Original paper

acupunctureIN MEDICINE

Effects of pain neuroscience educationand dry needling for the management ofpatients with chronic myofascial neckpain: a randomized clinical trial

Pedro Valiente-Castrillo1,2, Aitor Mart�ın-Pintado-Zugasti3,C�esar Calvo-Lobo4, Hector Beltran-Alacreu5,6 andJosu�e Fernandez-Carnero2,6,7

Abstract

Objectives: The aim of this study was to observe the medium-term effects on pain, disability, and psychological factors

of a combination of myofascial trigger point (MTrP) dry needling (DN) with pain neuroscience education (PNE) versus

DN alone versus control care as usual (CUC) in patients with chronic neck pain.

Methods: A total of 60 patients were randomly selected in a Spanish National Health Service Public Hospital and

divided into three groups: 6 sessions of DN with 3 sessions of PNE (TrPDNþ PNE group, n¼ 21), 6 sessions of DN

alone (TrPDN group, n¼ 20), or 10 sessions of usual care (CUC group, n¼ 19). The primary outcome was neck pain

intensity, while neck disability, medication intake, and psychological factors were secondary outcomes. These variables

were measured at baseline, post-treatment, and at 1 month and 3 months after treatment.

Results: TrPDNþ PNE and DN alone were associated with greater reductions in pain intensity and disability compared

to CUC (p< 0.01). TrPDNþ PNE resulted in greater improvements in kinesiophobia, pain anxiety, and pain-related

beliefs than DN alone and CUC (p< 0.01). No differences between groups were observed in medication intake, quality

of life, catastrophizing, depression, or fear of pain (p> 0.05).

Discussion: Provision of PNE and DN in the management of chronic neck pain in a Spanish National Health Service

Public Hospital was associated with greater improvements in psychological factors than DN therapy only.

Conclusion: DN alone was more effective at reducing chronic non-specific neck pain and disability than CUC at

3-month follow-up. However, the inclusion of PNE combined with DN resulted in greater improvements in kinesio-

phobia, pain anxiety, and pain-related beliefs.

Trial registration number: NCT03095365 (ClinicalTrials.gov).

Keywords

chronic pain, dry needling, myofascial trigger point, pain neuroscience education, patient education, spine

Accepted: 20 March 2020

1Physical Therapy Unit, Rehabilitation Service, Hospital Universitario

Infanta Sof�ıa, San Sebastian de los Reyes, Spain2Department of Physical Therapy, Occupational Therapy, Rehabilitation

and Physical Medicine, Universidad Rey Juan Carlos, Alcorc�on, Spain3Department of Physiotherapy, Facultad de Medicina, Universidad San

Pablo—CEU, Boadilla del Monte, Spain4Faculty of Nursing, Physiotherapy and Podiatry, Universidad

Complutense de Madrid, Madrid, Spain5Department of Physiotherapy, Centro Superior de Estudios

Universitarios La Salle, Universidad Aut�onoma de Madrid, Madrid, Spain

6CranioSPain Research Group, Centro Superior de Estudios

Universitarios La Salle, Universidad Aut�onoma de Madrid, Madrid,

Spain7Hospital La Paz Institute for Health Research (IdiPAZ), Madrid, Spain

Corresponding author:

Hector Beltran-Alacreu, Department of Physiotherapy, Centro Superior

de Estudios Universitarios La Salle, Universidad Aut�onoma de Madrid,

Calle Gan�ımedes 11, 28023 Madrid, Spain.

Email: hector.beltran@lasallecampus.es

Acupuncture in Medicine

0(0) 1–15

DOI: 10.1177/0964528420920300

! The Author(s) 2020

Article reuse guidelines:

sagepub.com/journals-permissions

journals.sagepub.com/home/aim

Acupuncture in Medicine 0(0)

Introduction

Neck pain is considered the fourth leading disease inthe United States in terms of the number of years livedwith disability, only ranking behind low back pain,major depressive disorders, and other musculoskeletaldisorders.1 Neck pain is prevalent in the adult popula-tion, ranging from 6% to 22%.2 In the United States,its mean prevalence is 7.6% and it has been estimatedthat 48.5% of the population will experience neck painover their lifetime.2 Chronic neck pain is normally con-sidered to be non-specific, since it has a mechanicalbasis; however, its etiological factors are multifactorialand poorly understood.3–5 Multiple structures, includ-ing the cervical intervertebral disks, zygapophysealjoints, or myofascial structures, could represent appar-ent primary sources of pain.6,7

Moreover, myofascial pain syndrome is a commonsource of pain among chronic non-specific neck painpatients,7–9 symptoms of which are associated with thepresence of myofascial trigger points (MTrPs). MTrPsare hypersensitive spots within taut bands of skeletalmuscle that are painful upon compression, trigger char-acteristic referred pain, and generate motor dysfunc-tion and autonomic phenomena.7 All chronic non-specific neck pain patients have MTrPs in muscles ofthe cervical region, such as the trapezius, splenius cer-vicis, elevator scapulae, and the multifidi.8

Accordingly, dry needling (DN) has been recom-mended for the relief of MTrP pain in the neck in theshort and medium term.10 Deep DN consists of theinsertion of solid filiform needles into the MTrP with-out introduction of any analgesic medication.11

Previous research in large samples of patients withchronic neck pain has shown positive short- andlong-term effects of TrPDN on pain, range ofmotion, neck disability, and neck muscle strength.12

The mechanisms of action and effects of DN are notclearly understood; however, it may be associated withthe mechanical disruption of dysfunctional motorendplates present in the MTrPs7,13 and peripheral orcentral neurophysiological junctions.11,14

Chronic pain is a complex biopsychosocial condi-tion, and its management requires the psychosocialaspects of pain to be addressed; these determine thepain experience and are thought to be enduring barriersto improvement using multiple therapeutic approaches.In this context, patients with chronic pain may benefitfrom programs that address the cognitive and behav-ioral aspects of pain.15,16 Pain neuroscience education(PNE) involves teaching patients about the neurobiol-ogy/neurophysiology of pain and its processing via thenervous system.16,17 Current evidence supports the useof PNE to reduce pain associated in chronic musculo-skeletal disorders and to lower disability or reduce

psychosocial factors.18 However, approaches that com-bine PNE with physical interventions, such as manualtherapy, have provided better results. Typically, it hasbeen recommended that PNE should be delivered inconjunction with other pain managementapproaches.18,19

Previous studies have investigated the effectivenessof the combination of TrPDN and PNE for the treat-ment of chronic pain.20,21 Considering chronic lowback pain, the integration of PNE with the DNapproach provided similar improvements in pain anddisability but decreased kinesiophobia to a greaterdegree. The authors recommended additional large-scale clinical trials with longer-term follow-up to con-firm the results of low back pain management usingPNE with the DN approach.20

To our knowledge, no previous studies have inves-tigated the effects of PNE for the management ofchronic neck pain in patients receiving TrPDN. Ourhypothesis was that TrPDN, and TrPDN combinedwith PNE, would yield greater improvements in neckpain, disability, and psychological factors compared tousual care electrotherapy. The aim of this study was tocompare the effects of a combination of TrPDN andPNE versus TrPDN alone versus (control) usual careon pain, disability, and psychological factors inpatients with non-specific neck pain.

Methods

This study was a single-blind, randomized controlledclinical trial conducted and reported in accordancewith the CONSORT statement.22 The trial was per-formed between March and August 2017 at theHospital Universitario Infanta Sof�ıa (HUIS; Madrid,Spain). All the procedures used in this study wereplanned in accordance with the ethical principles ofthe Declaration of Helsinki and approved by theEthics Committee of the Hospital of La Paz, Madrid,Spain (code-HULP:4255). All patients agreed voluntar-ily and signed informed consent to participate in thisstudy. The study protocol was registered atClinicalTrials.gov (NCT03095365) on 29 March 2017.

Participants

The sample was recruited from the RehabilitationService of the HUIS with the assistance of a physician.The participants were selected using a non-probabilisticmethod. To be included they needed to: be agedbetween 18 and 65 years; have had mechanical neckpain for at least 12 weeks; score 10% or higher onthe Neck Disability Index (NDI) questionnaire, or 30mm or more on a visual analogue scale (VAS) of painlocalized in the neck region;23 and have at least one

2 Acupuncture in Medicine

Acupuncture in Medicine 0(0)

active MTrP, defined in accordance with the guidelinesdescribed by Travell and Simons,24 in the upper trape-zius muscle, levator scapulae, cervical multifidi, or sple-nius cervicis. The active MTrP diagnosis was based onthe fulfillment of all the following criteria: (1) palpabletaut band; (2) presence of a hypersensitive tender spotwithin the taut band; (3) patient recognition of familiarreferred pain symptoms upon compression of thenodule; and (4) painful limitation of full stretch rangeof motion.

Subjects were excluded if they reported any of thefollowing: neck pain associated with whiplash injuries;medical red flag history (i.e. tumor, fracture, metabolicdisease, rheumatoid arthritis, osteoporosis); neck painwith cervical radiculopathy; neck pain associated withexternalized cervical disk herniation; fibromyalgia syn-drome according to the American College ofRheumatology criteria;25 previous neck surgery; andneck pain accompanied by vertigo caused by vertebro-basilar insufficiency or non-cervicogenic headaches.Participants were also not considered if they hadundergone any type of pain treatment within the pre-vious 6 months, had pending legal actions (e.g. com-pensation for injury, labor), psychiatric disorders orfear of needles, were pregnant, or had other problemsthat could contraindicate the use of the techniquesemployed in this study.

After sample selection, a technician, who was notinvolved in the assessment or treatment of the partic-ipants, was commissioned to perform the randomiza-tion using a web-based random number generator(GraphPad Software, Inc., La Jolla, CA, USA), andto allocate each participant to one of the threegroups. The assessor of all outcome measures wasblinded to the allocation of the participants (single-blind design).

Interventions

Once the participants were assigned to a treatmentgroup, two physiotherapists with more than 5 years’experience performed the corresponding treatment inaccordance with the randomization. All participants,regardless of group allocation, were instructed by thephysiotherapists to perform soft and maintain self-stretching of the upper trapezius and levator scapulaeof both sites three times a day during the 3-monthfollow-up as recommended by Travell and Simons.24

Three intervention groups were formed. Participantsallocated to the control group (control usual care;CUC) received conventional treatment, which con-sisted of five electrotherapy sessions per week (oneper day) for 2 weeks (total of 10 sessions). This con-ventional intervention is prescribed as the treatmentprotocol for non-specific neck pain of the rehabilitation

service in public health systems, so its inclusion as acomparative control group allows for the investigationof its effects and differences compared to othermethods.26

These sessions consisted of the application of 15 minof pulsating microwave and 15 min of analgesic trans-cutaneous electrical nerve stimulation (TENS). For theapplication of the pulsating microwave, a Radarmed2500CPVR Medical (Italy) emitter was used with athree-dimensional (3D)-shaped antenna. The emissionwas 120 W with a pulsatility of 70%. The patient wasplaced on a wooden chair with the 3D antenna posi-tioned at a distance 10–15 cm from the skin. For theapplication of TENS, a non-portable BTL-5000

VR

elec-trotherapy device with self-adhesive 6 cm� 6 cm elec-trodes was used. Moreover, a high frequency (100 Hz)and pulse width of 100 ls were used. The electrodeswere placed on both sides of the spinous processes atthe level where the patient felt the greatest pain. Theintensity was chosen by the participant according to thefollowing description given by the physiotherapists:“You should feel the current as the most intense butnot painful.”

Participants assigned to the experimental TrPDNgroup received DN of all the previously diagnosedactive MTrPs of the upper trapezius, levator scapulae,cervical multifidus, and cervical splenius in each session(Figure 1). DN was performed using the Hong tech-nique (“fast in, fast out”),27 in several directions toobtain five local twitch responses (LTRs).Acupuncture needles (0.32mm� 40mm) made ofstainless steel (ENER-QI; Henry Schein, Melville,NY, USA) with a guide tube were used. The therapistpre-cleaned the area with antiseptic solution and usednitrile gloves for the acupuncture application. Afterskin puncture, the needle was withdrawn and ischemiccompression was performed over the MTrP accordingto the technique described by Travell and Simons.24

Digital pressure was exerted on the MTrP, progressive-ly increased until the pressure sensation became a pain-ful sensation, then maintained until the painfulsensation decreased. Thereafter, the pressure wasincreased again until the pain reappeared, and the pro-cess was repeated over several cycles for a total of 2min. Finally, the area was again disinfected with anantiseptic solution. The treatment was carried out for3 days per week (Monday, Wednesday, and Friday)over 2 weeks (a total of six sessions). The presence ofpossible adverse effects from DN was evaluated duringthe follow-up period.

The experimental TrPDNþPNE group received thesame DN treatment as the TrPDN group. However,they also received three sessions of PNE for 30 minduring the week prior to DN. Each session was one-to-one and was carried out by a physiotherapist trained

Valiente-Castrillo et al. 3

Acupuncture in Medicine 0(0)

in pain neuroscience. The PNE protocol included anintroductory video on chronic pain introduced by theSpanish Pain Society (https://www.youtube.com/watch?v=JYA_mrNuLz0&feature=youtu.be) andexplanations of PNE that included the neurophysiolo-gy of pain, the importance of pain thoughts or beliefs,and the relevance of adaptive coping strategies, such asstress management, graduated physical activity, or pro-gressive return to work (Supplemental Digital Content1). This educational method performed by a physio-therapist over a few sessions is similar to othersdescribed and used in previous research.16

Outcome measurements

Sociodemographic data collected at baseline includedage, sex, and occupation, as well as the history of thepain, timing of clinical evolution, background history,prior treatments, and medication (drug type and timeadministered).

Primary outcome. The VAS consisted of a 100-mm line,the left and right extremes of which represented “nopain” and “worst pain imaginable,” respectively. Theparticipants marked on the line to indicate the intensityof their pain.28 The VAS has been shown to have astrong correlation with descriptive scales, as well ashigh sensitivity and reliability.29 Consensus recommen-dations for determining clinically important changes inoutcome measures for chronic pain trials suggest that adecrease of 2 points or a 30% reduction in pain inten-sity on the VAS represents the minimal clinically

important difference (MCID). Thus, it has been recom-

mended that the percentages of patients responding

with this degree of MCID pain relief should be

reported in clinical trials of chronic pain treatments,

since the MCID has more meaning to patients, in

terms of being associated with not requesting medica-

tion, than ratings such as “much” or “some”

improvement.30

Secondary outcomes. The NDI is a well-validated 10-

item questionnaire rated on a scale of 0–5.31 This

study used the NDI because it has sufficient support

in the literature, and it is the most commonly used

instrument for reporting neck pain.31,32 A Spanish val-

idation of the index was used.33 The minimum detect-

able change is 5 points (out of 50), and it is

recommended that 7 points be considered the MCID.32

In order to know how much pain medication the

participants were using, the number of pills that each

participant was taking daily was recorded at each mea-

surement time point. Only pain medication was

counted.To evaluate the participants’ pain-related fear of

movement and (re)injury, a Spanish-validated Tampa

Scale of Kinesiophobia (TSK) was used.34 An 11-item

version is also considered to have good psychometric

reliability for chronic pain.35 Each item is scored on a

4-point Likert-type scale that ranges from “strongly

agree” to “strongly disagree.” Total scores range

from 11 to 44, and higher scores indicate greater fear

Figure 1. Dry needling approaches to (a) cervical splenius, (b) levator scapulae, (c) cervical multifidus, and (d) upper trapezius.

4 Acupuncture in Medicine

Acupuncture in Medicine 0(0)

of movement and/or (re)injury. For chronic pain, theminimal detectable change is 5.6.36

The Pain Catastrophizing Scale (PCS) was used toevaluate the participants’ catastrophic thoughts ofpain. The PCS is a 13-item questionnaire designed tomeasure the three components of pain-related cata-strophizing (rumination, magnification, and helpless-ness) resulting in a unique score ranging from 0 to52. The Spanish version has also shown appropriatepsychometric properties.37 The Beck DepressionInventory (BDI) was used to evaluate symptoms andattitudes associated with depression. The scale contains21 items, and each item (ranging from 0 to 3) is eval-uated for severity of depression, with a total score rang-ing from 0 to 63 (0–10 indicates absent or minimaldepression, 10–18 mild to moderate depression, 19–29moderate depression, and 30–63 severe depression,respectively). This assessment has been used previouslyin a population with neck pain.38–40

To evaluate the fear of pain responses of the partic-ipants, the Fear Pain Questionnaire (FPQ) versionFPQ-III was used.41 This is a 30-item questionnaireusing a 5-point Likert-type scale ranging from 1 (notat all) to 5 (extreme). The Spanish version has alsoshown appropriate psychometric properties.41

The medication intake was registered as the numberof pills taken in the previous week (non-steroidal anti-inflammatory drugs or other analgesic drugs).

The patient’s pain attitudes were measured with the30-item brief version of the Survey of Pain Attitudes(SOPA), which assessed patients’ attitudes toward theirpain across seven dimensions using a 5-point Likert-type scale (0¼ very untrue to 4¼ very true).42 Thissurvey has good psychometric properties.42

The 20-point Pain Anxiety Symptoms Scale (PASS-20) was used to evaluate symptoms associated withanxiety. The 20-item scale was developed as a shortform of the original 40-item questionnaire that hadappropriate psychometric properties.43,44 The Spanishversion has also been validated.45 The measurementswere taken pre-treatment and post-treatment at theend of the last session, and then at the first and thirdmonth after the end of the treatment sessions.

Sample size

The VAS was chosen as the primary outcome measure.A power calculation was performed using G*Power 3software46 with analysis planned by repeated-measuresanalysis of variance (ANOVA) including within-subjectand between-subject factors, and their interactions. Itwas estimated that a total sample of 45 patients wouldbe required to detect a VAS effect size of 0.25 at 95%power and alpha level of 0.05. Anticipating a 20%dropout rate, it was considered that recruitment of at

least 54 patients would be necessary for this prelimi-nary study.

Statistical analysis

Statistical analysis was performed using the StatisticalPackage for the Social Sciences (SPSS) software version20.0 (SPSS Inc., Chicago, IL, USA). The mean, stan-dard deviation (SD), and 95% confidence interval (CI)for each variable was calculated. The distribution ofquantitative data was assessed using theKolmogorov–Smirnov test (p> 0.05) and all variablesshowed a normal distribution. Baseline data betweengroups were compared using chi square tests of inde-pendence for categorical data and one-factor ANOVAfor continuous data. Scores for all variables were sub-mitted to two-way repeated-measures ANOVA withtime (before intervention, after intervention, 1 month,and 3 months later) as the within-subject factor, andgroup (TrPDNþPNE vs TrPDN vs CUC) as thebetween-subject factor. Therefore, only interactionsbetween group and time represent significant differen-ces between groups in the studied variables. Bonferronicorrection was applied for within-group and between-group comparisons. The proportion of subjects thatreached an improvement superior to the MCID ofthe VAS (2 points) was calculated for each group andcompared between groups using the chi square test.The reported p values associated with the F statisticsfor ANOVA were adjusted via Greenhouse–Geissercorrection. For all analyses, statistical significancewas set at p< 0.05. Statistical analysis was conductedaccording to the intention-to-treat principle.

Results

A total of 120 patients with cervical myofascial painwere screened for eligibility and 62 patients were ran-domized, of which 60 patients successfully completedthe study protocol (9 males, 51 females). Specifically,19 subjects completed the study in the CUC group (3males, 16 females; 42.1� 9.07 years old), 20 in theTrPDN group (4 males, 16 females; 40.2� 11.37 yearsold), and 21 in the TrPDNþPNE group (2 males, 19females; 40.8� 8.06 years old). Figure 2 shows the pro-cess of recruitment and dropouts.

In the TrPDN groups, seven patients (17%) receivedneedling unilaterally and 34 patients (83%) bilaterally.The most prevalent muscles with MTrPs were theupper trapezius (37 patients; 90%), levator scapulae(35 patients; 85%), multifidi (12 patients; 29%), andsplenius cervicis (four patients; 0.9%). A total of 20subjects (48%) received DN in four or more muscles,12 patients (29%) in three muscles, eight patients(20%) in two muscles, and 1 patient (2%) in only one

Valiente-Castrillo et al. 5

Acupuncture in Medicine 0(0)

muscle. A total of 90% of patients presented post-

needling soreness during the follow-up period. No

other adverse effects were reported. There were no sig-

nificant differences between groups in terms of demo-

graphic or clinical characteristics at baseline (p> 0.05;

Table 1).

Neck pain intensity (primary outcome)

The 3� 4 mixed-model ANOVA showed statistically

significant differences in the time factor (F¼ 57.066;

p< 0.001; g2p ¼ 0:500) and a significant interaction

between group and time (F¼ 3.845; p< 0.001;

g2p ¼ 0:119) for the primary outcome of VAS score.

Post hoc analysis showed that the TrPDN and

TrDNþPNE groups exhibited a greater decrease in

pain than the CUC immediately after treatment

(p< 0.01). However, these differences were not seen

after 1 month (p> 0.05) or 3 months (p> 0.05) of

follow-up. The proportions of subjects with a pain

improvement that reached the MCID immediately

after treatment, at 1 month and at 3 months, respec-

tively, were 47%, 58%, and 53% in the CUC group;

80%, 70%, and 85% in the TrPDN group; and 100%,

91%, and 86% in the TrPDNþPNE group. The chi

square test showed that TrPDNþPNE was superior to

CUC at all follow-up time points (immediate:

p< 0.001; 1 month: p¼ 0.017; 3 months: p¼ 0.029),

and superior to TrPDN immediately after treatment

(p¼ 0.031). Furthermore, TrPDN was superior to

CUC immediately after treatment (p¼ 0.034) and at 3

months (p¼ 0.029) (Table 2).

Figure 2. CONSORT flow diagram.

6 Acupuncture in Medicine

Acupuncture in Medicine 0(0)

Neck disability

The 3� 4 mixed-model ANOVA showed statistically

significant differences in the time factor (F¼ 39.453;

p< 0.001; g2p ¼ 0:409) and a significant interaction

between group and time (F¼ 3.157; p< 0.01;

g2p ¼ 0:100). Post hoc analysis showed that the

TrDNþPNE group exhibited a greater decrease in

disability than the CUC after treatment and at 3

months (p< 0.01) (Table 2).

Medication intake

The 3� 4 mixed-model ANOVA showed statistically

significant differences in the time factor (F¼ 9.527;

p< 0.001; g2p ¼ 0:143) but no significant group� time

Table 1. Baseline sociodemographic and clinical characteristics of the sample and results of comparison between groups.

Parameter

CUC group

n¼ 19

TrPDN group

n¼ 20

TrPDN þ PNE group

n¼ 21 p value

Male/female (%) 3/16 (84.2%) 4/16 (80.0%) 2/19 (90.5%) 0.64

Age (years) 42.35� 9.43 40.33� 11.94 40.35� 7.97 0.81

Height (cm) 1.63� 0.12 1.69� 0.11 1.62� 0.07 0.08

Weight (kg) 68.05� 14.71 69.46� 19.18 65.22� 9.09 0.70

BMI 25.92� 4.97 24.32� 4.50 24.47� 2.25 0.42

NDI (points) 17.52� 5.06 17.88� 4.50 16.29� 4.71 0.57

Pain duration (months) 56.29� 67.74 43.39� 56.54 64.94� 62.93 0.77

Pain intensity (VAS) 5.52� 1.46 5.79� 1.89 5.52� 1.80 0.65

Medication 0.43� 0.49 0.59� 1.19 0.25� 0.38 0.36

Kinesiophobia 14.23� 6.16 13.05� 4.95 12.35� 7.70 0.36

Catastrophizing 18.47� 12.21 17.94� 11.59 17.05� 12.55 0.66

Depression 10.47� 6.62 10.33� 5.56 8.35� 4.94 0.60

Anxiety 26.41� 4.33 26.55� 5.99 25.94� 2.68 0.87

SOPA_solicitude 5.52� 3.90 5.50� 4.55 3.70� 4.93 0.23

SOPA_emotion 6.29� 3.45 6.11� 3.42 7.23� 4.03 0.75

SOPA_injury 7.70� 3.49 8.72� 3.56 9.35� 2.57 0.61

SOPA_pain control 8.64� 4.40 7.50� 2.43 8.82� 3.71 0.45

SOPA_medical procedure 8.41� 4.24 9.00� 3.56 6.82� 3.66 0.11

SOPA_disability 7.23� 3.34 6.44� 2.43 6.70� 2.28 0.60

PASS_1 26.70� 14.85 24.66� 7.49 25.47� 11.66 0.77

PASS_2 9.52� 6.00 9.55� 3.95 9.05� 5.11 0.93

FPQ 80.82� 20.61 70.11� 19.49 67.23� 14.50 0.14

CUC: control usual care; TrPDN: trigger point dry needling; PNE: pain neuroscience education; NDI: Neck Disability Index; VAS: visual analogue scale;

PPT: pressure pain threshold; SOPA: Survey of Pain Attitudes; FPQ: Fear Pain Questionnaire; BMI: body mass index; PASS: Point Pain Anxiety

Symptoms Scale.

Data are mean� SD.

Valiente-Castrillo et al. 7

Acupuncture in Medicine 0(0)

Table 2. Outcome data at baseline, post-treatment, and at 1 month and 3 months of follow-up.

CUC group

(n¼ 19)

TrPDN group

(n¼ 20)

TrPDN þ PNE group

(n¼ 21)

Between-group differences

(a) CUC vs TrPDN

(b) CUC vs TrPDN þ PNE

(c) TrPDN vs TrPDN þ PNE

Pain (VAS)

Baseline 5.26� 1.46 5.79� 1.89 5.52� 1.80

Post-treatment 3.85� 2.38 2.38� 1.85 1.17� 1.12 (a) 1.46 (0.01 to 2.92)*

(b) 2.68 (1.24 to 4.11)†

(c) 1.21 (�0.20 to 2.63)

1 month 3.57� 2.41 2.25� 2.22 1.90� 1.94 (a) 1.32 (�0.40 to 3.06)

(b) 1.67 (�0.04 to 4.11)

(c) 0.34 (�1.34 to 2.03)

3 months 3.91� 2.50 3.00� 1.73 2.47� 2.31 (a) 0.91 (�0.83 to 2.65)

(b) 1.43 (�0.28 to 3.15)

(c) 0.52 (�1.17 to 2.22)

Within-group improvement from baseline

Post-treatment 1.67 (0.09 to 2.72)* 3.40 (2.12 to 4.69)† 4.35 (3.09 to 5.60)†

After 1 month 1.95 (0.10 to 3.26)* 3.54 (1.99 to 5.08)† 3.61 (2.11 to 5.12)†

After 3 months 1.61 (�0.02 to 2.73) 2.79 (1.44 to 4.13)† 3.04 (1.73 to 4.36)†

Neck disability (NDI)

Baseline 16.78� 5.32 17.45� 4.94 15.80� 4.62

Post-treatment 14.42� 7.44 11.15� 5.84 7.57� 6.19 (a) 3.27 (�1.87 to 8.41)

(b) 6.85 (1.76 to 11.93)*

(c) 3.57 (�1.43 to 8.59)

1 month 13.21� 7.62 12.00� 5.68 7.19� 6.56 (a) 1.21 (�4.04 to 6.46)

(b) 6.02 (0.82 to 11.21)†

(c) 4.81 (�0.31 to 9.93)

3 months 13.78� 8.78 11.00� 6.06 7.57� 5.33 (a) 2.78 (�2.60 to 8.18)

(b) 6.22 (0.88 to 11.55)†

(c) 3.42 (�1.83 to 8.69)

Within-group improvement from baseline

Post-treatment 2.36 (�0.78 to 5.51) 6.30 (3.23 to 9.37)† 8.23 (5.24 to 11.23)†

After 1 month 3.58 (0.20 to 6.95)* 5.45 (2.15 to 8.74)† 8.61 (5.40 to 11.83)†

After 3 months 3.00 (�0.72 to 6.71) 6.45 (2.82 to 10.07)† 8.23 (4.70 to 11.77)†

Medication

Baseline 0.43� 0.49 0.59� 1.19 0.25� 0.38

(continued)

8 Acupuncture in Medicine

Acupuncture in Medicine 0(0)

interaction (F¼ 1.865; p¼ 0.090; g2p ¼ 0:061)

(Table 2).

Kinesiophobia

The 3� 4 mixed-model ANOVA showed statistically

significant differences in the time factor (F¼ 6.204;

p< 0.001; g2p ¼ 0:098) and a significant interaction

between group and time (F¼ 3.136; p< 0.01;

g2p ¼ 0:099). Post hoc analysis showed that the

TrDNþPNE group exhibited a greater decrease in

kinesiophobia than both the TrPDN and CUC groups

at every follow-up time point (p< 0.01) (Table 3).

Catastrophizing

The 3� 4 mixed-model ANOVA showed statistically

significant differences in the time factor (F¼ 20.420;

p< 0.0001; g2p ¼ 0:282) but did not show a significant

interaction between group and time (F¼ 1.693;

p¼ 0.126; g2p ¼ 0:061) (Table 3).

Depression

The 3� 4 mixed-model ANOVA showed statistically

significant differences in the time factor (F¼ 9.665;

p< 0.0001; g2p ¼ 0:152) but did not show group–time

interactions (F¼ 0.471; p¼ 0.733; g2p ¼ 0:017)

(Table 4).

Fear Pain Questionnaire

The 3� 4 mixed-model ANOVA showed statistically

significant differences in the time factor (F¼ 3.405;

p¼ 0.03; g2p ¼ 0:056) but did not show group–time

interactions (F¼ 0.565; p¼ 0.757; g2p ¼ 0:019)

(Table 4).

Pain anxiety

The 3� 4 mixed-model ANOVA showed statistically

significant differences in the time factor (PASS-1:

F¼ 18.578; p< 0.0001; g2p ¼ 0:246; PASS-2:

F¼ 10.671; p< 0.0001; g2p ¼ 0:158) and a significant

interaction between group and time for PASS-1

(F¼ 2.430; p¼ 0.038; g2p ¼ 0:079) but not PASS-2

(F¼ 1.796; p¼ 0.121; g2p ¼ 0:059). Post hoc analysis

showed that the TrDNþPNE group exhibited a great-

er decrease in PASS-1 than both the TrPDN and CUC

groups at every follow-up time point (p< 0.01)

(Supplemental Table 1).

Table 2. Continued

CUC group

(n¼ 19)

TrPDN group

(n¼ 20)

TrPDN þ PNE group

(n¼ 21)

Between-group differences

(a) CUC vs TrPDN

(b) CUC vs TrPDN þ PNE

(c) TrPDN vs TrPDN þ PNE

Post-treatment 0.22� 0.35 0.51� 0.69 0.09� 0.18 (a) �0.29 (�0.65 to 0.06)

(b) 0.13 (�0.22 to 0.48)

(c) 0.42 (0.07 to 0.77)

1 month 0.13� 0.19 0.30� 0.76 0.10� 0.35 (a) �0.16 (�0.56 to 0.22)

(b) 0.02 (�0.36 to 0.41)

(c) 0.19 (�0.19 to 0.57)

3 months 0.18� 0.31 0.14� 0.42 0.04� 0.10 (a) 0.04 (�0.20 to 0.28)

(b) 0.14 (�0.09 to 0.38)

(c) 0.10 (�0.13 to 0.34)

Within-group improvement from baseline

Post-treatment 0.21 (�0.14 to 0.58) 0.07 (�0.27 to 0.43)* 0.16 (�0.18 to 0.51)

After 1 month 0.30 (�0.24 to 0.85) 0.29 (�0.24 to 0.83)* 0.14 (�0.38 to 0.67)

After 3 months 0.25 (�0.20 to 0.72) 0.44 (�0.00 to 0.90)* 0.21 (�0.22 to 0.65)

CUC: control usual care; TrPDN: trigger point dry needling; PNE: pain neuroscience education; VAS: visual analogue scale; NDI: Neck Disability Index.

*p< 0.05; †p< 0.01.

Valiente-Castrillo et al. 9

Acupuncture in Medicine 0(0)

Beliefs and coping with pain

The 3� 4 mixed-model ANOVA showed statisticallysignificant differences in the time factor for the dimen-sions of solicitude (F¼ 4.675; p< 0.01; g2

p ¼ 0:077),

emotions (F¼ 4.108; p< 0.01; g2p ¼ 0:068), control

(F¼ 6.247; p< 0.01; g2p ¼ 0:099), physical harm

(F¼ 5.933; p< 0.01; g2p ¼ 0:096), disability

(F¼ 2.973; p< 0.05; g2p ¼ 0:050), and medication

Table 3. Kinesiophobia and catastrophizing outcome data at baseline, post-treatment, and at 1 month and 3 months of follow-up.

CUC group

(n ¼ 19)

TrPDN group

(n ¼ 20)

TrPDN þ PNE group

(n ¼ 21)

Between-group differences

(a) CUC vs TrPDN

(b) CUC vs TrPDN þ PNE

(c) TrPDN vs TrPDN þ PNE

Kinesiophobia

Baseline 24.15 � 6.65 24.00 � 5.43 21.42 � 8.13

Post-treatment 23.89 � 7.49 22.7 5 � 4.97 17.19 � 5.82 (a) 1.14 (�3.72 to 6.01)

(b) 6.70 (1.89 to 11.51)†

(c) 5.56 (�0.81 to 10.30)*

1 month 24.00 � 8.18 22.65 � 5.56 17.28 � 6.72 (a) 1.35 (�4.08 to 6.78)

(b) 6.71 (1.34 to 12.08)†

(c) 5.36 (0.61 to 10.66)*

3 months 24.84 � 7.50 21.85 � 5.20 18.80 � 5.32 (a) 2.99 (�1.79 to 7.78)

(b) 8.03 (3.29 to 12.76)†

(c) 5.04 (0.37 to 9.71)*

Within-group improvement from baseline

Post-treatment 0.26 (�2.38 to 2.90) 1.25 (�1.32 to 3.82) 4.23 (1.72 to 6 to 75)†

After 1 month 0.16 (�2.88 to 3.19) 1.35 (�1.61 to 4.31) 4.14 (1.25 to 7.03)†

After 3 months �0.68 (�3.85 to 2.48) 2.15 (�0.94 to 5.24) 4.61 (1.60 to 7.63)†

Catastrophizing

Baseline 19.41 � 11.37 16.95 � 11.39 16.55 � 12.36

Post-treatment 16.17 � 13.14 12.15 � 10.45 6.72 � 6.49 (a) 4.02 (�4.41 to 12.46)

(b) 9.45 (0.80 to 18.10)

(c) 5.42 (�2.88 to 13.74)

1 month 12.70 � 10.95 12.10 � 11.01 7.33 � 7.90 (a) 0.60 (�7.62 to 8.83)

(b) 5.37 (�3.06 to 13.81)

(c) 4.76 (�3.34 to 12.87)

3 months 14.70 � 10.26 11.75 � 10.48 6.61 � 7.86 (a) 2.95 (�4.90 to 10.81)

(b) 8.09 (0.03 to 12.88)

(c) 5.13 (�2.60 to 12.88)

Within-group improvement from baseline

Post-treatment 3.23 (�3.13 to 9.60) 4.80 (�1.07 to 10.67) 9.83 (3.64 to 16.02)†

After 1 mo 6.70 (1.09 to 12.31)† 4.85 (�0.31 to 10.01) 9.22 (3.77 to 14.67)†

After 3 mo 4.70 (�0.78 to 10.19) 5.20 (0.14 to 10.25)* 9.94 (4.61 to 15.27)†

CUC: control usual care; TrPDN: trigger point dry needling; TrPDNþ PNE: pain neuroscience education.

*p< 0.05; †p< 0.01.

10 Acupuncture in Medicine

Acupuncture in Medicine 0(0)

(F¼ 4.191; p< 0.01; g2p ¼ 0:070), but not medical care

(F¼ 0.126; p¼ 0.945; g2p ¼ 0:002) (Supplemental

Tables 2–4).No group–time interactions were identified for the

dimensions of solicitude (F¼ 0.613; p¼ 0.719;

g2p ¼ 0:021), emotions (F¼ 0.326; p¼ 0.923;

g2p ¼ 0:011), medical care (F¼ 0.713; p¼ 0.640;

g2p ¼ 0:025), and disability (F¼ 1.743; p¼ 0.114;

g2p ¼ 0:059).

Table 4. Depression and Fear Pain Questionnaire outcome data at baseline, post-treatment, and at 1 month and 3 months offollow-up.

CUC group

(n ¼ 19)

TrPDN group

(n ¼ 20)

TrPDN þ PNE group

(n ¼ 21)

Between-group differences

(a) CUC vs TrPDN

(b) CUC vs TrPDN þ PNE

(c) TrPDN vs TrPDN þ PNE

Depression

Baseline 10.11 � 6.60 10.05 � 5.54 8.10 � 4.65

Post-treatment 8.77 � 9.81 6.57 � 4.92 4.50 � 4.94 (a) 2.19 (�3.37 to 7.77)

(b) 4.27 (�1.22 to 9.78)

(c) 2.07 (�3.34 to 7.50)

1 month 8.05 � 9.90 5.94 � 4.66 4.30 � 4.31 (a) 2.10 (�3.32 to 7.54)

(b) 3.75 (�1.61 to 9.12)

(c) 1.64 (�3.64 to 6.94)

3 months 8.38 � 9.84 6.31 � 4.95 4.75 � 4.92 (a) 2.07 (�3.51 to 7.65)

(b) 3.63 (�1.87 to 9.15)

(c) 1.56 (�3.87 to 7.00)

Within-group improvement from baseline

Post-treatment 1.33 (�2.91 to 5.57) 3.47 (�0.65 to 7.60) 3.60 (�0.42 to 7.62)

After 1 month 2.05 (�1.95 to 6.06) 4.10 (0.20 to 8.00)* 3.80 (�0.00 to 7.60)*

After 3 months 1.72 (�2.74 to 6.19) 3.73 (�0.61 to 8.08) 3.35 (�0.89 to 7.59)

Fear Pain Questionnaire

Baseline 78.21 � 21.04 69.20 � 20.33 66.61 � 15.31

Post-treatment 78.47 � 19.77 64.85 � 20.25 60.28 � 15.65 (a) 13.62 (�1.08 to 28.32)

(b) 18.18 (3.65 to 32.72)

(c) 4.56 (�9.77 to 18.90)

1 month 74.78 � 22.09 65.80 � 20.07 60.85 � 15.65 (a) 8.98 (�6.30 to 24.28)

(b) 13.93 (�1.18 to 29.04)

(c) 4.94 (�9.97 to 19.85)

3 months 75.63 � 23.48 64.05 � 18.20 60.14 � 16.43 (a) 11.58 (�3.81 to 26.97)

(b) 15.48 (0.27 to 30.70)

(c) 3.90 (�11.10 to 18.91)

Within-group improvement from baseline

Post-treatment �0.26 (�9.30 to 8.78) 4.35 (�4.46 to 13.16) 6.33 (�2.27 to 14.93)

After 1 month 3.42 (�6.21 to 13.05) 3.40 (�5.99 to 12.79) 5.76 (�3.40 to 14.92)

After 3 months 2.57 (�6.31 to 11.47) 5.15 (�3.51 to 13.81) 6.47 (�1.98 to 14.93)

CUC: control usual care; TrPDN: trigger point dry needling; TrPDNþ PNE: pain neuroscience education.

*p< 0.05.

Valiente-Castrillo et al. 11

Acupuncture in Medicine 0(0)

Significant group–time interactions were observedfor the dimensions of pain control (F¼ 6.402;p< 0.001; g2

p ¼ 0:183), physical harm (F¼ 2.281;p< 0.05; g2

p ¼ 0:075), and medication (F¼ 2.127;p< 0.05; g2

p ¼ 0:071). Post hoc analysis showed thatthe TrDNþPNE group exhibited a greater improve-ment than the TrPDN and CUC groups at 1 month(p< 0.01) and 3 months (p< 0.05) of follow-up in thecontrol dimension. The TrDNþPNE group alsoexhibited a greater improvement than the CUC groupin the physical harm dimension at every follow-up timepoint (p< 0.01) and, finally, post hoc analysis showedthat the TrDNþPNE group exhibited a greaterimprovement than the TrPDN group post-treatment(p< 0.01) in the medication dimension.

Discussion

All groups showed significant improvements in chronicnon-specific neck pain during the follow-up, but thiseffect was not observed after 3 months in the CUCgroup. Deep DN (in both groups receiving it) was asso-ciated with greater immediate improvements in painand disability when compared with CUC; however,these differences were not observed at 1 month or 3months of follow-up. The integration of PNE withdeep DN led to significant reductions in kinesiophobia,anxiety, and pain attitudes regarding pain control,physical harm, and medication.

Pain intensity and disability

TrPDN alone or combined with PNE led to greaterimprovements in pain than CUC immediately aftertreatment. These differences were not observed 1 or 3months later. The mean neck pain improvements weresuperior to the MCID in the TrPDN andTrPDNþPNE groups, whereas the mean painimprovements in the CUC group did not reach theMCID at any of the follow-up time points. The pro-portion of subjects with clinically relevant improve-ments the TrPDNþPNE group was superior to theCUC group at all follow-up points.

In this context, to our knowledge, there is only onestudy with similar methodology, where various sessionsof DN eliciting multiple LTRs were applied to variousmuscles with active MTrPs in chronic non-specific neckpain patients with medium-term (6-month) follow-up.12 Cerezo-T�ellez et al.12 observed that DN pluspassive stretching was more effective than passivestretching alone, and associated with clinically mean-ingful improvements in neck pain and disability in themedium and long term.

However, this study compared a DN interventionwith another conservative treatment (electrotherapy)

so the between-group analysis could not be directlycompared. Our results also seem to show that theeffect of DN is superior to other conservative treat-ment, but the relevance of these differences is lessclear and limited to the immediate effect when consid-ering improvements in neck pain. Despite the fact that“conservative treatment” usually means expectantmanagement, our conservative treatment groupreceived electrotherapy, which may be considered an“active” intervention, due to the fact that electrothera-py is standard care and presumably effective.26

Therefore, the total effect size of TrPDN is likely tohave been underestimated.

The observed effect of DN could be attributed to themultiple neurophysiologic effects previously sug-gested,14 such as the mechanical disruption of the dys-functional endplates of the MTrP,13 the reduction ofsubstances associated with peripheral sensitization,47,48

the effects of activating central desensitization mecha-nisms, and the activation of inhibitory dorsal horninterneurons or the opioidergic descending inhibitorysystem.14,49

The addition of PNE to DN did not generate greatereffects on pain and disability compared to DN alone.Previous preliminary research in chronic low back painhas shown similar results, since patients receiving DNalone or combined with PNE experienced similarimprovements in pain and disability in the short term.20

However, the inclusion of PNE did seem to be asso-ciated with clinical benefit, according to other observedimprovements. The proportion of patients in theTrPDNþPNE group with improvements in neckpain intensity superior to the MCID was significantlygreater than those of the DN-only group immediatelyafter treatment and at every follow-up time point. Inaddition, only in the TrPDNþPNE group wereimprovements in the NDI superior to those observedin the CUC group, reaching the MCID of 7 points.Previous research has found that PNE might be effec-tive for musculoskeletal pain and reduce disabilitylevels,16,18 especially when combined with othermanual therapy or exercise strategies.18 However,only a few studies have investigated its effectivenessin patients with non-specific neck pain.50–52 Beltran-Alacreu et al.50 observed that PNE improved the effec-tiveness of manual therapy in terms of neck disabilitywhen incorporated into a multimodal approach inchronic non-specific neck patients.

Psychological factors

Here, we showed that PNE may reduce kinesiophobia,pain anxiety, and pain attitudes concerning pain con-trol, physical harm, and medication. Furthermore,these psychological factor differences reached the

12 Acupuncture in Medicine

Acupuncture in Medicine 0(0)

minimal detectable change for the TSK-11 (5.6

points),36 PASS-1 (8.23 points),53 and SOPA subscales

(0.20 points).54 Despite a lack of studies of PNE in

conjunction with TrPDN in patients with neck pain,

Beltran-Alacreu et al.50 showed that PNE combined

with a multimodal approach of manual therapy and

exercise might improve kinesiophobia and reach the

minimal detectable change in patients with chronic

neck pain.Previous preliminary research in patients with

chronic low back pain has also investigated the effects

of the inclusion of PNE with TrPDN. In accordance

with the current investigation, T�ellez-Garc�ıa et al.20

determined that patients treated with TrPDN com-

bined with PNE experienced a greater reduction of

kinesiophobia than those treated only with TrPDN.

They investigated these differences in the short term

(1 week), while in this study we also observed the

increased effect of PNE on kinesiophobia 1 month

and 3 months after treatment. The protocol of PNE

used in the study of T�ellez-Garc�ıa et al.20 shared similar

characteristics with this study, since they included 2–3

sessions of 30 min of PNE over 2 weeks and provided

face-to-face individual education focused on the neuro-

physiology of pain and the role of beliefs and attitudes

toward their pain.

Limitations and future research recommendations

This study has some limitations. First, we did not

include a placebo group to blind the patients to

group allocation or a control group without treatment.

Second, we only collected outcomes over a short-term

follow-up period (3 months). Third, we used TrPDN

alone or in combination with PNE, whereas physical

therapists usually apply a multimodal approach in clin-

ical practice.55 Fourth, we did not include a group

receiving PNE alone, which could otherwise have

allowed us to investigate the specific effect of PNE by

comparison with the other groups. Fifth, the study

population showed certain clinical characteristics and

predominantly comprised women, who may have dif-

ferent pain perception and responses to treatment.56

Finally, post-needling soreness was not considered

and could have been influenced by the role of psycho-

logical factors and PNE.57

Future research is needed to determine the effects of

TrPDN combined with PNE in the medium and long

term, compared with control groups receiving no treat-

ment or placebo. In addition, future studies with large

sample sizes should include other variables such as

muscle strength, cervical range of motion, or pressure

pain threshold.

Conclusion

TrPDN was effective at improving pain and disability.

Furthermore, the inclusion of PNE resulted in a reduc-

tion of kinesiophobia and pain anxiety and positively

impacted pain beliefs, coping with pain control, phys-

ical harm, and medication in the short term for patients

with mechanical neck pain.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with

respect to the research, authorship, and/or publication of this

article.

Funding

The authors received no financial support for the research,

authorship, and/or publication of this article.

Ethics committee board

This study was planned in accordance with the ethical prin-

ciples of the Declaration of Helsinki and approved by the

Ethics Committee of the Hospital of Universitario La Paz,

Madrid, Spain (code-HULP:4255).

Public trial registry

This clinical trial was registered in the US National Institutes

of Health Clinical Trials Registry at ClinicalTrials.gov (reg-

istration no. NCT03095365).

ORCID iD

Hector Beltran-Alacreu https://orcid.org/0000-0002-1971-

1510

Supplemental material

Supplemental material for this article is available online.

References

1. Murray CJL. The state of US health, 1990-2010. JAMA 2013;

310(6): 591–608.

2. Fejer R, Kyvik KO and Hartvigsen J. The prevalence of neck

pain in the world population: a systematic critical review of the

literature. Eur Spine J 2006; 15(6): 834–848.

3. Binder A. The diagnosis and treatment of nonspecific neck pain

and whiplash. Eura Medicophys 2007; 43(1): 79–89.

4. Merskey H and Bogduk N. Classification of chronic pain. Seattle,

WA: IASP Press, 1994.

5. Sterling M. Neck pain: much more than a psychosocial condi-

tion. J Orthop Sports Phys Ther 2009; 39(5): 309–311.

6. Bogduk N. Neck pain. Aust Fam Physician 1984; 13: 26–30.

7. Simons DG and Travell JGSL. Myofascial pain and dysfunction.

The trigger point manual, vol. 1. 2nd ed. Baltimore: Williams &

Wilkins, 1999.

8. Cerezo-T�ellez E, Torres-Lacomba M, Mayoral-del Moral O,

et al. Prevalence of myofascial pain syndrome in chronic non-

specific neck pain: a population-based cross-sectional descriptive

study. Pain Med 2016; 17(12): 2369–2377.

Valiente-Castrillo et al. 13

Acupuncture in Medicine 0(0)

9. Fernandez-de-las-Pe~nas C, Alonso-Blanco C and Miangolarra

JC. Myofascial trigger points in subjects presenting with mechan-

ical neck pain: a blinded, controlled study.Man Ther 2007; 12(1):

29–33.

10. Liu L, Huang Q-M, Liu Q-G, et al. Effectiveness of dry needling

for myofascial trigger points associated with neck and shoulder

pain: a systematic review and meta-analysis. Arch Phys Med

Rehabil 2015; 96: 944–955.

11. Dommerholt J, Mayoral del Moral O and Brobli C. Trigger

point dry needling. J Man Manip Ther 2006; 14: 70–87.

12. Cerezo-T�ellez E, Torres-Lacomba M, Fuentes-Gallardo I, et al.

Effectiveness of dry needling for chronic nonspecific neck pain: a

randomized, single-blinded, clinical trial. Pain 2016; 157(9):

1905–1917.

13. Domingo A, Mayoral O, Monterde S, et al. Neuromuscular

damage and repair after dry needling in mice. Evid Based

Complement Alternat Med 2013; 2013: 260806.

14. Cagnie B, Dewitte V, Barbe T, et al. Physiologic effects of dry

needling. Curr Pain Headache Rep 2013; 17(8): 348.

15. Moseley L. Combined physiotherapy and education is efficacious

for chronic low back pain. Aust J Physiother 2002; 48(4):

297–302.

16. Louw A, Diener I, Butler DS, et al. The effect of neuroscience

education on pain, disability, anxiety, and stress in chronic mus-

culoskeletal pain. Arch Phys Med Rehabil 2011; 92: 2041–2056.

17. Louw A, Puentedura E and Zimney K. Teaching patients about

pain: it works, but what should we call it? Physiother Theory

Pract 2016; 32(5): 328–331.

18. Louw A, Zimney K, Puentedura EJ, et al. The efficacy of pain

neuroscience education on musculoskeletal pain: a systematic

review of the literature. Physiother Theory Pract 2016; 32(5):

332–355.

19. Geneen LJ, Martin DJ, Adams N, et al. Effects of education to

facilitate knowledge about chronic pain for adults: a systematic

review with meta-analysis. Syst Rev 2015; 4: 132.

20. T�ellez-Garc�ıa M, de-la-Llave-Rinc�on AI, Salom-Moreno J, et al.

Neuroscience education in addition to trigger point dry needling

for the management of patients with mechanical chronic low

back pain: a preliminary clinical trial. J Bodyw Mov Ther 2015;

19(3): 464–472.

21. Anandkumar S. Effect of pain neuroscience education and dry

needling on chronic elbow pain as a result of cyberchondria: a

case report. Physiother Theory Pract 2015; 31: 207–213.

22. Cobos-Carb�o A and Augustovski F. Declaraci�on CONSORT

2010: actualizaci�on de la lista de comprobaci�on para informar

ensayos cl�ınicos aleatorizados de grupos paralelos. Med Clin

(Barc) 2011; 137: 213–215.

23. Mu~noz-Garc�ıa D, Lopez-Uralde-Villanueva I, Beltran-Alacreu

H, et al. Patients with concomitant chronic neck pain and myo-

fascial pain in masticatory muscles have more widespread pain

and distal hyperalgesia than patients with only chronic neck pain.

Pain Med 2017; 18: 526–537.

24. Travell J and Simons D. Dolor y Disfunci�on Miofascial. El

Manual de los Puntos Gatillo. Volumen 1. Mitad Superior del

Cuerpo. Madrid: Panamericana M�edica, 2002.

25. Wolfe F, Clauw DJ, Fitzcharles M-A, et al. The American

College of Rheumatology preliminary diagnostic criteria for

fibromyalgia and measurement of symptom severity. Arthritis

Care Res (Hoboken) 2010; 62(5): 600–610.

26. Kroeling P, Gross A, Graham N, et al. Electrotherapy for neck

pain. Cochrane Database Syst Rev 2013; 2013: CD004251.

27. Hong CZ. Lidocaine injection versus dry needling to myofascial

trigger point. The importance of the local twitch response. Am J

Phys Med Rehabil 1994; 73: 256–263.

28. Jensen MP, Karoly P and Braver S. The measurement of clinical

pain intensity: a comparison of six methods. Pain 1986; 27(1):

117–126.

29. Jensen MP, Turner JA, Romano JM, et al. Comparative reliabil-

ity and validity of chronic pain intensity measures. Pain 1999; 83:

157–162.

30. Dworkin RH, Turk DC, Wyrwich KW, et al. Interpreting the

clinical importance of treatment outcomes in chronic pain clini-

cal trials: IMMPACT recommendations. J Pain 2008; 99(2):

105–121.

31. Vernon H. The Neck Disability Index: state-of-the-art, 1991-

2008. J Manipulative Physiol Ther 2008; 31(7): 491–502.

32. MacDermid JC, Walton DM, Avery S, et al. Measurement prop-

erties of the neck disability index: a systematic review. J Orthop

Sports Phys Ther 2009; 39: 400–417.

33. Andrade Ortega JA, Delgado Mart�ınez AD and Alm�ecija Ruiz

R. Validation of the Spanish version of the Neck Disability

Index. Spine (Phila Pa 1976) 2010; 35: E114–E118.

34. G�omez-P�erez L, L�opez-Mart�ınez AE and Ruiz-Parraga GT.

Psychometric properties of the Spanish version of the Tampa

Scale for Kinesiophobia (TSK). J Pain 2011; 12(4): 425–435.

35. Roelofs J, Goubert L, Peters ML, et al. The Tampa Scale for

Kinesiophobia: further examination of psychometric properties

in patients with chronic low back pain and fibromyalgia. Eur J

Pain 2004; 8: 495–502.

36. Hapidou EG, O’Brien MA, Pierrynowski MR, et al. Fear and

avoidance of movement in people with chronic pain: psychomet-

ric properties of the 11-item Tampa Scale for Kinesiophobia

(TSK-11). Physiother Can 2012; 64: 235–241.

37. Garc�ıa Campayo J, Rodero B, Alda M, et al. Validation of the

Spanish version of the Pain Catastrophizing Scale in fibromyal-

gia. Med Clin (Barc) 2008; 131: 487–492.

38. B€orsbo B, Peolsson M and Gerdle B. Catastrophizing, depres-

sion, and pain: correlation with and influence on quality of life

and health—a study of chronic whiplash-associated disorders.

J Rehabil Med 2008; 40(7): 562–569.

39. M€antyselk€a P, Lupsakko T, Kautiainen H, et al. Neck-shoulder

pain and depressive symptoms: a cohort study with a 7-year

follow-up. Eur J Pain 2010; 14: 189–193.

40. Yalcinkaya H, Ucok K, Ulasli AM, et al. Do male and female

patients with chronic neck pain really have different health-

related physical fitness, depression, anxiety and quality of life

parameters? Int J Rheum Dis 2017; 20: 1079–1087.

41. Sol�e E, Castarlenas E, Sanchez-Rodr�ıguez E, et al. The reliability

and validity of the Spanish version of the Fear of Pain

Questionnaire. J Health Psychol 2019; 24: 1134–1144.

42. Tait RC and Chibnall JT. Development of a brief version of the

Survey of Pain Attitudes. Pain 1997; 70(2–3): 229–235.

43. Roelofs J, McCracken LM, Peters ML, et al. Psychometric eval-

uation of the Pain Anxiety Symptoms Scale (PASS) in chronic

pain patients. J Behav Med 2004; 27: 167–183.

44. Abrams MP, Carleton RN and Asmundson GJG. An explora-

tion of the psychometric properties of the PASS-20 with a non-

clinical sample. J Pain 2007; 8(11): 879–886.

45. L�opez-Mart�ınez AE, Esteve-Zarazaga R and Ram�ırez-Maestre

C. The Spanish version of the Pain Anxiety Symptoms Scale

(PASS-20): preliminary data on its reliability, validity and facto-

rial structure. Eur J Pain Suppl 2011; 5: 265.

46. Faul F, Erdfelder E, Lang A-G, et al. G*Power 3: a flexible

statistical power analysis program for the social, behavioral,

and biomedical sciences. Behav Res Methods 2007; 39: 175–191.

47. Hsieh Y-L, Yang S-A, Yang C-C, et al. Dry needling at myofas-

cial trigger spots of rabbit skeletal muscles modulates the bio-

chemicals associated with pain, inflammation, and hypoxia. Evid

Based Complement Alternat Med 2012; 2012: 342165.

14 Acupuncture in Medicine

Acupuncture in Medicine 0(0)

48. Shah JP and Gilliams EA. Uncovering the biochemical milieu of

myofascial trigger points using in vivo microdialysis: an applica-

tion of muscle pain concepts to myofascial pain syndrome.

J Bodyw Mov Ther 2008; 12(4): 371–384.

49. Hsieh Y-L, Yang C-C, Liu S-Y, et al. Remote dose-dependent

effects of dry needling at distant myofascial trigger spots of

rabbit skeletal muscles on reduction of substance P levels of

proximal muscle and spinal cords. Biomed Res Int 2014; 2014:

982121.

50. Beltran-Alacreu H, L�opez-de-Uralde-Villanueva I, Fernandez-

Carnero J, et al. Manual therapy, therapeutic patient education,

and therapeutic exercise, an effective multimodal treatment of

nonspecific chronic neck pain. Am J Phys Med Rehabil 2015;

94: 887–897.

51. Derebery J, Giang GM, Gatchel RJ, et al. Efficacy of a patient-

educational booklet for neck-pain patients with workers’ com-

pensation: a randomized controlled trial. Spine (Phila Pa 1976)

2009; 34: 206–213.

52. Moffett JK, Jackson DA, Gardiner ED, et al. Randomized trial

of two physiotherapy interventions for primary care neck and

back pain patients: “McKenzie” vs brief physiotherapy pain

management. Rheumatology 2006; 45: 1514–1521.

53. Shanbehzadeh S, Salavati M, Tavahomi M, et al. Reliability and

validity of the Pain Anxiety Symptom Scale in Persian speaking

chronic low back pain patients. Spine 2017; 42: 1.

54. Duquette J, McKinley PA and Litowski J. Test-retest reliability

and internal consistency of the Quebec-French version of the

Survey of Pain Attitudes. Arch Phys Med Rehabil 2005; 86(4):

782–788.

55. Segura-P�erez M, Hernandez-Criado T, Calvo-Lobo C, et al. A

multimodal approach for myofascial pain syndrome: a prospec-

tive study. J Manipulative Physiol Ther 2017; 40: 397–403.

56. Fillingim RB, King CD, Ribeiro-Dasilva MC, et al. Sex, gender,

and pain: a review of recent clinical and experimental findings.

J Pain 2009; 10: 447–485.

57. Mart�ın-Pintado-Zugasti A, L�opez-L�opez A, Gonzalez Guti�errezJL, et al. The role of psychological factors in the perception of

postneedling soreness and the influence of postneedling interven-

tion. PM&R 2017; 9: 348–355.

Valiente-Castrillo et al. 15

Acupuncture in Medicine 0(0)