See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/46273740

Neck Pain Treatment With Acupuncture: Does the Number of Needles Matter?

Article  in  The Clinical journal of pain · November 2010

DOI: 10.1097/AJP.0b013e3181e375c9 · Source: PubMed

CITATIONS READS

11 144

5 authors, including:

Francesco Ceccherelli Roberto Casale

University-Hospital of Padova Opusmedica PC&R Persons Care & Research. Piacenza Italy
80 PUBLICATIONS   859 CITATIONS    181 PUBLICATIONS   1,673 CITATIONS   

SEE PROFILE SEE PROFILE

Gagliardi Giuseppe

31 PUBLICATIONS   410 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

sepsis View project

Interaction between drugs and acupuncture View project

All content following this page was uploaded by Francesco Ceccherelli on 06 January 2018.

The user has requested enhancement of the downloaded file.

 ORIGINAL ARTICLE

Neck Pain Treatment With Acupuncture: Does the Number

of Needles Matter?
Francesco Ceccherelli, MD,*w Luigi Gioioso, MD,w z Roberto Casale, MD,y
Giuseppe Gagliardi, MD, PhD,*w and Carlo Ori, MD*

relevant variables in determining the useful dose in pain

Objectives: Acupuncture has been successfully used in myofascial
pain syndromes. However, the number of needles used, that is, the
dose of acupuncture stimulation, to obtain the best antinociceptive
efficacy is still a matter of debate. The question was addressed
comparing the clinical efficacy of two different therapeutic schemes,
characterized by a different number of needles used on 36 patients
between 29 60 years of age with by a painful cervical myofascial
syndrome.
Methods: Patients were divided into two groups; the first group of
18 patients were treated with 5 needles and the second group of 18
patients were treated with 11 needles, the time of needle stimulation
was the same in both groups: 100 seconds. Each group underwent
six cycles of somatic acupuncture. Pain intensity was evaluated
before, immediately after and 1 and 3 months after the treatment
by means of both the Mc Gill Pain Questionnaire and the Visual
Analogue Scale (VAS). In both groups, the needles were fixed
superficially excluding the two most painful trigger points where
they were deeply inserted.
Results: Both groups, independently from the number of needles
used, obtained a good therapeutic effect without clinically relevant
differences.
Conclusions: For this pathology, the number of needles, 5 or 11,
seems not to be an important variable in determining the
therapeutic effect when the time of stimulation is the same in the
two groups.
Key words: acupuncture, neck pain, randomized, blind, needle,
number, controlled study
(Clin J Pain 2010;26:807–812)
T he intensity of stimulation is a critical parameter in all
physical modalities used in pain medicine. Although
for those using electrical currents, the intensity of the
stimulation is determined by well-known and measurable
parameters, such as intensity duration and frequency along
with the number of sessions and the time of application,1
for other physical modalities, the intensity of the stimula-
tion, namely the “dosage,” is still an understudied topic.
This is the case of acupunctural stimulation in which the
control are quite numerous, but some of them are poorly
recognized. Parameters2 such as the number3 and frequen-
cy4 of therapeutic sessions, the duration of the single
therapeutic session,5 and the superficiality or the depth of
the puncture,6–8 have been investigated during both manual
stimulation and electro-stimulation; the latter has been
investigated in terms of frequency of stimulation9 and
intensity of needle stimulation as well.10
Acupuncture stimulation may be inadequate in 2
divergent ways: it can be too weak to evoke any thera-
peutical antinociceptive effect but also excessively strong to
evoke a pronociceptive response. If a weak stimulation that is
unable to evoke any therapeutic effect is intuitively accepted,
it is not so the other way around (Fig. 1). As a matter of fact,
although no reports are present in the literature on possible
overstimulation effects in humans, a decreased pain threshold
and response to morphine lasting 14 hours11 has been
observed in animals submitted to prolonged and high-
intensity electrical stimulation, clearly suggesting a pronoci-
ceptive action.
The number of needles inserted is a variable that can
be of importance in determining the intensity, that is, the
dose of the acupuncture stimulation; however, the number
of needles needed to reach the best pain control has not
been adequately studied.
Acupuncture has been recognized as an effective
treatment in myofascial neck pain.12 The aim of this article
was to verify whether the number of needles used in
myofascial neck pain is of any importance in determining
the best therapeutic effect for a pathology already shown to
be positively influenced by acupuncture.

Received for publication May 14, 2009; revised April 9, 2010; accepted
April 12, 2010.
From the *Department of Pharmacology and Anesthesiology, Uni-
versity of Padova; wA.I.R.A.S. (Associazione Italiana per la Ricerca
e l’Aggiornamento Scientifico), Padova; zService of Anesthesia and
Intensive Care, Florence; and yRehabilitation Center of Montes-
cano, Maugeri Foundation, Pavia, Italy
A.I.R.A.S. (Italian Association for Research and Scientific Update),
Padova, Italy provided financing for this study.
Reprints: Francesco Ceccherelli, MD, Department of Pharmacolgy and
Anesthesiology, University of Padova, via Cesare Battisti N1267,
35121 Padova, Italy (e-mail: istaneri@unipd.it). FIGURE 1. Three intensities of stimulation and 3 very distinct
Copyright r 2010 by Lippincott Williams & Wilkins effects.

Clin J Pain  Volume 26, Number 9, November/December 2010 www.clinicalpain.com | 807

Ceccherelli et al
MATERIALS AND METHODS
The experiment was carried out in the Pain Service of
the Anesthesia and Intensive Care unit of St. Maria Nuova
Hospital of Florence, Italy. Forty-four patients of both
sexes (13 male; 31 females aged between 26 to 60 y) affected
by cervical myofascial syndrome were enrolled in the study.
Inclusion criteria were pain present within the last 3 months
and localized in the head and neck also irradiating to the
shoulder; muscle contraction of at least 1 of the following
muscles: trapezius, supraspinatus, infraspinatus, levator
scapulae, deltoid. No criteria or diagnostic tests exist for the
diagnosis of myofascial pain syndrome. Despite this,
strongly suggestive data can emerge from a patient’s case
history or at examination.13
In the attempt to make the task of the physician easier,
Gerwin et al14 proposed simplified criteria for diagnosis,
which was used by us:
1. Presence of a palpable taut band;
2. Specific focal tenderness of a nodule in the taut band;
3. Recognition of the pain complaint by the patient upon
pressure on the tender nodule;
4. Painful limitation upon full extension. Additional signs
and symptoms, though not necessary for the diagnosis, yet
strongly suggestive, include the rapid local contraction
response after mechanic stimulus and referred pain.
Exclusion criteria were the presence of the radiologi-
cally determined severe arthritis of the vertebral column;
osteoporosis; root compression; secondary myofascial
syndrome to rheumatic, and rheumatoid diseases; fibro-
myalgia.
Patients affected by severe systemic disorders that
could interfere with the aim of the study, such as neuro-
logic, respiratory, and cardiac diseases and hypertension,
especially, if under treatment for low blood pressure with
reserpin or captoril, were also excluded.
Patients with history of hospitalization for psychiatric
disorders, drug addiction or alcoholism were not enrolled
in the study, nor were the patients who had past occupa-
tional exposure to heavy metals or neurotoxic organic
solvents, or who had head and neck traumatic injuries
(whiplash). Chronic consumers of tranquilizers, especially,
benzodiazepine or antidepressants inhibiting the reuptake
of serotonine, were not enrolled in the study for the possible
interference of the drugs on acupuncture action mechan-
isms.15–17
Patients were randomly divided into 2 homogeneous
groups for sex and age. Two tables were prepared for
randomization: 1 for males and 1 for females. In these
tables, the progressive number was paired with the letter A
or B, indicating the 2 groups to be confronted. Once a
patient was included in the study, he/she was given
a number and relative letter. Recruitment was stopped,
when 44 patients were enrolled. This method allowed us to
equally allocate the patients of different genders into 2
groups. Group A (5 males and 13 females, mean age 47 y)
underwent somatic acupuncture with 11 needles using the
following points18:
 Houxi—SI3: the point is proximal to the head of the V
metacarpal on the ulna side of the proximal extremity
in the joint after flexion of the wrist; the afferent nerve is
the dorsomedial branch of the V digital nerve, C8
dermatome;
 Waiguan—TE 5: 2 cm above the transverse bend on the
dorsal side of the wrist between the radius and the ulna
808 | www.clinicalpain.com
Clin J Pain  Volume 26, Number 9, November/December 2010
on the short extensors of the finger. Myomere C6 to C7
to C8 and dermatome C7;
 Shenmai—BL62: placed in the depression exactly below
the lateral malleolus in the dermatome S1;
 Fengchi—GB20: placed on the neck below the occipital
bone, in a depression in between the sternocleidomastoid
muscle (Myomere C2 to C3) and the superior segment of
the trapezius muscle (C2 to C3 to C4) in the C-2
dermatome;
 14 TM Dazhui—GV14: placed between the 7 degree
Cervical vertebrae and the spinal process of the 1 degree
thoracic vertebrae, in the C8 dermatome;
 The 2 most painful trigger points according to a known
and earlier used procedure.19 This procedure is based on
the use of a pressure dynamometer with a scale from 0.10
to 10.00 kg with which we measured the amount of
weight applied to the trigger point. The 2 trigger points
that evoked pain with the least amount of pressure were
chosen.
Group B (4 males and 14 females of mean age of
47.8 y) underwent somatic acupuncture after the thera-
peutic scheme used in group A, but with only 5 needles
(SEDATELEC, 34-mm long and 0.30-mm thick inserted
superficially (5 mm) using the following points18:
 Houxi—SI3: the point is proximal to the head of the V
metacarpal on the ulna side of the proximal extremity in
the joint after flexion of the wrist; the afferent nerve is the
dorsomedial branch of the V digital nerve, dermatome C8;
 Dazhui—GV14: placed between the 7 degree Cervical
vertebrae and the spinal process of the 1 degree thoracic
vertebrae, in the C8 dermatome;
 The 2 most painful trigger points according the
procedure described above. All patients underwent a
therapeutic cycle of 6 weeks with 1 acupuncture session a
week.
For both groups, sessions lasted 20 minutes, and
needles were stimulated at insertion and after 10 minutes.
In group A, the patients were treated with 11 needles, and
the time of each needle stimulation was 10 seconds; in
group B, the patients were treated with 5 needles, and the
time of stimulation was 20 seconds. This difference was
necessary to have an equal stimulation time (100 s), at each
stimulation for both groups. Therefore, all patients (groups
A and B) were stimulated for a total of 200 seconds at each
session. Needles used for both groups were SEDATELEC,
34-mm long and 0.30-mm thick, and were inserted super-
ficially (5 mm). SEDATELEC needles, 72-mm long and
0.40-mm thick were used only in the 2 trigger points of both
groups, and the needles were inserted deep into muscles.
The pain variables were measured at the beginning and
at the end of therapy after 1 month and after 3 months,
using the Italian version of the McGill Pain Questionnaire20
and the visual analogue scale by Scott and Huskisson.21
At the same time, pain relief and worsening, motor
performances, and the global opinion on the efficiency of
the therapy were measured by means of 5J point verbal
scale.22 No pain=0, mild/moderate=1, severe=2, very
severe=3, and excruciating=4.
Ethical Issues
Informed consent was obtained from all patients
before the study. All patients were informed of the
protocol, in which 2 types of acupuncture were being
compared: 11 against 5 needles. No objections were raised,
and all patients agreed to participate in the study. Patients
r 2010 Lippincott Williams & Wilkins
Clin J Pain  Volume 26, Number 9, November/December 2010 Neck Pain Treatment With Acupuncture

TABLE 1. Pain Trend Measured in the 2 Groups With Total Score Based on the McGill Pain Questionnaire
McGill Total Score Before Therapy End of Therapy 1 mo 3 mo
Group A (11 need) mean 21.16 8.66 8.16 11.83
SD ±6.43 ±4.15 ±4.87 ±6.69
Paired t test P<0.05 P<0.05 P<0.05
Group B (5 need) mean 22.72 7.77 7.00 8.27
SD ±6.54 ±3.33 ±3.21 ±4.32
Paired t test P<0.05 P<0.05 P<0.05
ANOVA, A versus B ns ns ns ns
The 2 groups reported significant reduction of pain. The analysis of the variable showed no difference in the trend of the 2 groups. Group A—11 needles
and group B—5 needles.
ns indicates no statistical significance.

were also informed that they could interrupt their
participation at any time. The local ethics committee
approved the study.
Statistical Analysis
For all variables and for each group at all time points,
the mean and standard deviation were calculated. The
significance of the difference between pretherapy and the
successive measurements was calculated using the variables
for repeated measurements. The significance of the differ-
ence between the 2 groups was calculated, using the analysis
of the variables and the test for paired data.
Blindness
Data analysis was conducted by an independent
observer who was not aware of the differences in treatments
applied to the study groups.
RESULTS
Only 35 of 44 patients enrolled in the study completed
it; 4 patients from each group left the study. Four patients
did not complete the study for personal reasons, whereas 4
skipped therapeutic sessions and were therefore dropped.
As far as we know, none of them dropped out for any
reported side effect. Data analysis was therefore performed
on the 36 patients who completed the study.
Data from the MPQ (total score, numbers of words)
are shown in detail in Tables 1 to 2. For both groups, a
significant reduction of values at the end of therapy
(P<0.05) was obtained. This reduction was maintained at
1 (P<0.05) and 3 (P<0.05) months after the end of
therapy. No statistical differences in these parameters were
found between groups.
VAS results are reported in Table 3, showed a
significant reduction of the intensity of pain for both
groups of patients at the end of therapy (P<0.05) and after
1 (P<0.05) and 3 (P<0.05) months. No statistical
difference was found between the groups.
In addition, the results based on the verbal descriptors
(Table 4) were very similar in the 2 groups based on. No
statistical differences in all these parameters were found
between the groups.
DISCUSSION
One of the most empirically used methods by acupunc-
turists to increase the intensity of stimulation is to increase
the number of needles inserted, or increase the duration of
the manual stimulation.23 The results of this study under-
line the poor efficiency of this strategy, because the number
of needles does not seem to be relevant.
A study comparing TENS, electroacupuncture with
normal needles and with needles insulated at the tip,24
reported that:
(1) TENS raised pain threshold only in the skin and,
modestly, in the muscle fibres;
(2) Electroacupuncture raised it in skin, fascia, and
muscle;
(3) Stimulation with insulated needle with conductive point
yielded an increased threshold in muscle and periostean
tissue only. An experimental study in rats reported that
deep puncture of the muscle provided a stronger
analgesic effect than superficial puncture, especially,
when acupoints contralateral to the painful stimulus
were used.6
The effectiveness of deep puncture was also tested
in 2 controlled randomized trials in humans.7,8 Both trials,

TABLE 2. Pain Trend Measured With the Number of Words in the McGill Pain Questionnaire in the Two Groups
McGill No. Words Before Therapy End of Therapy 1 mo 3 mo
Group A mean 11.22 7.50 7.00 7.83
SD ±3.29 ±3.71 ±3.85 ±3.94
Paired t test P<0.05 P<0.05 P<0.05
Group B mean 11.88 7.27 6.72 7.27
SD ±2.19 ±3.06 ±3.08 ±3.61
Paired t test P<0.05 P<0.05 P<0.05
ANOVA, A versus B ns ns ns ns
Significant reduction of pain in the 2 groups was reported. Analysis of the variable did not show any difference in the trend between the 2 groups. Group A—
11 needles and group B—5 needles.
ns indicates no statistical significance.

r 2010 Lippincott Williams & Wilkins www.clinicalpain.com | 809

Ceccherelli et al Clin J Pain  Volume 26, Number 9, November/December 2010

TABLE 3. Pain Trend Measured With VAS (Visual Analogue Scale) in the 2 Groups
VAS Before Ses 2 Ses 3 Ses 4 Ses 5 Ses 6 1 mo 3 mo
Group A (11 N) mean 7.1 5.37 4.67 3.71 3.55 2.43 2.37 2.95
SD ±1.11 ±1.08 ±0.91 ±1.34 ±1.05 ±1.16 ±1.22 ±1.39
Paired t test P<0.05 P<0.05 P<0.05 P<0.05 P<0.05 P<0.05 P<0.05
Group B (5 N) mean 6.94 5.45 4.77 3.77 2.95 2.04 2.02 2.60
SD 0.98 ±1.21 ±1.83 ±1.39 ±1.39 ±1.44 ±1.24 ±1.41
Paired t test P<0.05 P<0.05 P<0.05 P<0.05 P<0.05 P<0.05 P<0.05
ANOVA, A versus B ns ns ns ns ns ns ns ns
Significant reduction of pain in the 2 groups was reported. Analysis of the variables did not show any change in trend of the 2 groups. Group A—11 needles
and group B—5 needles.
ns indicates no statistical significance.

dealing with shoulder and lumbar myofascial pain, showed
that deep puncture was superior to superficial puncture in
pain relief, with a quicker, stronger, and more prolonged
response.
The relationship between the frequency of sessions and
the effectiveness of acupuncture have been investigated in
migraine without aura4: 2 groups of patients with migraine
were treated with the same acupoint selection and the same
puncture modality for 10 acupuncture sessions adminis-
tered once a week in the first group and a twice a week in
the other group. The former did better, whereas patients
undergoing 2 sessions a week, besides showing a smaller
improvement, suffered from hyperalgesia in 20% of cases at
the end of treatment.
The number of sessions has been investigated in
chronic low-back pain.3 Two groups of 20 patients each
received the same acupuncture treatment for 10J and 5J
times, respectively; the group receiving 10 applications
showed significant improvement, whereas the other showed
no improvement at all.
In studies concerning electroacupunture, stimulation
frequency and current intensity need to be considered: 2.0-Hz
electrostimulation seems to activate met-encephalin, whereas
a 100.0-Hz electrostimulation seems to activate dynor-
phine.25 Stimulation frequency has been studied in humans,
and electroacupuncture in chronic low back pain.9 In the
former, frequencies of 4/s, 100/s, and alternating trains of 15
to 30/s were compared with no stimulation; 3 sessions per
week, 30 minutes each, for 2 weeks, and each patient was
randomly treated with all frequencies. Train of 15/s to 30/s
resulted to be more effective than other frequencies.
The following variables, present in both groups, seem
to be efficient in determining the therapeutic result in the
present study:
The segmental logic of the stimulations;
Deep insertion in the trigger points;
The choice to flank the stimulation of the trigger points
with traditional acupuncture points, especially the ones
that have analgesic importance.
Group B had 2 points on the same myomere: SI 3
(Houxi) and GV14 (Dazhui), which converge to dermatome
C8 and the 2 triggers that are generally on the horizontal
and vertical fibers of the trapezius, innervated by the C2 to
C3 to C4 cervical roots. In group A, in addition other
points included the Waiguan points-TE 5 on the C6 to C7
to C8 myomere and dermatome C-7; Fengchi-GB20, found
on dermatome C-2 and on myomere C2 to C3 to C4 and
also the BL 62 point that converges to dermatome S-1.
The use of segmental distinction in acupunctural
stimulation has been shown to be an important aspect in
obtaining an analgesic effect.
Wu Chien-Ping et al26 showed with a deafferented cat
that introducing a nociceptive stimulus in the lower limbs
and either stimulating electrically or manually the inserted
needles in homo-segmental points of the same limb, an
inhibition of the action potential in the wide dynamic
range neurons was obtained. If the electrical or manual
acupunctural stimuli were transferred to the anterior limb,
segmentally further away from the pain stimulus, the
inhibitory effect of acupuncture became negligible. The
investigators concluded that the segmental approach in
the use of acupuncture in somatic pain therapy seems to be
the premise for a good therapeutic effect.
The fulfillment of the recommendation for a segmental
approach has been confirmed in numerous demonstrations
in our clinical and experimental practice.3,7,8,27 Besides the
segmental approach, another important choice seems to be

TABLE 4. Pain Trend Measured With Descriptions of Pain in the 2 Groups

Verbal Descriptors Before Ses 2 Ses 3 Ses 4 Ses 5 Ses 6 1 mo 3 mo
Group A (11 N) mean 3.11 2.05 1.77 1.50 1.50 1.00 1.05 1.44
SD ±0.75 ±0.80 ±0.64 ±0.61 ±0.51 ±0.34 ±0.23 ±0.61
Paired t test P<0.05 P<0.05 P<0.05 P<0.05 P<0.05 P<0.05 P<0.05
Group B (5 N) mean 2.83 2.00 1.72 1.55 1.27 1.05 1.05 1.16
SD ±0.78 ±0.68 ±0.57 ±0.70 ±0.46 ±0.23 ±0.23 ±0.38
Paired t test P<0.05 P<0.05 P<0.05 P<0.05 P<0.05 P<0.05 P<0.05
ANOVA. A versus B ns ns ns ns ns ns ns ns
Significant reduction of pain in the 2 groups was reported. Analysis of the variables did not show any change in trend of the 2 groups. Group A—11 needles
and group B—5 needles.
ns indicates no statistical significance.

810 | www.clinicalpain.com r 2010 Lippincott Williams & Wilkins

Clin J Pain  Volume 26, Number 9, November/December 2010
the association of the classical points of acupuncture with
trigger point puncture.
Travell and Simons13 in their work on myofascial pain
recommended the infiltration of local anesthetic in the trigger
points for the treatment of myofascial pain. However, in a
recent systemic review,28 investigators hold that the effective-
ness of such infiltration is not yet supported by sufficient
evidence. Over the past decade, the insertion of the needle
into the muscle has emerged as what seems to be the most
important stimulus. In fact, Cummings and White in a 2001
review29 examined the efficiency of injection therapy in the
management of the trigger points. Eight of the 10 trials
comparing the injection of different substances and all the 7
higher-quality trials found that the effect was independent
of the injected substance. All the 3 trials that compared dry
needling with injection, found no difference in effect. The
investigators concluded that there was no evidence proving
that the injected solution was superior to the dry needle.
In a successive review, despite the small number of
patients and the low quality of experimental procedures,
Furlan et al,30 concluded that dry needling and acupuncture
could be recommended as auxiliary therapeutic techniques to
the classical ones, such as “stretch and spray” and the use of
heat.
Through a systematic review, Tough et al31 attempted
to determine whether dry needling in the trigger points was
superior to placebo, or to superficial stimulation, or to
insertion in other muscle districts. The study showed
limited evidence of dry needling in the cure of myofascial
pain; this is exactly why, as earlier mentioned, we always
combine needle insertion into the trigger points with that
into acupuncture points found on the same segment,
favouring those points that have a recognized value in pain
therapy according to traditional Chinese medicine from the
analgesic, myorelaxant, or vascular point of view.
Finally, a further hypothesis can be made. It is possible
that the therapeutic scheme with 5 needles reaches per se a
ceiling effect and that, to find a difference in the number of
needles, therapeutic schemes with fewer needles need to be
compared: 11 versus 3 needles or 2 or 1 needle. Indeed, if
we had a larger sample, these differences could become
significant, but the fact remains that the differences between
the 2 groups are of limited dimension and clinically irrelevant.
Some clinical indications may be suggested by our
results and earlier investigations (cited above); these
indications that need to be confirmed by further studies
can be kept in mind and consider that:
For cervical myofascial pain, a therapeutic scheme with 5
needles may be sufficient as long as both Chinese
acupuncture points and trigger points are taken into
consideration. A therapeutic scheme with a smaller
number of needles may be sufficient as well, but this
needs to be investigated further; The time of needle
stimulation seems to be an important variable in
determining the therapeutic result. The depth of needle
penetration seems to be a variable that determines a better
therapeutic result in the treatment of myofascial pain;7,8
It has also been observed that in myofascial pain the
number of sessions is an important variable in
determining the therapeutic result;3 In patients with
migraines, excessive weekly treatments (2 sessions a
week vs. 1 weekly session) determine a less effective
result.4
Further studies need to be conducted to understand
the problems associated with the dose of stimulation during
r 2010 Lippincott Williams & Wilkins
Neck Pain Treatment With Acupuncture
acupuncture treatment to obtain an even greater predict-
ability of the result better.
ACKNOWLEDGMENTS
The authors thank Christina A. Drace via Cavalieri di
Vittorio Veneto N1 21–35129 Padova, Italy, for assistance in
manuscript preparation and editing.
REFERENCES
1. Barlas P, Lundeberg T. Transcutaneous electrical nerve
stimulation and acupuncture. In: McMahon SB, Koltzenburg
M, eds. Wall and Melzack’s Textbook of Pain. London:
Elsevier-Churchill Livingstone; 2005:583–590.
2. Ceccherelli F, Gagliardi G, Rossato M, et al. Variables of
stimulation and placebo in acupuncture reflexotherapy.
J Altern Complement Med. 2000;6:275–279.
3. Ceccherelli F, Gagliardi G, Barbagli P, et al. Correlation
between the number of sessions and therapeutical effect in
patients suffering from low back pain treated with acupunc-
ture: a randomized controlled blind study. Minerva Med.
2003;94:39–44.
4. Ceccherelli F, Munari A, Ambrosio F, et al. Stati di iperalgesia
dopo trattamento con riflessoterapia agopunturale. Minerva
Riflessoterapeutica e Laserterapeutica. 1987;4:23–24.
5. Hamza MA, Ghoname EA, White PF, et al. Effect of the
duration of electrical stimulation on the analgesic response
in patients with low back pain. Anesthesiology. 1999;91:
1622–1627.
6. Ceccherelli F, Gagliardi G, Visentin R, et al. Effects of deep vs
superficial stimulation of acupuncture on capsaicin-induced
edema. A blind controlled study in rats. Acupunct-Electrother-
Res Int J. 1998;23:125–134.
7. Ceccherelli F, Bordin M, Gagliardi G. Comparison between
superficial and deep acupuncture in the treatment of the
shoulder’s myofascial pain: a randomized and controlled study.
Acupunct-Electrother-Res Int J. 2001;26:229–238.
8. Ceccherelli F, Rigoni MT, Gagliardi G, et al. Comparison
between superficial and deep acupuncture in the treatment of
lumbar myofascial pain. A double blind randomised and
controlled study. Clin J Pain. 2002;18:149–153.
9. Ghoname EA, Craig WF, White PF, et al. The effect of
stimulus frequency on the analgesic response to percutaneous
electrical nerve stimulation in patients with chronic low back
pain. Anesth Analg. 1999;88:841–846.
10. Wang B, Tang J, White PF, et al. Effect of the intensity
of transcutaneous acupoint electrical stimulation on the
postoperative analgesic requirement. Anesth Analg. 1997;85:
406–413.
11. Han JS, Li SJ, Tang J. Tolerance to electroacupuncture and its
cross tolerance to morphine. Neuropharmacology. 1981;20:
593–596.
12. Trinh KV, Graham N, Gross AR, et al. Cervical Overview
Group. Acupuncture for neck disorders. Cochrane Database of
Systematic Reviews 2006, Issue 3. Art. No.: CD004870. pub3.
DOI: 10.1002/14651858.
13. Travell JG, Simons DG. Myofascial Pain and Disfunction:
the Trigger Point Manual. Vol. 1. Baltimore: Williams and
Wilkins; 1983.
14. Gerwin R, Shannon S, Hong C-Z, et al. Interrater reliability in
myofascial trigger point examination. Pain. 1997;69:65–73.
15. Ceccherelli F, Altafini L, Varotto E, et al. The effect of benzo-
diazepines administration on auricular symptomatological
evidence. Acupunct-Electrother-Res Int J. 1990;15:95–106.
16. Eriksson SV, Lundeberg T, Lundeberg S. Interaction of
diazepam and naloxone on acupuncture induced pain relief.
Am J Chin Med. 1991;19:1–7.
17. Xu SF, Cao XD, Mo WY, et al. Effect of combination of drugs
with acupuncture on analgesic efficacy. Acupunct Electrother
Res. 1989;14:103–113.
www.clinicalpain.com | 811
Ceccherelli et al
18. The Academy of Traditional Chinese Medicine. An Outline
of Chinese Acupuncture. Peking: Foreign Languages Press;
1975.
19. Ceccherelli F, Altafini L, Lo Castro G, et al. Diode laser in
cervical myofascial pain: a double blind study versus placebo.
Clin J Pain. 1989;5:301–304.
20. Maiani G, Sanavio E. Semantics of pain in Italy: the Italian
version of the McGill Pain Questionnaire. Pain. 1985;22:
399–405.
21. Scott J, Huskisson EC. Graphic representation of pain. Pain.
1976;2:175–184.
22. Tamburini M, Selmi S, De Conno F, et al. Semantic
descriptors of pain. Pain. 1987;29:187–193.
23. White A, Cummings M, Barlas P, et al. Defining an adequate
dose of acupuncture using a neurophysiological approach—a
narrative review of the literature. Acupunct Med. 2008;26:
111–120.
24. Ishimaru K, Kawakita K, Sakita M. Analgesic effects induced
by TENS and electroacu-puncture with different types of
stimulating electrodes on deep tissues in human subjects. Pain.
1995;63:181–187.
25. Chen X-H, Han J-S. Analgesia induced by electroacupuncture
of different frequencies is mediated by different types of opioid
812 | www.clinicalpain.com
View publication stats
Clin J Pain  Volume 26, Number 9, November/December 2010
receptors: another cross-tolerance study. Behavioural Brain
Res. 1992;47:143–149.
26. Chen-ping W, Chih-chi C, Jen-yü W. Inhibitory effect
produced by stimulation of afferent nerves on responses of
cat dorsolateral fasciculus fibres to nocuous stimulus. Sci Sin.
1974;27:688–697.
27. Ceccherelli F, Altafini L, Avila A, et al. Reflextherapeutische
Behandlung von myofaszialem Schmerz bei Patienten mit
Zervikalarthrose. Dtsch Z Akupunkt. 1989;32:74–82.
28. Scott NA, Guo B, Barton PM, et al. Trigger point injections
for chronic non-malignant musculoskeletal pain: a systematic
review. Pain Med. 2009;10:54–69.
29. Cummings TM, White AR. Needling therapies in the manage-
ment of myofascial trigger point pain: a systematic review.
Arch Phys Med Rehabil. 2001;82:986–992.
30. Furlan AD, van Tulder M, Cherkin D, et al. Acupuncture and
dry-needling for low back pain: an updated systematic review
within the framework of the Cochrane Collaboration. Spine.
2005;30:944–963.
31. Tough EA, White AR, Cummings TM, et al. Acupuncture and
dry needling in the management of myofascial trigger point
pain: a systematic review and meta-analysis of randomised
controlled trials. Eur J Pain. 2009;13:3–10.
r 2010 Lippincott Williams & Wilkins