Kaneko Yasuhisa, et al.. Japanese Acupuncture and Moxibustion, 2009; Vol.5(1): 22-30

Translated Articles from JJSAMThe Effects of Press Tack Needle Treatment on
Muscle Soreness after Triathlon Race
- Sham-controlled StudyKANEKO Yasuhisa, FURUYA Eiji, SAKAMOTO Ayumi
Tokyo Therapeutic Institute
Abstract[Purpose] To examine the effect of press tack needle (PTN) treatment on muscle soreness after triathlon race in asham (S)-controlled study.
[Methods] Subjects were 149 healthy triathletes randomly divided into 2 groups, PTN group and S group. PTN andS were placed on the L 3 to S 2 dermatome area (BL 23, BL 24, BL 25, BL 26 and BL 32) only during the race.
The visual analog scale (VAS) was used to measure muscle soreness at 6 points (anterior thigh, posterior thigh,anterior lower legs, posterior lower legs, lower back and hip). Measurements were obtained before the race (PRE),after the race (POST 1), and on the day after the race (POST 2) to evaluate the effect of PTN treatment.
[Results] All of the VAS values were increased on POST 1 compared to that on PRE (p<0.01) for both groups. In
the PTN group, the VAS values were decreased on POST 2 compared to those on POST 1 except for the buttock
area (p<0.01, p<0.05), and muscles recovered to the pre-race condition. In the S group, the VAS value of the posterior thigh was decreased on POST 2 compared to that on POST 1 and the VAS values of anterior thigh, posterior
thigh, and posterior lower legs were still increased on POST 2 compared to that on PRE (p<0.05).
[Conclusion] It was suggested that occurrence of delayed onset muscle soreness is suppressed by the use of press
tack needles during the race.
*This is an English translation of a paper published in the journal of the Society of Acupuncture & Moxibustion:
2005: Vol.56, 158-165
Key words: triathlon, press tack needle, sham, muscle sorenessⅠ．Introduction
When an athlete estimates one's own condition at theclinical site, subjective symptoms, such as fatigue or
muscle soreness are frequently complained of. Muscle
soreness can be classified as acute muscle soreness,
which occurs right after exercise, and delayed onset
muscle soreness (hereinafter referred to as DOMS),
which occurs from a few hours to 24 hours after exercise,
Corresponding author Kaneko Yasuhisa
Tokyo Therapeutic Institute
3, Sanei-cho, Shinjuku-ku, Tokyo, 160-0008

and reaches a peak in 24 to 72 hours. There are various
views1) about the developmental mechanism of muscle
soreness. The predominant theory is that the former isderived from the accumulation of algogenic substances,such as lactic acid or hydrogen ions, resulting from lackof local circulation, and the latter is derived from inflammation, which follows the injury of muscle fibers or
surrounding connective tissue caused by extraordinary
movement. Although it has been reported that acupunc-

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ture treatment prevents or relieves the occurrence ofmuscle soreness2), the influence on competitive performance has not been established yet. Careful study isrequired regarding the characteristics of racing, quantityof stimulation associated with needling, and needling
location in order to optimize athletic conditioning
through the use of acupuncture treatment.
Opportunities for acupuncturists to take on the role ofathletic trainer (hereinafter referred to as AT) have been
increasing in recent years. There are also study results
which indicate that acupuncturists form the largest number of qualified ATs working with competitive sport
teams3). Local acupuncturist and massage therapist associations take a main role in providing AT activities forathletes by opening up acupuncture and massage corners
in nationwide sporting events, such as in national athletic meets, and other such events as part of their volunteer
activities4).
There are great expectations for acupuncturists to partake in AT in the future, especially for those who haveacquired medical knowledge and AT techniques because
the role of AT covers various fields, such as injury prevention, first aid treatment, rapid recovery from exhaustion, and conditioning for performance enhancement.
In order to study the possibilities of conditioning by
acupuncture stimulus, triathlon athletes, whose sport isconsidered a severe endurance sport, were used as subjects. The athletes raced with press tack needles indwelled, and the effects on muscle soreness occurring
right after the race and the day after the race were studied by using a comparison group.

Ⅱ．Methods
1. Subjects and Informed Consent
This study was conducted during the triathlon race(swimming 1.5 km, bicycling 40 km, running 10 km,
total of 51.5 km) held in the Nishi Lake area of Yamanashi-ken on August 11, 2001, August 10, 2002, andAugust 16, 2003. At the initial stage of this study, therace director notified the participating athletes that thisstudy was going to be conducted and asked for theircooperation as subjects when recruiting participants. The
total number of participants in the race was 163, consisting of males and females. The contents and methods ofthis study, and any adverse events that could happen
were sufficiently explained orally and in writing, and inorder to conduct this study the consent for cooperation inthis study was granted via signatures of all of the athletes.
2. Intervention(1) Press tack needle and shamThe pyonex needle manufactured by Seirin Co., Ltd.
(needle length 0.6 mm) was used as the press tack needle(hereinafter referred to as PTN). A sham (hereinafterreferred to as S), which has the same shape but without aneedle tip, that causes contact pressure stimulation without invading the body, was made by the manufacturer
for this purpose. Furthermore, the packaging was also
made to look exactly the same as the PTN, so that thesham could not be distinguished in any way by appearance from the PTN (Fig. 1).
(2) Method of allocation
The coordinator assigned the subjects to 2 groups, thePTN group and the S group, according to a random
number table, and one or the other of these was handed
to the subject without revealing the content when the

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subject registered for the race.
(3) Treatment
Three full-time instructors from our school affiliatedacupuncture clinic performed treatment. The practitioners did not contact the coordinators in advance, and were
not involved in the allocation at all. The practitioners
treated without confirming the existence or nonexistence of the PTNs or S needles, which were brought
in by the subjects.

(4) Stimulus sites
The stimulus sites were a total of 10 points that werelocated on the left and right side, 2 cm lateral to a point
between the spinous processes of L 2 through S 1, andthe 2 nd posterior sacral foramina which correlates withthe posterior branch of the spinal nerves that are thesame level as the nerves innervating the muscles of thelower extremities. These were BL 23, BL 24, BL 25, BL
26, and BL 32 (Fig. 2). In addition, the treatment was
performed just before the start of the race, and the PTNs
or Ss were removed immediately after crossing the finish
line with the objective of indwelling the patches only
during the race in order to quantify the amount of stimulus.
3. Survey Items
The subject's age, athletic career, height, weight, andmedical history were surveyed by questionnaire before
the race. Furthermore, 6 sites were surveyed in respect tolower extremity muscle soreness resulting from overstraining during triathlon racing: (1) anterior thigh(quadriceps femoris), (2) posterior thigh (hamstring
muscles), (3) anterior crus (anterior tibialis), (4) posterior crus (gastrocnemius, soleus), (5) lower back (erector
spinalis, lumbar quadratus, etc.), and (6) buttocks (glute-

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us maximus, gluteus medius, etc.). It was decided to
conduct the survey 3 times: (1) before the race (hereinafter referred to as PRE), (2) immediately after the race
(POST 1), corresponding with the onset of acute muscle
soreness, and (3) the day following the race (POST 2),
corresponding with the onset of DOMS. The visual analogue scale (hereinafter referred to as VAS) was used forthe assessment of muscle soreness. In the VAS, the left
end of the 100 mm black line was established as "Nopain" in respect to muscle soreness, and the right end
was established as "Unbearable pain". It was decided
that the degree of perception should be checked on theline5). Processing of the VAS values involved measuring
the length from the left end to the marked point in mmunits, expressed numerically. Accordingly, the VAS
value becomes larger as "muscle soreness become more
severe". In addition, the VAS was directly input by the
subject with the assistance of a race volunteer. The subject answered with his/her own supposition whether theattached item was a PTN or as S, and described his/her
impressions at POST 1 and at POST 2 in a free format.
The flow of the entire study is shown in Fig. 3.
4. Statistical Analysis
Stat View 4.5 (product of Abacus Concepts) and SPSS
11.5 J (product of SPSS) were used in the statisticalanalysis.
A significance test was conducted using the t-test between the PTN group and the S group for age, height,
weight, and athletic career. The kappa statistic was usedregarding the reliability of S for PTN. Transition of the
VAS values before the race, immediately after, and the
day following were compared using the replicate determination analysis of variance and the multiple comparison (Bonferroni). In addition, the chi-square test wasused for the impressions immediately after the race andthe day following. The evaluation of the statisticallysignificant difference was considered a significance levelof less than 5%.
Ⅲ．Results
1. Background of the Subjects (Table 1)
There were 149 subjects who were eligible for thisstudy out of 163 who participated in the race, excluding
retired athletes and individuals whose responses to thesurvey were somewhat incomplete, making it impossible
to work with statistically. The breakdown (mean ±standard deviation) of the PTN group was as follows:
total 79 subjects, including 67 male and 12 female; age
28.5 ± 10.7 years; height 169.6 ± 7.4 cm; weight 61.7 ±7.4 kg; and athletic career 4.7 ± 3.9 years. The S groupconsisted of a total of 70 subjects, including 14 females
and 56 males, with an age of 27.3 ±8.5 years old, heightof 169.2 ± 8.5 cm, weight of 60.7 ± 9.0 kg, or an athletic
career of 4.9 ± 4.6 years. No significant difference wasrecognized between the 2 groups in respect to age,height, weight, and athletic career. Moreover, in theprevious medical history, the number of subjects who
experienced low back soreness was 13 in the PTN group(including 1 subject with a herniated lumbar disk) and
12 in the S group (including 1 subject with sciatica); andknee joint pain was 13 subjects in the PTN group and theS group, respectively; and ankle sprain was 2 subjects in
the PTN group and 3 subjects in the S group.
2. Reliability of Sham as a Press Tack Needle (Table
2)
In the PTN group, 34 subjects answered that the attached needle was a PTN, and 45 subjects answered thatthe attached needle was an S. In the S group, 54 subjects
answered that the attached needle was as S, 16 subjects
answered that the attached needle was a PTN, and the
kappa value was 0.20.
3. Changes in the VAS Value of Muscle Soreness(Table 3)(1) PTN group
The change in the VAS values at PRE, POST 1, andPOST 2 were measured, and it was found that the VAS
value increased in the order of PRE to POST 1 with asignificance (p<0.001). The VAS values for all parts ofthe body except for the buttock area decreased whencomparing values at POST 1 with POST 2, demonstrating a significant difference (p< 0.05). In addition, no

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significant difference was recognized between POST
2 and PRE for any areas of the body.
(2) S group
In the S group, the VAS values increased for all partsof the body when comparing the values at PRE to POST
1, resulting in a significant difference (p<0.01). The
VAS values of the posterior thigh decreased when comparing the values at POST 1 to POST 2 resulting in asignificant difference (p< 0.05). The VAS values of
POST 2 compared to PRE were higher in the anterior
thigh, posterior thigh, and posterior lower extremity,
resulting in a significant difference (p<0.05). In the buttock area, VAS values at POST 2 showed a high tendency compared to the values of PRE (p=0.08).

4. Impressions(1) Impressions immediately after the race
Thirty subjects out of 79 in the PTN group and 22
subjects out of 70 in the S group described their impressions after the race. The impressions described wereclassified into the 5 categories : "No low back soreness,
not as sore as usual", "Light fatigue", "Heavy fatigue","Felt uneasy about needles", and "Have no idea" forcomparison. In the PTN group, the impression of "No
low back soreness, not as sore as usual" was describedby 12 subjects; "Light fatigue" was described by 12
subjects; "Heavy fatigue" was described by 1 subject;"Felt uneasy about needles" was described by 1 subjectand "Have no idea" was described by 5 subjects. On the

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other hand, in the S group, "No low back soreness, notas sore as usual" was described by 4 subjects; "Lightfatigue" was described by 11 subjects; "Heavy fatigue"
was described by 3 subjects; "Felt uneasy about needles"
was described by 1 subject; and "Have no idea was described by 3 subjects (Fig. 4).
(2) Impressions regarding the day following the race
Thirty eight subjects in the PTN group and 24 subjects
in the S group described their impressions on the day
following the race. The impressions described were classified into the 5 categories : "No muscle soreness, lightmuscle soreness", "Low back soreness that is less thanusual, or no soreness", "Light fatigue", "Strong muscle
soreness", and "Have no idea" for comparison. In the
PTN group, "No muscle soreness, light pain" was described by 15 subjects; "Low back soreness that is lessthan usual, or no soreness" was described by 9 subjects;"Light fatigue" was described by 13 subjects, "Strong
muscle soreness" was described by 0 subjects; and"Have no idea " was described by 1 subject.
On the other hand, in the S group, impressions were
described as: "No muscle soreness, light soreness" by 4
subjects; "Low back soreness that is less than usual, orno soreness" by 4 subjects; "Light fatigue" by 10 subjects; "Strong muscle soreness" by 2 subjects; and "Haveno idea" by 4 subjects. The PTN group and the S groupdemonstrated a significant difference (p<0.05) (Fig. 5).
Ⅳ．Discussion
1. Action Mechanism and Muscle Soreness Control
Effects of the PTN
We studied the effects of PTN stimulation during exercise on muscle soreness after exercise. Previous studies suggest that there are various influences on exercise
resulting from PTN stimulation. Ueno et al. reported that
the PTN indwelled during exercise accelerates the synchronization of motor units accompanied with the muscle contraction6-8), and the author et al. have confirmedthat the metabolism of lactic acid in the blood in theinitial period of exercise was accelerated9) by PTN indwelling in the low back and buttock area when a maximal exercise stress test was conducted by cycle ergometer. In addition, Sugiyama et al. reported that the lowering of muscle strength was controlled when the isokinetic extension and flexion exercise of the knee joint was
performed under the above described stimulation10,11). In
a previous study on these PTNs, Kusumoto et al. report-

ed that the recovery of muscle twitching of the gastrocnemius muscle, which had been reduced after tetanic
contraction, could be accelerated by needling on theparavertebral muscle in the rat, and this mechanism wascaused by the excitation of the sympathetic vascularexpansion nerve by the somatic autonomic nervous reflex12). Stimulation with acupuncture in this report isperformed on the muscle branch of the posterior branchof the spinal nerve. It is believed that stimulation with
PTN, which performed on the cutaneous branch of theposterior branch of the spinal nerve, may induce thesomatic autonomic nervous reflex based on the samemechanism as the stimulation on the motor branch. The
VAS values at POST 1 increased in all the parts in bothgroups compared with PRE, and the effects of PTN for
acute muscle soreness were not recognized. Althoughsome participants reported that acute muscle sorenesswas sedated by PTN stimulation at POST 1, no difference with the S group was recognized. It is thought thata reason for this is that promotion of blood circulation in
the lower extremities by PTN intervention could notexert a sufficient effect because of the notable production of chemical substances and their accumulation,
which led to acute muscle soreness due to the intense
exercise involved in the triathlon race. On the other hand,
it is believed that the PTN stimulation contributed to thesedation of the DOMS occurrence because the VAS
values of POST 2 decreased significantly compared withthe values from POST 1 in all parts except the buttock
area in the PTN group. There were many impressions of"less muscle soreness" or "less fatigue" than the day
following the other races, and a significant differencecompared with the S group was recognized. In respect tothe effects on DOMS occurrence by needle stimulation,
there are reports in which needle stimulation performedon active muscle before and after exercise results inlessened DOMS13,14), and it is believed that these effects
are derived from an increase in muscle blood flow
through the axon reflex15,16). Although it is believed that
sedation of the development of DOMS in the low backin this study includes the axon reflex because of thecorrespondence between the parts being stimulated andthe parts experiencing soreness, the sedation of DOMS
in other remote parts cannot be explained by the axonreflex alone. Analgesic action of needle stimulation also
reveals the intervention of endogenous opioids17); however, the stimulation in this study was only performed
during the race, and, moreover, it is difficult to suppose

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that the influence on the DOMS occurring the next day
would be that serious because the stimulus quantity was
extremely small compared to the stimulus quantity usedin so-called acupuncture analgesia. It is conjectured thatthe burden on the muscle fiber during racing is reducedby the intervention of the PTN, which accelerates synchronization of the motor unit, and as a result, the secondary inflammation occurring in the muscle and surrounding connective tissue is alleviated, and thus thedevelopment of DOMS is prevented. It is plausible thatthe occurrence of DOMS could interfere with training ora game, so in the future we would like to further study
the region and timing of the stimulation, in order to establish a methodology which would more effectively
prevent the occurrence of DOMS.
2. Adverse Events
In this study, 1 subject complained of uncomfortablefeeling, and 1 subject experienced heavy fatigue. On theother hand, in the S group we heard from one person thats/he worried about the needle during the race and fromthree people who became strongly aware of exhaustion.
Moreover, in the S group, there were two people whocomplained of feeling more fatigue and muscle sorenessthan usual. According to our experience, well-trained
athletes are very sensitive to changes in their physicalcondition, and it is also frequently observed that theychange their condition by a small amount of needle
stimulation. Therefore, it seems that those who felt uncomfortable or who worried about the needles did so
because of their original high sensitivity, and they overreacted in the race situation, a situation that induces a lotof nervous tension or psychological effects. In addition,
the possibility of PTN stimulation reaching the level ofan overdose for the subject cannot be denied, but it isthought that such an impression could have been given
because of muscle fatigue, which was within the physiological range and psychological factors were overlapping
due to the fact that the triathlon is a very strenuous competition and that fatigue and muscle soreness during therace or on the day following the race are usual. Whenconditioning the athlete in the field, the onset of adverse
events should be prevented by carefully paying attention
to the observation of physical and psychological aspects.
3. Applications in the Field
According to this study, it is thought that PTN should
not just be used temporarily for improving physical abil-

ity in important races; rather it should also be used continuously during daily training. It is supposed that an
athlete stays in good condition by suppressing muscle
soreness after training, by preventing injury, and by
reducing fatigue; and furthermore, it can be said thatspeeding up the recovery from fatigue is associated withimproving the quality and quantity of training.
Ⅴ．Conclusion
The muscle soreness on the day following a race wascontrolled by the press tack needle stimulation on the
low back and buttock area during the triathlon race. It isbelieved that continuous use of the press tack needle
during a race or in daily training can contribute to effective training because it alleviates the burden on the lowback and lower extremities, and improves the athlete's
condition.
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