EFFECT OF DRY NEEDLING ON SPASTICITY,

SHOULDER RANGE OF MOTION, AND PRESSURE

PAIN SENSITIVITY IN PATIENTS WITH STROKE: A
CROSSOVER STUDY
Ana Mendigutia-Gómez, PT, PhD, a Carolina Martín-Hernández, PT, a Jaime Salom-Moreno, PT, PhD, b c and
César Fernández-de-las-Peñas, PT, PhD b c
ABSTRACT

Objective: The purpose of this study was to determine the effects of the inclusion of deep dry needling (DDN) in
spastic shoulder muscles into a rehabilitation program on spasticity, pressure pain sensitivity, and shoulder range of
motion in subjects who had experienced a stroke.
Methods: A controlled, repeated-measures, crossover, double-blinded, randomized trial was conducted. Twenty
patients who have had a stroke were randomly assigned to receive rehabilitation alone or rehabilitation combined with
DDN over the upper trapezius, infraspinatus, subscapularis, and pectoralis mayor muscles on the spastic shoulder.
Subjects received both interventions separated at least 15 days apart. Each intervention was applied once per week
over 3 weeks. Spasticity (Modified Ashworth Scale), pressure pain thresholds over the deltoid and infraspinatus
muscles and C5-C6 zygapophyseal joint, and shoulder range of motion were collected 1 week before and 1 week after
each intervention by a blinded assessor.
Results: Reduction in spasticity was similar after both conditions for the upper trapezius, pectoralis major, and
subscapularis muscles. A greater number of individuals receiving DDN exhibited decreased spasticity within the
infraspinatus muscle. The analysis of covariance showed that all pressure pain thresholds, shoulder abduction, and
external rotation of the shoulder increased significantly more after DNN intervention (P b .05). Shoulder flexion
showed similar changes after both conditions.
Conclusions: Our results suggest that inclusion of DDN into a multimodal rehabilitation program was effective for
decreasing localized pressure sensitivity and improving shoulder range of motion in individuals who had experienced
stroke; however, we did not observe significant differences in muscle spasticity. (J Manipulative Physiol Ther
2016;xx:1-11)
Key Indexing Terms: Stroke; Muscle Spasticity; Pain Threshold; Range of Motion; Shoulder

a
Clinical Researcher, Department of Physical Therapy/Reha-
bilitation, Hospital Beata María Ana, Madrid, Spain.
b
Professor, Department of Physical Therapy, Occupational
Therapy, Physical Medicine and Rehabilitation of Universidad
Rey Juan Carlos, Alcorcón, Spain.
c
Professor, Cátedra de Investigación y Docencia en Fisioter-
apia: Terapia Manual y Punción Seca, Universidad Rey Juan
Carlos, Alcorcón, Madrid, Spain.
Submit requests for reprints to: César Fernández-de-las-Peñas,
PT, PhD, Professor, Departamento de Fisioterapia, Facultad de
Ciencias de la Salud, Universidad Rey Juan Carlos, Avenida de
Atenas s/n, 28922 Alcorcón, Madrid, Spain.
(e-mail: cesar.fernandez@urjc.es8 cesarfdlp@yahoo.es).
Paper submitted September 5, 2015; in revised form March 31,
2016; accepted April 17, 2016.
0161-4754
Copyright © 2016 by National University of Health Sciences.
http://dx.doi.org/10.1016/j.jmpt.2016.04.006
INTRODUCTION
Stroke is a disabling condition with an estimated annual
incidence ranging from 144 to 148 per 100,000 people 1,2 A
systematic review found that men suffered from stroke
more frequently than women; however, large variations
between populations were observed. 3 Although stroke has
dropped from being the third main leading cause of death to
the fourth cause, 4 it still remains the main cause of physical
disability, particularly due to the presence of spasticity
because subjects with spasticity exhibit lower motor
activity performance than those without. 5
Spasticity was defined as “a motor disorder characterized
by velocity-dependent increase in tonic stretch reflexes
(muscle tone) with exaggerated tendon jerks, resulting from
hyper-excitability of stretch reflexes, as a main component
of upper motoneuron syndrome.” 6 The prevalence of
spasticity reaches 43% at 6 months after a first-ever
stroke 7 and 38% at 1 year after stroke. 8 It seems that the
2 Mendigutia-Gómez et al
Dry Needling in Patients With Stroke
primary lesion in subjects with spasticity is neural in origin;
however, increasing evidence suggests profound secondary
changes in the muscles due to muscle contractures
occurring secondary to spasticity. In fact, some studies
had observed that spastic musculature shows decreased
mitochondrial volume fraction, appearance of intracellular
amorphous material, reduction in muscle fiber length, and
decrease in the number of serial sarcomeres within muscle
fibers. 9,10
Several therapeutic approaches can be proposed for the
management of spastic muscles. Intramuscular botulinum
toxin A (BTX-A) injection is the most popular tool for the
management of spasticity. 11 A meta-analysis found that
application of BTX-A in patients who had experienced a
stroke was associated with moderate improvements in
upper extremity performance. 12 Because some subjects
exhibit allergic responses to BTX-A, the use of other
needling therapies, such us acupuncture or dry needling, for
the management of poststroke spasticity has been proposed.
A recent meta-analysis showed that acupuncture signifi-
cantly decreased wrist, knee, and elbow spasticity in
patients who had experienced a stroke. 13
On the contrary, evidence for the application of dry
needling in neurological conditions is still lacking. An old
study found that inclusion of dry needling into an early
rehabilitation program was effective for improving pain
outcomes in hemiparetic shoulder pain. 14 The only
randomized clinical trial on dry needling and spasticity
found that dry needling was effective for decreasing
spasticity in the leg muscles and pressure pain hypersen-
sitivity in individuals with poststroke spasticity. 15 Howev-
er, evidence on the upper extremity is related to case reports
including a patient who had experienced a stroke 16 or a
4-year-old child suffering from spastic tetraparesia. 17
To our knowledge, no previous study has investigated
the effects of deep dry needling (DDN) in patients with
poststroke spasticity in the upper extremity. Hence, the
purpose of this randomized clinical trial was to determine
the effects of the inclusion of DDN in spastic shoulder
muscles into a rehabilitation program on spasticity, pressure
pain sensitivity, and shoulder range of motion in individuals
who had suffered a stroke. We hypothesized that individ-
uals receiving DDN into their rehabilitation program will
exhibit greater improvements in spasticity, pressure pain
sensitivity, and range of motion than those patients
receiving only the rehabilitation program.
METHODS
Design
A controlled, repeated -measures, cros-over, double-
blinded, randomized study was conducted (registered
ClinicalTrials.gov, NCT02377804). The study protocol
was approved by the human research committee of the
Journal of Manipulative and Physiological Therapeutics
Month 2016
Hospital Beata María Ana, Spain (URJC-HBMA), and all
subjects signed an informed consent before participation in
the study.
Participants
Consecutive subjects who had experienced a stroke were
screened for eligibility criteria from January 2014 to March
2015. To be included, participants must have met the
following criteria: (1) first-ever unilateral stroke, (2)
hemiplegia resulting from stroke, (3) age between 40 and
65 years old, (4) presence of hypertonicity in the upper
extremity, and (5) restricted range of motion of the
shoulder. They were excluded if they exhibited any of the
following: (1) recurrent stroke; (2) previous treatment with
nerve blocks and/or motor point injections with neurolytic
agents for spasticity; (3) previous treatment with BTX-A
within the 6 months before the study; (4) severe cognitive
deficits; (5) progressive or severe neurologic diseases, for
example, heart conditions, unstable hypertension, or
fracture or implants in the lower extremity; (6) fear of
needles; or (70 any contraindication for DDN, e.g.,
anticoagulants, infections, bleeding, or psychotic.
Spasticity: Modified Modified Ashworth Test
Muscle spasticity was evaluated with the Modified
Modified Ashworth Scale (MMAS) 18 in the following
muscles: upper trapezius, subescapular, infraspinatus, and
pectoralis mayor. The examiner passively moved the upper
extremity in the stretching direction of each muscle (ie,
shoulder depression, shoulder external rotation, shoulder
internal rotation, and shoulder abduction at 90° with external
rotation, respectively) back and forth at least 5 times and
evaluated the degree of resistance to the movement on a scale
from 0 to 4. The MMAS is a modification of the modified
Ashworth scale, 19 which is the most commonly scale used for
assessing spasticity, 20 where the grade “1+" is omitted and
the grade “2" is redefined.
In the MMAS, spasticity is scored on an ordinal scale
from 0 to 4 as follows: 0, no increase in muscle tone; 1,
slight increase in muscle tone (minimal resistance at the end
of the range of motion); 2, marked increase in muscle tone
(resistance throughout the range of motion, but some
sections are easily moved); 3, considerable increase in
muscle tone (passive movement difficult throughout the full
range of motion); or 4, affected part(s) rigid. The MMAS
has exhibited good intraexaminer (kappa = 0.84) 21 and
interexaminer (kappa = 0.74) 22 reliability for assessing
spasticity in the upper extremity musculature in patients
with a stroke.
Shoulder Range of Motion
A universal goniometer was used to determine the
participant’s shoulder range of motion. Because patients
Journal of Manipulative and Physiological Therapeutics
Volume xx, Number
Fig 1. Manual technique for decreasing tone applied on the pectoralis major muscle.
with stroke can exhibit some difficulties to maintain the
upper extremity by themselves, the clinician assisted all
movements. All measures were conducted following the
international guidelines. 23 The universal goniometer has
exhibited good intrarrater reliability (intraclass correlation
coefficient, 0.91-0.99) if consistent anatomical landmarks
are used. 24 In general, it is accepted that a change of 6°-11°
is needed to consider that a change has occurred with
goniometric measurements of the shoulder. 25
Shoulder range of motion was assessed in flexion,
abduction, and external rotation. Three measurements of
each movement were recorded, and the average was
calculated for data analyses.
Pressure Pain Thresholds
Pressure pain thresholds (PPTs), defined as the amount of
pressure applied for the pressure sensation first change to pain
sensation, 26 was assessed with a mechanical pressure
algometer (Pain Diagnosis and Treatment Inc, New York,
NY) unilaterally over affected infraspinatus and deltoid
muscles, and bilaterally over the C5/C6 zygapophyseal joint.
Participants were instructed to press a switch when the
sensation first changed from pressure to pain. The mean of 3
Mendigutia-Gómez et al 3
Dry Needling in Patients With Stroke
trials was calculated, converted to kilopascal (SI unit), and used
for analysis. A 30-second resting period was allowed between
each trial. This algometer has shown high intraexaminer and
interexaminer reliability (intraclass correlation coefficient,
0.80-0.97) for PPT assessment in patients with pain. 27,28 No
reliability available data exist for patients with spasticity
Rehabilitation Intervention
Participants received in both intervention assignments 3
sessions, once per week, of best-evidence rehabilitation
program for spasticity in patients who had experienced a
stroke. A Cochrane review concluded that no single
rehabilitation approach is more effective in promoting
recovery of function and mobility after a stroke. 29 In fact,
several interventions, for example, unilateral arm training,
Bobath therapy, strength training, repetitive task training,
muscle stretching, and positioning, may be effective for
improving function in these patients. 30 Therefore, all
participants received unilateral arm training focusing on
decreased muscle tone (Fig 1), passive positioning of the
shoulder girdle (Fig 2), and repetitive task training exercises
(Fig 3). The session had a duration approximately of
45 minutes.
4 Mendigutia-Gómez et al Journal of Manipulative and Physiological Therapeutics
Dry Needling in Patients With Stroke Month 2016

Fig 2. Modulatory intervention for positioning of the shoulder girdle.

Fig 3. Repetitive task training exercise of the upper extremity.

Journal of Manipulative and Physiological Therapeutics
Volume xx, Number
Fig 4. Deep dry needling applied over taut bands within the upper trapezius (A), infraspinatus (B), subscapularis (C), and pectoralis
mayor (D) muscles.
Deep Dry Needling
Patients assigned to the experimental intervention re-
ceived DDN with disposable stainless steel needles (0.3 mm
× 50 mm, Novasan) that were inserted into the skin over taut
bands of the upper trapezius (Fig 4A), infraspinatus (Fig 4B),
subscapularis (Fig 4C), and pectoralis mayor (Fig 4D)
muscles. In the current study, the fast-in and fast-out
technique described by Hong 31 was applied. Once the most
painful spot was located within a palpable spastic taut band
with pincer palpation within the upper trapezius or pectoralis
mayor, or with flat palpation in the infraspinatus or
subscapularis muscles, the overlying skin was cleaned with
alcohol. The needle was inserted, penetrating the skin about
15-20 mm, until the first local twitch response (LTR) was
obtained. Once the first LTR was obtained, the needle was
then moved up and down (5 to 10 mm vertical motions with
no rotation) in the muscle at approximately 1 Hz for 25-30
seconds. It is suggested that LTRs should be elicited during
DDN for a proper technique; therefore, in our study, we
applied DDN for 45-60 seconds on each muscle.
Study Protocol
Each subject received both intervention programs
separated at least 15 days apart as a washout period. Each
Mendigutia-Gómez et al 5
Dry Needling in Patients With Stroke
intervention was applied once per week over 3 weeks. The
approximate length of each session was 45 minutes. At each
intervention program, participants received 1 treatment
condition (experimental or comparative), assigned in a
random fashion. An assessor blinded to intervention
allocation took the outcomes 1 week before and 1 week
after each intervention program.
Participants were randomly assigned to receive rehabil-
itation alone (comparative) or rehabilitation combined with
DDN (experimental) intervention as follows. Concealed
allocation was performed using a computer-generated
randomized table of numbers created before start of data
collection by an external researcher not involved in the
study. Individual and sequentially numbered index cards
with the random assignment were prepared. The index cards
were folded and placed in sealed opaque envelopes. A
second therapist, blinded to outcome findings, opened the
envelope and proceeded with treatment according to the
group assignment for the first intervention program.
Statistical Analysis
Data were analyzed with SPSS version 18.0. Mean,
standard deviations or 95% confidence intervals (CIs)
were calculated for each variable. The Kolmogorov-
6 Mendigutia-Gómez et al Journal of Manipulative and Physiological Therapeutics
Dry Needling in Patients With Stroke Month 2016

Patients with stroke screened for eligibility

criteria (n = 25)

Excluded (n = 5):
Repetitive stroke (n = 2)
BTX-A treatment previous month (n = 2)
Fear to needles (n = 1)

Baseline Measurements (n = 20)

Spasticity
Pressure pain thresholds
Shoulder range of motion

Cross-Over Randomization (n = 20)

Allocated to the dry needling

intervention (n = 10) Allocated to the comparative
intervention (n = 10)

Post-intervention (n = 10)
Spasticity Post-intervention (n = 10)
Pressure pain thresholds Spasticity
Shoulder range of motion Pressure pain thresholds
Shoulder range of motion

Comparative intervention (n = 10) Dry needling intervention (n = 10)

Post-intervention (n = 10) Post-intervention (n = 10)

Spasticity Spasticity
Pressure pain thresholds Pressure pain thresholds
Shoulder range of motion Shoulder range of motion

Fig 5. Flow diagram of patients throughout the course of the study.

Smirnov test showed normal distribution of data. Indepen-
dent Student t tests for continuous data and χ 2 tests of
independence for categorical data were used to assess
differences in the outcomes before each intervention:
experimental or comparative. A mixed χ 2 test (McNemar-
Bowker test) was applied to analyze changes in MMAS
between both conditions before and after each intervention
A 2 × 2 mixed repeated-measure analysis of covariance
(ANCOVA) with time (before, after) as within-subjects
factor, intervention (experimental, comparative) as
between-subjects factor, and baseline scores and sex as
covariates was used to determine the effects of intervention
on PPTs over deltoid and infraspinatus muscles, and
shoulder range of motion. Separate ANCOVAs were done
for each dependent variable. A 2 × 2 × 2 mixed ANCOVA
with time and side (homolateral or contralateral) as
within-subjects factors, intervention as the between-
subjects factor, and baseline scores and sex as covariates
was used to determine the effects on PPTs over the C5-C6
zygapophyseal joint. The hypothesis of interest was the
group * time interaction. A P value b .05 was considered
statistically significant.
RESULTS
Twenty-five consecutive patients who had experienced a
stroke were screened for eligibility criteria. Twenty (mean ±
standard deviation age, 58 ± 2 years; 45% female) satisfied
all the eligibility criteria, agreed to participate, and were
Journal of Manipulative and Physiological Therapeutics Mendigutia-Gómez et al 7
Volume xx, Number Dry Needling in Patients With Stroke

Table 1. Clinical Outcomes for the Entire Sample at Baseline of Both Interventions
Experimental Intervention Comparative Intervention
Spasticity
Upp. Trap Pect. Maj Subscap Infrasp Upp. Trap Pect. Maj Subscap Infrasp
Ashworth scale (n, %)
Grade 0 3 (15%) 0 (0%) 1 (5%) 0 (0%) 5 (25%) 4 (20%) 1 (5%) 4 (20%)
Grade I 6 (30%) 6 (30%) 6 (30%) 8 (40%) 8 (40%) 7 (35%) 7 (35%) 7 (35%)
Grade II 7 (35%) 9 (45%) 5 (25%) 8 (40%) 7 (35%) 6 (30%) 5 (25%) 4 (20%)
Grade III 3 (15%) 4 (20%) 5 (25%) 3 (15%) 0 (0%) 2 (10%) 5 (25%) 5 (25%)
Grade IV 0 (0%) 0 (0%) 2 (10%) 0 (0%) 0 (0%) 1 (5%) 2 (10%) 0 (0%)
Shoulder range of motion (°)
Flexion affected side 83.7 ± 17.0 81.3 ± 22.6
Abduction affected side 49.7 ± 19.3 57.0 ± 21.4
External rotation affected side 14.5 ± 15.7 15.5 ± 16.5
Pressure pain thresholds (kPa)
PPT deltoid affected side 376.1 ± 128.0 425.6 ± 136.8
PPT infraspinatus affected side 450.1 ± 98.5 465.2 ± 79.2
C5-C6 joint affected side 356.1 ± 96.0 386.1 ± 89.1
C5-C6 joint nonaffected side 376.1 ± 98.2 405.8 ± 99.0
Infrasp, infraspinatus; Pect. Maj., pectoralis major; PPT, pressure pain threshold; Subscap, subscapularis; Upp. Trap., upper trapezius
Values are expressed as mean ± standard deviation except for Ashworth Scale.

included in the study. The reasons for ineligibility are found
in Figure 5 which provides a flow diagram of patient
recruitment. Eleven patients (55%) had the left side
affected, whereas the remaining 9 (45%) had the right
side. The mean time from the stroke event was 6.0 ± 0.7
months. Baseline features between both interventions were
similar for all variables (Table 1).
Changes in Spasticity
The nonparametric McNemar-Bowker test did not reveal
significant differences in MMAS after both conditions for
the upper trapezius (χ 2 = 0.923, P = .630), pectoralis major
(χ 2 = 4.342, P = .362), and subscapularis (χ 2 = 2.269, P =
.686) muscles: reduction in spasticity in these muscles was
similar after both treatment conditions. In addition, the
McNemar-Bowker test also observed that a greater number
of patients receiving the experimental condition exhibited a
lower degree of spasticity after the intervention for the
infraspinatus muscle ((χ 2 = 11.071, P = .01). Table 2 shows
changes in spasticity, as expressed by the MMAS, after
each treatment condition in all muscles.
scores and sex as covariates did not influence PPT (all,
P N .245). Table 3 summarizes preintervention and
postintervention scores as well as within-groups and
between-groups differences with their associated 95% CI
for PPTs data.
Changes in Shoulder Range of Motion
The 2 × 2 ANCOVA revealed significant group * time
interactions for range of motion in shoulder abduction (F =
11.057, P = .001) and external rotation (F = 3.365, P =
.045) but not for shoulder flexion (F = 0.600, P = .444):
shoulder abduction and external rotation increased signif-
icantly more after the experimental condition including
DDN as compared with the comparative condition, but
shoulder flexion showed similar changes after both
intervention conditions (time effect: F = 7.671, P = .009).
Again, the inclusion of baseline scores and sex as covariates
did not influence shoulder range of motion (all, P N .146).
Table 4 details preintervention and postintervention scores
as well as within-groups and between-groups differences
with their associated 95% CI for shoulder range of motion.

Changes in Pressure Pain Sensitivity

The ANCOVA revealed significant group * time
interactions for PPT at all points: deltoid muscle (F =
13.884, P b .001), infraspinatus muscle (F = 6.309, P =
0.017), and C5-C6 zygapophyseal joint (F = 19.192, P b
.001). Furthermore, no significant group * time * side
interaction for C5-C6 zygapophyseal joint was observed
(F = 1.247, P = .268): PPT increased significantly more
after the experimental condition including DDN compared
with the comparative condition. The inclusion of baseline
DISCUSSION
The current randomized crossover trial found that the
inclusion of DDN into a multimodal rehabilitation program
was effective for decreasing localized pressure pain
sensitivity and improving shoulder range of motion in
subjects who had experienced a stroke; however, we did not
observe significant changes in muscle spasticity.
In the current study, we observed that individuals who
had experienced a stroke exhibited significant decrease in
8 Mendigutia-Gómez et al Journal of Manipulative and Physiological Therapeutics
Dry Needling in Patients With Stroke Month 2016

Table 2. Changes in Modified Ashworth Scale Before and After Each Intervention
Modified Ashworth Scale Experimental Intervention Comparative Intervention P Value
Upper trapezius muscle Preintervention (n, %) .630
Grade 0 3 (15%) 5 (25%)
Grade I 6 (30%) 8 (40%)
Grade II 7 (35%) 7 (35%)
Grade III 3 (15%) 0 (0%)
Postintervention (n, %)
Grade 0 6 (30%) 4 (20%)
Grade I 10 (50%) 11 (55%)
Grade II 3 (15%) 5 (25%)
Pectoralis major muscle Preintervention (n, %)
Grade 0 0 (0%) 4 (20%) .362
Grade I 6 (30%) 7 (35%)
Grade II 9 (45%) 6 (30%)
Grade III 4 (20%) 2 (10%)
Grade IV 0 (0%) 1 (5%)
Postintervention (n, %)
Grade 0 3 (15%) 4 (20%)
Grade I 11 (55%) 7 (35%)
Grade II 4 (20%) 8 (40%)
Grade III 1 (5%) 0 (0%)
Grade IV 0 (0%) 1 (5%)
Subscapularis muscle Preintervention (n, %) .686
Grade 0 1 (5%) 1 (5%)
Grade I 6 (30%) 7 (35%)
Grade II 5 (25%) 5 (25%)
Grade III 5 (25%) 5 (25%)
Grade IV 2 (10%) 2 (10%)
Postintervention (n, %)
Grade 0 3 (15%) 3 (15%)
Grade I 6 (30%) 5 (25%)
Grade II 5 (25%) 4 (20%)
Grade III 5 (25%) 6 (30%)
Grade IV 0 (0%) 2 (10%)
Infraspinatus muscle Preintervention (n, %) .01
Grade 0 0 (0%) 4 (20%)
Grade I 8 (40%) 7 (35%)
Grade II 8 (40%) 4 (20%)
Grade III 3 (15%) 5 (25%)
Postintervention (n, %)
Grade 0 8 (40%) 3 (15%)
Grade I 5 (25%) 9 (45%)
Grade II 5 (25%) 6 (30%)
Grade III 1 (5%) 2 (10%)

Table 3. Preintervention, Postintervention, and Change Scores for Pressure Pain Thresholds (kPa)
Intervention Preintervention Postintervention Within-Group Change Scores Between-Group Difference in Change Scores
Deltoid muscle affected side
Experimental 376.1 ± 128.0 494.5 ± 138.1 118.4 (69.2 to 178.0) 108.9 (49.5 to 168.1) ⁎
Comparative 425.6 ± 136.8 435.1 ± 118.7 9.5 (− 9.1 to 29.7)
Infraspinatus muscle affected side
Experimental 450.1 ± 98.5 534.1 ± 101.6 84.0 (39.5 to 138.4) 64.6 (9.5 to 128.6) ⁎
Comparative 465.2 ± 79.2 484.6 ± 105.7 19.4 (− 20.1 to 39.0)
C5-C6 zygapophyseal joint nonaffected side
Experimental 356.1 ± 96.0 464.8 ± 97.2 108.7 (59.3 to 168.1) 99.2 (39.5 to 158.2) ⁎
Comparative 386.1 ± 89.1 395.6 ± 98.5 9.5 (− 29.5 to 39.6)
C5-C6 zygapophyseal joint affected side
Experimental 376.1 ± 98.2 445.0 ± 99.2 68.9 (40.1 to 118.7) 59.3 (10.1 to 99.5) ⁎
Comparative 405.8 ± 99.0 415.4 ± 95.1 9.6 (α19.8 to 29,7)
Values are expressed as mean ± standard deviation for preintervention and postintervention means and as mean (95% CI) for within- and between-group
change scores.
⁎ Statistically significant differences (ANCOVA, group * time, P b .01).
Journal of Manipulative and Physiological Therapeutics
Volume xx, Number
Table 4. Preintervention, Postintervention, and Change Scores for Shoulder Range of Motion (°)
Intervention Preintervention Postintervention
Shoulder flexion affected side
Experimental 83.7 ± 17.0 90.8 ± 18.5
Comparative 81.3 ± 22.6 85.3 ± 24.9
Shoulder abduction affected side
Experimental 49.7 ± 19.3 65.5 ± 18.5
Comparative 57.0 ± 21.4 58.8 ± 20.5
Shoulder external rotation affected side
Experimental 14.5 ± 15.7 23.4 ± 15.8
Comparative 15.5 ± 16.5 18.0 ± 16.2
Values are expressed as mean ± standard deviation for preintervention and postintervention means and as mean (95% CI) for within- and between-group
change scores
⁎ Statistically significant differences (ANCOVA, group * time, P b .05).
spasticity after both conditions; however, the inclusion of
DDN did not induce higher decrease in spasticity in the
shoulder musculature. These results disagree with those
previously observed with acupuncture in the upper
extremity 13 or with DDN in the lower extremity. 15
Discrepancies among the studies may be related to the
areas receiving intervention, for example, acupuncture was
effective for reducing spasticity in the wrist, elbow, and
knee, but no data on the shoulder region were reported, 13
and Salom-Moreno et al 15 found changes in spasticity after
a single session of DDN in spastic leg muscles. The main
difference of our study with previous trials is that we
included DDN combined with a multimodal rehabilitation
program and not as an isolated intervention. The fact that
we did not find significant differences between interven-
tions does not mean that DDN is not effective for reducing
spasticity in the shoulder muscles because both interven-
tions induced similar decreases in muscle tone.
The mechanisms involved in changes in spasticity after the
application of DDN are unclear, but some hypotheses will be
discussed in the current article. Because spasticity can result
in structural changes and contractures in the muscle tissues
and increasing stiffness of spastic muscles, 9,10 it is possible
that DDN helps to induce localized stretch of the contractured
cytoskeletal structures and reduction of the overlap between
muscle actin and myosin filaments. 32,33 This hypothesis
would support the fact that DDN reduces muscle stiffness 34
and therefore decreases muscle resistance to passive
movement. Other hypothesis may be that DDN may
modulate motoneuron activity and modify synaptic trans-
mission from muscle afferents to spinal motoneuron by
different reflex mechanisms 32,33 and hence decrease excit-
ability of spinal reflexes associated to muscle spasticity.
Nevertheless, in the current study, the inclusion of DDN into
the rehabilitation program did not significantly decrease
muscle spasticity, although other outcomes improved.
We found that the inclusion of DDN into rehabilitation
program reduced pressure pain sensitivity in subjects who had
experience a stroke because significant increases in PPT were
Mendigutia-Gómez et al 9
Dry Needling in Patients With Stroke
Within-Group Change Scores Between-Group Difference in Change Scores
7.1 (2.3 to 11.8) 3.1 (− 5.0 to 11.2)
4.0 (− 2.5 to 10.5)
15.8 (8.4 to 22.6) 14.0 (5.5 to 22.5) ⁎
1.8 (− 4.0 to 7.5)
8.9 (3.0 to 14.4) 6.4 (1.6 to 11.3) ⁎
2.5 (− 2.4 to 7.5)
observed; however, these changes were small over C5-C6
joint. A significant decrease in pressure sensitivity supports a
segmental antinociceptive effect of DDN. 35 In fact, our results
confirmed this hypothesis because increases in PPT were
observed in the shoulder musculature receiving DDN. The
physiological mechanism for the hypoalgesic effect of DDN is
unknown, and both segmental and central processes have been
proposed. 36 Salom-Moreno et al 15 found widespread changes
in pressure pain sensitivity after a single application of DDN in
patients who had experienced a stroke, suggesting a central
effect. We cannot determine any central hypoalgesic effect of
the inclusion of DDN into a rehabilitation program because we
did not assess widespread pressure pain sensitivity. It is
possible that the inclusion of DDN in the management of
individuals who had experienced a stroke can help to modulate
central sensitization mechanisms observed in these patients 37
and prevent the development of poststroke pain.
Finally, the inclusion of DDN into rehabilitation induced a
significant increase in shoulder abduction and external
rotation in individuals who had experienced a stroke. This
improvement in active shoulder range of motion may be
related to decreased muscle tension with DDN, but this needs
further research. Independently of the mechanism, an
increase in shoulder range of motion can help the patients
during daily life activities. In fact, improvements in the arm
function following spasticity reduction or muscle tone would
be corroborated through a meta-analysis conclusion that
reducing spasticity can be translated into functional benefit in
the spastic arm of patients who had experienced a stroke. 38
Limitations
Although the results of our randomized crossover trial are
promising, potential limitations should be recognized. First, we
collected short-term outcomes. We do not know if the observed
changes lasted for longer duration. This is particularly
important in individuals who had experienced a stroke because
these patients have a chronic condition. The fact that significant
changes have been observed supports future research in this
10 Mendigutia-Gómez et al
Dry Needling in Patients With Stroke
area. Second, the use of the MMAS for assessing muscle
spasticity is still under debate because it is considered as a
subjective outcome and there are issues concerning validity
and reliability. Nevertheless, the MMAS is the most commonly
used outcome in clinical practice and research in neurological
conditions. Third, we did not include any scale assessing motor
performance, for example, Fugl-Meyer Assessment, 39 to
determine functional changes after the application of DDN.
Fourth, the same clinician applied the DDN to all patients in
our study, which decreases the overall generalizability. Fifth,
we applied DDN for 3 sessions. Future trials should include a
higher number of treatment sessions with a greater number of
clinicians and longer follow-up periods. Finally, the sample
size may be considered small, and larger sample sizes are now
needed to confirm the current results; however, the fact that
significant results were observed suggests that a greater sample
would not alter the direction of the results.
CONCLUSION
The results of this study suggest that the inclusion of
DDN into the rehabilitation program of subjects who had
experienced a stroke was effective for decreasing localized
pressure pain sensitivity and improving shoulder range of
motion in subjects. However, the inclusion of DDN was not
able to induce significant changes in muscle spasticity.
Future studies with larger sample sizes and long-term
follow-ups are now needed.
FUNDING SOURCES AND CONFLICTS OF INTEREST
No funding sources or conflicts of interest were reported
for this study.
CONTRIBUTORSHIP INFORMATION
Concept development (provided idea for the research):
A.M.-G., C.M.-H., J.S.-M., C.F.-de-las-P.
Design (planned the methods to generate the results): all authors.
Supervision (provided oversight, responsible for orga-
nization and implementation, writing of the manuscript):
J.S.-M., C.F.-de-las-P.
Data collection/processing (responsible for experiments,
patient management, organization, or reporting data):
A.M.-G., C.M.-H.
Analysis/interpretation (responsible for statistical analy-
sis, evaluation, and presentation of the results): A.M.-G.,
C.M.-H., C.F.-de-las-P.
Literature search (performed the literature search): all authors.
Writing (responsible for writing a substantive part of the
manuscript): A.M.-G., C.M.-H., J.S.-M., C.F.-de-las-P.
Critical review (revised manuscript for intellectual
content; this does not relate to spelling and grammar
checking): A.M.-G., C.M.-H., J.S.-M., C.F.-de-las-P.
Journal of Manipulative and Physiological Therapeutics
Month 2016
Practical Applications
• Our study suggests that the inclusion of dry
needling into a rehabilitation program of subjects
who had experienced a stroke was effective for
decreasing localized pressure pain sensitivity and
improving shoulder range of motion.
• The inclusion of dry needling did not induce
significant changes in muscle spasticity in the
shoulder musculature.
• Future studies should continue to compare these
effects at long term.
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