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Brazilian Journal of
Physical Therapy
https://www.journals.elsevier.com/brazilian-journal-of-physical-therapy

Effects of dry needling of the obliquus capitis inferior on

sensorimotor control and cervical mobility in people
with neck pain: A double-blind, randomized sham-
controlled trial
Carlos Murilloa,b,*, Julia Treleavenc, Barbara Cagniea, Javier Perald,e, Deborah Fallaf,
Enrique Lluchb,e

a
Department of Rehabilitation Sciences, Ghent University, Ghent, Belgium
b
Pain in Motion International Research Group, Brussels, Belgium
c
Division of Physiotherapy, SHRS, University of Queensland, Brisbane, Australia
d
Department of Physical Therapy, University of Alcala, Madrid, Spain
e
Department of Physical Therapy, University of Valencia, Valencia, Spain
f
Center of Precision Rehabilitation for Spinal Pain, School of Sport, exercise and Rehabilitation Sciences, University of Birmingham,
Birmingham, United Kingdom

Received 6 August 2020; received in revised form 14 June 2021; accepted 30 July 2021
Available online xxx

KEYWORDS Abstract
Dry needling; Background: Impairments of sensorimotor control relating to head and eye movement control
Flexion-rotation test; and postural stability are often present in people with neck pain. The upper cervical spine and
Neck pain; particularly the obliquus capitis inferior (OCI) play an important proprioceptive role; and its
Obliquus capitis impairment may alter cervical sensorimotor control. Dry needling (DN) is a valid technique to
inferior; target the OCI.
Sensorimotor function Objectives: To investigate if a single DN session of the OCI muscle improves head and eye move-
ment control-related outcomes, postural stability, and cervical mobility in people with neck pain.
Methods: Forty people with neck pain were randomly assigned to receive a single session of DN
or sham needling of the OCI. Cervical joint position error (JPE), cervical movement sense, stand-
ing balance and oculomotor control were examined at baseline, immediately post-intervention,
and at one-week follow-up. Active cervical rotation range of motion and the flexion rotation test
were used to examine the global and upper cervical rotation mobility, respectively.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The study was
approved by the Ethical Committee at University of Valencia, Spain (reference number H1542206264486) and was prospectively registered in
ClinicalTrial.gov with registration number NCT03838224.
* Corresponding author at: Department of Rehabilitation Sciences, Ghent University, Ghent, Belgium.
E-mail: [email protected] (C. Murillo).

https://doi.org/10.1016/j.bjpt.2021.07.005
1413-3555/© 2021 Associação Brasileira de Pesquisa e Pós-Graduação em Fisioterapia. Published by Elsevier España, S.L.U. All rights reserved.

Please cite this article in press as: C. Murillo, J. Treleaven, B. Cagnie et al., Effects of dry needling of the obliquus capitis
inferior on sensorimotor control and cervical mobility in people with neck pain: A double-blind, randomized sham-
controlled trial, Brazilian Journal of Physical Therapy (2021), https://doi.org/10.1016/j.bjpt.2021.07.005
JID: BJPT
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C. Murillo, J. Treleaven, B. Cagnie et al.

Results: Linear mixed-models revealed that the DN group showed a decrease of JPE immediately
post-intervention compared to the sham group (mean difference [MD]= -0.93°; 95% confidence
interval [CI]: -1.85, -0.02) which was maintained at one-week follow-up (MD= -1.64°; 95%CI:
-2.85, -0.43). No effects on standing balance or cervical movement sense were observed in both
groups. Upper cervical mobility showed an increase immediately after DN compared to the sham
group (MD= 5.14°; 95%CI: 0.77, 9.75) which remained stable at one-week follow-up (MD= 6.98°;
95%CI: 1.31, 12.40). Both group showed an immediate increase in global cervical mobility (MD=
-0.14°; 95%CI: -5.29, 4.89).
Conclusion: The results from the current study suggest that a single session of DN of the OCI
reduces JPE deficits and increases upper cervical mobility in patients with neck pain. Future tri-
als should examine if the addition of this technique to sensorimotor control training add further
benefits in the management of neck pain.
© 2021 Associação Brasileira de Pesquisa e Pós-Graduação em Fisioterapia. Published by Elsevier
España, S.L.U. All rights reserved.

Introduction muscle on head and eye movement control-related out-

comes and postural stability in people with neck pain. In
Impairments of sensorimotor control relating to head and addition, this study also explored the effects of DN of the
eye movement control and postural stability are often OCI on both global and upper cervical mobility.
observed in people with persistent neck pain regardless of
the symptoms’ onset.1
3 These impairments, which are
thought to be related to altered cervical input and the sub- Methods
sequent changes to sensorimotor integration of combined
visual, vestibular, and proprioceptive information, seem to Trial design
contribute to some extent to the patient’s symptoms.1 Thus,
identifying and targeting these deficits are recommended as This study was a double-blind, parallel randomized sham-
part of the management of neck pain disorders.4,5 Tailored controlled trial. Research methods and reporting were in
training directed towards head and eye movement control accordance with the STRICTA (extension of CONSORT for
disturbances have shown to improve sensorimotor function acupuncture studies) guidelines.26 This study was prospec-
as well as patients’ symptoms.4,6
10 However, addressing tively registered (NCT03838224).
the local source of altered cervical afferent input (i.e.
reduced cervical mobility or impaired muscle function) is Participants
thought to be also important for treatment
success.4,6
8,10,11 Forty participants with either traumatic or idiopathic neck
Previous research has shown greater head and eye move- pain were recruited from the metropolitan area of Valencia
ment control and postural stability impairments in those (Spain) through poster advertisement between March and
people with neck pain presenting with an upper cervical June 2019. Volunteers were screened for potential eligibility
spine dysfunction.12,13 The upper cervical spine contains a via phone prior to the baseline assessment. Participants
great abundance of cervical afferents,14 with the obliquus were included if they were 18
65 years old and had neck
capitis inferior (OCI) muscle having the greatest density of pain as defined by the International Association for the Study
muscle spindle compared to other cervical muscles.15,16 of Pain
3 months in the last year with a current pain inten-
Moreover, electromyographic research suggests a primary sity
30/100 mm on a visual analogue scale (VAS) and neck
proprioceptive role for the OCI muscle as it contributes disability
10/50 on the Neck Disability Index (NDI).27,28 Par-
more to head and eye movement control than providing a ticipants also had to exhibit impaired cervical joint position
strong directional torque in neck rotation.17 These findings error (JPE) in at least one direction of neck rotation deter-
indicate that OCI impairment (e.g., lack of extensibility) mined by a cut-off value of 4.5°.29 Participants were
may contribute to the above sensorimotor disturbances excluded if they had a history of head trauma, cervical frac-
often observed in people with neck pain. ture, stenosis, surgery, or neurological signs/deficits sug-
Due to its deep location in the upper cervical region, dry gesting nerve root compression as well as known or
needling (DN) is probably the only feasible technique for suc- suspected vestibular pathology and vertigo or dizziness from
cessfully targeting the OCI.18,19 DN has been shown to be an ear or brain disorders or sensory nerve pathways (e.g.
effective technique to reduce pain and disability as well as BPPV). Additionnaly, pregnancy, bleeding disorders, use of
improve cervical mobility in the short-term in patients with anticoagulant medication, or needle phobia as well as previ-
neck pain.20
22 Some research indicates that DN improve ous experience with DN treatment in the upper cervical
muscle function22
25; but studies on the effects of DN on region were reasons for exclusion.
cervical sensorimotor control are lacking. We hypothesized The study was approved by the Ethical Committee at the
that DN of the OCI improves cervical sensorimotor control in University of Valencia, Spain (reference number
people with neck pain possibly by increasing cervical affer- H1542206264486)) and all procedures were performed in
ent input. Consequently, the aim of this study was to investi- accordance with the Declaration of Helsinki. All participants
gate the short-term effects of a single DN session of the OCI provided written informed consent prior to participation.

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Data collection and treatment took place at the department each side were performed and the mean was calculated to
of physical therapy, University of Valencia reduce the vulnerability to outliers.38,39 The impaired side
(i.e. right or left) was taken for the analysis when
Interventions JPE
4.5° was only found in one direction and the mean
was calculated when both sides were
4.5°. A moderate-
Both interventions were performed by the same physical good (0.71) between-day reliability has been reported for
therapist with 3 years of DN experience. A 40 £ 0.32 mm this procedure and the minimal detectable change (MDC) is
sterile needle with guided tube (AGU-A1041P, Agu-punt S.L.,
0.51°.40,41
Spain) was used for DN whereas the Park sham device (Dong- Cervical movement sense was evaluated using the zigzag
Bang, AcuPrime, UK), a blunted needle which appearance is pattern (see Werner, Ernst, Treleaven, Crawford42), which is
similar to a DN needle, was used for sham needling.19,30 This proposed to examine cervical proprioceptive or kinaesthetic
sham needle has been previously validated and used as con- afferent input as well as visuomotor function.43 Participants
trol in previous DN trials in patients with neck pain.31,32 For were sitting with the laser-pointer attached to their fore-
the DN intervention, the needle was inserted into the OCI head 100 cm away from the pattern. They were asked to
muscle following a previously described and validated trace the main bold band of the pattern “as accurately as
approach.19 The needle was inserted perpendicular to the possible” in a clockwise direction to start and end in the cen-
skin at a mid-point between the spinous process of C2 and ter of the pattern.42 One familiarization trial was allowed.
the transverse process of C1 (supplemental online material). The test was filmed and the number and magnitude of errors
Then, the needle formed an angle of 45° with the spinous and time were analyzed using SMIPlayer.42 This procedure
process of C2 and the transverse process of C1 and was has shown excellent intra-rater reliability (>0.90).42,43
directed into a postero-anterior direction towards the ana- The clinical assessment of the SPNT proposed by Daly,
tomical location of the OCI with a slight inferior angle of 10° Giffard, Thomas, Treleaven44 was used to evaluate oculomo-
until reaching the C2 vertebra lamina. Once the first local tor control. Patients were sitting on a swivel chair. The
twitch response was obtained, the needle was rapidly moved examiner, who was at 1 m distance, moved a pen horizon-
up and down within the muscle using the “fast-in and fast- tally across the patient’s visual field in a range of 40° at a
out” technique described by Hong33 for a total of 12 inser- speed of approximately 20°/s. Participants performed first
tions. As previous DN studies evaluating changes in muscle the test in a neutral position (trunk and neck forward); fol-
function, DN was performed bilaterally.23,34 A similar proce- lowed by 45° trunk torsion to each side with the head fixed
dure to DN was adopted for the sham intervention to repli- by the examiner. The examiner carefully observed the pur-
cate an authentic clinical experience and maintain suit of the patient’s eyes in each position and rated accord-
credibility and participants' blinding.35 Contextual clues ing to the score described by Della Casa and colleagues45
associated with DN such as skin’s cleaning, needle insertion, and adapted by Daly et al.44 The test was positive when
and manipulation (simulation in sham needling), and haemo- more saccadic eye movements (excluding the outer limits
static compression after procedure were therefore identical and directional changes) were detected in either left and or
in both interventions. right torsion when compared to neutral.

Outcomes Postural stability

Cervical JPE was the primary outcome. Secondary sensori- Standing balance evaluation consisted of one 30 s trial for
motor related outcomes were cervical movement sense, the each of four test conditions; firm and soft surface (high-den-
smooth pursuit neck torsion test (SPNT), and standing bal- sity 9 cm thick foam rubber) with eyes open and eyes closed.
ance. Global cervical rotation range of motion (ROM), the These test conditions were selected because they are sug-
flexion-rotation test (FRT) and pain intensity were also eval- gested to examine static balance disturbances due to cervi-
uated as secondary outcome measures. Measurements were cal proprioceptive dysfunction rather than vestibular
taken at baseline, immediately post-intervention, and at function and for their ability to demonstrate altered stabil-
one-week follow-up. Outcome assessment was blinded to ity in people with neck pain.46,47 A force platform (Dinas-
treatment allocation. can/IBV, Biomechanics Institute of Valencia, Spain) with a
plate (600 £ 370 £ 100 mm) comprised of four force trans-
Head and eye movement control-related measures ducers was used. Participants were requested to take a com-
fortable standing position (feet shoulder-width apart in an
Cervical JPE has been suggested to evaluate cervical propio- angle of 20°) and look at an eye level reference point
ception or kinesthesis.36 This was measured using a laser- located 2 m in front. Signals were recorded with 40Hz-fre-
pointer mounted onto a lightweight headband with the par- quency by an amplified analogue-to-digital converter. The
ticipants sitting blindfolded 90 cm away from a wall.29,36 center of pressure displacement data were obtained in
Participants were asked to slowly perform full head rotation antero-posterior (AP) direction using NedSVE/IBV analysis
to limit vestibular input and return to the neutral position as software (Biomechanics Institute of Valencia, Spain).
accurately as possible and verbally indicate when they felt
they were back in the neutral position.37 The examiner man- Cervical mobility
ually repositioned the participant’s head after each trial to
realign the laser-pointer with the starting position. The dif- A CROM device (Performance Attainment Associates, USA)
ference between start and end positions was measured in was used to evaluate both tests of cervical mobility. To mea-
centimeters and converted into degrees.29,36 Six trials to sure global cervical rotation ROM, patients were sitting on a

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chair, with the back supported on the backrest and the random effect models, and restricted maximum likeli-
shoulders relaxed with the arms resting on their thighs. hood were used to model the intervention effect over
Then, they were requested to perform an active complete time for primary and secondary outcome measures. We
pain-free cervical rotation.48 modeled the random effects of individuals and fixed
The FRT was used to evaluate the rotation mobility of C1- effects of group (DN and Sham), time (baseline, post-
C2 with the participants lying supine on a plinth.49 The intervention, and one-week follow-up), and group x
examiner first passively pre-positioned participants’ neck in time. All randomized participants were included in the
maximal full flexion and then rotated the head to each side. analysis because the linear mixed-model estimates val-
The end of the movement was determined either by a firm ues for missing data.55 Pairwise comparisons with Bon-
resistance felt by the examiner or participant’s pain. Each ferroni adjustment were used when interaction effect
of the cervical mobility test was repeated twice to each side group x time or time was significant and change scores
and the mean of both repetitions and sides was calculated (compared with baseline) for post-intervention and one-
for the analysis.48 An excellent between-day reliability has week follow-up were calculated to examine if MDC was
been reported for the global cervical rotation ROM and the exceeded. Percentages of positive SNPT per group per
FRT (>0.9) and the MDC is 7.6° and 7.0° respectively.48,50,51 timepoint were reported.

Neck pain intensity

Current neck pain intensity was scored at baseline and at Results

one-week follow-up using a VAS/100 mm with “no pain” on
the left side and ‘‘maximum pain ever experienced’’ on the Of the 68 potential participants who were eligible, 12 were
right side. Neck pain intensity was not assessed at post- excluded at the screening phone interview, and 16 were
intervention since post-needling soreness may have biased excluded at baseline assessment for not presenting with a
patients’ perceptions on pain. The VAS has shown an excel- JPE
4.5°. The final sample (40 participants) was random-
lent between-day reliability and the minimal clinically ized into the 2 groups (Fig. 1). Groups were comparable at
meaningful change for patients with neck pain is 24 mm.52,53 baseline in terms of patients’ characteristics and outcomes
(Tables 1 and 2).
Table 2 summarizes the results of each outcome
Sample size
assessment for DN and sham groups, as well as within-
Sample size was determined using G*Power 3.1.9.2. and cal- and between-group changes. The linear mixed-models
culated based on a significance level of 0.05 and a power of revealed a significant time-by-group interaction for JPE
80% to detect a difference of 2° in cervical JPE based on pre- (p = 0.034), where the DN group showed a greater
vious data.6 Following these criteria, at least 16 participants decrease of JPE compared to the sham group at post-
were required per group; and so, 40 participants in total intervention (mean difference [MD]=
0.93°; 95% Confi-
were included, accounting for a drop-out rate of 20%. dence Interval [CI]:
1.85,
0.02) and at one-week fol-
low-up (MD:
1.64°; 95%CI:
2.85,
0.43) (Fig. 2). No
time-by-group interaction was found for cervical move-
Randomization and blinding
ment sense number (p = 0.075) and magnitude
Following the baseline assessment, patients were randomly (p = 0.123) of errors as well as performance time
assigned to each group. Randomization was achieved using a (p = 0.159). Additionally, no time by-group interaction
computer-generated sequence of numbers, created prior to was observed for AP displacement in any standing bal-
data collection by an independent researcher, which were ance conditions; firm surface with eyes open and eyes
concealed in sealed and opaque envelopes. The therapist, closed (p = 0.566 and p = 0.232, respectively) and soft
who was blinded to baseline assessment results, opened the
envelope and proceeded according to the group allocation.
Outcome assessment and data analysis were conducted by a
researcher who was blinded to participant’s treatment allo- Table 1 Patient’s characteristics.
cation. Participants were blinded to group allocation and
were instructed to not reveal any treatment experience to Dry needling Sham needling
the outcome assessment examiner. Participants blinding was (n = 20) (n = 20)
evaluated at one-week follow-up with a written form and Sex (%male) 8 (40%) 5 (25%)
the Bang’s blinding index (BI) with a 2(DN and sham) x 3(DN, Age (years) 37.60 § 11.88 36.85 § 11.05
sham, and do not know) format was calculated.54 BMI (kg/m2) 25.35 § 3.17 24.25 § 4.04
Neck pain onset 13 (65%) 15 (75%)
Statistical analysis (%idiopathic)
Current pain inten- 53.20 § 11.00 48.00 § 15.00
Statistical analysis was performed using SPSS statistics sity (VAS/100 mm)
V25.0 and conducted according to an intention-to-treat Neck disability (NDI) 33.50 § 8.32 31.80 § 7.81
approach. Inferential analysis including parametric and
Data are mean § standard deviation or frequency (proportion).
chi square tests were used to examine baseline BMI, body max index; NDI, neck disability index; VAS, visual ana-
between-group differences in patient’s characteristics. logue scale.
Linear mixed-models with repeated-measures analysis,

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Fig. 1 Flow diagram of patients throughout the course of the study.

surface with eyes open and eyes closed (p = 0.386 and Discussion
p = 0.659, respectively).
Significant time-by-group interaction was found for FRT This study is to our knowledge the first to show that a single
(p = 0.007). FRT showed an increase immediately (MD= session of DN of the OCI can decrease JPE and increase upper
5.14°; 95%CI: 0.77, 9.75) and one-week after DN (MD= cervical mobility in the short-term.
6.98°; 95%CI: 1.31, 12.40) compared to the sham group In the present study, OCI was selected for treatment due
(Fig. 2). No time by-group interaction was observed for the to its hypothesized contribution to the correct head and eye
global cervical rotation ROM (p = 0.196). However, there was movement control and the normal function of the upper cer-
a main effect for time (p = 0.002), with both groups showing vical spine rather than patients’ symptoms.15
17,20,57,58 Evi-
similar gains inmediately post-intervention. dence supports that tailored interventions targeting
Finally, time-by-group interaction was found for VAS impairments of sensorimotor control related to head move-
(p = 0.034). A reduction in pain intensity at follow-up was ment control can decrease neck pain and disability.6,7,9 How-
observed in the DN group compared to the sham group (MD= ever, it is suggested that addressing the local source of

13.11 mm; 95%CI:
20.88,
2.41). Two patients reported altered cervical afferent input, such as neuromuscular
adverse effects after DN (headache for the following 2,3 impairments or reduced cervical mobility, can contribute
days). The BI was 0.65 (95%CI: 0.36, 0.94) in the DN group further to restore normal sensorimotor function; and subse-
and
0.50 (95% CI:
0.88,
0.12) in the sham group, which quently, improve patient’s complaints.4,6
8,10,11
suggests that patients tended to believe they received the A decrease in JPE greater than the MDC (
0.93°) was
true intervention.56 Further details on BI results and inter- observed immediately after the DN session compared to
pretation can be found in Table 3. sham needling; and this was also maintained one-week post-

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Table 2 Outcome data.

Outcome Dry needling Sham needling Between-group change score
JPE (°)
Baseline 6.34 § 1.23 5.79 § 1.38
Post-intervention 5.19 § 1.30 5.34 § 1.28
Within-group change I
1.23 (
2.05,
0.40)
0.55 (
1.41, 0.31)
0.93 (
1.85,
0.02)
One-week follow-up 4.77 § 1.07 5.48 § 1.75
Within-group change II
1.60 (
2.45,
0.74)
0.27 (
1.15, 0.61)
1.64 (
2.85,
0.43)
CMS number of errors
Baseline 17.00 § 5.31 17.31 § 5.57
Post-intervention 17.54 § 6.04 15.06 § 5.57
Within-group change I 0.54 (
3.78, 4.86)
2.21 (
6.15, 1.65) 2.75 (
1.34, 7.13)
One-week follow-up 14.15 § 6.16 17.26 § 5.86
Within-group change II
2.85 (
7.17, 1.48)
0.40 (
4.11, 4.03)
2.46 (
7.80, 2.40)
CMS magnitude of errors
Baseline 20.54 § 8.70 23.56 § 8.44
Post-intervention 20.92 § 8.49 18.44 § 8.44
Within-group change I 0.39 (
6.68, 7.45)
5.13 (
11.49, 1.24) 4.80 (
2.18, 12.52)
One-week follow-up 15.31 § 7.90 20.77 § 8.29
Within-group change II
5.23 (
12.30, 1.84)
2.80 (
9.44, 3.85)
2.43 (
11.18, 6.01)
CMS performance time (s)
Baseline 36.46 § 7.94 31.88 § 7.71
Post-intervention 36.31 § 8.62 26.69 § 7.71
Within-group change I
0.15 (
6.48, 6.17)
5.19 (
10.89, 0.51) 5.03 (
0.28, 15.57)
One-week follow-up 30.62 § 5.94 27.52 § 8.39
Within-group change II
5.85 (
12.17, 0.48)
4.36 (
10.46, 1.74)
1.48 (
6.92, 7.23)
FS-EO AP (mm)
Baseline 16.95 § 6.86 20.36 § 6.86
Post-intervention 15.74 § 6.86 20.44 § 6.96
Within-group change I
1.21 (
4.70, 2.29) 0.07 (
3.48, 3.63)
1.28 (
3.82, 4.00)
One-week follow-up 15.97 § 7.08 21.60 § 7.08
Within-group change II
0.98 (
4.60, 2.64) 1.24 (
2.39, 4.86)
2.22 (
4.60, 3.64)
FS-EC AP (mm)
Baseline 22.68 § 10.17 23.94 § 9.31
Post-intervention 19.25 § 7.10 23.31 § 11.33
Within-group change I
6.40 (
12.89, 0.10) 0.11 (
6.50, 6.72)
6.51 (
12.19, 2.51)
One-week follow-up 22.18 § 9.65 22.94 § 6.81
Within-group change II
2.84 (
9.57, 3.89) 0.72 (
6.01, 7.45)
3.56 (
7.68, 5.13)
SS-EO AP (mm)
Baseline 33.79 § 9.41 29.95 § 9.41
Post-intervention 32.05 § 9.41 30.14 § 9.64
Within-group change I
1.73 (
8.13, 4.66) 0.19 (
6.68, 6.29)
1.92 (
7.68, 5.13)
One-week follow-up 30.99 § 9.88 32.39 § 9.88
Within-group change II
2.80 (
9.39, 3.79) 2.45 (
4.15, 9.04)
5.25 (
14.28, 4.76)
SS-EC AP (mm)
Baseline 62.58 § 15.17 61.49 § 15.17
Post-intervention 61.12 § 15.17 55.76 § 15.45
Within-group change I
1.46 (
10.28, 7.37)
5.73 (
14.70, 3.24) 4.27 (
4.59, 14.57)
One-week follow-up 63.57 § 15.77 58.64 § 15.77
Within-group change II 1.00 (
8.13, 10.14)
2.86 (
12.00, 6.27) 3.86 (
4.28, 16.50)
SPNT (% + tests)
Baseline 2 (10%) 2 (10%)
Post-intervention 0 (0%) 2 (10%)
Within-group change I
One-week follow-up 0 (0%) 2 (10%)
Within-group change II
Global ROM (°)
Baseline 66.32 § 12.34 65.35 § 11.51
Post-intervention 70.06 § 8.17 70.21 § 12.23
Within-group change I 4.68 (0.83, 9.26) 4.82 (0.23, 9.43)
0.14 (
5.29, 4.89)

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Table 2 (Continued)
Outcome Dry needling Sham needling Between-group change score
One-week follow-up 71.32 § 7.33 66.18 § 11.74
Within-group change II 5.06 (0.37, 9.74) 0.83 (
3.87, 5.52) 4.23 (
2.30, 9.87)
FRT (°)
Baseline 33.53 § 13.36 37.50 § 11.24
Post-intervention 40.94 § 7.87 40.00 § 10.79
Within-group change I 7.72 (3.93, 11.51) 2.58 (
1.29, 6.45) 5.14 (0.77, 9.75)
One-week follow-up 41.63 § 8.63 38.75 § 10.35
Within-group change II 8.25 (4.38, 12.12) 1.27 (
2.60, 5.14) 6.98 (1.31, 12.40)
VAS (mm)
Baseline 53.20 § 11.00 48.00 § 15.00
One-week follow-up 37.20 § 19.40 45.00 § 19.30
Within-group change II
15.83 (
24.32,
7.43)
2.90 (
11.34, 5.53)
13.11 (
20.88,
2.41)
Data are mean § standard deviation, frequency (proportion) or mean difference (95% confidence interval).
AP, antero-posterior displacement of center of pressure; CMS, cervical movement sense; FRT, flexion rotation test; FS-EC, firm surface
eyes closed; FS-EO, firm surface eyes open; JPE, joint position error; ROM, range of motion; SPNT, smooth pursuit neck torsion test; SS-EC,
soft surface eyes closed; SS-EO, soft surface eyes open; VAS, visual analogue scale.
Within-group change I (baseline
post-intervention).
Within-group change II (baseline
one-week follow-up).

intervention (
1.64°).41 Similar results have been found It could be argued that post-needling soreness may have
after other therapeutic modalities targeting cervical neuro- influenced the result of some of the sensorimotor tests
muscular impairments such as endurance-strength immediately after DN.61,62 However, post-needling soreness
training,6,11 but conflicting findings have been reported for normally lasts only few days; so this cannot explain the lack
manual therapy techniques.59,60 By contrast, no short-term of gains at one-week follow-up and should have also possibly
gains in postural stability or cervical movement sense were affected the JPE test.63 Previous research has shown no
observed after DN. Consistent with the current findings, association between cervical JPE deficits and postural stabil-
non-tailored interventions such as manual therapy or exer- ity or cervical movement sense disturbances;4,38,64,65 and
cise training have been shown to be uneffective for this factor analysis has recently shown that each of these tests
aim11,60; and as this is the first study to our knowledge to measure unique aspects of the cervical sensorimotor control
evaluate the effect of a non-sensorimotor intervention on (i.e. proprioception/kinesthesis or oculomotor control).65
cervical movement sense, comparisons with previous find- This evidence, together with the current results, suggests
ings cannot be made. that different treatment approaches may be required to

Fig. 2 Between-group comparison in JPE and FRT throughout the study.

Data are mean and standard error.
JPE, joint position error; FRT, flexion rotation test; T0, baseline; T1, post-intervention; T2, one-week follow-up. Dashed line repre-
sent the JPE cut-off value (4.5°)
Post-hoc: * p < 0.05, ** p < 0.01; y
than the (between-group) minimal detectable change.

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Table 3 Blinding assessment and interpretation.

Assignment Dry needling Sham needling Do not know Total
Dry needling 15 (75%) 2 (10%) 3 (15%) 20
Sham 13 (72.2%) 4 (22.2%) 1 (5.6%) 18
Total 28 (73.7%) 6 (15.8%) 4 (10.5%) 38
Data are fequency (proportion).
Bang’s blinding index (BI)=0.65 (95% CI: 0.36, 0.94) in the DN group and
0.50 (95% CI:
0.88,
0.12) in the sham group. BI scores range
from
1.00 (incorrect guessing; all participants mistakenly guess the other intervention) to +1.00 (correct guessing; all participants cor-
rectly guess their allocation) where 0.00 means random guessing.56 In the present study, the BI shows a positive value in the dry needling
(DN) group and a negative value in the sham needling group. This scenario is referred as unblinded (DN)/opposite (Sham). Under this sce-
nario, patients tend to believe they received the true treatment regardless of actual treatment received, which reflects patients’ expect-
ations and wish to receive the true intervention.

target the patient’s specific cervical sensorimotor control improvements in sensorimotor control lead to reductions in
impairments.4 Thus, while gains in cervical propioception or pain and disability is still unclear.78
kinesthesis can be obtained through interventions aiming to
restore the normal cervical neuromuscular function; others, Strengths and limitations
such as impaiments in standing balance, may require tai-
lored programs including specific exercises for postural con- Our study has several strengths. It was prospectively regis-
trol. tered and followed an appropriate reporting guideline.26 Simi-
DN of the OCI was also effective in increasing global cer- larly, it used a validated DN procedure,19 concealed allocation
vical rotation ROM; but contrary to previous research, these and blinded outcome evaluation, which improves the internal
gains did not exceed the MDC.20
22,48 The beforementioned validity of the study. Another strength of this study was the
non-clinically meaningful reduction in pain intensity sham needling protocol, which followed the most recent pro-
(13.11 mm) may explain this finding.21,22,66 Conversely, pre- cedure recommendations published.35 The successful blinding
vious studies have shown that manual therapy techniques measured with the BI also provides more robustness to the
such as sustained natural apophyseal glide (SNAG) or transla- results of this study because poor blinding is associated with
toric spinal mobilization are effective to increase upper cer- outcome bias in favor of DN.79 A further strength of the pres-
vical spine mobility measured with FRT in patients with ent research is the clinical rather than laboratory nature of
cervicogenic headache or neck pain.67
69 This is, however, most of the measures; which provides a more relevant mes-
to our knowledge, the first study to report gains in the FRT sage for clinical practice. On the other hand, some limitations
similar to the MDC one-week after a single session of DN should also be acknowledged. The low number of positive
(6.98°) in patients with neck pain.50 Post-needling soreness SNPT did not allow for any meaningful interpretation of the
could explain that the gains in FRT did not exceed the MDC effects of the intervention on eye movement disturbances.
immediately after DN. The inclusion of a large proportion of people with idiopathic
So far, current evidence suggests that restoring global neck pain in our sample, who exhibit less marked SPNT impair-
cervical rotation mobility does not lead to reductions in cer- ments,14 may be a possible explanation.
vical JPE following head rotation.60,70 The C1
C2 segment
contributes to around half of the total cervical rotation
ROM,71 and in vitro research has revealed that C1-C2 rota- Conclusion
tion is related to the OCI muscle extensibility.72 Thus, a
decreased mobility of this segment could affect the normal A single session of DN of the OCI provide short-term improve-
sensorimotor function of this muscle73,74; and by doing so ment of cervical JPE and upper cervical mobility in patients
alter the afferent cervical input and JPE following rota- with neck pain. Future studies should explore whether the
tion.13 However, the current study design does not allow to addition of this technique to sensorimotor control training
investigate whether or not the decrease in JPE after head within a multimodal program add further benefits to other
rotation was mediated by gains in the FRT and future aspects of the cervical sensorimotor control.
research should test this hypothesis.75
Future studies should also futher examine the clinical
implications of the current research. Current evidence does Declarations of Interest
not support a long-term added benefit of DN to traditional
therapeutic modalities for neck pain.76,77 Thus, it should be None.
explored if the addition of DN to tailored sensorimotor train-
ing can provide additional gains in sensorimotor control
measures. Also, a reduction in pain intensity (which was Supplementary materials
close to be clinically meaningful) was observed after DN;
which is consistent with previous studies targeting the local Supplementary material associated with this article can be
source of altered cervical afferent input in people with neck found, in the online version, at doi:10.1016/j.
pain and impaired sensorimotor function.6
9 However, how bjpt.2021.07.005.

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Brazilian Journal of Physical Therapy 00 (xxxx) 1
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