2017; Koppenhaver et al., 2015; Ziaeifar et al., 2016).

388 Postneedling soreness has shown to be higher immediately (Martín-Pintado-Zugasti

389 et al., 2015) or a few hours after needling (Hong, 1994), so it could associate with

390 reduced pain or disability improvements immediately after dry needling.

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391

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392 It is the authors’ recommendation that post-needling soreness may occur and

393 should be considered when assessing post-needling treatment effects. Furthermore,

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394 postneedling soreness should be separately evaluated from the original MTrP pain.

395 Patients can describe postneedling soreness differently and separately from the

396 original MTrP pain (Hong, 1994).

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398 Recommendations and directions for future research

399
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400 The clinical relevance that postneedling soreness has for myofascial pain
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401 patients receiving deep dry needling procedures needs to be investigated. It is not

402 clear whether postneedling soreness could in some cases have an impact on
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403 function or reduce the treatment adherence.

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404
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405 Further research could consider the importance of the information provided to

406 the patient about postneedling soreness and whether its relevance is influenced

407 when presented as a positive sign associated to dry needling therapies (Dommerholt

408 et al., 2015).

409

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410 Future research on the effectiveness of dry needling in the treatment of

411 myofascial pain should include the assessment of postneedling soreness, since it

412 could mask the original myofascial pain and influence the short-term pain or

413 pressure pain threshold ratings (Irnich et al., 2002).

414

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415 CONCLUSIONS

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417 Post-needling soreness after deep dry needling is likely to be the result of

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418 neuromuscular injury, and hemorrhagic and inflammatory changes produced by the

419 needle. The therapists’ technique may influence the development of these events.

420
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Post-needling soreness is a very frequent event, but usually lasts less than 72 hours
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421 when using filiform needles and when LTRs are elicited. The duration is longer when
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422 hollow, beveled needles are used. Post-needling soreness may be more severe

423 when there is significant central sensitization and hypersensitivity. Post-needling

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424 soreness may not be especially distressing for most patients, but further research
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425 about its clinical relevance is needed. Postneedling soreness needs to be taken into

426 account when studying the effect of dry needling as treatment of specific pain
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427 syndromes.
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435 REFERENCES

436

437 Alburquerque-Sendín F, Camargo PR, Vieira A, Salvini T. Bilateral myofascial

438 trigger points and pressure pain thresholds in the shoulder muscles in patients

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619

TABLE 1: Postneedling soreness characteristics.

PNS max
Neddle PNS
N LTRs MTrPs (muscle) % PNS intensity
(Diameter) duration
(0-10)

PT
Monofilament LTR 1.73-1.83
Ga et al, 2007 40 Active (UT) 50%-55% -
(0.3 mm) exhaustion days
Llamas-Ramos et al, Monofilament 1st LTR and

RI
45 Active (UT) 55% - 24-36 hours
2014 (0.3 mm) 30 seconds
Monofilament 1st LTR and Active (shoulder girdle
Arías-Buria et al, 2015 10 60% - 24-36 hours
(0.3mm) 30 seconds muscles)

SC
Tellez-Garcia et al, Monofilament 1st LTR and Active: (quadratus
12 83% - 24-32 hours
2014 (0.3mm) 30 seconds lumborum and gluteus)

U
Mejuto-Vazquez et al, Monofilament 1st LTR and
9 Active: (UT) 88% - 24-36 hours
2014 (0.3mm) 30 seconds
AN
72 hours or
Salom-Moreno et al, Monofilament LTR
90 Active (Infraspinatus) 100% 5.6±1,5 superior (Not
2017 (0.32mm) exhaustion
specified)
M

Various dry
Fernandez-Carnero et Monofilament
84 needling Active (UT) 91.4% - -
al, 2017 (0.32mm)
dosages
D

Leon-Hernadez et al, Monofilament Two LTR

TE

62 Active (UT) - 5(6,25-3.12) -

2016 (0.32mm) elicited

LTR
Hong, 1994 15 Beveled (0.4mm) Active (UT) 100% 4.3±1,7 5±1.7 days
exhaustion
EP

LTR 90%-
Torres et al, 2004 28 Monofilament (-) Latent (UT) - 24-72 hours
exhaustion 100%
C

LTR
17 Active (UT) 29.4 %
exhaustion
Myburgh et al, 2012 Monofilament (-) - -
AC

Absence of active
20 No LTR 0%
(UT)
Martín-Pintado- Monofilament LTR
60 Latent (UT) 100% 4±1,4 24-72 hours
Zugasti et al, 2015 (0.26mm) exhaustion
LTR=Local Twitch Response; PNS=Postneedling Soreness; UT=Upper Trapezius; - = Not specified. Values ; PNS max intensity values
are Mean±SD or median (Interquartile range)
620

621

26