Mechanical Neck 2021

Pain Medicine, 0(0), 2021, 1–12
doi: 10.1093/pm/pnab134
Advance Access Publication Date: 8 April 2021
Original Research Article
Downloaded from https://academic.oup.com/painmedicine/advance-article/doi/10.1093/pm/pnab134/6217368 by University of Cambridge user on 26 May 2021

Can Patient Expectations Modulate the Short-Term Effects of Dry
Needling on Sensitivity Outcomes in Patients with Mechanical Neck
Pain? A Randomized Clinical Trial
Gracia M. Gallego-Sendarrubias, PT, PhD,* Lennard Voogt, PhD,†,‡ Jose Luis Arias-Burıa, PT, PhD,§,¶
Joel Bialosky, PT, PhD,k,kk and Ce
sar Ferna ~ as, PT, PhD§,¶
ndez-de-las-Pen
*Department of Physical Therapy, Camilo Jose Cela University, Madrid, Spain; †Department of Physiotherapy, Research Centre for Innovations in Care,
Rotterdam University of Applied Sciences, Rotterdam, The Netherlands; ‡Pain in Motion Research Group (PAIN), Department of Physiotherapy, Human
Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium; §Department of Physical
Therapy, Occupational Therapy, Rehabilitation and Physical Medicine, Universidad Rey Juan Carlos, Alcorc on, Spain; ¶C
atedra Institucional en
Docencia, Clınica e Investigacion en Fisioterapia: Terapia Manual, Puncion Seca y Ejercicio Terapeutico, Universidad Rey Juan Carlos, Alcorc
on,
Madrid, Spain; kDepartment of Physical Therapy, University of Florida, Gainesville, Florida, USA; kkBrooks-PHHP Research Collaboration, Gainesville,
Florida, USA
Correspondence to: Jose Luis Arias-Burıa, PT, MSc, PhD, Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Avenida de Atenas
s/n, 28922 Alcorcon, Madrid, Spain. Tel: þ34 91 488 89 50; Fax: þ34 91 488 8957; E-mail: joseluis.arias@urjc.es.
Funding sources: There are no funding sources to report for this study.
Conflicts of interest: The authors have no conflicts of interest to declare.
Trial registration: Clinicaltrials.org ID: NCT04417491.
Abstract
Objective. Dry needling is commonly used for the management of patients with musculoskeletal pain. However, the
effects of patient expectations are uncertain. Our aim was to determine the effect of patient expectations on short-
term clinical outcomes after the application of a single session of dry needling in individuals with neck pain.
Methods. We conducted a randomized, placebo-controlled clinical trial including 50 patients with mechanical neck
pain. Participants received a single session of dry needling or sham needling in a blinded design. Predicted patient
expectation was categorized as positive, neutral, or negative. Outcomes including neck pain intensity (visual analog
scale, 0–100), pressure pain thresholds, and self-perceived improvement (Global Rating of Change, 7 to þ7) were
assessed at baseline, 1 day after the intervention (immediately after), and 7 days after the intervention (1 week after)
by a blinded assessor. Repeated-measures analyses of covariance were conducted to assess the effects of real/
sham needling adjusted by patient expectations. Results. Individuals receiving dry needling exhibited better out-
comes immediately and 1 week after the intervention than did those receiving sham needling (all P < 0.01). No gen-
eral effects of patient expectations, either related to pain recovery or functional improvement, were observed on the
clinical outcomes, except for a small association of questionable clinical relevance between positive expectations
and localized pressure pain thresholds in the dry needling group. Conclusion. This study did not find a significant ef-
fect of predicted patient expectations on the short-term effects of dry needling on pain intensity and pressure pain
thresholds in people with mechanical neck pain.
Key Words: Dry Needling; Sham Needling; Expectations; Neck Pain; Cervical Spine
Introduction lifetime prevalence rates of 6.6%, 21.4%, and 44.4%, re-

spectively, and accounting for an annual cost of $87.6
Neck pain is the fourth most common cause of pain-
billion in the United States of America [1]. Clinical
related disability, with estimated point, annual, and
C The Author(s) 2021. Published by Oxford University Press on behalf of the American Academy of Pain Medicine.
V
All rights reserved. For permissions, please e-mail: journals.permissions@oup.com 1
2 Gallego-Sendarrubias et al.
practice guidelines currently recommend exercise, mobi- predicated expectations provided by the therapist). In the
lization, manipulation, massage, and electrotherapy for present study, we focused on predicted patient expecta-
the treatment of patients with neck pain [2, 3]. Physical tions about the result of a specific (dry needling)
therapists commonly treat individuals with neck pain intervention.
according to clinical practice guideline recommenda- The role of expectations in patients with neck pain

tions; however, patient preferences and clinical experi- has been previously investigated in some studies; how-
ence may support the inclusion of other interventions not ever, it is important to consider which type of expecta-
included in clinical practice guidelines. tion was used in each one. For instance, Malfliet et al.
Dry needling is one intervention that is commonly found that positive (“This is a very effective intervention
used by physical therapists for managing patients with used to treat neck pain and we expect it to reduce your
neck pain [4] but that lacks support from clinical practice pain experience”) and neutral (“This is an intervention
guidelines. Guideline–non-adherent provision of dry nee- used to treat neck pain that has unknown effects on per-
dling may persist not because of evidence against its use ception of your pain”) expectation instructional sets de-
but rather the heterogeneous results of trials examining livered by the therapist led to higher decreases in pain
its use. In recent years, there has been more consistent ev- intensity and pressure pain sensitivity (i.e., by increasing
idence supporting the effects of dry needling for the man- pressure pain thresholds [PPTs]) after the application of
agement of neck pain–related symptoms [5, 6]. In fact, joint-based interventions in individuals with mechanical
an updated meta-analysis reported low to moderate evi- neck pain than did a negative expectation instructional
dence suggesting a moderate clinical effect of dry nee- set (“This is an ineffective intervention used to treat neck
dling for decreasing neck pain and pain-related disability pain and we expect it to temporarily worsen your pain
in people with neck pain symptoms associated with trig- experience”) [14]. Similarly, the only study investigating
ger points (TrPs) in the short term but not in the middle expectations of dry needling treatment recently observed
or long term [7]. no differences in changes in pain intensity, pain-related
Although it is not fully understood, the theoretical ba- disability, and pressure pain hyperalgesia between neu-
sis for applying dry needling in patients with neck pain is tral- and positive-expectation instructional sets delivered
grounded in identifying and targeting TrPs in the neck by the therapist [15]. Both studies manipulated expecta-
muscles that are able to reproduce the symptoms of the tions through randomly assigned instructional sets rather
patient [8]. Potential mechanisms through which dry nee- than considering the predicted expectations participants
dling could be effective for patients with neck pain in- brought to the clinical encounter.
clude a decrease in spontaneous electrical activity, an Bishop et al. investigated the effects of predicted pa-
increase in muscular blood flow and oxygenation, a de- tient personal expectations before manual therapy (i.e.,
crease in algogenic and pro-inflammatory mediator lev- spinal manipulation, massage) or exercise (i.e., strength-
els, and stimulation of peripheral nerve fibers and the ening, range of motion) in individuals with neck pain
release of endogenous opioid and neurotransmitters [9]. and observed that positive expectations were associated
More recently, Fernandez-de-las-Pe~ nas and Nijs have with better clinical outcomes [16]. Similarly, Palmlöf
highlighted the role of patients’ expectations and a poten- et al. also reported that positive predicted personal
tial placebo effect in the underlying mechanisms behind expectations were associated with better clinical out-
dry needling [10], on the basis of the fact that changes in comes, but expectations seemed to have a greater influ-
clinical outcomes after a particular treatment are com- ence on recovery in male patients [17]. In contrast, a
plex and can be attributed to condition-related factors recent study concluded that patient predicted personal
(e.g., natural history of disease, regression to the mean), expectations did not predict treatment outcomes in the
specific treatment effect (e.g., underlying mechanisms of long term in individuals with neck pain receiving man-
that intervention), and nonspecific effects (e.g., placebo ual therapy [18].
and nocebo effects) [11]. No previous study has investigated predicted personal
Among the nonspecific effects, patients’ expectations, expectations in clinical outcomes after the application of
a commonly overlooked factor in physical therapy inter- dry needling. Understanding patient recovery expecta-
ventions, can play an important role in clinical treatment tions of treatment outcomes after the application of dry
outcomes [12]. Thompson and Sunol described four needling is an important part of developing treatment
types of patient expectation: 1) predicted expectation— plans and stimulating therapy preferences or adherence.
what the person believes will occur; 2) ideal expecta- Therefore, the objective of the present study was to deter-
tion—what the individual wants to occur; 3) normative mine the effect of predicted personal patient expectations
expectation—what the subject believes should occur; and on short-term clinical outcomes after the application of a
4) unformed expectation—the lack of a preconceived no- single session of dry needling in people with neck pain.
tion about an intervention [13]. In addition, clinicians We hypothesized that those patients with positive pre-
should differentiate between personal patient expecta- dicted personal expectations would exhibit better short-
tions (i.e., personal conceivable ideas the patient brings term outcomes than those with neutral or negative
to the clinician) and delivered expectations (i.e., expectations.
Patient Expectations and Effects of Dry Needling 3
Methods generated block randomization for 50 participants and

two groups) created before the start of the study.
Design
Individual and sequentially numbered index cards with
A randomized, placebo-controlled clinical trial was con-
the random assignments were prepared in sealed opaque
ducted according to the Consolidated Standards of
envelopes that were opened for proceeding with treat-
Reporting Trials (CONSORT) extension for clinical tri-

ment allocation. Participants and assessors were blinded
als [19]. Ethical approval was provided by the local com-
to the needling treatment received.
mittee of La Paz Hospital, Madrid, Spain (HULP 5006),
and the study was registered in Clinicaltrials.org
(NCT04417491). Eligible participants were informed of Interventions
the study and signed an informed consent form before After being randomly allocated to the dry needling or
their enrollment. sham needling group, one physical therapist, blinded to
the allocation group, marked the location of the most
Participants painful active TrPs in the upper trapezius muscle on each
Eligible participants were recruited from the patient pop- patient, and a second therapist performed the needling
ulation of a private practice for physical therapy in intervention. Both therapists have 15 years of experience
Madrid, Spain, from June 5, 2020, to October 15, 2020. in identification and management of TrPs with dry nee-
Patients who had had nonspecific neck pain symptoms dling (GMGS, JLAB).
for at least 3 months were included when they met the Patients allocated to the dry needling group were
following inclusion criteria: 1) pain in the neck area, in- asked to lie in a prone position with both upper extremi-
cluding the upper trapezius muscle; 2) age between 18 ties along the body. Once the active TrP was located, the
and 60 years; 3) at least one active TrP (i.e., TrP which overlying skin was cleaned with alcohol, and the needle
referred pain is able to reproduce the patient symptoms) was inserted, penetrating the skin 10–15 mm into the
in the upper trapezius; 4) ability to read and understand TrP (Figure 1). The physical therapist inserted a needle
Spanish; and 5) at least 6 months from the last physical through the skin into the active TrP using the “fast-in-
therapy treatment session. The upper trapezius was cho- and-fast out” needling technique in the upper trapezius
sen because it is the muscle most commonly affected by muscle [23]. It has been suggested that this intervention
TrPs in individuals with neck pain [20]. Medical records, should elicit local twitch responses for a successful out-
including imaging studies, from all participants were col- come; however, no consensus exists on how many local
lected. Participants were excluded if they presented with twitch responses are needed [24]. In the present study,
1) neurological symptoms or signs compatible with cervi- the needling was in and out of the upper trapezius muscle
cal radiculopathy or myelopathy, 2) cervical trauma, 3) (3- to 5-mm vertical motions, no rotations) at approxi-
systemic diseases, 4) pregnancy, 5) psychiatric problems, mately 1 Hz until four local twitch responses were eli-
or 6) fear of needles. Participants were asked to avoid cited, as one study reported that 3–4 local twitch
any analgesic or muscle-relaxing medication intake dur- responses are enough to obtain a positive outcome in
ing the study period. patients with mechanical neck pain [25]. If four local
Demographic (age, sex) and clinical data (time with twitch responses could not be elicited in a particular pa-
symptoms, pain intensity, and pain-related disability) tient, that participant was excluded from the analysis.
were registered at baseline. Neck pain intensity at rest Patients allocated to the sham needling group received
and during cervical movement was measured on a 100- a sham intervention with a sham needle (Steitberger’s
mm visual analog scale ranging from 0 (no pain) to 100 Park sham device [PSD], Figure 2). This device has a
(maximal possible pain), as it has been shown to be reli-
able and valid for assessment of musculoskeletal pain
[21]. The Neck Disability Index (NDI) evaluates pain-
related disability by measuring pain and limitations in
daily work (lifting, concentration, driving) and leisure
(personal care, reading, sleeping) activities. The NDI
includes 10 items scored on a six-point Likert-scale
(0: no limitations, 5: maximal limitation). A total score is
the sum of all the items (0–50), where higher scores mean
greater pain-related disability. The internal consistency
and test–retest reliability of the NDI have been shown to
be good [22].
Randomization and Masking

Concealed allocation was performed by using a
computer-generated randomization list (computer- Figure 1. Dry needling applied to the upper trapezius muscle.
blunt tip and retractable handle that creates the illusion The primary outcome in the present trial was neck
of a needle penetrating the skin. When this needle pain intensity. Participants rated the intensity of their
touches the skin, a pricking sensation is created. current pain and their pain during cervical movement at
However, when pressure is increased, the shaft of the rotation on a 100-mm horizontal visual analog scale
needle disappears into the handle, creating the impres- [21]. Changes of 30% from baseline are considered as

sion that the needle is actually entering into the skin. The clinically relevant [29].
needle is held in position by a small adhesive plastic ring. Secondary outcomes included PPTs and self-perceived
The Streitberger needle is a common sham comparator improvement assessed with the Global Rating of Change
used in studies of acupuncture and has been validated in (GROC). PPTs were assessed bilaterally (the mean of
terms of maintaining blinding and creating similar both sides was used in the analysis) over the upper trape-
impressions of skin penetration [26]. zius muscle (symptomatic area), the spinous process of
C7 (cervical innervated-related area), and the heel (re-
Patient Expectations mote pain-free distant area) by using an analog Fisher
Patients’ predicted expectations, i.e., those related to the algometer (Force Dial, Wagner Instruments, Greenwich,
anticipated outcomes of the intervention, were collected CT, USA). Data were collected in kilograms per square
at baseline by adapting the Patient ShOulder centimeter (kg/cm2) and converted into kilopascals (kPa)
Expectancies (PSOE) questionnaire [27]. The original (1 kg/cm2 ¼ 98.066 kPa). Participants were instructed to
questionnaire evaluated expectations (“compared with say “stop” when the pressure sensation first became
now, I think my shoulder problem overall will be . . .”) painful. The mean of three consecutive trials was used in
about pain, function, and the global effect of an interven- the main analysis [30]. A 30-second resting period was
tion over the shoulder, with six possible responses: much allowed between trials to avoid temporal summation
worse (1), worse (2), a little worse (3), the same (4), bet- [31]. The reliability of PPT assessment in the cervical
ter (5), and much better (6) [27]. The original score arose spine has been shown to be good in patients with neck
from the sum of all questions (0–18), with higher scores pain [32, 33]. The minimal detectable changes for PPTs
indicating more positive expectancies. In the present over the neck and the lower extremity (tibialis anterior
study, we applied three modifications: First, we adapted muscle) in patients with acute neck pain are 47.2 kPa and
the questionnaire from the shoulder to the cervical spine, 97.9 kPa, respectively [33].
as has been done previously by Skatteboe et al. [28]; sec- Finally, self-perceived improvement was assessed with
ond, we categorized patient expectations as positive a GROC scale, from 7 (a very great deal worse) to þ7
(responses 5 and 6), neutral (response 4), or negative (a very great deal better), where scores of þ4 and þ5 are
(responses 1–3); and third, we analyzed patient expecta- highly indicative of moderate changes in patient status
tions about pain recovery and those about function re- and scores of þ6 and þ7 indicate large changes in self-
covery separately. reported patient status [34]. We defined a successful rate
when the GROC score was þ5. The GROC was
assessed 7 days (1 week) after the intervention.
Outcomes
Outcomes were assessed at baseline (before), 1 day after
the intervention (immediately after), and 7 days after the Sample Size Determination
intervention (1 week after) by an assessor blinded to the Sample size determination was calculated in Ene 3.0 soft-
treatment allocation group (CFdlP). ware (Autonomous University of Barcelona, Barcelona,
Spain) and was based on detecting between-groups dif-
ferences of 30% on a 100-mm visual analog scale [29],
assuming a standard deviation of also 30%, a two-tailed
test, an alpha level (a) of 0.05, and a desired power (b) of
90%. The estimated desired sample size was calculated
to be at least 22 subjects per group. We finally included
25 participants per group.
Statistical Analysis
Statistical analysis was performed in SPSS software, ver-
sion 25.0 (Chicago, IL, USA), and it was conducted
according to intention-to-treat analysis for participants
in the group to which they were originally allocated.
Means, standard deviations, or 95% confidence intervals
are presented. The Kolmogorov-Smirnov test revealed a
Figure 2. Sham needling procedure applied to the upper trape- normal distribution of the variables, and the results also
zius muscle. showed that assumption of homogeneity was confirmed;
hence, parametric tests were used. Baseline data were Dry Needling vs Sham Needling
compared between groups through the use of indepen- After adjustment for baseline outcomes, the mixed-
dent Student tests for continuous data and v2 tests of in- model ANCOVA revealed significant group time
dependence for categorical data. interactions for neck pain intensity at rest (F ¼ 34.514,
The analysis of covariance (ANCOVA) using baseline P < 0.001, partial g 2: 0.528), neck pain intensity with

values as covariates has been shown to be more powerful movement (F ¼ 34.091, P < 0.001, partial g 2: 0.501),
than repeated-measures analysis of variance when ran- and PPTs over the upper trapezius (F ¼ 40.008,
dom group assignments are used [35]. Therefore, sepa- P < 0.001, partial g 2: 0.514), but not for PPTs over the
rate 3 3 2 repeated-measures ANCOVAs with time spinous process of C7 (F ¼ 1.008, P ¼ 0.369, partial g 2:
(baseline, immediately after the intervention, and 1 week 0.020) and PPTs in the lower extremity (F ¼ 0.075,
after the intervention) and expectation (positive, neutral, P ¼ 0.928, partial g 2: 0.002). Patients receiving dry
or negative) as the within-subjects factors, group (dry needling exhibited greater decreases in neck pain inten-
needling or sham needling) as the between-subjects fac- sity at rest and with neck movement than those receiv-
tor, and adjustment for baseline data were conducted for ing sham needling immediately after the intervention
evaluating between-groups differences in pain intensity (pain at rest: D 19.5 mm, 95% confidence interval
and PPTs. The effect size was calculated when the partial [CI] 26.5 to 12.5 mm; pain with movement:
eta squared (partial g2p) was significant. A partial eta D 20.0 mm, 95% CI 27.0 to 13.0 mm) and 1 week
squared of 0.01 was considered small, 0.06 was moder- after the intervention (pain at rest: D 29.0 mm, 95%
ate, and 0.14 was large [36]. For determining between- CI 35.0 to 23.0 mm; pain with movement:
groups differences in the outcomes, the hypothesis of in- D 25.0 mm, 95% CI 32.5 to 17.5 mm). In addition,
terest was the group time interaction, whereas for de- patients in the dry needling group exhibited higher
termining the effect of the expectation, the hypotheses of increases in PPTs over the upper trapezius than those in
interest were the expectation time and the expecta- the sham needling group immediately after the inter-
tion time group interactions. In general, P values vention (D 42.0 kPa, 95% CI 20 to 64 kPa) and 1 week
<0.05 are set as statistically significant; however, be- after the intervention (D 93.5 kPa, 95% CI 69.0 to
cause of the inclusion of multiple comparisons, a 118 kPa) (Table 3). Between-groups effect sizes were
Bonferroni correction was applied (corrected significance large in favor of the dry needling group. Both groups
level P < 0.05 / 3 ¼ 0.017). Finally, we used v2 tests to showed similar changes in PPTs over the spinous pro-
compare self-perceived improvement (GROC) and success of C7 and over the lower extremity, although they
cess rate at 1 week after each intervention, with and were small (Table 3).
without considering patients’ expectations. A significantly (v2: 31.345; P < 0.001) greater number
of patients (n ¼ 10, 40%) receiving dry needling achieved
a successful outcome (GROC þ5) than those receiving
sham needling (n ¼ 1, 4%).
Results
Participants Effect of Patient Expectations About Pain
Between June 15 and October 15, 2020, a total of 60 Symptom Recovery
consecutive patients with neck pain were screened for eli- The mixed-model ANCOVA revealed a significant
gibility. Fifty (mean age 43 years, 60% female) patients expectation / pain time interaction for PPTs over the
satisfied all criteria, agreed to participate, and were ran- upper trapezius (F ¼ 3.755, P ¼ 0.003, partial g 2: 0.135)
domly allocated to dry needling (n ¼ 25) or sham nee- but not for pain intensity at rest (F ¼ 0.627, P ¼ 0.54,
dling (n ¼ 25). The flow diagram of patient recruitment partial g 2: 0.025), pain intensity with movement
and retention shows the reasons for ineligibility (F ¼ 0.227, P ¼ 0.797, partial g 2: 0.009), PPTs over the
(Figure 3). Six patients (24%) assigned to the dry nee- spinous process of C7 (F ¼ 0.248, P ¼ 0.781, partial g 2:
dling group experienced post-needling soreness, but it re- 0.010), and PPTs in the lower extremity (F ¼ 1.495,
solved spontaneously without any action in 36–48 hours. P ¼ 0.210, partial g 2: 0.059). Clinical outcomes were
No other adverse event was reported by any participant similar in patients with positive, neutral, or negative
during the study. Randomization resulted in similar base- expectations related to pain in all outcomes except in
line features between the dry and sham needling groups PPTs over the upper trapezius, where individuals with
(Table 1). Similarly, baseline comparisons among sub- positive expectations exhibited higher increases 1 day af-
jects with positive (48–56%), neutral (16–32%), or nega- ter the intervention than did those with neutral or nega-
tive (20–28%) expectations were comparable in all the tive expectations (Table 4).
outcomes (Table 2); subjects with negative expectations Similarly, no significant expectation /
had higher current pain intensity than did those with pos- pain time group interactions were observed for any
itive or neutral expectations, but differences did not outcome (pain intensity at rest: F ¼ 1.975, P ¼ 0.105,
reach statistical significance (P ¼ 0.08). partial g 2: 0.081; pain intensity with movement:
Patients with neck pain symptoms screened for

eligibility criteria (n=60)
Excluded (n=10):
x No TrP in upper trapezius (n=5)

x Fear to needles (n=3)
x Previous whiplash (n=2)
Baseline Measurements (n=50)

Pain intensity at rest and with movement, PPTs
Randomized (n=50)
Positive expectations Neutral expectations Negative expectations

Pain-Related Symptoms (n=28) Pain-Related Symptoms (n=8) Pain-Related Symptoms (n=14)
Function (n=14) Function (n=16) Function (n=10)
Allocated to dry needling (n=25) Allocated to sham needling (n=25)
1 day a post-intervention (n=25)

1 day a post-intervention (n=25)
Pain intensity at rest and with
Pain intensity at rest and with
movement, PPTs
movement, PPTs
1-week a post-intervention (n=25)

1-week a post-intervention (n=25) Pain intensity at rest and with
Pain intensity at rest and with movement, PPTs, GROC
movement, PPTs, GROC
Figure 3. Flow diagram of patients throughout the course of the study.
Table 1. Baseline characteristics by treatment assignment
Dry Needling Group (n ¼ 25) Sham Needling Group (n ¼ 25)

Gender, n, male/female 10/15 11/14
Age, years 43.0 6 12.0 42.0 6 10.5
Months with neck pain 9.1 6 1.4 9.3 6 1.6
Pain intensity at rest (VAS, 0–100) 59.0 6 13.0 56.0 6 11.0
Pain intensity with movement (VAS, 0–100) 43.5 6 12.0 41.0 6 11.0
Neck Disability Index (NDI, 0–50) 13.5 6 2.5 12.5 6 2.5
PPT upper trapezius, kPa 219.5 6 41.0 228.0 6 61.0
PPT spinous process of C7, kPa 297.5 6 55.0 305.0 6 94.5
PPT lower extremity, kPa 436.0 6 72.0 420.5 6 100.5
VAS¼ visual analog scale.
F ¼ 1.773, P ¼ 0.141, partial g 2: 0.073; PPTs over the Within the dry needling group, individuals with positive
spinous process of C7: F ¼ 1.642, P ¼ 0.171, partial g 2: expectations experienced greater increases in PPT over
0.068; PPTs in the lower extremity: F ¼ 1.309, the upper trapezius than did those with neutral and nega-
P ¼ 0.273, partial g 2: 0.055), except for PPTs over the tive expectations (D 45.0 kPa, 95% CI 23 to 67 kPa;
upper trapezius (F ¼ 3.714, P ¼ 0.008, partial g 2: 0.142). P < 0.01).
Table 2. Baseline characteristics by patient expectations
Positive (n ¼ 28) Neutral (n ¼ 8) Negative (n ¼ 14)

Patient expectations related to function
response Positive (n ¼ 24) Neutral (n ¼ 16) Negative (n ¼ 10)
Patient expectations related to pain response

Gender, n, male/female 12/16 4/4 5/9
Age, years 42.0 6 11.0 42.0 6 12.0 44.0 6 15.0
Months with neck pain 9.1 6 1.4 9.2 6 2.0 9.4 6 1.4
Pain intensity at rest (VAS, 0–100) 55.5 6 12.0 55.0 6 12.5 63.50 6 9.5
Pain intensity with movement (VAS, 0–100) 43.0 6 13.0 37.0 6 6.0 43.5 6 12.5
Neck Disability Index (NDI, 0–50) 13.0 6 2.5 12.0 6 2.5 13.5 6 3.0
PPT upper trapezius, kPa 217.5 6 44.5 247.5 6 69.0 217.5 6 50.0
PPT spinous process of C7, kPa 311.5 6 59.0 317.0 6 98.5 287.0 6 79.0
PPT lower extremity, kPa 406.0 6 70.0 445.5 6 119.0 445.0 6 95.5
Gender, n, male/female 11/13 7/9 3/7
Age, years 43.0 6 10.0 41.0 6 11.0 45.0 6 16.0
Months with neck pain 9.1 6 1.4 9.3 6 1.7 9.2 6 1.4
Pain intensity at rest (VAS, 0–100) 55.0 6 13.0 58.0 6 11.0 64.50 6 8.0
Pain intensity with movement (VAS, 0–100) 43.0 6 13.5 40.0 6 9.0 45.0 6 13.0
Neck Disability Index (NDI, 0–50) 13.5 6 2.5 12.5 6 1.5 13.5 6 3.5
PPT upper trapezius, kPa 218.9 6 50.0 247.5 6 55.0 215.0 6 50.0
PPT spinous process of C7, kPa 307.0 6 69.0 325.5 6 79.0 267.5 6 79.5
PPT lower extremity, kPa 406.0 6 64.5 465.0 6 100.0 435.5 6 105.0
VAS¼visual analog scale.
Table 3. Primary and secondary outcomes at baseline, 1 day after the intervention, and 1 week after the intervention, as well as
within-group mean scores by randomized treatment assignment
Outcomes Dry Needling Sham Needling

Mean intensity of neck pain at rest (VAS, 0–100)*
Baseline 59.0 6 13.0 (54.0, 64.0) 56.0 6 11.0 (51.0, 61.0)
One day after intervention 37.0 6 13.5 (32.0, 42.0) 53.5 6 13.5 (48.0, 59.0)
Change from baseline to 1 day 22.0 6 12.5 (27.0, 17.0) 2.5 6 13.5 (8.0, 3.0)
One week after intervention 33.5 6 14.0 (28.0, 39.0) 59.5 6 13.0 (54.0, 65.0)
Change from baseline to 1 week 25.5 6 10.0 (29.5, 21.5) 3.5 6 12.5 (1.5, 8.5)
Intensity of neck pain with cervical movement (VAS, 0–100)*
Baseline 43.5 6 12.0 (39.0, 48.0) 41.0 6 11.0 (36.0, 46.0)
PPT upper trapezius, kPa*
Baseline 219.5 6 41.0 (200.0, 239.0) 228.0 6 61.0 (207.0, 249.0)
PPT spinous process of C7, kPa
Baseline 297.5 6 55.0 (267.0, 328.0) 305.0 6 94.5 (274.5, 335.5)
Change from baseline to 1 day 58.5 6 59 (40.0, 77.0) 48.5 6 54.5 (15.0, 82.0)
Change from baseline to 1 week 51.0 6 60 (30.0, 72.0) 42.5 6 64.0 (10.0, 75.0)
PPT lower extremity, kPa
Baseline 436.0 6 72.0 (401.0, 471.0) 420.5 6 100.5 (384.0, 457.0)
Timeline scores given as mean 6 SD (95% CI).

*Statistically significant differences among the groups (ANCOVA, P < 0.01).
within-group mean scores by patient expectations related to pain symptoms response
Outcomes Positive (n ¼ 28) Neutral (n ¼ 8) Negative (n ¼ 14)

Mean intensity of neck pain at rest (VAS, 0–100)
Baseline 55.5 6 12.0 (51.0, 60.0) 55.5 6 12.5 (46.5, 64.5) 63.5 6 9.5 (57.5, 69.5)

One day after intervention 42.0 6 16.5 (36.5, 47.5) 50.0 6 17.0 (39.0, 61.0) 48.5 6 12.0 (40.0, 57.0)
Change from baseline to 1 day 13.0 6 12.0 (19.0, 7.0) 5.5 6 15.0 (19.0, 8.0) 15.0 6 17.5 (25.0, 5.0)
One week after intervention 43.0 6 11.1 (36.0, 50.0) 50.5 6 18.0 (37.0, 64.0) 51.0 6 13.0 (41.0, 61.0)
Change from baseline to 1 week 12.5 6 10.0 (19.5, 5.5) 5.0 6 17.0 (20.0, 10.0) 12.5 6 17.5 (22.0, 3.0)
Intensity of neck pain at cervical movement (VAS, 0–100)
Baseline 43.0 6 13.0 (39.0, 47.0) 41.0 6 11.0 (32.0, 50.0) 43.5 6 12.5 (37.0, 50.0)
Baseline 217.5 6 44.5 (200.0, 235.0) 247.5 6 69.0 (213.0, 282.0) 217.5 6 50.0 (198.0, 237.0)
One week after intervention 300.0 6 59.5 (270., 360.0) 297.0 6 79.0 (247.5, 346.5) 257.5 6 45.0 (230.5, 294.5)
Baseline 311.5 6 59.0 (282.0, 341.0) 317.0 6 98.5 (274.5, 335.5) 287.0 6 79.0 (242.5, 331.5)
Baseline 406.0 6 70.0 (376.0, 436.0) 445.5 6 119.0 (395.5, 495.5) 445.0 6 95.5 (406.0, 484.0)

*Statistical significant differences among the groups (ANCOVA, P < 0.01).
Effect of Patient Expectations About Function PPTs over the spinous process of C7 (F ¼ 1.007,
Recovery P ¼ 0.408, partial g 2: 0.043), and PPTs in the lower ex-
After adjustment for baseline outcomes, the mixed-model tremity (F ¼ 0.886, P ¼ 0.476, partial g 2: 0.038). Within
ANCOVA did not reveal significant expectation / the dry needling group, individuals with positive expecta-
function time interactions for any outcome (pain inten- tions experienced greater decreases in pain intensity with
sity at rest: F ¼ 0.730, P ¼ 0.487, partial g 2: 0.030; pain neck motion (D 10.0 mm, 95% CI 7.5 to 12.5 mm)
intensity with movement: F ¼ 0.251, P ¼ 0.779, parti- and higher increases in PPTs over the upper trapezius (D
al g 2: 0.010; PPTs over the spinous process of C7: 40.0 kPa, 95% CI 20 to 60 kPa) than those with negative
F ¼ 0.056, P ¼ 0.946, partial g 2: 0.002; and PPTs in the expectations (P < 0.05), but these changes were similar in
lower extremity: F ¼ 1.838, P ¼ 0.170, partial g 2: patients with positive and those with neutral
0.071), except for PPTs over the upper trapezius expectations.
(F ¼ 3.001, P ¼ 0.045, partial g 2: 0.111). Outcomes were
similar in individuals with positive, neutral, or negative
expectations related to pain in all outcomes except in
PPTs over the upper trapezius, where individuals with Discussion
positive expectations exhibited higher increases 1 day This study found that dry needling was effective in the
and 1 week after the intervention than did those with short term for decreasing pain symptoms and pain sensi-
neutral or negative expectations (Table 5). tivity in comparison with sham needling for patients pre-
In addition, significant expectation / senting with mechanical neck pain. No significant effect
function time group interactions were found for pain of predicted patient expectations, either related to pain
intensity with movement (F ¼ 2.830, P ¼ 0.03, partial g 2: recovery or function recovery, were found for most out-
0.112) and PPTs over the upper trapezius (F ¼ 3.308, comes, except for a potential effect of positive expecta-
P ¼ 0.014, partial g 2: 0.128), but not for neck pain inten- tions over localized pressure pain sensitivity in response
sity at rest (F ¼ 1.795, P ¼ 0.137, partial g 2: 0.074), to dry needling.
within-group mean scores by patient expectations related to function response
Outcomes Positive (n ¼ 14) Neutral (n ¼ 16) Negative (n ¼ 10)

Mean intensity of neck pain at rest (VAS, 0–100)*
Baseline 55.0 6 13.0 (50.0, 60.0) 58.0 6 11.0 (51.0, 65.0) 64.5 6 8.0 (57.5, 71.5)

Intensity of neck pain at cervical movement (VAS, 0–100)
Baseline 43.0 6 13.5 (38.0, 48.0) 40.0 6 9.0 (33.5, 46.5) 45.0 6 13.0 (37.0, 53.0)
Baseline 219.5 6 50.0 (200.0, 239.0) 247.5 6 55.0 (218.0, 277.0) 215.0 6 50.0 (173.0, 257.0)
Baseline 307.0 6 69.0 (277.0, 347.0) 325.5 6 79.0 (287.5, 363.5) 267.5 6 79.5 (217.5, 317.5)
Change from baseline to 1 day 49.5 6 59 (30.0, 68.5) 31.0 6 54.5 (0.5, 62.5) 69.0 6 54.5 (42.0, 96.0)
Change from baseline to 1 week 45.0 6 60 (18.0, 72.0) 22.0 6 44.0 (1.0, 43.0) 39.5 6 40.0 (1.0, 80.0)
Baseline 406.0 6 64.5 (366.0, 446.0) 465.0 6 100.0 (415.0, 515.0) 435.5 6 105.0 (386.0, 486.0)

*Statistical significant differences among the groups (ANCOVA, P < 0.01).
We found that a single session of dry needling was predicted, normative), or the use of different interven-
more effective than sham needling for reducing pain and tions [37]. It is interesting to note that half of the popula-
pressure pain sensitivity in the short term. The present tion included in the present study expected that dry
findings are in agreement with a recent meta-analysis [7]. needling would bring them favorable results in terms of
However, it should be considered that we applied one pain or pain-related function. These rates of positive
treatment session. Importantly, our study is the first one expectations are lower than those previously reported for
investigating the effects of patient expectations on clini- other interventions such as spinal manipulation or exer-
cal outcomes after the application of dry needling. We cise, which reached almost 75% of the population [16,
did not find a significant influence of predicted patient 17]. It is possible that patient expectations are different
expectations on the clinical outcomes after just one ses- depending on which treatment approach is being evalu-
sion. In fact, literature about the effects of expectations ated or depending on previous experiences with that par-
in individuals with neck pain is conflicting, although it ticular intervention. In fact, Haanstra et al. described five
should be considered that these studies included longer factors that appeared to influence patients’ expectations:
follow-ups [16–18]. Our findings agree with those of previous experiences with the intervention, other
Mutsaers et al., who also did not find a significant effect patients’ experiences, knowledge about the treatment,
of patient expectations on clinical outcomes [18], but our personal beliefs, and the treatment setting [38]. Patient
findings are in contrast to those of Bishop et al. [16] and preferences for an intervention, as well as personal moti-
Palmlöf et al. [17], who reported that positive expecta- vation about recovery, may further account for differen-
tions were associated with better outcomes after the ap- ces in expectations.
plication of manual therapy or exercise in patients with We observed a potential effect of expectations for
mechanical neck pain. Several factors may explain the in- changes in pressure pain sensitivity over the upper trape-
consistent findings, such as heterogeneity of the concep- zius muscle after the application of dry needling but not
tualization and assessment of patient expectations, after sham needling. In such a scenario, positive expecta-
failure to specify the type of expectation studied (e.g., tions were associated with higher hypoalgesic response
(higher increases in PPTs) at the needle site (upper trape- of dry needling and the combination of dry needling with
zius muscle). Our results agree with those previously other evidence-based interventions, such as manual ther-
reported by Bialosky et al., who also found that expecta- apy or exercise. In addition, although the sham needles
tions have an influence on spinal manipulative-induced used in the present study have previously been shown to
hypoalgesia in healthy subjects [39] and patients with maintain blinding (78%) [26], we did not confirm the

low back pain [40], as negative expectation was associ- success of proper blinding of the sham procedure in our
ated with less hypoalgesic effect after manipulation. sample. Second, because of the sample size, gender differ-
Furthermore, the region-specific nature of our findings ences in expectations were not possible to determine
(i.e., in the area of treatment and not remotely) is consis- [48]. Third, we adapted the PSOE questionnaire, an out-
tent with placebo literature in which placebo analgesia come with limited data on its psychometric properties,
can be isolated to specific locations. For example, an an- for evaluating patient expectation; hence, measuring pre-
algesic effect was isolated to half of the forearm in a dicted patient expectation as a potential single-factor var-
study of sham acupuncture [41] and to a single finger in a iable could have led to oversimplification of the reality.
study of a placebo cream [42]. However, these studies in- Several other factors, such as motivation, personal pref-
vestigated instructional expectations (i.e., those provided erences, or therapist-provided expectations, could also
by the therapist) but not the expectations about the inter- have an influence on this process. Finally, we did not
ventions with which the participant presented. control previous medication intake in the patients, which
Current clinical guidelines for the management of could have influenced the results.
individuals with mechanical neck pain recommend the
use of manual therapy and exercises but not the use of
dry needling [2, 3]. Although there is evidence supporting Conclusion
the positive effects of dry needling when compared This study found that individuals with mechanical neck
against other interventions for the management of pain receiving dry needling exhibited better results in sen-
patients with neck pain [43, 44], its effects are reduced sory outcomes than did those receiving sham needling
when combined with manual therapy and exercise pro- immediately and 1 week after the intervention. No signif-
grams [45, 46]. Because patients with mechanical neck icant effect of predicted patient expectations, either re-
pain are a heterogeneous population, it is likely that not lated to pain recovery or functional improvement, was
all patients will respond positively to dry needling, and observed in the response to dry needling. A potential ef-
possibly only those patients with neck pain and TrPs fect of positive expectations on localized pressure pain
should receive this intervention. In addition, it would be sensitivity within the dry needling group was observed,
interesting to determine the role of patient expectations although the clinical relevance was small.
about each of the interventions (e.g., manual therapy, dry
needling, exercise) in trials investigating multimodal
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Pain Medicine, 0(0), 2021, 1–12

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Conflicts of interest: The authors have no conflicts of interest to declare.

Trial registration: Clinicaltrials.org ID: NCT04417491.

Introduction lifetime prevalence rates of 6.6%, 21.4%, and 44.4%, re-

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Methods generated block randomization for 50 participants and

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Randomization and Masking

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Patients with neck pain symptoms screened for

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Baseline Measurements (n=50)

Positive expectations Neutral expectations Negative expectations

Allocated to dry needling (n=25) Allocated to sham needling (n=25)

1 day a post-intervention (n=25)

1-week a post-intervention (n=25)

Figure 3. Flow diagram of patients throughout the course of the study.

Table 1. Baseline characteristics by treatment assignment

Dry Needling Group (n ¼ 25) Sham Needling Group (n ¼ 25)

VAS¼ visual analog scale.

Table 2. Baseline characteristics by patient expectations

Positive (n ¼ 28) Neutral (n ¼ 8) Negative (n ¼ 14)

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VAS¼visual analog scale.

Outcomes Dry Needling Sham Needling

Timeline scores given as mean 6 SD (95% CI).

Outcomes Positive (n ¼ 28) Neutral (n ¼ 8) Negative (n ¼ 14)

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Timeline scores given as mean 6 SD (95% CI).

Outcomes Positive (n ¼ 14) Neutral (n ¼ 16) Negative (n ¼ 10)

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Timeline scores given as mean 6 SD (95% CI).

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