Furuya Eiji, et al.. Japanese Acupuncture and Moxibustion, 2009; Vol.5(1): 12-21

Translated Articles from JJSAMThe Effects of Press Tack Needle Treatment onUpper Back Muscle Stiffness-Comparative Study Using Sham NeedleFURUYA Eiji NAYUKI Takane YAKAME Mayumi FURUUMI Hiroko
SHINOHARA Ryuzo NIMURA Ryuiti KANEKO Yasuhisa SAKAMOTO Ayumi
Tokyo Therapeutic Institute
Abstract[Purpose] A controlled Clinical Trial (CCT) was conducted using the Press Tack Needle (PTN) as the control forstudying the effects of the PTN on upper back muscle stiffness.
[Subjects and Method] The subjects were male and female volunteers (total 53) who had experienced upper backmuscle stiffness. The areas treated with the PTN or sham were tender points in the posterior cervical region, theupper back region, and the interscapular region. The needles were continuously indwelt for three days. An evaluation was performed on the awareness of upper back muscle stiffness 3 days after treatment, utilizing the VAS values for the degree of upper back muscle stiffness before treatment, immediately after treatment, and 3 days after
treatment.
[Results] The number of subjects reporting the "existence of upper back shoulder stiffness" decreased to 12 of 28
persons in the PTN group, and to 23 of 25 in the sham group, with a significant difference between the 2 groups (p<0.01).
Regarding VAS values for upper back muscle stiffness, the sham group demonstrated 55.2 ± 17.5 mm before treatment, 46.5 ± 19.7 mm immediately after treatment, and 45.9 ± 21.7 mm 3 days after treatment, and the PTN groupdemonstrated 52.5 ± 20.7 mm before treatment, 40.5 ± 22.4 immediately after treatment, and 34.2 ± 19.7 mm 3days after treatment. The PTN group showed a decrease immediately after treatment （p<0.05） and 3 days after
treatment (p< 0.01).
[Conclusion] It was suggested that the continuous indwelling of the PTN improves upper back muscle stiffness.
*This is an English translation of a paper published in the journal of the Society of Acupuncture & Moxibustion;
2002: Vol.52, 553-561.
Key words: upper back muscle stiffness, acupuncture, Press Tack Needle, sham , CCT

Ⅰ．Introduction
Acupuncture-and-moxibustion treatment is one of thetreatment methods widely used for upper back muscle
stiffness, along with warm or cold therapy, phototherapy,
Corresponding author Furuya Eiji
Tokyo Therapeutic Institute3 Sanei-cho, Shinjuku-ku, Tokyo 160-0008, Japan

electrotherapy, and massage therapy1).
These therapies are widely used in daily life despite
the few large scale randomized controlled trials. This isthought to be because a certain sensitization can be expected and also because there are few complications

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associated with these therapies, so they can continued
for a long period2). Although the Press Tack Needle(PTN) is frequently used with the objective of prolonging the duration of response to general acupuncture andmoxibustion treatment and for alleviation of chronic
symptoms, such as upper back muscle stiffness, there arestill few reports verifying the efficacy of PTN treatment,
performed independently of regular (non-patch style)needling in clinical trials.
Since treatment using PTNs is comparatively simple
and it can be easily performed without sophisticatedtechnology, it certainly has potential as a self-care tool.
If the efficacy of press tack needling can be proved on ascientific basis, this treatment system may also contribute to the marketing development of acupuncture andmoxibustion therapy.
This study was conducted in order to verify the treatment effects of the PTN, using volunteers who suffered
upper back muscle stiffness, by comparing the changes
in subjective symptoms before and after treatment with
PTN or sham, so that the clinical merit of PTN treatment
could be assessed.
Ⅱ．Methods
1. Informed consent
The trial was conducted by obtaining signatures ofconsent after having orally explained the meaning of thestudy and the possibility of the occurrence of adverse
events associated with participation in the study. The
main points of this study are: (1) there haven't been any
reports that have examined the effects of a single treatment using PTNs for upper back muscle stiffness; (2) the
goal of this study is to grasp the changes in upper backmuscle stiffness by leaving a needle of 0.6 mm in length
continuously indwelled on the surface of the stiff muscle
for 3 days; (3) In this clinical trial, the treatment effects
are compared by randomly assigning the patients complaining of upper back muscle stiffness to either a shamgroup or a PTN group; (4) there is a possibility that subjects may be assigned to a sham group, and; (5) thisclinical trial will be an important reference, which scientifically bears out the clinical effects of acupuncture
treatment.
2. Subjects
There were a total of 53 male and female subjects,
who were described as "having upper back muscle stiff-ness" and who were experiencing (III) dysphoria, according to the Questionnaire on Subjective Symptoms of
Fatigue3) by the Working Group for Occupational Fatigue, Japan Society for Occupational Health, out of 56
staff members and students in our college with subjective upper back muscle stiffness who were recruited asvolunteers. Furthermore, the target of this trial was "upper back muscle stiffness" presenting with chronic subjective symptoms, while excluding temporary upperback muscle stiffness, such as acute muscle pain or delayed onset muscle soreness caused by exercise or work
activity. As a matter of course, subjects were asked torefrain from receiving acupuncture and moxibustion
treatment, massage, applying poultices, and taking drugs
for the treatment of upper back muscle stiffness during
the trial period.
3. Study Procedures and Method of Allocation(1) Screening and allocation of subjective upper backmuscle stiffness
The Questionnaire on Subjective Symptoms of Fatigue was used prior to starting the trial, on the actual
day of the trial, in order to screen subjects being recruited as volunteers for the existence of upper back stiffness.
The coordinator carried out the informed consent related
procedures for the subjects who became trial candidates,
and after that allocation was performed by dividing thecandidates into 2 groups, the sham group and the PTN
group. This was conducted according to the cast draw
method by the subject him/herself, a method by which
the subject does not know his/her own assignment. The
coordinator prepared the shams and PTNs, which could
not be differentiated before the start of the trial by package appearance, and once the allocation was completed
one or the other of these packages was handed to thesubject according to the results of the assignment.
(2) Evaluation, cervicobrachial manual test, and implementation of treatment procedures
The subject went to a practitioner that used PTN
treatment in order to determine the area to be treated.
The practitioner conducted an inquiry and a manual teston the cervicobrachial areas, and then detected specificpressure sensitive areas on the subject by palpating theposterior aspect of the cervical region, the upper part ofthe back, and the interscapular area. At this point, thesubject wrote down "the level of the upper back muscle
stiffness experienced before the treatment" on a VAS(visual analog scale). The practitioner then performed

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treatment by applying shams or PTNs on the subject,depending on what s/he had been assigned and then thesubject marked the "the level of upper back muscle stiffness experienced immediately after treatment" on the
VAS.
The subject visited the clinic again after the continuous application of indwelled sham(s) or the PTN(s) for
three days, and filled out the Questionnaire on Subjective Symptoms of Fatigue by his/herself.
The sham or the PTN were then removed by a different practitioner than the one who had inserted the needle,
and the subject immediately marked "the level of upperback muscle stiffness after 3 days" on the VAS.
(3) Confirmation and ways of handling the generation ofadverse events
1) Response at the time of treatment
The coordinator indicated that the PTN should be
withdrawn immediately if pain were experienced fromthe skin puncture or if discomfort occurred and that the
subject should report the circumstances associated withthe pain caused by the skin puncture or the discomfort
felt immediately after the skin puncture.
2) Response under continuous indwelling
When adverse events, such as discomfort, pain, or
itchiness were generated during the continuous indwelling of the sham or the PTN, the subject was instructed tocontact the coordinator promptly about the situation. We
decided that, as a general rule, when an adverse event
occurred, the subject would visit our clinic to have thesham or PTN removed and thereafter the subject's progress would be observed.
4. Manual Testing
The manual tests for cervicobrachial pain are performed in the orthopedics field, and are used for thescreening of thoracic outlet syndrome. In this study, theJackson Test, Spurling Test, biceps brachii muscle tendon reflex, brachioradial muscle tendon reflex, triceps
brachii muscle tendon reflex, and the dysesthesia test
were conducted for detecting radiculopathy; the Morrie's
Test, Adson's Test, and the Allen Test were conducted
for the scalenus syndrome as part of the thoracic outlet
syndrome; the Wright Text was conducted for the minor
pectoralis muscle syndrome; and the Eden Test was
performed for the costoclavicular syndrome.

5. Intervention
The PTN used was a Pyonex acupuncture needle, 0.6
mm in length and 0.2 mm in diameter, made by SeirinCo., Ltd. The sham was created by taking the same typeof needle as the PTN and removing the tip during the
manufacturing process so it would cause tactile pressure
stimulation, without puncturing the body. These PTNs
were packed individually and provided by the abovementioned company in such a way that the PTNs and theshams were indistinguishable.
The treatment points consisted of less than four
marked parts of induration in the posterior cervical region, upper back region, and interscapular region detected by the practitioner during palpation, and were notlimited to Meridian Points. Treatment using either the
PTNs or the shams was performed in the sitting position.
The trial period was scheduled from October 10 toNovember 27, 2000 and the subjects participated for 3
continuous days.
The practitioners in charge consisted of five full-time
instructors, who worked in the school affiliated acupuncture clinic, and seven acupuncture and moxibustion clinical training students. The coordinator and the practitioners had no contact with each other; and moreover,the practitioners applied the PTNs that the subjects hadbrought in without knowing whether they were shams or
PTNs.
6. Endpoints
The VAS values for: before practice, immediately after practice, and 3 days later, and the III group "having
upper back muscle stiffness" on the Questionnaire for
Subjective Symptoms of Fatigue before the treatment,
and the values for 3 days after practice were used forevaluating the effects of treatment for upper back muscle
stiffness. The VAS method utilized a 100 mm length
black line, on which the current degree of upper backmuscle stiffness was marked on a continuum extending
from the left end which represented "no upper backmuscle stiffness" and the right end that represented "thestrongest upper back muscle stiffness in one's life".
In the processing of the VAS value, the measured distance from the left end to the marked point was expressed numerically in 1 mm units. Therefore, as the
VAS values would become larger, the stronger the upperback muscle stiffness would be.

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7. Statistical Work
The test of significance was conducted on the shamgroup and the PTN as follows: (1) t-test for the height,
weight, and period of continuation of the upper backmuscle stiffness from the subject's background, and (2)χ2 test for comparing the change before practice and 3days after among the subjects "having upper back muscle stiffness" in (III) dysphorias(4). The two-way
ANOVA was used to evaluate successive change of the
VAS values for the "before treatment", "immediately
after treatment", and "3 days after" periods; the difference was evaluated using (Fisher's PLSD test); and amultiple comparison and determination of the statistically significant difference was evaluated with a significance level of 5%.
Ⅲ．Results
1. Subject's Progress and Follow-up
The subject's progress and follow-up are shown in Fig.
1 by the trial flow chart. Although there were 56 people
who applied for this trial and from whom consent was
obtained in writing, 3 of these people were excluded
because they were deemed inappropriate as trial subjects
due to the fact that they did not fall under the category of"having upper back muscle stiffness" in the Questionnaire on Subjective Symptoms of Fatigue performed on

the trial day.
A random allocation of 53 trial subjects was conducted by assigning subjects to the sham group (n=25) or to
the PTN group (n=28). Since no one dropped out during
the three days of the intervention, all subjects in each of
the groups were used as analysis subjects at the completion of the trial.
2. Subject Backgrounds(1) Background factors
The subjects in the sham group included: 7 males and
18 females who were 31.8 ± 9.0 years old (mean ± S.D.,
hereinafter described as same); 161.0±6.9 cm in heighth;
and 57.1 ± 10.4 kg in weight. The subjects in the PTN
group included: 8 males and 20 females who were 35.1
± 11.9 years old; 162.0 ± 9.5 cm in heighth; and 57.4 ±11.3 kg in weight. The duration of upper back muscle
stiffness was: 7.7 ± 5.3 years for the sham group and 9.7± 7.8 years for the PTN group. In addition, a significant
difference was not recognized between these groups.
Two out of twenty-five in the sham group had been
diagnosed in a medical institution as having
cervicobrachial syndrome or cervical spondylosis. Whenthe manual tests were performed, 6 out of 25 subjects,
including the 2 who had been diagnosed, were recognized to have at least one positive finding. Three out oftwenty- eight subjects in the PTN group had been diag-

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nosed in a medical institute, each with a diagnosis of
cervical spondylosis, upper back muscle stiffness, ormuscle pain, respectively. When the manual tests for
cervicobrachial pain were performed, nine out of twentyeight subjects were recognized to have at least one positive finding; however, the positive findings found in the
manual test were not found in the subjects who had been
diagnosed with upper back muscle stiffness or muscle
pain (Table 1).
(2) Number of PTNs or a shams used
The number of PTN insertions was 3.50 per person on
the average, and the number of sham insertions was 3.96
per person on the average.
(3) Conditions for generation of skin puncture pain andthe discomfort derived from the skin immediately after
puncture The skin puncture pain and the discomfort
generated immediately after skin puncture were studied
in the sham group and the PTN group.
Skin puncture pain and generation of discomfort were
not recognized in either of the groups.
(4) Site of tender point origin
The tender points in the posterior cervical region, theupper back region, and the interscapular region of thesubject were detected by practitioner palpation. 99 sites
were detected in the sham group, including 5 sites in theposterior cervical region, 66 sites in the upper back region, and 28 sites in the interscapular region.98 sites
were detected in the PTN group, including 1 site in theposterior cervical region, 73 sites in the upper back region, and 24 sites in the interscapular region.

3. Changes in "having upper back muscle stiffness"
The existence of upper back muscle stiffness wasstudied, after three days, in the sham group and the PTN
group, which was determined as "existing upper backmuscle stiffness" according to the Questionnaire on Subjective Symptoms of Fatigue performed before treatment.
The number of subjects who complained of upperback muscle stiffness in three days after treatment was
12 out of 28 subjects in the PTN group in contrast to 23
out of 25 subjects in the sham group. Awareness of upper back muscle stiffness decreased by continual indwelling of the PTNs, and this was significant at lessthan 1% of percentage of risk (Fig. 2).
4. Effects of the PTN in upper back muscle stiffness(1) Total calculation using VAS values
The degree of upper back muscle stiffness was expressed by the VAS value, and the successive change foreach group was compared. The VAS values of the shamgroup (n= 25) were 55.2±17.5 ㎜ before treatment, 46.5
±19.7 ㎜ immediately after treatment, and 45.9±21.7㎜ 3 days after treatment. The PTN group (n= 28)
demonstrated 52.5±20.7 ㎜ before treatment, 40.5±
22.4 mm immediately after treatment, and 34.2±19.7 ㎜
within 3 days after treatment. A significant change was
not recognized in the values for the sham group for immediately after treatment and 3 days after treatment
when compared with the values before treatment. The
VAS values of the PTN group demonstrated a decrease
compared to the values of immediately after treatment

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Furuya Eiji, et al.. Japanese Acupuncture and Moxibustion, 2009; Vol.5(1): 12-21(p< 0.05) and the values three days after treatment (p<0.01) in the PTN group and the sham group (Fig. 3).
(2) Calculation with VAS values -Positive findings exist
in the manual testThe degree of upper back muscle stiffness in subjects
recognized to have positive findings by the conductionof manual testing for the cervicobrachial region was
expressed with a VAS value as a comparison. The VAS
values of the sham group (n= 6) were 56.8±7.1 ㎜ before treatment, 40.7±21.7 ㎜ immediately after treatment, and 43.8±13.6 ㎜ 3 days after the treatment. The
VAS values of the PTN group (n= 9) demonstrated 55.6
±23.8 ㎜ before treatment, 43.7±26.6 ㎜ immediately
after treatment, and 37.4 ± 20.6 ㎜ 3 days after thetreatment. There wasn't a recognized significant difference in the VAS values of either group immediately
after treatment and the values 3 days after treatment (Fig.
4 a).
(3) Calculation with VAS values -Positive findings did
not exist in the manual testThe degree of upper back muscle stiffness in subjects
whom positive findings had not been recognized in the
conducting of manual testing for the cervicobrachialregion was expressed with VAS values as a comparison.
The VAS values of the sham group (n= 19) were 54.6±
20.㎜ before treatment, 48.4±19.3 ㎜ immediately after
treatment, and 46.6±23.9 ㎜ within 3 days after treatment. The VAS values of the PTN group (n= 19)

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demonstrated 51.5±19.6 ㎜ before treatment, 39.1±
20.8 ㎜ immediately after treatment, and became 32.7±
19.6 ㎜ 3 days after treatment. A significant change was
not recognized in the values for the sham group immediately after treatment and 3 days after treatment.
The VAS values of the PTN group demonstrated a decrease at 3 days after treatment compared to the values
before treatment of the PTN group and the sham group(p< 0.01) (Fig. 4 b).
5. Generating Circumstances of adverse events
Pain derived from skin puncture during PTN treatment
or discomfort generated immediately after needle insertion was not recognized. There weren't any examples of
re-insertion of PTNs. When the PTNs or shams were
continuously indwelt for 3 days, some adverse events

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occurred: in the sham group, itchiness occurred in 3
subjects, and discomfort in 1 subject; in the PTN group:
itchiness occurred in 4 subjects and "annoyance resulting
from keeping the needles inserted" occurred in 1 subject.
Among these symptoms, "annoyance resulting fromkeeping the needles inserted" disappeared immediately
after removing the needles, and other symptoms naturally disappeared in a few days. Moreover, there weren't
any subjects who removed the PTNs due to generationof adverse events during the three-day trial period ofcontinuous indwelling.
Ⅳ．Considerations
1. Appropriateness of this trial using the shamIn this study design, the sham group, which applies a
non-invasive sham needle, was provided as the control
group because it is recommended that a method using a
non-invasive sham needling group as the control group4),
or a single blind method5), which considers only the
influence on the subjects, be set up. Since the idea of aplacebo is to "have a psychological influence and to nothave a therapeutic effect", apparent differences that may
influence the effects must be avoided. In addition, it
cannot be overemphasized that the manifestation of painat the time of skin puncture with the PTN influences
whether a sham can become a placebo or not. Therefore,
in this survey, the shape of the sham and the PTN andthe respective packaging were prepared to be strictly
identical in the manufacturing process, so that only theinsertion of the needle insertion into the body would be
different. In addition, since the needle insertion method
for the PTN is a simple method in which the entire sticker with the needle is applied to the target area, and theneedle aspect of the PTN is only 0.6 ㎜ in length and 0.2㎜ in diameter, it was considered hard for a difference inneedle insertion technique to be produced among thepractitioners in charge of performing the needle insertion.
However, since the existence of the pain derived fromskin puncture at the time of treatment was not checked,
and all the subjects were assigned to either the sham or
the PTN group, the existence of the psychological influence cannot be denied.
The subjects in this study were a group that did nothave any uneasiness about acupuncture treatment at all,and in the preceding study6), it was confirmed that selecting subjects who were familiar with the effects ofacupuncture was one of the methods for removing thepsychological tension associated with the practice ofacupuncture itself in order to verify the effect of acupuncture treatment. Nevertheless, in order to handle thebias as a trial control group, it is necessary to take into
consideration and study the condition setting according
to the study purpose.
2. Occurrence Factors of Upper Back Muscle Stiffness and the Improvement Effects associated with the
PTN
Although Ishida7) based upper back stiffness on theassumption of a subjective feeling of stiffness and reported that it could be objectively confirmed as "extraordinary tonus of muscle, pleasant feeling upon pressure, and lumpiness" in the upper back muscle, Sasaki8)
described that these two do not necessarily go together,and that in addition to physical factors, psychologicaland social factors are intricately intertwined in the occurrence of upper back muscle stiffness. Furthermore, since
there are many people who chronically feel upper backmuscle stiffness, it is also important to find the factorsthat may relate to this occurrence in the individual's
living conditions.
An extensive investigation3) was conducted on the relationship between the occurrence of upper back muscle
stiffness and fatigue, and complaints about feelings offatigue accompanied with work progress were analytically tracked. Studying the level of the feeling of fatigue
accompanied with acute fatigue or subacute fatigue has
important meaning9). The group III of "localized
dysphoria" in the Questionnaire on Subjective Symptoms of Fatigue used in this study expresses a projectionof the fatigue to a body part, and it is believed that theoccurrence of upper back muscle stiffness is a stress
reaction, which means that there are problems in theautonomic nervous system that are caused by depressionof the brain-stem reticular activating system and a dysfunction in the cerebral limbic system and hypothalamus10).
The effect11) on the autonomic nerve by acupuncture
treatment was studied using the heart rate. Stimulationon the skin/subcutaneous tissue evokes the reaction of
the parasympathetic nervous system as the efferent nerve,
and it is advocated that three factors of shallow needle
insertion, needle insertion during exhalation, and thetreatment in sitting position are used in order to evoke
this reaction effectively. The PTN treatment of this study
includes the two above-mentioned factors because the20
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inserted depth of the PTN used for this study is shallow
due to its 0.6 mm needle length, and consequently, thestimulation is to the skin or subcutaneous tissue, and is
performed in the sitting position. Therefore, it is believed that the function of the parasympathetic nervous
system was continuously excited immediately after
treatment with the PTN, and as a result, this effectively
acted to improve the upper back muscle stiffness derived
from the stress reaction.
Furthermore, it is considered that a single treatment
with the PTN has a self-care aspect in the prevention of
fatigue and the acceleration of recovery from fatigue
because the treatment can be performed in a comparatively easy manner. Accordingly, the possibility of composing a new avenue for the PTN as one of the acupuncture and moxibustion treatment methods for health enhancement, which correlates in Oriental medicine with
so-called "treatment before the onset of disease", hasbeen suggested.
On the other hand, there is a possibility that the occurrence of upper back muscle stiffness may originate incervicobrachial impairment12). The existence of such adiagnosis was checked by inquiry and also a manual test
for cervicobrachial disorder was performed. The subjects
included those who had been diagnosed with cervicalspondylosis or cervicobrachial syndrome, or suspected
thoracic outlet syndrome according to manual testing
performed by the practitioner, or those who had not undergone a diagnosis for such. Although we could notclarify the effects on subjects who had been recognizedor suspected to have thoracic outlet syndromes becauseof the few number of subjects, it is believed that theimportance of finding the cause of occurrence of upperback muscle stiffness in order to select the practicemethod and the stimulus method has become re-clarified.
It is necessary to conduct further studies on determining
the treatment method for treating upper back muscle
stiffness originating from cervicobrachial disorders.
3. Selection of Tender points
It is believed that the tender point13) is an area where
the pain threshold is low and the pain receptor for thatarea elicits hyperalgesia by sensitization. Although
Kawakita14) reported that the origin of the tender point
has not been sufficiently studied yet, he suggested thatthe decrease in local blood flow and the hypoxic condition due to poor posture forces long time muscle contraction, which triggers the destruction of the cell mem-brane and injury to the muscle by the production of various active enzymes, and the polymodal receptor is sensitized or results in neurogenic inflammation, which is
generated as a result. Consequently, he suggested thepossibility that this may cause a localized dot shape,
which is the low pain threshold area, in other words, it is
the tender point.
In this study, the muscle branches of the 3 rd and 4 thcervical nerves were distributed on the muscle where
tender points accompanied by upper back muscle stiffness were recognized. Moreover, the supraclavicularnerves, which are the cutaneous branches of the abovementioned nerves, innervate the region of the skin in theproximity of the upper back, which covers these muscles.
Therefore, since the PTN treatment on the tactile tender
point can be stimulation on the skin, which is innervatedby the same nerve as the muscle where the upper backmuscle stiffness has occurred, it is thought that the upperback muscle stiffness improved by the change in pain
threshold through the receptor of the skin sensory nerve.
4. Response to Adverse Events
When the practitioner in charge was to report the circumstances surrounding the generation of discomfort
experienced immediately after needle insertion or uponneedle tip insertion, there weren't any reports on thegeneration of discomfort immediately after skin puncture
or pain derived from skin puncture of the needle tip, andthere weren't any reports on re-insertion of the PTN.
When the inserted PTN had been indwelled for 3 days,
itchiness was the most frequent of adverse events. Thisphenomenon occurred despite whether the treatment was
conducted among the sham group or the PTN group,
such that itchiness can be said to be a disadvantage ofusing the PTN, which is generally left indwelled continuously. The method of attaching the PTN and the selection of sealing materials and adhesives are subjects thatmust be studied in the future. In addition, the sensitivityof the subject should be taken into consideration when
determining the length of needle for treatment of upperback muscle stiffness, because there were subjects who
felt discomfort or uneasiness upon needle insertion.
Ⅴ．Conclusion
The following results were obtained in the comparative study about the short term effects of the PTN treat-

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ment with the objective of improving upper back muscle
stiffness.
1. Consciousness of the "existence of upper back muscle stiffness" decreased in three days after the PTN
treatment (p< 0.01).
2. The VAS values of the subjects who have upperback muscle stiffness (total calculation) decreased
immediately after the PTN treatment (p< 0.05) andin three days after the treatment (p< 0.01).
3. The VAS values of the subjects who didn't havepositive findings during manual testing, even though
they experienced upper back muscle stiffness, decreased in 3 days after the treatment (p< 0.05).
4. The fact that PTN treatment resulted in remarkable
improvement in upper back muscle stiffness, suggested that PTN treatment may cause recovery fromfatigue at an early stage, and has the possibility ofcontributing to the maintenance and improvement ofhealth as one of the self-care treatment methods.
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