Immediate and short-term effects of the combination of dry needling and percutaneous TENS on post-needling soreness in patients with chronic myofascial neck pain
León-Hernández et al. · Brazilian Journal of Physical Therapy · 2016
Evidence Level
MODERATEOBJECTIVE
To compare the immediate and short-term effects of combining dry needling with percutaneous TENS versus dry needling alone
WHO
62 patients with chronic myofascial neck pain and trigger points in the upper trapezius
DURATION
72-hour follow-up after a single treatment
POINTS
Active trigger points in the upper trapezius muscle
🔬 Study Design
Dry needling
n=31
Deep dry needling until two local twitch responses are obtained
Dry needling + TENS
n=31
Dry needling followed by percutaneous TENS for 15 minutes
📊 Results in numbers
Post-needling pain reduction at 24h
Immediate neck pain reduction
Statistical difference, post-needling pain
Statistical difference, neck pain
Percentage highlights
📊 Outcome Comparison
Post-needling pain at 24h (0-10 scale)
Immediate neck pain (0-10 scale)
This study shows that adding electrical stimulation after dry needling significantly reduces the soreness some people feel after the procedure. This is an important finding because many patients avoid continuing treatment due to that temporary pain.
Article summary
Plain-language narrative summary
This study investigated whether the addition of percutaneous transcutaneous electrical nerve stimulation (percutaneous TENS) after dry needling could reduce post-needling pain and improve outcomes in patients with chronic myofascial neck pain. A single-blind randomized controlled trial was conducted with 62 patients who presented active trigger points in the upper trapezius muscle. Participants were divided into two groups: one received only deep dry needling until two local twitch responses were obtained, while the other received dry needling followed by percutaneous TENS for 15 minutes using the needle as the negative electrode. Researchers evaluated participants immediately after treatment and over 72 hours, measuring post-needling pain intensity, neck pain, disability, pressure pain threshold, and cervical range of motion.
The results showed that the combination of dry needling with percutaneous TENS was significantly more effective at reducing post-needling pain at all follow-up time points. At 24 hours after treatment, the dry-needling-only group reported mean pain of 5.0 on a 0-10 scale, while the combined group reported only 2.75. This difference remained statistically significant throughout the 72-hour period. As for neck pain, the combined group showed an immediate 2.5-point reduction on the visual analog scale, while the dry needling group showed no immediate improvement.
Both groups showed improvements in neck disability and overall pain at 72 hours, but with no significant differences between them. The pressure pain threshold improved significantly only in the combined group, indicating reduced mechanical hypersensitivity. Cervical range of motion showed no significant differences between groups. Post-needling pain is one of the main side effects leading to patient dissatisfaction and treatment dropout.
The results suggest that applying percutaneous TENS immediately after dry needling may be an effective strategy to minimize this issue. The proposed mechanism involves activation of different analgesic pathways: while dry needling acts primarily through stimulation of the dorsal horn of the spinal cord, percutaneous TENS activates the gate control of pain and stimulates the release of endogenous opioids, providing faster and more effective relief. The study has some limitations, including the focus on only the upper trapezius muscle, the absence of a placebo group, and the relatively short duration of TENS (15 minutes). Future studies could investigate longer durations of electrical stimulation and include multiple cervical muscles.
Strengths
- 1Rigorous methodology with randomization and assessor blinding
- 2Direct comparison between clinically relevant treatments
- 3Multiple outcome measures and structured follow-up
- 4Adequate sample size with a low dropout rate
Limitations
- 1Study limited to a single muscle (upper trapezius)
- 2Absence of a placebo group to control for nonspecific effects
- 3Follow-up of only 72 hours, not assessing long-term effects
- 4Percutaneous TENS duration of only 15 minutes may not be optimal
Expert Commentary
Dr. Marcus Yu Bin Pai
MD, PhD · Pain Medicine · Physical Medicine and Rehabilitation · Medical Acupuncture
▸ Clinical Relevance
Post-needling pain is one of the greatest obstacles to adherence to dry needling in chronic myofascial neck pain — and this randomized trial offers a direct and immediately applicable solution. Patients with active trigger points in the upper trapezius frequently report exacerbated pain in the first 24 to 48 hours, which compromises the therapeutic bond and feeds early dropout from the protocol. The addition of 15 minutes of percutaneous TENS, using the needle itself as the negative electrode, reduced the intensity of this pain by 50% at 24 hours, with a highly significant difference. For the physician who incorporates dry needling into musculoskeletal pain practice, this represents a low-cost technical modification with high impact on the patient experience. The immediate 2.5 cm improvement in neck pain in the combined group — versus no improvement in the dry-needling-alone group — also reinforces the value of the combination for patients with acutely worsened symptoms at presentation.
▸ Notable Findings
The most striking finding is the significant improvement in pressure pain threshold only in the combined group, suggesting modulation of peripheral sensitization beyond the simple immediate analgesic effect — a finding that goes beyond control of post-procedural pain and points to a mechanism of action with its own clinical relevance. The mechanistic complementarity is biologically plausible: while dry needling promotes mechanical disruption of trigger-point nociceptors and activation of descending inhibitory controls via serotonin and norepinephrine, percutaneous TENS adds activation of spinal gate control and release of endogenous opioids, configuring a multimodal analgesia strategy at the target tissue itself. The fact that both groups converged on neck disability and overall pain at 72 hours, with no difference between them, suggests that the benefit of the combination is especially relevant in the critical window of post-procedural tolerability, and not necessarily in the magnitude of the long-term therapeutic effect.
▸ From My Experience
In my practice in the musculoskeletal pain outpatient clinic, post-needling pain in the upper trapezius is usually the main reason for patient hesitation before the second session. I have observed that patients with more pronounced central sensitization — those with chronicity exceeding 12 months and high scores on catastrophizing questionnaires — are exactly the ones who suffer most in this 24- to 48-hour window and, paradoxically, the ones who benefit most from the long-term treatment. The combination with percutaneous TENS has become a routine part of my protocol in these profiles. I usually observe perceptible functional improvement starting in the third or fourth session, with cycles of eight to ten sessions until stabilization, followed by monthly maintenance. I usually combine this with supervised cervical kinesiotherapy and, when there is a central sensitization component, with low-dose duloxetine. I do not recommend needling without subsequent TENS in patients with prior negative experience of post-procedural pain — therapeutic retention noticeably improves with this approach, and this study provides the technical support for what I was already applying empirically.
Full original article
Read the full scientific study
Brazilian Journal of Physical Therapy · 2016
DOI: 10.1590/bjpt-rbf.2014.0176
Access original articleScientific Review
Marcus Yu Bin Pai, MD, PhD
CRM-SP: 158074 | RQE: 65523 · 65524 · 655241
PhD in Health Sciences, University of São Paulo. Board-certified in Pain Medicine, Physical Medicine and Rehabilitation, and Medical Acupuncture. Scientific review and curation of every entry in this library.
Learn more about the author →Medical disclaimer: This content is for educational purposes only and does not replace consultation, diagnosis, or treatment by a qualified professional. Some information may be assisted by artificial intelligence and is subject to inaccuracies. Always consult a physician.
Content reviewed by the medical team at CEIMEC — Integrated Centre for Chinese Medicine Studies, a reference in Medical Acupuncture for over 30 years.
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