## 4 Discussion  
In the treatment of neck pain or headache, PDN is an unconventional modality in modern clinical practice [26,28]. Recommendations from current practice guidelines for  
Figure 4: FOTO Neck FS outcomes from intake to discharge. Abbreviations: FOTO, Focus On Therapeutic Outcomes; FS, functional status. \begin{table}
\begin{tabular}{c c c c} \hline \hline
**Measure** & **Intake** & **Discharge** & **One Month Post Discharge** \\ \hline FOTO Neck FS & 61 & 73 & N/A \\ \hline Pain (NPRS) at rest & 2/10 & 0/10 & 0/10 \\ \hline \multirow{2}{*}{Cervical AROM} & \multirow{2}{*}{Intake} & \multirow{2}{*}{Follow-Up (Visit 3)} & \multirow{2}{*}{Discharge} & Pain (NPRS 0-10) \\  & & & 1/F/D \\ \hline Flexion & 45 degrees & 48 degrees & 50 degrees & 0/10, 0/10, 0/10 \\ \hline Extension & 50 degrees & 50 degrees & 52 degrees & 8/10, 2/10, 0/10 \\ \hline Right lateral flexion & 25 degrees & 28 degrees & 30 degrees & 8/10, 2/10, 0/10 \\ \hline Left lateral flexion & 30 degrees & 30 degrees & 30 degrees & 0/10, 0/10, 0/10 \\ \hline Right rotation & 60 degrees & 68 degrees & 71 degrees & 8/10, 2/10, 0/10 \\ \hline Left rotation & 70 degrees & 70 degrees & 73 degrees & 0/10, 0/10, 0/10 \\ \hline \hline \end{tabular} Abbreviations; AROM, active range of motion; I, intake; F, follow up (visit 3); D, discharge; NPRS, numeric pain rating scale; FOTO, Focus On Therapeutic Outcomes; FS, functional status.  
\end{table} 
Table 3: Outcome measures from intake to discharge. neck pain [61] or neck pain with headache [53] do not include dry seedling. Yet, TrPDN seems preferred by clinicians [62]. Validation studies of deep spinal muscle TrPDN advocate that the needle-tip contact the vertebral lamina as an indicator of safe placement [63; 64; 65]. For instance, needing active TrPs in the cervical multifidi involves the needle tip picking the cervical lamina after the muscle is punctured to verify the target muscle was reached [64]. Aside from being an indicator of safety, clinicians should consider that needing to bone will engage mechanisms related to periosteal stimulation that may offer unique therapeutic benefits [1]. Periosteal needling may induce analgesia within a sclerotome via segmental mechanisms [66; 67]; however, studies supporting the segmental arrangement of sclerotomes are lacking [68]. Spinal mechanisms mediating bone pain differ from muscle, skin, and other tissues [68; 69]. While segmental mechanisms can be triggered by seedling down to bone [70], they may be mediated by a spinal segment or segments different than the ones innervating the overlying myotomes and dermatomes stimulated along the needle pathway [71]. A limitation to this case study is the inability to distinguish between the therapeutic effects of PDN from those of needing the muscles and other tissues lying over the CAPs during the treatment. It is also likely that the adjunct interventions that were part of the treatment plan contributed to the positive outcomes. In addition, no imaging was available to confirm that the needle tip reached the periosteal region of the cervical articular pillars; this was only confirmed by needle palpation. Periosteum is innervated by mechanosensitive, A\(\delta\) and C-fiber nerve endings that are encapsulated in the cambium layer [72; 73; 74; 75]. In the upper cervical spine, medial branches from the dorsal rami wrap along the articular pillar before giving rise to articular branches that supply the zygapophysseal joints [76]. Afferent nerves in the periosteum project to lamina 1 in the dorsal horn and transmit impulses along the spinoparabrachal pathway [75]. It is conceivable that PDN to the articular pillar, using multiple taps within a small area (Figure 3), induces distortion of the bone surface, selectively activating mechanosensitive afferents that send impulses to projection neurons in the parabrachial complex. The noxious input from PDN is then transmitted to the periaqueductal gray and rostral ventromedial medulla to trigger descending pain inhibition [77; 78; 79].