Pain Medicine, 00(0), 2020, 1–10

doi: 10.1093/pm/pnaa279
Original Research Article

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Benefits of Adding Gluteal Dry Needling to a Four-Week Physical
Exercise Program in a Chronic Low Back Pain Population. A
Randomized Clinical Trial
Cristina Martın-Corrales, PT,* Irene Victoria Bautista, PT,† Jose
 Enrique Mendez-Mera, PT,‡
Ruben Fernandez-Matıas, PT,§ Alexander Achalandabaso-Ochoa , PT, PhD,¶
Toma s Gallego-Izquierdo, PT, PhD,§,k,** Susana Nun ~ ez-Nagy, PT, PhD,k and
§,k,
Daniel Pecos-Martın, PT, PhD, **

*Bonn Center, Madrid, Spain; †Meblanc Center, Madrid, Spain; ‡Binomio Center, Madrid, Spain; §Research Institute of Physiotherapy and Pain.
a, Spain; ¶Department of Health Sciences, Universidad de Ja
Universidad de Alcala, Alcal en, Jaen, Spain; kDepartment of Physical Therapy and
kk
 
Nursing, Universidad de Alcala, Alcala, Spain; Physiotherapy and Pain Group, Universidad de Alcala, Alcal
 a, Spain

Correspondence to: Alexander Achalandabaso-Ochoa, PT, PhD, Department of Health Sciences, University of Jaen, Building B3, Office 203,
Campus Las Lagunillas s/n, 23071 Jaen, Spain. Tel: þ34-670596145; Fax: þ34-953-212943; E-mail: [email protected].

Funding sources: We affirm that we have no financial affiliation (including research funding) or involvement with any commercial organization that has
a direct financial interest in any matter included in this manuscript, except as disclosed in an attachment and cited in the manuscript.

Conflicts of interest: Any other conflict of interest (i.e., personal associations or involvement as a director, officer, or expert witness) is also disclosed
in an attachment.

Abstract
Objective. To determine if adding dry needling to a four-week exercise program has an additional benefit compared
with adding sham dry needling to the same exercise program in subjects with chronic low back pain. Design.
Randomized clinical trial. Setting. Physiotherapy and Pain Clinic of Alcala University. Subjects. Forty-six patients with
chronic low back pain. Methods. Subjects were randomized to two groups: the dry needling group (N ¼ 23) or sham
dry needling group (N ¼ 23). Both groups received a four-week exercise program and before the exercise started a
session of dry needling or sham dry needling. Pain (visual analog scale), disability (Roland-Morris Questionnaire),
and fear avoidance beliefs (Fear Avoidance Beliefs Questionnaire) were assessed at baseline, after treatment, and at
three-month follow-up. Pressure pain thresholds (algometer) were measured at baseline, after the dry needling or
the sham dry needling, and after treatment. Results. Both groups showed significant improvements for all variables.
In the between-group comparison, the dry needling group improved significantly in pain at three-month follow-up
and pressure pain thresholds at the end of treatment for all measures, and at three-month follow-up there was no
improvement in gluteus medium. Conclusions. In chronic low back patients, adding dry needling to a four-week exer-
cise program has an additional benefit in pain and sensitivity compared with adding sham dry needling to the same
exercise program.

Key Words: Puncture; Gluteal Exercise Program; Pain; Disability; Fear Avoidance Beliefs

Introduction different degrees of disability [1, 3] and constitutes a ma-

jor burden to health care systems and society [4]. A spe-
Low back pain (LBP) is usually defined as pain, muscle
cific pathoanatomical cause cannot be identified in most
tension, or stiffness localized below the costal margin
cases, with nonspecific LBP (NLBP) being the most prev-
and above the inferior gluteal folds, with or without leg
alent form (90–95% of cases) [5, 6].
pain [1]. LBP is an extremely common problem that most
One potential cause of NLBP, which often is over-
people experience at some point in their life [2]. It causes
looked by the clinician, is hip abductor dysfunction [7–

C The Author(s) 2020. Published by Oxford University Press on behalf of the American Academy of Pain Medicine.
V
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2 Martı n-Corrales et al.

10]. In fact, gluteus medius muscle weakness and associ- one of two groups: the exercise pelvic protocol plus DN
ated tenderness is a common presentation in people with or exercise pelvic protocol plus sham DN.
chronic NLBP [10]. Myofascial trigger points (MTrPs) Randomization into two groups was performed using

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have been associated with various degrees of sensory and a computer-generated random-sequence table with a
motor dysfunction, including spontaneous pain, referred two-balanced block design (Epidat software, version
pain, hyperalgesia, and muscle weakness [11, 12], and 4.0). The allocation was performed by a physiotherapist
are characterized by abnormal focal contractures within who was blinded to the intervention. The trial was ap-
the muscle [13]. Postural stresses, inefficient biomechan- proved by the ethics committee of Alcala University
ics, and repetitive overuse are the most frequently de- (CEIM/HU/2016/14) and was registered in the ANZCTR
scribed etiologies of MTrPs [14]. registry (ACTRN12617000074392). The study was con-
A variety of interventions have been described for the ducted in accordance with the Declaration of Helsinki
treatment of NLBP [15], but no single treatment has been (2013).
shown to be superior [16]. The effect of physical therapy
modalities, such as exercise [6], and dry needling (DN) Participants
[17] have shown positive therapeutic results in patients Subjects with chronic NLBP were laborers who were
with NLBP. An exercise intervention focused on the ab- recruited from Alcala University via mail. One hundred
dominal and lumbar musculature strength has been six were recruited between September 2017 and June
shown to improve pain and disability in people with 2018.
NLBP [6]. An alternative to the core muscles may be to The inclusion criteria were age 18–65 years, nonspe-
focus on the hip abductor musculature [10]. cific low back pain perceived and localized below the
DN is a technique in which a fine needle is used to costal margin and above the inferior gluteal folds with
penetrate the skin, subcutaneous tissues, and muscle, more than three months of evolution, positive single-leg
with the intent to mechanically disrupt tissue without the stance test, and presence of active MTrP in the gluteus
use of an anesthetic often used to treat MTrPs [18]. medius muscle [20].
Although the effects of DN remain unclear, changes have Exclusion criteria were a history of systemic or degen-
been shown in muscle tissue mechanosensitivity, range of erative diseases, lumbopelvic trauma, previously had sur-
motion, decreased muscle tone, and decreased pain in gery in the lumbopelvic area, lumbar radiculopathy,
patients with musculoskeletal conditions [18]. Moderate fibromyalgia syndrome, MTrP-DN in the back within
evidence has shown that DN of MTrPs, especially if asso- the previous six months, evidence of cognitive deficits, or
ciated with other therapies, could be recommended to re- needle phobia [21–23].
lieve the intensity of LBP [17].
Exercise and DN techniques have shown positive Procedure
results in patients with NLBP, but so far no studies have The subjects came to the center twice a week for three
studied the effectiveness of both procedures applied to- months. The participants who were eligible for the study
gether. So, we hypothesized that the application of a spe- and who signed an informed consent were informed of
cific hip abductor exercise program combined with DN the study protocol. First, all participants were assessed
of MTrPs of the gluteus medius muscle would prove using a visual analog scale (VAS), the Roland-Morris
more effective than the application of a specific hip ab- Questionnaire (RMQ), and the Fear Avoidance Beliefs
ductor exercise program combined with sham DN of Questionnaire (FABQ). Subsequently, we measured pres-
MTrPs of the gluteus medius muscle at three months in sure pain sensitivity in the lumbar spinous process, glu-
patients with chronic nonspecific low back pain. teus medius, and adductor pollicis muscle. The
Therefore, the primary aim of this study was to inves- measurements were taken before DN, after DN, at the
tigate the efficacy of adding DN to a four-week exercise end of the treatment, and three months after the end of
program on pain intensity in chronic nonspecific low the treatment. Finally, the patients received a DN or
back pain patients at three months. The secondary aim sham DN intervention on the gluteus medius muscle, and
was to determine the effects of adding DN to a four- they were contacted the following week to begin the ex-
week exercise program on disability, psychological fac- ercise program (Figure 1).
tors, and pressure pain sensibility.
Outcome Measures
Pain
Methods The primary outcome measure was pain, which was eval-
This study was conducted at the Physiotherapy and Pain uated using the visual analog scale (VAS). VAS scores
Clinic of Alcala University from September 2017 to June range from 0 (no pain) to 100 (worst experienced pain);
2018 on patients with chronic NLBP. The authors fol- they were individually marked on a 100-mm line, ori-
lowed the Consolidated Standards of Reporting Trials ented horizontally [24]. The VAS has shown an intraclass
(CONSORT) guidelines [19]. Subjects were assigned to correlation coefficient of 0.94–0.97 [25].
Gluteal Puncture in Chronic Lumbopelvic Pain 3

Assessed for eligibility (n=106)

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Excluded
Not presenting MTrP (n=34)

Enrollment
Previous lumbar surgery (n=4)
Pregnant (n=2)
Fibromyalgia (n=3)
Belonephobia (n=7)
Did not want to be treated (n=10)

Randomized (n=46)
Allocation

Allocated to DN group (n=23) Allocated to Sham-DN group (n=23)

Received allocated intervention (n=23) Received allocated intervention (n=23)
Did not receive allocated intervention (n=0) Did not receive allocated intervention (n=0)

Base line
VAS, PPTs, RMQ, n=23 n=23
FABQ.

Post DN/Sham
DN session
PPTs
Analysis

4-weeks
VAS, PPTs, RMQ,
FABQ.

3-months flow-up
VAS, RMQ, n=32 n=32
FABQ

Figure 1. Consort diagram demonstrating patient flow through the study.

Pressure Pain Sensitivity with LBP [28]. It consists of 24 items, which reflect limi-
A handheld algometer (Wagner Instruments FPN 100, tation in different activities of daily living attributed by
Greenwich, CT, USA) with a 1-cm2 probe (covered by a the patient to LBP. The scores range between 0 (no dis-
disposable latex sheath) was used to record pressure pain ability caused by LBP) and 24 (the maximum possible
thresholds (PPTs) at different locations on the body: lum- disability) [28]. The RMQ-S has been shown an intra-
bar spinous process, gluteus medius, and adductor polli- class correlation coefficient of 0.874 and a Cronbach’s
cis muscle. A minimum interval of 20 seconds was kept alpha the 0.83–0.91 [28].
between each PPT assessment. The PPT was defined to
the participant as “the point at which the pressure sensa- Fear Avoidance Beliefs
tion just becomes painful.” A constant pressure was ap- Fear avoidance beliefs were measured with the Fear
plied at 1 kg/sec until patients reported pain or Avoidance Beliefs Questionnaire (FABQ), Spanish ver-
discomfort. Each measure was repeated three times, and sion (FABQ-S) [29]. The FABQ is a self-rated belief in-
averages of the measurement were used for analysis. strument that has been shown to be a valid and reliable
Several studies have documented high intra-examiner instrument [30]. It consists of 16 sentences related to
and interexaminer reliability (intraclass correlation coef- physical activity (first five items) and work (last 11
ficient ¼ 0.80–0.97) for PPT assessment [26, 27]. items). The patient has to rate each sentence from 0 (to-
tally disagree) to 6 (totally agree). The score range is 0 to
Disability 96, with a higher value reflecting a higher degree of fear
Disability was measured with the Roland-Morris avoidance beliefs [29]. The scale contains statements
Questionnaire (RMQ), Spanish version (RMQ-S) [28]. about pain that reflect pain-related fear and avoidance
The RMQ-S is a reliable and valid instrument for the behavior. The original scale has been evaluated for valid-
measurement of disability in Spanish-speaking patients ity and reliability in several types of pain and has shown
4 Martı n-Corrales et al.

good psychometric properties [30]. Cronbach’s alpha for Statistical Analysis

the Spanish version has been shown to be 0.93. Data normality was evaluated with the Shapiro-Wilk
test. All continuous variables were normally distributed.

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Intervention Homogeneity between groups at baseline was assessed
The patients were allocated randomly to one of two with the Student t test for continuous variables, Mann-
treatment groups: exercise and DN or exercise and sham Whitney U test for ordinal variables, and Pearson chi-
DN. Both groups received the same four-week exercise square test for nominal variables. For the descriptive
program. The exercise program consisted of two weekly analysis of continuous variables, mean and SD were
supervised group sessions of an hour and involved spe- reported. For categorical variables, absolute frequencies
cific gluteus medius exercises including double leg bridge, and percentages were reported [37].
For the differences between groups on pain intensity,
traditional hip claim exercise, prone heel squeeze, and
disability, and fear avoidance beliefs, two-by-three
side-lying hip abduction with internal rotation exercises.
mixed-model analyses of variance (ANOVAs) were con-
Each exercise was performed on three sets of 10 repeti-
structed, with time (baseline, four weeks, three months)
tions bilaterally. The first two weeks, the required exer-
as the within-subjects factor and group (dry needling,
cise level was lower than in the last two, as
sham) as the between-subjects factor. For the differences
recommended in a recent systematic review [31]. between groups on pressure pain threshold, two-by-three
All participants underwent a single session of DN
mixed-model ANOVAs were constructed, with time
therapy or sham DN performed by one experienced phys- (baseline, post-treatment, four weeks) as the within-
ical therapist who was trained in DN and blinded to the subjects factor and group as the between-subjects factor.
baseline assessment outcomes. The subjects were asked Post hoc pairwise comparisons were analyzed with the
to lie down in the prone position on the examination ta- Student t test with Bonferroni correction. Partial eta
ble. The needling procedure started with systematic man- squared (gp2) was used as an estimator of the effect size
ual flat palpation of the gluteus medius muscles. This of the main effects and interactions of the ANOVAs.
was performed to determine the presence or absence of Between-group differences in postneedling soreness were
perceived MTrPs, and the points were considered gluteus analyzed with the Mann-Whitney U test [37].
medius MTrPs when tenderness and pain recognition For the evaluation of the relationship between the oc-
were present [21, 32]. The DN technique included inser- currence of local twitch response and the improvement
tion of a sterile, disposable 0.30  0.60-mm acupuncture observed in outcome measures in the dry needling group,
needle (Agu-punt, Barcelona, Spain) into the gluteus the point-biserial correlation coefficient (rpb) was used.
medius muscles bilaterally. The needles were directed Due to multiple comparisons in the correlation analysis,
into the gluteus medius muscle to the depth of the pelvis. two families were established for controlling the type 1
Then, DN was applied on the basis of the technique de- error rate. One family was composed of pain intensity,
scribed by Hong [33]. disability, and fear avoidance beliefs. The other family
Sham DN (Park Sham Device, AcuPrime, UK), which was composed of pressure pain threshold measurements.
has been shown to have an ideal blinding scenario [34], The Benjamini and Hochberg correction was used sepa-
was utilized in the other group. The Park sham needles rately in each family [38].
cause a pricking sensation on the skin as the real needle, Point-biserial correlation analyses and Benjamini and
but do not penetrate the skin as the shaft telescoped into Hochberg corrections were conducted with R statistical
the handle. The sham needle process was similar to that software, version 3.5.3 (R Foundation for Statistical
Computing, Vienna, Austria). All the other analyses were
for DN group. This procedure has proven to be reliable
conducted with SPSS, version 22 (SPSS Inc., Chicago, IL,
[35].
USA). An a level of 0.05 and 95% CIs were assumed for
all analyses.
Sample Size
The main outcome in this study was pain (VAS). An ef-
fect size of TE ¼ 0.25 was considered. The correlation be- Results
tween repeated measures was assumed to be 0.5. The final sample was composed of 46 subjects, 23 in the
Assuming the performance of four measurements (base- dry needling group with a mean age (SD) of 49 (11.36)
line, after the DN, at the end of the treatment, and three years and 23 in the sham group with a mean age (SD) of
months after the end of the treatment) in the two treat- 47.58 (11.08) years. There were no statistically signifi-
ment groups, the sphericity correction was determined to cant between-group differences at baseline in demo-
be 0.5. Using the Gpower 3.0.18 program with a statisti- graphic and outcome variables. The characteristics of
cal power of 0.95, with an alpha level of 0.05, it was esti- included subjects are presented in Table 1.
mated that a total sample size of 36 patients would be
needed. Taking into account 25% losses, it was necessary Pain
to reach 46 patients (23 per group) [36]. Descriptive statistics for pain are presented in Table 2.
Gluteal Puncture in Chronic Lumbopelvic Pain 5

The two-by-three mixed ANOVA for pain intensity –3.62 to –1.13). Pairwise comparisons are presented in
revealed a significant main effect for time (F ¼ 131.15, P Table 2.
< 0.01, gp2 ¼ 0.75) and group (F ¼ 5.58, P ¼ 0.02, gp2

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¼ 0.11). There was a significant time-by-group interac-
tion (F ¼ 11.10, P < 0.01, gp2 ¼ 0.20).
The dry needling group showed a greater decrease in
pain intensity at three-month follow-up compared with Pressure Pain Threshold
the sham group (mean difference ¼ –2.38, 95% CI ¼ Descriptive statistics for pressure pain threshold are pre-
sented in Table 3.
Table 1. Demographic characteristics of the subjects (N ¼ 46) The two-by-three mixed ANOVA for pressure pain
threshold measured at the gluteus medius revealed a sig-
Dry Needling Sham nificant main effect for time (F ¼ 85.84, P < 0.01, gp2 ¼
Characteristic* (N ¼ 23) (N ¼ 23)
0.80) and group (F ¼ 5.89, P ¼ 0.02, gp2 ¼ 0.12). There
Age, y 49 (11.36) 47.57 (11.08) was a significant time-by-group interaction (F ¼ 19.06, P
Height, cm 168 (8.41) 167.09 (11.32)
Weight, kg 74.43 (14.36) 74.52 (16.82) < 0.01, gp2 ¼ 0.47). The two-by-three mixed ANOVA
BMI, kg/m2 26.40 (4.91) 26.49 (3.96) for pressure pain threshold measured at the adductor
Sex, No. (%) revealed a significant main effect for time (F ¼ 197.55, P
Women 13 (56.50) 14 (60.90) < 0.01, gp2 ¼ 0.82) and group (F ¼ 21.71, P < 0.01, gp2
Men 10 (43.50) 9 (39.10)
Pattern, No. (%) ¼ 0.33). There was a significant time-by-group interac-
Flexion 10 (43.5) 5 (21.70) tion (F ¼ 26.95, P < 0.01, gp2 ¼ 0.38). The two-by-three
Active Ext. 8 (34.80) 11 (47.80) mixed ANOVA for pressure pain threshold measured at
Passive Ext. 5 (21.70) 7 (30.40) the lumbar region revealed a significant main effect for
LTR, No. (%) 10 (43.50) 0 (100)
time (F ¼ 4.28, P ¼ 0.045, gp2 ¼ 0.09) and group
BMI ¼ body mass index; LTR ¼ local twitch response. (F ¼ 5.89, P ¼ 0.02, gp2 ¼ 0.12). There was a significant
*Values are mean (SD) unless otherwise specified. time-by-group interaction (F ¼ 11.87, P < 0.01, gp2 ¼
0.21). Pairwise comparisons are presented in Table 3.

Table 2. Within- and between-group differences for pain, disability, and fear avoidance beliefs

Variable* Baseline Four Weeks Three Months

VAS, cm
Dry needling 5.99 (1.21) 2.94 (1.50) 0.74 (1.17)
Sham 5.56 (1.62) 3.61 (1.43) 2.70 (1.66)
Roland Morris
Dry needling 6.09 (3.03) 4.70 (3.25) 2.48 (2.13)
Sham 5.57 (2.56) 3.87 (2.69) 2.30 (2.01)
FABQ-W
Dry needling 22.83 (8.94) 16.17 (8.46) 8.04 (7.25)
Sham 25.09 (8.54) 17.30 (7.55) 8.35 (6.76)
FABQ-PA
Dry needling 18.65 (4.51) 15.17 (4.89) 11.13 (6.22)
Sham 17.83 (4.59) 13.00 (4.79) 8.48 (5.27)
Within-group changes from baseline, mean (95% CI)
VAS, cm Dry needling –3.05‡ (–4.00 to –2.09) –5.24‡ (–6.19 to –4.30)
Sham –1.95‡ (–2.90 to –0.99) –2.87‡ (–3.81 to –1.92)
Roland Morris Dry needling –1.39† (–2.57 to –0.21) –3.61‡ (–4.80 to –2.42)
Sham –1.70‡ (–2.88 to –0.51) –3.26‡ (–4.45 to –2.08)
FABQ-W Dry needling –6.65‡ (–9.83 to –3.47) –14.78‡ (–19.24 to –10.33)
Sham –7.78‡ (–10.96 to –4.60) –16.74‡ (–21.20 to –12.28)
FABQ-PA Dry needling –3.48‡ (–5.48 to –1.47) –7.52‡ (–10.22 to –4.83)
Sham –4.83‡ (–6.83 to –2.82) –9.35‡ (–12.04 to –6.66)
Between-group differences in within-group changes from baseline, mean (95% CI)
VAS, cm –1.10 (–2.36 to 0.16) –2.38‡ (–3.62 to –1.13)
Roland Morris 0.31 (-1.25, 1.86) –0.35 (–1.91 to 1.22)
FABQ-W 1.13 (–3.06 to 5.32) 1.96 (–3.92 to 7.83)
FABQ-PA 1.35 (–1.30 to 3.99) 1.83 (–1.73 to 5.38)

FABQ-PA ¼ Fear Avoidance Beliefs Questionnaire–Physical Activity dimension; FABQ-W ¼ Fear Avoidance Beliefs Questionnaire–Work dimension; VAS ¼
visual analog scale.
*Values are mean (SD).
†
Statistically significant (P < 0.05).
‡
Statistically significant (P < 0.01).
6 Martı n-Corrales et al.

Table 3. Within- and between-group differences for pressure pain threshold

PPT,* kg/cm2 Baseline Post-treatment Four Weeks

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Gluteus medius
Dry needling 4.61 (0.88) 5.78 (0.95) 5.82 (1.29)
Sham 4.57 (0.76) 4.83 (0.76) 5.27 (0.76)
Adductor
Dry needling 2.94 (0.35) 4.33 (0.57) 4.38 (0.54)
Sham 2.86 (0.48) 3.42 (0.50) 3.62 (0.44)
Lumbar
Dry needling 4.42 (0.70) 5.30 (0.45) 5.42 (0.37)
Sham 4.37 (0.58) 4.74 (0.50) 4.99 (0.46)
Within-group changes from baseline, mean (95% CI)
Gluteus medius Dry needling 1.17‡ (0.91 to 1.43) 1.21‡ (0.83 to 1.60)
Sham 0.26† (0.01 to 0.51) 0.70‡ (0.32 to 1.09)
Adductor Dry needling 1.40‡ (1.16 to 1.63) 1.45‡ (1.21 to 1.69)
Sham 0.56‡ (0.32 to 0.79) 0.77‡ (0.52 to 1.00)
Lumbar Dry needling 0.88‡ (0.71 to 1.05) 1.00‡ (0.76 to 1.23)
Sham 0.37‡ (0.20 to 0.54) 0.62‡ (0.38 to 0.86)
Between-group differences in within-group changes from baseline, mean (95% CI)
Gluteus medius 0.91‡ (0.57 to 1.25) 0.51 (–0.1 to 1.02)
Adductor 0.84‡ (0.53 to 1.15) 0.68‡ (0.36 to 1.00)
Lumbar 0.51† (0.29 to 0.73) 0.37† (0.06 to 0.69)

PPT ¼ pressure pain threshold.

*Values are mean (SD).
†
Statistically significant (P < 0.05)
‡
Statistically significant (P < 0.01).

Disability Relationship Between Local Twitch Response and

Descriptive statistics for disability are presented in Observed Changes in Outcome Measures for the
Table 2. Dry Needling Group
The two-by-three mixed ANOVA for the Roland- There were no significant correlations between local
Morris questionnaire revealed a significant main effect twitch response and changes in outcome measures from
for time (F ¼ 57.99, P < 0.01, gp2 ¼ 0.57) but not for baseline to last follow-up (Table 5).
group (F ¼ 0.54, P ¼ 0.47, gp2 ¼ 0.01). There was a non-
significant time-by-group interaction (F ¼ 0.52, P ¼ 0.60,
gp2 ¼ 0.01). Pairwise comparisons are presented in Discussion
Table 2. Low back pain patients have been shown to have a
weaker gluteal medius muscle, more tenderness, and
Fear Avoidance Beliefs greater numbers of MTrPs when compared with healthy
Descriptive statistics for fear avoidance beliefs are pre- subjects [39]. It has been proposed that weakness and
sented in Table 2. presence of MTrPs in the gluteus medius muscle can con-
The two-by-three mixed ANOVA for the FABQ- tribute to lumbopelvic dysfunction and pain in LBP
Work (FABQ-W) questionnaire revealed a significant patients [10, 40]. Hence, we performed a study to assess
main effect for time (F ¼ 115.11, P < 0.01, gp2 ¼ 0.72) the efficacy of adding gluteus medius DN to an exercise
but not for group (F ¼ 0.37, P ¼ 0.54, gp2 ¼ 0.01). There program in chronic LBP patients. The main result of this
was a nonsignificant time-by-group interaction (F ¼ 0.45, study is a decrease of pain at the end of treatment and af-
P ¼ 0.61, gp2 ¼ 0.01). The two-by-three mixed ANOVA ter three-month follow-up for both groups, showing a
for the FABQ–Physical Activity (FABQ-PA) question- between-group significant decrease in pain for the DN
naire revealed a significant main effect for time group after follow-up. Besides, we found a significant in-
(F ¼ 85.56, P < 0.01, gp2 ¼ 0.66) but not for group crease for all PPTs for both groups after the first session.
(F ¼ 2.10, P ¼ 0.15, gp2 ¼ 0.05). There was a nonsignifi- These increases were maintained for both groups at the
cant time-by-group interaction (F ¼ 0.52, P ¼ 0.60, gp2 end of treatment. Nevertheless, the DN group obtained a
¼ 0.02). Pairwise comparisons are presented in Table 2. significant increase for all PPTs when compared with the
sham DN group after the first session, and after the end
Postneedling Soreness of treatment for all PPTs except for the gluteus medius.
There were no significant between-group differences re- Finally, our results showed significant improvements for
garding the occurrence of postneedling soreness both groups at the end of treatment and after follow-up
(U ¼ 230.00, Z ¼ –0.82, P ¼ 0.41) (Table 4). in perceived disability and fear avoidance beliefs and did
Gluteal Puncture in Chronic Lumbopelvic Pain 7

Table 4. Between-group differences in postneedling soreness up. Similar results have been obtained with a single ses-
occurrence sion [41, 48, 49] or with two sessions [44, 45] of DN.
Nevertheless, Griswold et al. [46] found no statistically

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Dry Needling Sham
Category, No. (%) (N ¼ 23) (N ¼ 23) significant increase in PPTs after DN. This difference
could be because while we used the technique described
No pain 6 (26.10) 11 (47.80)
24-h pain 14 (60.90) 7 (30.40) by Hong, Griswold et al. used a technique where they
48-h pain 0 (0) 1 (4.30) only used puncture (no needle manipulation). Wang-
72-h pain 3 (13) 4 (17.40) Price et al. [49] have shown that puncture with needle
manipulation is superior to puncture without needle ma-
nipulation in reducing mechanical pressure sensitivity in
Table 5. Point-biserial correlation between local twitch re- patients with LBP.
sponse and changes of outcome measures from baseline to Multiple reasons have been proposed for the pain-
last follow-up
modulating effect of DN. Dry needling has been related
Variable rpb 95% CI P Value to local release of substances such as nitric oxide or beta-
endorphins. Nitric oxide release after DN [50] has a
VAS 0.25 –0.18 to 0.60 .45
Rolland Morris –0.24 –0.59 to 0.19 .45 vessel-dilating effect, promoting an increase in local mi-
FABQ-W 0.21 –0.22 to 0.57 .45 crocirculation, which generates a washing effect of sensi-
FABQ-PA 0.15 –0.28 to 0.53 .49 tizing substances [51]. In addition, nitric oxide has
PPT GM –0.15 –0.53 to 0.28 .67 shown to potentiate the antinociception mediated by
PPT adductor 0.13 –0.30 to 0.51 .67
beta-endorphins [52]. Furthermore, an increase of beta-
PPT lumbar –0.09 –0.49 to 0.33 .67
endorphin levels after a single session of DN has been
FABQ-PA ¼ Fear Avoidance Beliefs Questionnaire–Physical Activity di- reported [53]. This local release of substances could ex-
mension; FABQ-W ¼ Fear Avoidance Beliefs Questionnaire–Work dimen- plain the decrease in pain perception and the local in-
sion; GM ¼ gluteus medius; PPT ¼ pressure pain threshold; VAS ¼ visual
crease of PPTs observed in our study. Finally, it has been
analog scale.
suggested that DN might also stimulate Ad fibers and ac-
tivate the serotonergic and noradrenergic descending in-
not show significant between-group differences at any
hibitory system [54], which could explain the increase of
time point.
PPT of the adductor pollicis muscle found in our study.
Regarding pain perception, our data indicate that
The fact that both groups experienced increases in PPTs
patients receiving gluteus medius DN who underwent a after the first session, when the exercise program had not
four-week exercise program experienced a statistically yet started, suggests that expectations and beliefs may in-
significant decrease in low back pain, as measured by the fluence treatment. This has been previously proposed
VAS, just after treatment and at three-month follow-up. [55, 56] and should be considered for both clinical and
These findings are in agreement with the previous litera- research purposes.
ture, in which a single session [41, 42] or two to six ses- Finally, the fact that the DN group had improved pain
sions [43–46] of DN were shown to decrease pain. perception compared with the sham DN group at three-
Besides, a significant decrease was obtained for the sham month follow-up indicates that adding DN to an exercise
DN group at the end of the exercise program and at program has an additional benefit for chronic low back
three-month follow-up, showing that both interventions pain patients.
are effective at reducing low back pain in a chronic LBP Psychological features such as disability or fear avoid-
population. Nevertheless, when comparing both inter- ance beliefs have also been observed to negatively affect
ventions, we found a significant decrease in pain favoring chronic LBP. Concerning disability, our data indicate
the DN group. For a clinically meaningful reduction in that both groups experienced statistically significant
pain, a decrease of at least 2 cm on the VAS is recom- decreases, as measured by the RMQ-S, after the end of
mended for chronic LBP [47]. In our study, we found a the treatment and at three-month follow-up. However,
reduction >2 cm at the end of treatment and at three- we found no between-group differences at any time mea-
month follow-up for the DN group and after three- sure. These findings are in accordance with the previous
month follow-up for the sham DN group. Although there literature, were a single session [57] or three to six ses-
were no between-groups significant differences at the end sions [43, 46, 58, 59] of DN were found to decrease dis-
of the exercise program, only the DN group reached a ability. Although no between-group differences were
clinical meaning change. found, the within-group score at three-month follow-up
In terms of mechanosensitivity, a statistically signifi- for the DN group surpassed the 3.5 points established as
cant increase in PPTs, as measured by a handheld algo- the minimal clinically important difference (MCID) [47],
meter, was found for all recorded points after DN and at suggesting a clinically relevant effect on disability after
the end of treatment, when compared with the applica- three months of follow-up. The fact that the DN group
tion of sham DN, except for the gluteus medius PPT, experienced a decrease in disability that exceeded the
which did not reach significance at three-month follow- MCID may suggest that for clinical purposes adding a
8 Martı n-Corrales et al.

DN to an exercise program may be a treatment option. However, our study has strengths; to the best of our
Furthermore, our data indicate that both groups experi- knowledge, this is the first study conducted in patients
enced a statistically significant decrease of fear avoidance with chronic LBP where the focus of treatment was the

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beliefs, as measured by the FABQ-S, just after treatment gluteus medius muscle. Furthermore, the use of the sham
and at three-month follow-up. Our results are in accor- DN allows us to reduce the bias of expectations.
dance with those of Tellez-Garcıa et al. [58] and Tüzün
et al. [60] for chronic low back pain patients. However,
Conclusions
we found no between-group differences at any time
measure. In our sample of chronic LBP patients, adding DN to a
Although DN has been shown to be effective at de- four-week gluteus medius muscle–specific exercise pro-
creasing pain in different pathologies [17, 61–63], it is gram resulted in a decrease in pain that lasted up to three
not without adverse effects. The most frequently reported months after treatment ended and an immediate increase
adverse effect after DN is postneedling soreness [58, 64]. of PPTs, when compared with a simulated DN associated
In our sample, 73.91% of patients in the DN group expe- with the same exercise program. With regard to disability
rienced postneedling soreness. This result is in line with and fear avoidance beliefs, although both groups im-
the result obtained by Tellez et al. [58], who reported proved, there were no significant differences between the
that 83% of chronic low back pain patients suffered two.
from postneedling soreness. This adverse event has been
associated with overstimulation or tissue injury from the Acknowledgments
needle [64–66]. Nevertheless, postneedling soreness was
also present in the sham DN group (52.17%). This We want to thank everyone who participated in the
allows a new interpretation, where psychological aspects study.
associated with postneedling soreness, such as the
patient’s expectations and beliefs, become relevant. References
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