Dry Needling and Photobiomodulation in the Treatment of Myofascial Pain
Phase: NA
Conditions: Myofascial Pain, Trigger Points
Sponsor: Universidade Federal de Santa Catarina

 
UNIVERSIDADE FEDERAL DE SANTA CATARINA 
CAMPUS ARARANGUÁ-ARA 
Rodovia Jorge Lacerda (SC 449), KM 35,4. Bairro Jardim das Avenidas - CEP 88900-000 – Araranguá/SC 
Phone: +55 (48) 3721-6448 / + 55 (48) 3522-2408 
 
 
 
 
RESEARCH PROJECT 
 
 
 
Dry Needling and Photobiomodulation in the treatment of Myofascial Pain  
 
 
 
Study Principal Investigator: Rafael Inácio Barbosa, PhD. 
 
 
 
 
 
 
 
2017 
 

ABSTRACT 
 
Myofascial Pain is a clinical condition of myalgic pain characterized mainly by the presence of 
Myofascial Trigger Points. Trigger points can be active or latent and they are described as a 
hypersensitive spot within a taut band in the muscle. The use of a computer for long periods 
has been shown as a trigger the trigger points. Dry Needling and Low-Level Laser Therapy 
(LLLT) has been described as good resources to treat myofascial pain. The hypothesis is that 
the association of the purposed interventions will have greater effects than only the dry needling 
intervention. The objective is to evaluate the effects of the dry needling and the laser in the 
treatment of upper trapezius trigger point on women. This study is composed of an evaluation 
and an intervention proposal with dry needling and LLLT to treat myofascial trigger points. 
The sample will be composed of 60 women, with 18 to 65 years old, divided into three groups. 
Twenty individuals will be in group Dry-On that will receive dry needling intervention on the 
trigger point, followed by LLLT intervention on. Twenty individuals will be in group Dry-Off 
that will receive dry needling intervention on the trigger point, followed by LLLT intervention 
turned off. Twenty individuals will be in group Control that will receive dry needling 
intervention at 1.5 cm from the trigger point, followed by LLLT intervention turned off. All 
interventions will be performed in one session. Outcome measures for pain, pressure pain 
threshold, functionality, and muscle activity will be collected.  
 
Key-words: Myofascial pain; Pressure Pain Threshold; Low-Level Laser Therapy; Dry 
needling; 
 
 

1. INTRODUCTION 
 
 
The International Association for the Study of Pain (IASP) defines pain as “an 
unpleasant sensory and emotional experience associated with actual or potential tissues 
damage, or described in terms of such damage” (1). The Myofascial Pain is the clinical 
condition where the patient presents regional muscle pain, and that is characterized by the 
presence of symptomatic trigger points in one or more sites, which can be associated to local 
or referred pain, muscle spasms, increase in sensibility, stiffness, muscle weakness, decrease in 
range of motion, and autonomic dysfunction (2,3). 
 
Women are the most affected by myofascial pain. It may be explained once women have 
lower pain pressure threshold (PPT) compared to men, which means higher hypersensibility to 
mechanical stimulation (4). Moreover, both gender also has differences in electromyographic 
findings when induced to muscle pain, suggesting that women have a mechanism of protector 
adaptation less efficient to pain stimulation than men’s protector mechanism (5). 
 
According to Simons & Travell (6), the myofascial trigger point is a hyperirritable spot, 
hypersensitive nodule palpable inside of a tender band that is painful on compression and that 
can give rise to referred pain, tenderness, and autonomic phenomena. This palpable nodule is 
usually located in hyperalgesic areas inside muscle, ligaments, and tendons, and it is associated 
with several conditions of chronic pain (2,7,8). The trigger points are classified as active and 
latent, where active trigger points have spontaneous local pain and referred pain away from the 
trigger point spot. The latent trigger point demonstrates pain only when stimulated with 
mechanical pressure, what can evoke local and/or referred pain without spontaneous pain (7). 
 
Several studies have shown a variety of therapeutic resources that can be used in the 
treatment of trigger points and the myofascial pain, as: lidocaine injection (3,9), exercise and 
stretching (10), dry needling (7,11,12), photobiomodulation (13), therapeutic ultrasound 
(14,15) and ischemic compression (16). 
 
The dry needling technic has been growing and gaining space among physical therapists 
as an option to treat myofascial pain and trigger points (7). The technic is described as an 
intervention where a fine, solid and filiform needle is inserted through the skin to stimulate 
trigger points, muscle and connective tissue to modulate neuromusculoskeletal pain and 
movement limitation (2,17). One mode of dry needling application is the fast-in and fast-out 

technique developed by Hong, which consists in moving the needle up and down during 
approximately 30 seconds or until the local twitch response disappears (9,18).  
 
Clinical trials using the dry needling technique in trigger points on upper and lower 
trapezius demonstrate improvement in pain, increase of PPT and on neck pain questionnaires 
scores, and an increase of cervical range of motion (ROM) compared with groups where the 
dry needling was applied away from the trigger point or that do not receive intervention (19,20). 
Espejo-Antúnez et al (12), in 2017, concluded in their systematic review that the dry needling 
can result in positive effects at short-term on pain, the range of motion, and quality of life when 
compared to placebo groups or groups without intervention; and it has similar effects to 
pharmacological intervention.  
 
Photobiomodulation resources, like Low-Level Laser Therapy (LLLT), have been 
studied as a resource to treat trigger points and myofascial pain. Ilbuldu et al (13), in 2004, 
verified that the LLLT has an effect on the treatment of upper trapezius trigger point by 
decreasing pain, increasing pain pressure threshold, increasing the cervical range of motion, 
and improving functional activities before 4 weeks of intervention. The treatment was 
performed 3 times per week for 4 weeks and used a He-Ne laser equipment, 632.8 nm, 2J of 
energy. Uemoto et al. (21), in 2013, used a dose of 4 J/cm²m wavelength of 795nm, 80mW, on 
masseter trigger points and they find positive results to inhibit trigger point, improve pain and 
increase PPT.  
 
These effects can be explained on the red light spectrum, near to infrared (660nm-
905nm), have good effects to reduce inflammation, relieve pain, and accelerate the tissue 
regeneration (22). According to Gerwin (4), 2010, the LLLT has level B of the recommendation 
of probable effect on the treatment of pain caused by myofascial trigger points. Gattie et al (23), 
2017, in their systematic review, state that the current information on dry needling intervention, 
whether compared to placebo treatment or when compared to another intervention, has very 
low to moderate quality of evidence. Furthermore, although the trigger points demonstrate 
changes in muscle activation obtained through electromyography (EMG), there are few studies 
that present EMG findings in order to demonstrate the effects of dry needling directly on muscle 
activity (24,25) 
 
In this context, the present study aims to answer if the association of dry needling and 
photobiomodulation will have a greater effect on the treatment of myofascial trigger points than 
the dry needling alone or the placebo treatment.  

2. OBJECTIVES  
2.1. General Objective  
The present study has the objective to evaluate the effects of dry needling and 
photobiomodulation application in the treatment of trigger points in upper trapezius on women 
with myofascial pain.  
 
2.2. Specific Objectives 
To evaluate the pain level before, during, and after the dry needling and 
photobiomodulation applications on the trigger point. 
To identify the pain pressure threshold before and after dry needling and 
photobiomodulation applications on the trigger point 
To verify the electromyographic activity of upper trapezius before and after the 
proposed treatments 
To compare the effects fond intra and inter-groups for the applications of dry needling, 
dry needling and photobiomodulation, and control protocol.  
 
3. METHODS 
3.1. Study Design  
The present study is characterized as a randomized clinical trial, controlled, with a 
proposal of evaluation and intervention of dry needling associated to the low-level laser therapy 
(LLLT) to treat the trigger point caused by myofascial pain. The subjects will be randomized 
into three groups: 
• Group On: application of dry needling and LLLT turned on directly on the trigger point; 
• Group Off: application of dry needling and LLLT turned off directly on the trigger point; 
• Placebo/Control group: application of dry needling and LLLT turned off away from the 
trigger point.  
 
3.2. Local of the Study 
The study will be performed at the Laboratory of Evaluation and Rehabilitation of the 
Locomotor Apparatus (LARAL), located at Universidade Federal de Santa Catarina, Campus 
Araranguá, Santa Catarina, Brazil. 
3.3. Subjects 

 
Women, with age between 18 and 65 years old, students, workers, and professors at 
Universidade Federal de Santa Catarina (UFSC) will be invited to participate in the research.  
 
The invitation of subjects to participate in the study will be done through digital and 
printed folders that will be delivered at UFSC and on the social media. Those subjects that show 
interest to participate will be forwarded to an evaluation selection where it will be identified if 
the participant fits the inclusion criteria and where the Consent Form will be presented. 
 
The sample will be composed by 20 subjects in each group, a total of 60 subjects, 
according to a convenience sample based on review studies of Cagnie at al., 2015(26), and 
Espejo-Antúnez et al., 2017 (12).  
3.3.1. Inclusion Criteria 
• Presence of active trigger point in upper trapezius. 
• Use of computer for typing activities for, at least, 20 hours per week. 
• Presence of mechanic pain in cervical region for less than three months. 
• Pain level higher than 3 and lower than 8 on the Visual Analogue Scale (VAS) for neck 
and cervical regions in the last 30 days. 
 
3.3.2. Exclusion Criteria  
 
• Body Mass Index (BMI) higher than 30 
• Presence of whiplash injury or other cervical pathologies such as herniated disc and 
Thoracic Gorge Syndrome; 
• Presence of contraindication to the treatment with low-level laser therapy or with dry 
needling 
• Fear of needles 
• To be receiving treatment for the pain in neck and/or shoulder regions  
• Make use of analgesic drugs, anti-inflammatory and/or muscle relaxants and 
anticoagulant medications.  
 
3.4. Evaluation procedures  
 
The active trigger point in upper trapezius will be localized through manual palpation 
and the location will be marked with a special pen for the skin. A second mark located 1.5 
centimeters medially from the trigger point will be made in all subjects. The trigger point 
identification will follow Simons et al. (6,27) criteria, featuring 3 of 4itens: (1) presence of 

palpable taut band in the muscle; (2) presence of hypersensitive spot inside the taut band; (3) 
subject recognize the familiar pain; and (4) painful limitation of the range of motion during 
total stretch. 
 
The surface electromyography (EMG) will be used to evaluate the muscle recruitment 
pattern. It will be used the equipment Miotec® (Miotool 400, Software Miograph®), with 
analog to digital (A/D) converter of 14 bits of resolution, amplified acquisition in 2000 Hz, 
common rejection mode of 100 dB, and band-pass filter set between 10-500 Hz. Disposable 
electrodes, made with polyethylene foam and with hypoallergenic adhesive, solid gel adherent, 
bipolar contact of Ag/AgCl (silver/silver chloride), will be used and positioned with 20mm of 
distance between poles. The Medtrace® reference electrode will be positioned in the ipsilateral 
wrist of the data collection. The electrodes will be positioned in the upper trapezius muscle as 
recommended by SENIAM (Surface ElectroMyoGraphy for the Non-Invasive Assessment of 
Muscles). 
 
The skin where the electrodes will be positioned will be prepared according to SENIAM 
recommendation. It will be performed the removal of local hairs with the aid of a disposable 
razor and the skin will be slight exfoliated with dermatological sandpaper. The process of skin 
preparation will be finished with the use of a cotton moistened with 70% alcohol on the site 
with the purpose of reducing the electrical impedance of the skin for the posterior capture of 
EMG signals (28). The subject will be asked to perform a shoulder abduction of 90º, without 
additional load and with the hand facing down, and maintain this position for 15 seconds. This 
movement will be repeated four times, with 30 seconds of rest interval (24,29). For data analysis 
will be used the Root Mean Square (RMS) and Medium Frequency (FMed) data in microvolts 
and Hertz, respectively.  
 
The Visual Analogue Scale (VAS) will be used so the subjects can graduate their pain 
in shoulder and neck regions. The VAS level of pain will be acquired before the intervention 
(baseline), soon after the intervention (T1), 30 minutes after the intervention (T2), one week (T3) 
and one month (T4) after the intervention.  
 
Pressure algometry will be used to evaluate the pain pressure threshold (PPT). This 
measured will be obtained before the intervention (baseline), soon after the intervention (T1), 
and 30 minutes after the intervention (T2). The equipment will be positioned on the trigger point 
mark and the subject will be instructed to report when the sensation changes from pressure to 
pain (16). The force measured in kilograms per square centimeter (kg / cm²) will correspond to 

the quantity of pressure needed so the subject report change in pressure pain sensation (14). 
The pressure will increase constantly on 1 kg / cm ² / s. It will be collected three measured, with 
an interval of 20 seconds between each measure, and the average of the three values will be 
used in data analysis.  
 
The Neck Disability Index (NDI) is a unidimensional questionnaire composed of 10 
items that have the aim to evaluate the limitation caused by pain and disability on the neck (30). 
This questionnaire is organized according to the type of activity performed and express positive 
levels of functional capability. Its score ranges from 0 to 50, where 0 to 4 is considered total 
capacity, 5 to 14 is mild incapacity, 15 to 24 is moderate incapacity, 25 to 34 is serious 
incapacity, and >35 is severe incapacity. The questionnaire will be self-applied and the subject 
will answer it before the intervention, one week and one month after intervention.  
3.5. Intervention Protocols 
3.5.1. Dry needling protocol  
 
The Dry Needling (DN) protocol will be performed in one session. It will be used 
acupuncture needles, individually packaged and sterilized, with 0.25 mm of thickness and 0.40 
mm of length. Before the intervention, the skin will be clean will 70% alcohol. The therapist, 
then, will perform the grip in upper trapezius on the site of one of the two previously marked 
locations, according to the subject group allocation, and will insert the needle in the skin with 
help of a guide tube and will deepen the needle approximately 10 to 15 mm inside the trigger 
point (31).  
 
The needle will be moved up and down as in the “fast-in and fast-out” technique 
described by Hong (18). The movement will be repeated during 30 seconds in a cadence of 
approximately 1 Hz (31). Once the study of Perreault, Dunning & Butts (32), in 2017, 
demonstrated that there is no need to seek the local twitch response to the DN have an effect, 
we do not have the aim to seek such response to the stimulus. The protocol will be the same for 
the groups that will receive the application directly on the trigger point and for the group that 
will receive the application away from the trigger point.  
3.5.2. Photobiomodulation protocol 
 
The photobiomodulation protocol will be performed using an equipment from Ibramed 
Equipamentos Médicos® of Aluminized Gallium Arsenide (AsGaAl) laser diode, with a 
wavelength of 830 nm, fluency of 20 J/cm², 30 mW, beam area of 0.116 cm², energy of 2,3 J 

per point, continuous beam (22). The low-level laser therapy (LLLT) will be applied for 30 
seconds at one point on the trigger point in upper trapezius, right after the dry needling 
application.  
3.5.3. Placebo protocol  
 
The placebo/control group will receive the DN application 1.5 cm away from the trigger 
point and will follow the application protocol described above. The LLLT equipment will be 
turned off during the intervention. As the other groups, it will be performed one session of the 
dry needling followed by the intervention with the laser turned off.  
3.6. Statistical Analysis  
 
Data analysis will be performed through the GraphPad Prisma® software, version 6.01 
(GraphPad Software, La Jolla, California, USA). The Shapiro-Wilk test will be run to verify 
sample normality distribution. The Two-Way ANOVA test will be used for comparative 
analysis inter and intra-groups. The P value (p<0.05) will be used to establish the significance 
of the results, in addition to the 95% Confidence Interval (95% CI). The values will be described 
as a mean ± standard deviation.  
3.7. Ethical Aspects 
 
The present study is grounded on the ethical principles, with base on the Resolution no 
466 of December 12th, 2012, of the National Health Council, which incorporates under the 
individual and collectivities optics, the four basic references of the bioethics: autonomy, non-
maleficence, beneficence, and justice, among others, aiming to ensure the rights and duties 
which concern the scientific community, the research subjects, and the State. 
  
 
 

4. CHRONOGRAM 
 
 
The present research project will attend the following steps: 
1. Bibliography review 
2. Writing the project 
3. Submission to the Ethics Committee in Research with Humans of the Universidade 
Federal de Santa Catarina 
4. Execution of pilot project  
5. Data collection and intervention 
6. Data analysis 
7. Discussion of the data and results  
8. Submission of manuscripts and presentation of the results on national or international 
events 
Etapa 
08-11/17 
12/17 
02-03/18 
04/18 
05-12/18 
01-04/19 
05/19 
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APPENDICE 
INFORMED CONSENT FORM 
 
Dry Needling and Photobiomodulation in the treatment of Myofascial Pain 
 
Participant’s Name: ___________________________________________________________ 
Address: ___________________________________________________________________ 
Phone: _____________________________________________________________________ 
 
 
Dear participant, the information presented in this document, delivered by the professor 
Rafael Inácio Barbosa, have the aim to firm the writing agreement by which you authorize your 
participation in this research with full knowledge of the nature of the procedures and the risks 
that you will be submitted,  
 
1. RESEARCH PRESENTATION: the present study aims to analyze the effects of dry 
needling protocols associated with photobiomodulation and to compare it with a placebo 
protocol. You will be submitted to a pre-intervention evaluation and you will be 
allocated randomly in one of the three groups where a single intervention will be 
performed, followed by reassessment soon after the intervention, and two other 
evaluations one week and one month after the intervention. The groups of participants’ 
allocation are: DN-ON Group, DN-OFF Group, and Control / Placebo Group. 
 
2. 
DISCONFORTS AND EXPECTED RISKS: you will be subjected to one of the 
protocols that may have some risk and discomfort. The intervention with 
photobiomodulation presents minimal risks and discomforts. Since Dry Needling is a 
more invasive intervention, it can cause discomforts. The participant may feel 
discomfort and pain during the technique, however, this should be resolved within a few 
hours after application. There is a minimal risk of contamination of the needle, which 
will be controlled through the use of individual and sterilized needles, as well as 
application site asepsis and the use of glove by the therapist. Finally, the dry needling 
technique in upper trapezius muscle has the risk of pneumothorax, which will be 
avoided by performing the correct grip and the control of the needling depth.  
 
3. 
INFORMATION: you are guaranteed that you will receive the answer to any 

question or clarification of any doubt regarding the procedures, risks, benefits and other 
subjects related to the research by the principal researcher. The results of the research 
will be made public through publication in reports, articles, presentations at scientific 
events and / or dissemination of another nature. 
 
4. 
WHITDRAW OF THE CONSENT: you have the freedom to withdraw your 
consent at any time and stop to participate in the study without penalty. 
 
5. 
LEGAL ASPECTS:  the present study is grounded on the ethical principles, 
with base on the Resolution no 466 of December 12th, 2012, of the National Health 
Council, which incorporates under the individual and collectivities optics, the four basic 
references of the bioethics: autonomy, non-maleficence, beneficence, and justice, 
among others, aiming to ensure the rights and duties which concern the scientific 
community, the research subjects, and the State. If you have any doubt, or if you feel 
the need, you can contact the Ethics Committee in Research with Human of the 
Universidade Federal de Santa Catarina (UFSC), located at Campus Florianópolis, 222, 
Desembargador Vitor Lima Street, store 401, Trindade, Florianopólis/SC, by the phone 
+55 (48) 3721-6094 or though the e-mail cep.propesq@contato.ufsc.br. 
 
6. 
PRIVACY GUARANTEE: the researcher ensures the privacy of the participants 
as to the confidential data involved in the research. 
 
7. 
LOCAL OF THE RESEARCH: the study will be developed in the Laboratório 
de Avaliação e Reabilitação do Aparelho Locomotor (LARAL), located at Universidade 
Federal de Santa Catarina / Campus Araranguá, Rodovia Jorge Lacerda, no 3201 – km 
35,4 – Jardim das Avenidas, Araranguá/SC, Brazil. Zip Code: 88906-072. 
 
8. 
BENEFITS: by participating in this research, you may experience improvement 
in pain related to trigger points, increase in pressure pain threshold, improvement in 
pain questionnaire score and neck dysfunction, among other beneficial effects such as 
muscle relaxation provided by the therapeutic resources used in research. Once the study 
will compare different intervention protocols, if you are allocated in a group to which 
the final result shows less effect compared to the others, you can request the intervention 
that obtained the best result after the end of the study. Moreover, your participation will 
enable the researcher to obtain important information regarding muscular behavior and 

pain related to the use of therapeutic resources in myofascial pain. 
 
9. 
PAYMENTS: you will have no onus for participating in this research, nor will 
you pay anything for your participation. If there is any transportation cost, it will be the 
responsibility of the responsible research. Furthermore, if any extraordinary expenses 
associated with the research occur, you will be reimbursed under the law. 
 
10. 
PREJUDICE TO THE PARTICIPANT: if you have material or immaterial 
damages as a result of the investigation, you may request compensation, guaranteed by 
the Resolution no 466 of December 12, 2012, in accordance with current and widely 
constituted legislation. 
 
11. 
CONTACT: you can contact the responsible researcher for this study, Rafael 
Inácio Barbosa, PhD, though the phones +55 (48) 3721-6448 and +55 (48) 99688-7711, 
or though the e-mail rafael.barbosa@ufsc.br 
 
12. 
CONSENT POST-INFORMATION 
 
 
I, ___________________________________, CPF/RG __________________, after 
the reading and understanding this Informed Consent Form, understand that my participation is 
voluntary, and that I can leave the study at any moment, without prejudice. I confirm that I 
received one copy of this Informed Consent Form, and I authorize the execution of the research 
and the divulgation of the data obtained in this study in the scientific environment.  
 
 
DO NOT SIGN THIS FORM IF YOU HAVE ANY DOUBT ABOUT IT 
 
 
Araranguá, ____________________, 20__ 
 
 
 
__________________________________ 
Participant 
 
 

ONLY FOR THE STUDY PRINCIPAL INVESTIGATOR 
 
 
I declare that I have obtained in an appropriate and voluntary manner the Informed 
Consent of this participant as a condition for participation in this study. 
 
Araranguá, ___________________, 20__ 
 
 
 
___________________________________ 
Rafael Inácio Barbosa, PhD. 
Study Principal Investigator.