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\begin{document}

\title{Dry Needling in the Management of Chronic Tension Type Headache
Associated with Levator Scapulae Syndrome: A Case Report}



\author[1]{Peter Gagnon}%
\author[1]{James Dunning}%
\author[1]{Paul Bliton}%
\author[1]{Casey Charlebois}%
\author[1]{Nathan Henry}%
\author[1]{Patrick Gorby}%
\author[2]{Firas Mourad}%
\affil[1]{American Academy of Manipulative Therapy Fellowship in Orthopaedic Manual Physical Therapy}%
\affil[2]{LUNEX International University of Health, Exercise and Sport}%


\vspace{-1em}



  
  \date{June 18, 2024}


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\textbf{Dry Needling in the Management of Chronic Tension Type Headache
Associated with}

\textbf{Levator Scapulae Syndrome: A Case Report}

\textbf{ABSTRACT}

\textbf{Background/purpose:} Chronic tension-type headaches (CTTH) have
a lifetime prevalence of 42\% and account for more lost workdays than
migraine headaches. Dry needling is being increasingly used by physical
therapists in the management of CTTH; however, to date, the supporting
evidence is limited.

\textbf{Case Description:} The purpose of this case report was to
describe how three sessions of dry needling (DN) targeting myofascial
trigger points in the levator scapulae muscle and its distal enthesis
was used to treat a 63-year-old male patient who presented with
work-related CTTH associated with levator scapulae syndrome (LSS).

\textbf{Outcome:} The patient was treated for five visits over the
course of two months. At discharge and 6-month follow-up, the patient
reported full resolution of symptoms. Self-report outcomes included the
numeric pain rating scale and the neck disability index.

\textbf{Discussion:} The use of DN to the levator scapulae muscle and
its distal enthesis may be a valuable addition to a multi-modal plan of
care in the treatment of work-related chronic tension-type headaches
associated with LSS.

\textbf{Level of Evidence:} Level IV

\textbf{Dry Needling in the Management of Chronic Tension Type Headache
Associated with}

\textbf{Levator Scapulae Syndrome: A Case Report}

\textbf{BACKGROUND}

Headache ranks among the top ten most disabling conditions
worldwide.\textsuperscript{1} Tension type headache is the most frequent
primary headache and is characterized by bilateral, non-throbbing, mild
to moderate pain of the head and neck that is not exacerbated by routine
physical activity.\textsuperscript{2} According to the International
Headache Society (IHS), there are 2 distinct types of tension type
headache. Episodic tension type headaches (sub-classified as infrequent
or frequent) occur between 1-14 days per month. Less common, chronic
tension-type headaches (CTTH) are present on greater than or equal to 15
days per month.\textsuperscript{2} Population-based studies suggest a
lifetime prevalence of 42\%\textsuperscript{1} with three times more
work days lost when compared to migraine
headaches.\textsuperscript{3}The IHS criteria for diagnosis of CTTH
includes (1) headache occurring [?]15 days per month on average for
\textgreater{}3 months (2) lasting hours to days and (3) demonstrating
at least two of the following four characteristics: bilateral location,
pressing or tightening (non-pulsating) quality, mild or moderate
intensity, not aggravated by routine physical
activity.\textsuperscript{2}

The onset of episodic headache can occur due to peripheral tissue
irritation with central pain mechanisms underlying the evolution to
CTTH.\textsuperscript{4-6} Patients with CTTH demonstrate greater
headache intensity and frequency compared to those with episodic tension
type headache, indicating temporal summation of noxious afferent
input.\textsuperscript{7} Recurrent, low-frequency nociceptor
stimulation progressively sensitizes peripheral nerve terminals and
spinal dorsal horn neurons related to the neck and shoulder region,
contributing to the formation and maintenance of myofascial trigger
points (MTrP) in patients with CTTH.\textsuperscript{8,9} Previous
studies have demonstrated neck and shoulder MTrPs, along with
surrounding soft tissues including tendons, ligaments, and fascia may
reproduce the symptoms associated with CTTH.\textsuperscript{10-14}

Simons and Travell defined a MTrP as a hyperirritable spot within a taut
band of a skeletal muscle that is painful on compression, stretch,
overload, or contraction with referred pain perceived distant from the
hyperirritable spot.\textsuperscript{15} Although a systematic review
found no high-quality studies reporting the inter-rater reliability of
identifying the location of a MTrP in a symptomatic muscle, good
reliability was reported for diagnostic signs including local tenderness
(k= 0.22 to 1.0) and pain recognition (k= 0.57 to
1.0).\textsuperscript{16} Advanced imaging techniques like
sonoelastography and magnetic resonance elastography appear to
contribute to the objective identification of
MTrPs.\textsuperscript{17,18}

The integrated hypothesis of MTrP formation proposed by Simons,
speculates excessive acetylcholine release at the neuromuscular junction
leads to sustained contraction of sarcomeres, local ischemia and an ATP
driven `energy crisis'. The resultant hypoxic state of the muscle
induces secretion of inflammatory chemical mediators followed by the
antidromic release of neuropeptides from local nerve endings, lowering
pH levels and sensitizing neural pathways that contribute to the
formation of MTrPs.\textsuperscript{19} Active MTrPs are clinically
associated with spontaneous pain (without palpation or manual
compression) in the immediate surrounding tissue and/or distant,
referred sites. In contrast, latent MTrPs elicit local or referred pain
only upon palpation and are not recognized as familiar pain to the
patient.\textsuperscript{20} Both active and latent MTrPs can provoke
tissue dysfunction characterized by reduced range of motion, muscle
fatigue and altered activation patterns.\textsuperscript{21,22}

Approximately 70\% of patients with CTTH appear to experience muscle
spasms in the cervical region.\textsuperscript{23,24} More specifically,
pathophysiological changes in the muscular activity of the
sub-occipitals, sternocleidomastoid, upper trapezius, and levator
scapulae have been recognized in the development of
CTTH.\textsuperscript{13,25}

Levator scapulae syndrome (LSS) is a musculoskeletal disorder,
characterized by pain and stiffness in the upper thoracic and cervical
regions, with limited cervical range of motion and tenderness to
palpation at the medial aspect of the superior angle of the
scapula.\textsuperscript{26-28} Distal levator scapulae muscle belly and
teno-osseous attachment tenderness has been reported in patients with
LSS and may play a role in the development of ``enthesopathy resulting
from sustained MTrP tension''.\textsuperscript{15} Increased heat
emission has been measured from the medial aspect of the superior angle
of the scapula in more than 60\% of patients diagnosed with LSS,
suggestive of an active metabolic process.\textsuperscript{28} Notably,
this specific region is the anatomical correlate for the enthesis
attachment in LSS. Following mechanical damage, tissue repair responses
and vessel ingrowth have been observed.\textsuperscript{29} Similar to
tendons in disrepair, pain and tenderness at the enthesis is associated
with increased vascularity on color imaging.\textsuperscript{30}

Physical therapy is one of the most commonly used non-pharmacological
approaches in the management of CTTH and can include manipulation and
mobilization, postural control, exercise, soft tissue release, and dry
needling.\textsuperscript{31,32} Dry needling is a skilled treatment
technique that uses solid filiform needles inserted into MTrPs, tendons,
teno-osseous structures and other soft
tissues.\textsuperscript{33-35}Dry needling has been found to
significantly improve headache frequency, MTrP tenderness, cervical
range of motion and health-related quality of life in patients with CTTH
by providing a more comprehensive treatment approach than exercise and
manual therapy alone.\textsuperscript{36-38}

This case report describes the history, physical examination findings,
specific treatments, and outcomes of a patient with CTTH associated with
LSS and highlights the importance of a thorough palpatory examination,
including both myofascial and teno-osseous structures. Considering the
documented effects of postural stress on musculoskeletal dysfunction in
the workplace, such as decreased ability to concentrate, increased
sedentary behavior associated with the use of technological devices may
lead to a higher prevalence of tension type headache in the
future.\textsuperscript{39-45}

\textbf{CASE DESCRIPTION}

\textbf{Patient History}

A 63-year-old male presented to the physical therapist with a primary
complaint of insidious onset headaches over the past 5 months while
typing at the computer with a secondary complaint of chronic neck and
shoulder tightness. The headache pain was described as a diffuse, dull
ache originating near the medial aspect of the superior spine of the
scapula bilaterally and progressively radiating upward toward the
occiput. The patient reported a steady increase in symptoms while typing
that peaked in the afternoon and decreased in the evening after
self-administered treatment. Past medical history included concussion
and an acute bout of neck pain after a traumatic biking accident 5 years
prior. Imaging ruled out red flags and aside from some intermittent
lingering stiffness, a full recovery was achieved.

Relief from headache symptoms occurred while taking a hot shower, using
a heating pad, or applying self-massage to muscles in the neck and
scapulothoracic region. At worst, headache pain was 6/10 on the Numeric
Pain Rating Scale (NPRS) and negatively affected the patient's ability
to concentrate while working. The NPRS is a reliable and valid
instrument to assess pain intensity.\textsuperscript{46-48} The minimal
clinical important difference (MCID) for the NPRS has been shown to be
1.74 in patients with chronic pain
conditions;\textsuperscript{47}however, the MCID for tension type
headache pain has not yet been established. Nevertheless, a change of 2
points or a 30\% decrease in pain from baseline can be considered as a
MCID in patients with chronic musculoskeletal
pain.\textsuperscript{47,49}

The Neck Disability Index (NDI) score at the initial examination (i.e.,
baseline) was 19/50 (38\%). The NDI is the most widely used instrument
for assessing self-rated disability in patients with neck
pain.\textsuperscript{50-52} The NDI is a self-report questionnaire with
10 items rated from 0 (no disability) to 5 (complete
disability).\textsuperscript{53} The numeric responses for each item are
summed for a total score ranging between 0 and
50.\textsuperscript{50,54} Higher scores represent increased levels of
disability. The NDI has been found to possess excellent test-retest
reliability, strong construct validity, strong internal consistency, and
good responsiveness in assessing disability in patients with
cervicogenic headache.\textsuperscript{48} Although the MCID for CTTH
has not yet been determined, the MCID for the NDI has been reported to
be 7.5 in patients with cervicogenic headache.\textsuperscript{48}

\textbf{Physical Examination}

The initial physical examination was performed by a physical therapist
with 8 years of clinical experience. In addition, this clinician was
also Certified in Dry Needling and a fellow-in-training within an
APTA-accredited orthopaedic manual physical therapy fellowship program.
The patient provided consent for treatment and for publication of the
case details in a scholarly journal. Objective examination findings can
be found in (\textbf{Table 1)} . Notably, the patient reported severe
tenderness and specific reproduction of posterior neck and suboccipital
pain with pincer grasp palpation to the distal levator scapulae muscle
bilaterally (i.e., approximately one thumbwidth superior and medial to
the superior angle of the scapula). Tenderness with referred pain was
also reported during palpation over the muscle's distal enthesis (i.e.,
the medial aspect of the superior angle of the scapula), bilaterally.

The patient demonstrated pronounced thoracic kyphosis and forward head
posture while using a laptop computer. Correlations have been reported
between forward head posture and increased incidence of neck and
headache pain, with greater forward head posture demonstrated in
patients with CTTH when compared to controls.\textsuperscript{55-58} A
3-D kinematics study of desk workers found increased head-neck flexion
angles to be associated with increased upper trapezius muscle activity,
a synergist of the levator scapulae.\textsuperscript{59} Additionally,
significant weakness of the rhomboid and middle trapezius muscles have
been reported in patients with neck pain when compared to controls,
potentially increasing mechanical load to the scapular
elevators.\textsuperscript{60,61} Among patients with work-related
myofascial disorders, several prior studies have reported changes in
muscle activity, stiffness and microcirculation during prolonged
computer tasks, likely contributing to the onset and continuation of
tension type headache.\textsuperscript{40,41,43,59,62}

\textbf{Differential Diagnosis}

Potential diagnoses included CTTH, cervicogenic headache (CH), cervical
facet arthropathy and cervical spondylosis. Notably, the patient
presentation did not match the revised diagnostic criteria for
CH\textsuperscript{63} developed by the Cervicogenic Headache
International Study Group (CHISG)\textsuperscript{63-65} consisting of
(1) unilaterality of head pain without side shift, starting in the upper
posterior neck or occipital region, eventually spreading to the
oculofrontotemporal area on the symptomatic side, (2) pain triggered by
neck movement and/or sustained awkward positions, (3) reduced range of
motion in the cervical spine\textsuperscript{66} (i.e., less than or
equal to 32 \selectlanguage{ngerman}° of right or left passive rotation on the Flexion-Rotation
Test),\textsuperscript{67-69} (4) pain elicited by external pressure
over at least one of the upper cervical joints (C0-3), and (5) moderate
to severe, non-throbbing and non-lancinating pain. Nevertheless, the
diagnosis was guided by the patient's subjective presentation of
bilateral headache pain, the IHS criteria for CTTH including (1)
headache occurring \selectlanguage{english}[?]15 days per month on average for \textgreater{}3
months (2) lasting hours to days and (3) demonstrating at least two of
the following four characteristics: bilateral location, pressing or
tightening (non-pulsating) quality, mild or moderate intensity, not
aggravated by routine physical activity,\textsuperscript{2} and specific
reproduction of the patient's headache symptoms with palpation of the
levator scapulae muscle and it's enthesis.

\textbf{Interventions}

Cervical and thoracic mobilization was performed at the initial visit
and the patient was provided a home exercise
program.\textsuperscript{70} At the second visit, 1-week following
initial evaluation, DN was performed and was directed to the levator
scapulae muscle belly one thumb width medial and cephalad to the
superior angle of the scapula and to the distal teno-osseous attachment,
bilaterally. The patient was placed in a prone position with his arm
internally rotated behind the back and a rolled towel placed under the
anterior shoulder to further expose the superior angle of the scapula. A
pincer grip was used to bracket the superior angle of the scapula as
well as draw the tissue superiorly, thus avoiding proximity to the
ribcage and underlying lungs. Seiren needles (0.30 mm diameter x 50 mm
length) were inserted obliquely from lateral-to-medial,
superior-to-inferior and posterior-to-anterior through the upper
trapezius and into the levator scapulae muscle belly, one thumb width
medial and cephalad to the superior angle of the scapula (\textbf{Figure
1} ). At the muscle belly, the needle was partially withdrawn and
re-angled using a fanning technique to target 3-4 unique points within a
narrow cone-shaped area. The observation or lack thereof for local
twitch responses during DN did not appear to correlate with a subjective
change of symptoms, consistent with a recent literature review that
concluded that local twitch responses during DN are not necessary for
analgesia.\textsuperscript{71}

Periosteal pecking at the distal enthesis of the left and right levator
scapulae was also performed at the junction between the root of the
spine of the scapula and the superior angle of the scapula, bilaterally
(\textbf{Figure 1} ). The superior angle was marked superiorly by the
left index finger and medially by the third (long) finger to ensure the
needle did not migrate superiorly or medially and miss the scapula. The
patient reported reproduction of headache symptoms during unidirectional
winding of the needle targeting the distal MTrPs and enthesis of the
levator scapulae muscle, bilaterally. The technique of winding or
twisting needles enhances the physiological effects of dry needling, by
increasing local tissue stimulation, activating mechanoreceptors and
subsequently amplifying the transmission of sensory signals to the
central nervous system.\textsuperscript{72} This heightened sensory
input has been linked to the release of neurotransmitters, including
endorphins and serotonin, which are crucial for pain modulation and
regulation.\textsuperscript{73} Interstitial adenosine, one of the
body's natural anti-inflammatory mechanisms, has been shown to remain
elevated for 30 minutes post needle insertion, if the needle is inserted
and unidirectionally rotated.\textsuperscript{74}

All interventions performed during each session along with prescribed
home exercise program can be found in (\textbf{Table 2)} .

\textbf{Outcomes}

Immediately following DN treatment, the patient reported decreased neck
stiffness and a pain intensity reduction (NPRS, 0-10) to 3/10 (from
6/10) for headache pain. At the third appointment, near complete relief
of work-related headaches (1/10 on the NPRS) was described with onset
occurring only during prolonged periods of work without attention to
ergonomics.

Eight weeks from the initial evaluation, a complete cessation of
work-related headaches with a significant reduction in muscle stiffness
was reported. In addition, the patient demonstrated increased active
range of motion in cervical rotation, side bend, flexion and extension,
along with increased strength of middle trapezius, rhomboids, and
shoulder external rotators. Emphasis was placed on a modified at-home
workspace to optimize computer ergonomics and progressive strength
training focusing on retraction-based exercises.

The patient was seen for a total of 5 visits over the course of two
months. Timeline of interventions can be found in \textbf{Figure 2} . At
discharge (8 weeks after initial evaluation) and at 6-month follow-up,
the patient reported no headaches during the workday, no disability
(i.e., a 0/50 score on the NDI), and no pain (i.e., 0/10 score on the
NPRS). (\textbf{Table 1} ).

\textbf{DISCUSSION}

The results of this case report suggest the addition of DN targeting
MTrPs of the distal levator scapulae muscle and distal enthesis over the
medial aspect of the superior angle of the scapula, along with joint
mobilization (C1-C4 in supine and T1-T6 in prone grade III/IV), strength
training and ergonomic education may be useful when treating individuals
with CTTH associated with LSS.

Manual therapy, therapeutic exercise and ergonomics are common types of
physical therapy interventions for CTTH and were addressed with this
patient.\textsuperscript{70,75} Notably, resistance training has been
found to stimulate collagen turnover and increase levels of growth
factor that further insulate tissue from pathology and be beneficial for
CTTH patients.\textsuperscript{76,77}

Although multiple interventions were utilized and no cause-and-effect
relationship can be established in a single case report, DN targeting
MTrPs in the distal belly and enthesis of the levator scapulae
reproduced and appeared to improve the patient's headache symptoms,
reflecting a change in pain intensity scores (NPRS, 0-10) from 5/10 on
the second visit to 1/10 on the third visit after the first inclusion of
the DN intervention. Notably, the amount of reported change in pain
intensity was considerably smaller (i.e., from 6/10 at the initial visit
to 5/10 on the second visit) when cervical and thoracic mobilization
along with a home exercise program was only administered. In addition,
the observed changes in pain intensity following the addition of the DN
treatment to MTrPs suggests the etiology for this specific patient was
likely not from underlying facet joint dysfunction.\textsuperscript{78}

Inactivation of MTrPs can improve local circulation, increase range of
motion, decrease muscle tightness and improve the overall functional
status of a muscle.\textsuperscript{78} Two meta-analyses concluded that
trigger point DN may be effective in decreasing pain in the short and
medium term compared to control or sham
needling.\textsuperscript{79,80}Reductions in headache intensity,
frequency and duration have been demonstrated following 3 sessions of DN
to active MTrPs in muscles of the head and
neck.\textsuperscript{31}Additionally, a recent meta-analysis reported
that DN produces similar effects to other interventions for short term
headache relief.\textsuperscript{79}Results demonstrate that potential
benefits of DN included an increase in cervical ROM and a decrease in
MTrP tenderness and headache frequency. Notably, DN was shown to provide
significant improvement in short-term disability in patients with
tension type headache.\textsuperscript{79}

Notably, this case study performed targeted DN to the levator scapulae
enthesis or teno-osseous junction, i.e., the interface between the
periosteum and the tendon of the levator scapulae. Poor tendon
vascularization and vessel anastomosis may justify DN to this
region;\textsuperscript{81} in addition, previous clinical trials have
reported successful outcomes in pain and disability when DN to the
enthesis at the periosteal region was
included.\textsuperscript{34,82-85}

\textbf{CONCLUSION}

Myofascial trigger points and sensitive entheses associated with the
levator scapulae muscle may reproduce headache symptoms in individuals
with CTTH. Particular areas of interest for both diagnosis and treatment
are the region medial and cephalad to the superior angle of the scapula
and also the distal teno-osseus attachment site over the medial aspect
of the superior angle of the scapula. These two pathoanatomic lesions
appeared to respond favorably to a multimodal treatment approach that
included DN targeting MTrPs, periosteal DN targeting the enthesis,
education, and strength training. A future randomized clinical trial
with an active comparison group would be a useful next step to ascertain
whether the changes seen in this single case study are apparent in a
two-arm trial and not attributable to natural history.

\textbf{REFERENCES}

1. Stovner L, Hagen K, Jensen R, et al. The global burden of headache: a
documentation of headache prevalence and disability
worldwide.\emph{Cephalalgia} . Mar 2007;27(3):193-210.
doi:10.1111/j.1468-2982.2007.01288.x

2. The International Classification of Headache Disorders: 2nd
edition.\emph{Cephalalgia} . 2004;24 Suppl 1:9-160.

3. Rasmussen BK, Jensen R, Olesen J. Impact of headache on sickness
absence and utilisation of medical services: a Danish population
study.\emph{J Epidemiol Community Health} . Aug 1992;46(4):443-6.
doi:10.1136/jech.46.4.443

4. Ashina S, Bendtsen L, Ashina M. Pathophysiology of tension-type
headache. \emph{Curr Pain Headache Rep} . Dec 2005;9(6):415-22.
doi:10.1007/s11916-005-0021-8

5. Fernandez-de-Las-Penas C, Alonso-Blanco C, Cuadrado ML, Gerwin RD,
Pareja JA. Myofascial trigger points and their relationship to headache
clinical parameters in chronic tension-type headache. \emph{Headache} .
Sep 2006;46(8):1264-72. doi:10.1111/j.1526-4610.2006.00440.x

6. Fernandez-de-las-Penas C, Cuadrado ML, Arendt-Nielsen L, Simons DG,
Pareja JA. Myofascial trigger points and sensitization: an updated pain
model for tension-type headache. \emph{Cephalalgia} . May
2007;27(5):383-93. doi:10.1111/j.1468-2982.2007.01295.x

7. Mense S. Peripheral Mechaniism of Muscle Nociception and Local Muscle
Pain. \emph{Journal of Musculoskeletal Pain} . 1993/01/01
1993;1(1):133-170. doi:10.1300/J094v01n01\_10

8. Hubbard DR, Berkoff GM. Myofascial trigger points show spontaneous
needle EMG activity. \emph{Spine (Phila Pa 1976)} . Oct 1
1993;18(13):1803-7. doi:10.1097/00007632-199310000-00015

9. Novak CB. Upper extremity work-related musculoskeletal disorders: a
treatment perspective. \emph{J Orthop Sports Phys Ther} . Oct
2004;34(10):628-37. doi:10.2519/jospt.2004.34.10.628

10. Fernandez-de-las-Penas C, Alonso-Blanco C, Cuadrado ML, Gerwin RD,
Pareja JA. Trigger points in the suboccipital muscles and forward head
posture in tension-type headache. \emph{Headache} . Mar
2006;46(3):454-60. doi:10.1111/j.1526-4610.2006.00288.x

11. Fernandez de las Penas C, Cuadrado ML, Gerwin RD, Pareja JA.
Referred pain from the trochlear region in tension-type headache: a
myofascial trigger point from the superior oblique
muscle.\emph{Headache} . Jun 2005;45(6):731-7.
doi:10.1111/j.1526-4610.2005.05140.x

12. Fernandez-de-Las-Penas C, Ge HY, Arendt-Nielsen L, Cuadrado ML,
Pareja JA. The local and referred pain from myofascial trigger points in
the temporalis muscle contributes to pain profile in chronic
tension-type headache. \emph{Clin J Pain} . Nov-Dec 2007;23(9):786-92.
doi:10.1097/AJP.0b013e318153496a

13. Fernandez-de-las-Penas C, Fernandez-Mayoralas DM, Ortega-Santiago R,
Ambite-Quesada S, Palacios-Cena D, Pareja JA. Referred pain from
myofascial trigger points in head and neck-shoulder muscles reproduces
head pain features in children with chronic tension type
headache.\emph{J Headache Pain} . Feb 2011;12(1):35-43.
doi:10.1007/s10194-011-0316-6

14. Kamali F, Mohamadi M, Fakheri L, Mohammadnejad F. Dry needling
versus friction massage to treat tension type headache: A~randomized
clinical trial. \emph{J Bodyw Mov Ther} . Jan 2019;23(1):89-93.
doi:10.1016/j.jbmt.2018.01.009

15. Simons DG, Travell JG, Simons LS. \emph{Travell \& Simons'
Myofascial Pain and Dysfunction: Upper half of body} . Williams \&
Wilkins; 1999.

16. Lucas N, Macaskill P, Irwig L, Moran R, Bogduk N. Reliability of
physical examination for diagnosis of myofascial trigger points: a
systematic review of the literature. \emph{Clin J Pain} . Jan
2009;25(1):80-9. doi:10.1097/AJP.0b013e31817e13b6

17. Sikdar S, Shah JP, Gebreab T, et al. Novel applications of
ultrasound technology to visualize and characterize myofascial trigger
points and surrounding soft tissue. \emph{Arch Phys Med Rehabil} . Nov
2009;90(11):1829-38. doi:10.1016/j.apmr.2009.04.015

18. Vulfsons S, Ratmansky M, Kalichman L. Trigger point needling:
techniques and outcome. \emph{Curr Pain Headache Rep} . Oct
2012;16(5):407-12. doi:10.1007/s11916-012-0279-6

19. Simons DG. Clinical and Etiological Update of Myofascial Pain from
Trigger Points. \emph{Journal of Musculoskeletal Pain} . 1996/01/01
1996;4(1-2):93-122. doi:10.1300/J094v04n01\_07

20. Fernandez-de-Las-Penas C, Ge HY, Alonso-Blanco C, Gonzalez-Iglesias
J, Arendt-Nielsen L. Referred pain areas of active myofascial trigger
points in head, neck, and shoulder muscles, in chronic tension type
headache. \emph{J Bodyw Mov Ther} . Oct 2010;14(4):391-6.
doi:10.1016/j.jbmt.2009.06.008

21. Celik D, Mutlu EK. Clinical implication of latent myofascial trigger
point. \emph{Curr Pain Headache Rep} . Aug 2013;17(8):353.
doi:10.1007/s11916-013-0353-8

22. Ge HY, Arendt-Nielsen L, Madeleine P. Accelerated muscle
fatigability of latent myofascial trigger points in humans. \emph{Pain
Med} . Jul 2012;13(7):957-64. doi:10.1111/j.1526-4637.2012.01416.x

23. Pourahmadi M, Mohseni-Bandpei MA, Keshtkar A, et al. Effectiveness
of dry needling for improving pain and disability in adults with
tension-type, cervicogenic, or migraine headaches: protocol for a
systematic review. \emph{Chiropractic \& manual therapies} . 2019;27:43.
doi:10.1186/s12998-019-0266-7

24. Ashina S, Bendtsen L, Lyngberg AC, Lipton RB, Hajiyeva N, Jensen R.
Prevalence of neck pain in migraine and tension-type headache: a
population study. \emph{Cephalalgia} . Mar 2015;35(3):211-9.
doi:10.1177/0333102414535110

25. Liang Z, Galea O, Thomas L, Jull G, Treleaven J. Cervical
musculoskeletal impairments in migraine and tension type headache: A
systematic review and meta-analysis. \emph{Musculoskeletal Science and
Practice} . 2019;42:67-83.

26. Estwanik JJ. Levator Scapulae Syndrome. \emph{Phys Sportsmed} . Oct
1989;17(10):57-68. doi:10.1080/00913847.1989.11709889

27. Henry JP, Munakomi S. Anatomy, Head and Neck, Levator Scapulae
Muscles. \emph{StatPearls} . StatPearls Publishing

Copyright (c) 2023, StatPearls Publishing LLC.; 2023.

28. Menachem A, Kaplan O, Dekel S. Levator scapulae syndrome: an
anatomic-clinical study. \emph{Bull Hosp Jt Dis} . Spring
1993;53(1):21-4.

29. Benjamin M, McGonagle D. The enthesis organ concept and its
relevance to the spondyloarthropathies. \emph{Adv Exp Med Biol} .
2009;649:57-70. doi:10.1007/978-1-4419-0298-6\_4

30. Kiris A, Kaya A, Ozgocmen S, Kocakoc E. Assessment of enthesitis in
ankylosing spondylitis by power Doppler ultrasonography. \emph{Skeletal
Radiol} . Jul 2006;35(7):522-8. doi:10.1007/s00256-005-0071-3

31. Gildir S, Tuzun EH, Ero\selectlanguage{polish}ğ\selectlanguage{english}lu G, Eker L. A randomized trial of trigger
point dry needling versus sham needling for chronic tension-type
headache. \emph{Medicine (Baltimore)} . Feb 2019;98(8):e14520.
doi:10.1097/md.0000000000014520

32. Fern\selectlanguage{ngerman}ández-de-las-Peñas C, Cuadrado ML. Therapeutic options for
cervicogenic headache. \emph{Expert Rev Neurother} . Jan
2014;14(1):39-49. doi:10.1586/14737175.2014.863710

33. Mitchell UH, Johnson AW, Larson RE, Seamons CT. Positional changes
in distance to the pleura and in muscle thickness for dry
needling.\emph{Physiotherapy} . Sep 2019;105(3):362-369.
doi:10.1016/j.physio.2018.08.002

34. Dunning J, Butts R, Henry N, et al. Electrical dry needling as an
adjunct to exercise, manual therapy and ultrasound for plantar
fasciitis: A multi-center randomized clinical trial. \emph{PLoS One} .
2018;13(10):e0205405. doi:10.1371/journal.pone.0205405

35. Lewit K. The needle effect in the relief of myofascial
pain.\emph{Pain} . 1979;6(1):83-90.

36. France S, Bown J, Nowosilskyj M, Mott M, Rand S, Walters J. Evidence
for the use of dry needling and physiotherapy in the management of
cervicogenic or tension-type headache: a systematic
review.\emph{Cephalalgia} . Oct 2014;34(12):994-1003.
doi:10.1177/0333102414523847

37. Kamonseki DH, Lopes EP, van der Meer HA, Calixtre LB. Effectiveness
of manual therapy in patients with tension-type headache. A systematic
review and meta-analysis. \emph{Disabil Rehabil} . May
2022;44(10):1780-1789. doi:10.1080/09638288.2020.1813817

38. Vázquez-Justes D, Yarzábal-Rodríguez R, Doménech-García V, Herrero
P, Bellosta-López P. Effectiveness of dry needling for headache: A
systematic review. \emph{Neurologia (Engl Ed)} . Jan 13 2020;Análisis de
la efectividad de la técnica de punción seca en cefaleas: revisión
sistemática. doi:10.1016/j.nrl.2019.09.010

39. Cagnie B, Barbe T, De Ridder E, Van Oosterwijck J, Cools A, Danneels
L. The influence of dry needling of the trapezius muscle on muscle blood
flow and oxygenation. \emph{J Manipulative Physiol Ther} . Nov-Dec
2012;35(9):685-91. doi:10.1016/j.jmpt.2012.10.005

40. Ishikawa H, Muraki T, Morise S, et al. Changes in stiffness of the
dorsal scapular muscles before and after computer work: a comparison
between individuals with and without neck and shoulder
complaints.\emph{European journal of applied physiology} . 2017/01//
2017;117(1):179-187. doi:10.1007/s00421-016-3510-z

41. Johnston V, Jull G, Darnell R, Jimmieson NL, Souvlis T. Alterations
in cervical muscle activity in functional and stressful tasks in female
office workers with neck pain. \emph{Eur J Appl Physiol} . Jun
2008;103(3):253-64. doi:10.1007/s00421-008-0696-8

42. Larsson SE, Cai H, Oberg PA. Continuous percutaneous measurement by
laser-Doppler flowmetry of skeletal muscle microcirculation at varying
levels of contraction force determined electromyographically. \emph{Eur
J Appl Physiol Occup Physiol} . 1993;66(6):477-82.
doi:10.1007/bf00634295

43. Sjøgaard G, Rosendal L, Kristiansen J, et al. Muscle oxygenation and
glycolysis in females with trapezius myalgia during stress and
repetitive work using microdialysis and NIRS. \emph{European journal of
applied physiology} . 2010/03// 2010;108(4):657-669.
doi:10.1007/s00421-009-1268-2

44. Ta\selectlanguage{polish}ş \selectlanguage{english}S, Korkusuz F, Erden Z. Neck Muscle Stiffness in Participants
With and Without Chronic Neck Pain: A Shear-Wave Elastography
Study.\emph{J Manipulative Physiol Ther} . Sep 2018;41(7):580-588.
doi:10.1016/j.jmpt.2018.01.007

45. Lee E, Lee S. Impact of Cervical Sensory Feedback for Forward Head
Posture on Headache Severity and Physiological Factors in Patients with
Tension-type Headache: A Randomized, Single-Blind, Controlled
Trial.\emph{Med Sci Monit} . Dec 15 2019;25:9572-9584.
doi:10.12659/msm.918595

46. Cleland JA, Childs JD, Whitman JM. Psychometric properties of the
Neck Disability Index and Numeric Pain Rating Scale in patients with
mechanical neck pain. \emph{Arch Phys Med Rehabil} . Jan
2008;89(1):69-74. doi:10.1016/j.apmr.2007.08.126

47. Farrar JT, Young JP, Jr., LaMoreaux L, Werth JL, Poole MR. Clinical
importance of changes in chronic pain intensity measured on an 11-point
numerical pain rating scale. \emph{Pain} . Nov 2001;94(2):149-158.
doi:10.1016/s0304-3959(01)00349-9

48. Young IA, Dunning J, Butts R, Cleland JA, Fern\selectlanguage{ngerman}ández-de-Las-Peñas C.
Psychometric properties of the Numeric Pain Rating Scale and Neck
Disability Index in patients with cervicogenic
headache.\emph{Cephalalgia} . Jan 2019;39(1):44-51.
doi:10.1177/0333102418772584

49. Salaffi F, Stancati A, Silvestri CA, Ciapetti A, Grassi W. Minimal
clinically important changes in chronic musculoskeletal pain intensity
measured on a numerical rating scale. \emph{Eur J Pain} . Aug
2004;8(4):283-91. doi:10.1016/j.ejpain.2003.09.004

50. MacDermid JC, Walton DM, Avery S, et al. Measurement properties of
the neck disability index: a systematic review. \emph{J Orthop Sports
Phys Ther} . May 2009;39(5):400-17. doi:10.2519/jospt.2009.2930

51. Pietrobon R, Coeytaux RR, Carey TS, Richardson WJ, DeVellis RF.
Standard scales for measurement of functional outcome for cervical pain
or dysfunction: a systematic review. \emph{Spine (Phila Pa 1976)} . Mar
1 2002;27(5):515-22. doi:10.1097/00007632-200203010-00012

52. Vernon H. The Neck Disability Index: state-of-the-art,
1991-2008.\emph{J Manipulative Physiol Ther} . Sep 2008;31(7):491-502.
doi:10.1016/j.jmpt.2008.08.006

53. Vernon H, Mior S. The Neck Disability Index: a study of reliability
and validity. \emph{J Manipulative Physiol Ther} . Sep
1991;14(7):409-15.

54. Vernon H. The psychometric properties of the Neck Disability
Index.\emph{Arch Phys Med Rehabil} . Jul 2008;89(7):1414-5; author reply
1415-6. doi:10.1016/j.apmr.2008.05.003

55. Fernández-de-las-Peñas C, Alonso-Blanco C, Cuadrado ML, Pareja JA.
Forward head posture and neck mobility in chronic tension-type headache:
a blinded, controlled study. \emph{Cephalalgia} . Mar 2006;26(3):314-9.
doi:10.1111/j.1468-2982.2005.01042.x

56. Moore MK. Upper crossed syndrome and its relationship to
cervicogenic headache. \emph{J Manipulative Physiol Ther} . Jul-Aug
2004;27(6):414-20. doi:10.1016/j.jmpt.2004.05.007

57. Sohn J-H, Choi H-C, Lee S-M, Jun A-Y. Differences in cervical
musculoskeletal impairment between episodic and chronic tension-type
headache. \emph{Cephalalgia} . 2010;30(12):1514-1523.
doi:10.1177/0333102410375724

58. Yip CH, Chiu TT, Poon AT. The relationship between head posture and
severity and disability of patients with neck pain. \emph{Man Ther} .
May 2008;13(2):148-54. doi:10.1016/j.math.2006.11.002

59. Szeto GP, Straker LM, O'Sullivan PB. A comparison of symptomatic and
asymptomatic office workers performing monotonous keyboard work--1: neck
and shoulder muscle recruitment patterns. \emph{Man Ther} . Nov
2005;10(4):270-80. doi:10.1016/j.math.2005.01.004

60. Shahidi B, Johnson CL, Curran-Everett D, Maluf KS. Reliability and
group differences in quantitative cervicothoracic measures among
individuals with and without chronic neck pain. \emph{BMC Musculoskelet
Disord} . Oct 31 2012;13:215. doi:10.1186/1471-2474-13-215

61. Cagnie B, Struyf F, Cools A, Castelein B, Danneels L, O'leary S. The
relevance of scapular dysfunction in neck pain: a brief
commentary.\emph{journal of orthopaedic \& sports physical therapy} .
2014;44(6):435-439.

62. Ashina M, Bendtsen L, Jensen R, Sakai F, Olesen J. Muscle hardness
in patients with chronic tension-type headache: relation to actual
headache state. \emph{Pain} . Feb 1999;79(2-3):201-5.
doi:10.1016/s0304-3959(98)00167-5

63. Sjaastad O, Fredriksen TA, Pfaffenrath V. Cervicogenic headache:
diagnostic criteria. The Cervicogenic Headache International Study
Group. \emph{Headache} . 1998;38doi:10.1046/j.1526-4610.1998.3806442.x

64. Sjaastad O, Fredriksen TA. Cervicogenic headache: criteria,
classification and epidemiology. \emph{Clin Exp Rheumatol} . Mar-Apr
2000;18(2 Suppl 19):S3-6.

65. Vincent MB, Luna RA. Cervicogenic headache: a comparison with
migraine and tension-type headache. \emph{Cephalalgia} . Dec 1999;19
Suppl 25:11-6. doi:10.1177/0333102499019s2503

66. Zwart JA. Neck mobility in different headache
disorders.\emph{Headache} . Jan 1997;37(1):6-11.
doi:10.1046/j.1526-4610.1997.3701006.x

67. Hall T, Robinson K. The flexion-rotation test and active cervical
mobility--a comparative measurement study in cervicogenic
headache.\emph{Man Ther} . 2004;9doi:10.1016/j.math.2004.04.004

68. Hall TM, Briffa K, Hopper D, Robinson KW. The relationship between
cervicogenic headache and impairment determined by the flexion-rotation
test. \emph{J Manipulative Physiol Ther} . Nov-Dec 2010;33(9):666-71.
doi:10.1016/j.jmpt.2010.09.002

69. Ogince M, Hall T, Robinson K, Blackmore AM. The diagnostic validity
of the cervical flexion-rotation test in C1/2-related cervicogenic
headache. \emph{Man Ther} . 2007;12doi:10.1016/j.math.2006.06.016

70. Hong C-Z. Treatment of myofascial pain syndrome. Report

Author abstract

Disease/Disorder overview. \emph{Current Pain and Headache Reports} .
09/01/ 2006;10(5):345. doi:10.1007/s11916-006-0058-3

71. Perreault T, Dunning J, Butts R. The local twitch response during
trigger point dry needling: Is it necessary for successful
outcomes?\emph{J Bodyw Mov Ther} . Oct 2017;21(4):940-947.
doi:10.1016/j.jbmt.2017.03.008

72. Tough EA, White AR, Cummings TM, Richards SH, Campbell JL.
Acupuncture and dry needling in the management of myofascial trigger
point pain: a systematic review and meta-analysis of randomised
controlled trials. \emph{Eur J Pain} . Jan 2009;13(1):3-10.
doi:10.1016/j.ejpain.2008.02.006

73. Smith CA, Collins CT, Levett KM, et al. Acupuncture or acupressure
for pain management during labour. \emph{Cochrane Database Syst Rev} .
Feb 7 2020;2(2):Cd009232. doi:10.1002/14651858.CD009232.pub2

74. Takano T, Chen X, Luo F, et al. Traditional acupuncture triggers a
local increase in adenosine in human subjects. \emph{J Pain} . Dec
2012;13(12):1215-23. doi:10.1016/j.jpain.2012.09.012

75. Kim I-G, Lee S-Y. The Effect of Forward Head Posture and Tension
Type Headache on Neck Movement: For Office Worker. \emph{J Kor Phys
Ther} . 2018;30(4):108-111. doi:10.18857/jkpt.2018.30.4.108

76. Kjaer M, Langberg H, Miller BF, et al. Metabolic activity and
collagen turnover in human tendon in response to physical
activity.\emph{J Musculoskelet Neuronal Interact} . Mar 2005;5(1):41-52.

77. Varangot-Reille C, Suso-Martí L, Romero-Palau M, Suárez-Pastor P,
Cuenca-Martínez F. Effects of different therapeutic exercise modalities
on migraine or tension-type headache: a systematic review and
meta-analysis with a replicability analysis. \emph{The Journal of Pain}
. 2022;23(7):1099-1122.

78. Hong CZ. Treatment of myofascial pain syndrome. \emph{Curr Pain
Headache Rep} . Oct 2006;10(5):345-9.

79. Kietrys DM, Palombaro KM, Azzaretto E, et al. Effectiveness of dry
needling for upper-quarter myofascial pain: a systematic review and
meta-analysis. \emph{J Orthop Sports Phys Ther} . Sep 2013;43(9):620-34.
doi:10.2519/jospt.2013.4668

80. Liu L, Huang QM, Liu QG, et al. Evidence for Dry Needling in the
Management of Myofascial Trigger Points Associated With Low Back Pain: A
Systematic Review and Meta-Analysis. \emph{Arch Phys Med Rehabil} . Jan
2018;99(1):144-152.e2. doi:10.1016/j.apmr.2017.06.008

81. Schneeberger AG, Masquelet AC. Arterial vascularization of the
proximal extensor carpi radialis brevis tendon. \emph{Clin Orthop Relat
Res} . May 2002;(398):239-44. doi:10.1097/00003086-200205000-00033

82. Fenwick SA, Hazleman BL, Riley GP. The vasculature and its role in
the damaged and healing tendon. \emph{Arthritis Research \& Therapy} .
2002;4(4):1-9.

83. Gungor E, Karakuzu Gungor Z. Comparison of the efficacy of
corticosteroid, dry needling, and PRP application in lateral
epicondylitis. \emph{Eur J Orthop Surg Traumatol} . Dec
2022;32(8):1569-1575. doi:10.1007/s00590-021-03138-2

84. Uygur E, Aktas B, Ozkut A, Erinc S, Yilmazoglu EG. Dry needling in
lateral epicondylitis: a prospective controlled study. \emph{Int Orthop}
. Nov 2017;41(11):2321-2325. doi:10.1007/s00264-017-3604-1

85. Uygur E, Aktas B, Yilmazoglu EG. The use of dry needling vs.
corticosteroid injection to treat lateral epicondylitis: a prospective,
randomized, controlled study. \emph{J Shoulder Elbow Surg} . Jan
2021;30(1):134-139. doi:10.1016/j.jse.2020.08.044

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