Dry needling versus instrument assisted soft tissue mobilization with cervical mobilization for upper trapezius myofascial pain syndrome: a quasi-experimental study

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INTRODUCTION

Upper trapezius myofascial pain is a chronic condition due to trigger point (TrP) activation in muscle fibers, causing neck pain and discomfort. Static positions for long periods of time cause muscles to contract continuously so that they experience spasm, which is characterized by taut bands, tenderness, and pain and can cause Range of Motion (ROM) limitations.

The high usage of gadgets among students as a means of supporting the learning process, communication, social media, and other activities causes unergonomic postures such as prolonged slouching, causing static positions and potentially triggering upper trapezius Myofascial Pain Syndrome (MPS).

The prevalence of MPS in America reaches 85 % in the age group of 27–50 years [1]. Studies in Spain show MPS is mostly found in the trapezius muscle with the location of active Myofascial Trigger Points (MTrPs) most often found on the right side (82.1 %), left (79 %) [2]. Meanwhile, the incidence of MPS in Indonesia is 54 % for women and 45 % for men [3]. The prevalence of MPS of the upper trapezius muscle reaches 40 % in 1 year and often occurs in the general population in Indonesia [4].

TrPs are localized pain trigger points that when suppressed will cause hypersensitive pain. Excessive muscle work causes local ischemia, due to compression of capillaries by taut bands in the muscle. Pain or discomfort in the form of stinging, throbbing, cutting, and burning in the loose connective tissue that wraps the trapezius muscle due to trigger points [5].

The upper trapezius muscle is a muscle that functions in the control of cervical movement, so if upper trapezius MPS occurs, it can affect the range of motion of the neck. Limited ROM due to MPS if left unchecked will interfere with students’ daily activities, especially in lectures such as studying, reading, typing, and other activities. Given the large number of MPS cases, there are also various physiotherapy interventions, including the use of Dry Needling (DN) and Instrument Assisted Soft Tissue Mobilization (IASTM) and cervical mobilization with unilateral down glide technique.

Dry Needling is a procedure of needle insertion into MTrPs until a local twitch response occurs [6]. DN can improve blood circulation so that it carries more oxygen and nutrients and helps remove metabolic waste products, thereby reducing pain intensity [7]. Research shows that patients with upper trapezius MTrPs who received dry needling report a significant decrease in pain intensity and an increase in ROM after several therapy sessions [8].

IASTM provides mechanical stimulation where pressure on the upper trapezius taut band can destroy adhesion so that it releases muscle fibers, which then reduces muscle tightness and has an impact on reducing pain and improving cervical ROM. This is in line with research that reports that IASTM produces significant improvements in lateral flexion and cervical rotation, as well as increasing pain pressure threshold values and reducing pain compared to ischemic compression in TrP upper trapezius conditions for badminton players [9].

Joint mobilization is a manual therapy technique consisting of a series of passive movements in the joint complex [10]. C3 and C4 cervical mobilization can increase cervical lateral flexion ROM and pain pressure threshold (PPT) in latent upper trapezius TrPs conditions [11]. Mobilization can normalize muscle tone and improve PPT, because the upper trapezius is innervated by the C2–C4 nerve roots, allowing mobilization of these segments to have a positive impact on upper trapezius MTrPs [12].

Existing studies mostly compare dry needling and IASTM while research on Unilateral Down Glide cervical mobilization is still limited. There is no research that specifically discusses the combination between them, so this is the basis for researchers to discuss this research.

AIM

To determine the difference in effect between dry needling with IASTM on the application of unilateral down glide on pain reduction and cervical ROM in upper trapezius MPS physiotherapy department students.

MATERIALS AND METHODS

Types of research

This study used a quasi-experimental design with a quantitative approach and two-group pretest–posttest design were employed.

Research location and time

This research was conducted at the Health Polytechnic Ministry of Health Makassar between February and May 2025. It was approved by the Local Ethics Committee of the Health Polytechnic Ministry of Health Makassar (Makassar, Indonesia), under Protocol No. 0136/M/KEPK-PTKMS/II/2025, dated February 7, 2025.

Population and Sample

The population of the study were physiotherapy students with restricted cervical ROM. The sample comprised physiotherapy students diagnosed with upper trapezius MPS based on the established inclusion criteria, with a total of 30 participants. 1st treatment group was given Dry Needling and Unilateral Down Glide while 2nd treatment group was given IASTM and Unilateral Down Glide. Then the researcher conducted random allocation by randomizing the sample into two treatment groups.

The sampling technique used was purposive sampling, by selecting samples according to the specified criteria. The inclusion criteria for this study were patients with positive MPS upper trapezius based on examination, which included (a) history taking showing neck and shoulder pain and referred pain, (b) palpation showing tenderness and taut band nodules, (c) limited cervical ROM, (d) Spurling test (+) contralateral local pain, (e) PACVP-PAUVP segmental pain at C3–C4, and (f) provided consent to be involved in the study.

Data collection

Data were gathered using a questionnaire to evaluate MPS by measuring pain using NRS and cervical ROM using a goniometer. Based on the preliminary observations, the researcher found that 78 % experienced severe pain, 14 % moderate pain and 8 % mild pain. This is characterized by the presence of taut bands, tenderness, and pain and can cause ROM limitations.

Dry needling is performed using (0.25–0.30 × 40–50 mm) needle to the upper trapezius muscle. The technique used is pistoning with a pincer and pull palpation technique. For a total of six treatments, dry needling will be performed once a week to avoid side effects and give the tissue time to heal.

IASTM is a soft tissue mobilization method performed using a special tool to stroke or rub in parallel or in the same direction as the upper trapezius muscle fibers. The dosage given is stroking for 3 minutes, with a therapy frequency of twice a week and a total of 6 interventions.

Unilateral down glide performed in the supine lying position by applying lateral down (downward) pressure on the C3–C4 segment to facilitate gliding movement in the facet joint. The dosage consists of six interventions twice a week, ten repetitions of accessory/physiological movements and intensity grades 3–4.

Processing and analysis of data

Measurements were carried out at the beginning of the study as pre-test data and at the end of the study after intervention as post-test data. Data analysis involved examining changes within each group from pre-test to post-test, along with inter-group comparisons to determine the effectiveness. Shapiro-Wilk normality test was employed to assess whether the data distribution was normal (p > 0.05) or not normal (p > 0.05). If the data were normally distributed, hypothesis testing was performed using parametric statistical test, namely the Paired Sample t-test to identify the difference between pre-test and post-test result within each group, while an independent Sample t-test to evaluate the difference result between both groups.

RESULTS

Sample characteristic

Table 1 shows that majority of female experienced MPS in both groups. Based on gadget using duration, most of the sample in both groups using gadget > 6 hours/day where in 1st treatment group are 66.7 % and 2nd treatment group are 86.7 %. Based on age, the average age in 1st treatment group was 19.53 and in 2nd treatment group was 19.60.

 

Table 1. Characteristics of respondents

Sample characteristic	1st treatment group		2nd treatment group
	n	%	n	%
Gender
Male	4	26.7	3	20.0
Female	11	73.3	12	80.0
Gadget using duration, day
2–6 hours	5	33.3	2	13.3
> 6 hours	10	66.7	13	86.7
	Mean	SD	Mean	SD
Age, years	19.53	1.060	19.60	0.910

 

Data description

Table 2 present the mean values of NRS, rotation and lateral flexion ROM in both groups.

 

Table 2. Mean cervical range of motion and numeric rating scale by value pre test, post test and difference

Sample group	M ± SD
	Pre test	Post test	Difference
1st treatment group
NRS	6.60 ± 1.993	2.53 ± 1.264	4.07 ± 1.792
Rotation	56.87 ± 10.433	78.73 ± 6.170	21.87 ± 11.801
Lateral flexion	28.53 ± 6.457	41.00 ± 5.305	12.47 ± 6.545
2nd treatment group
NRS	6.93 ± 1.387	3.60 ± 1.805	3.33 ± 1.633
Rotation	51.13 ± 18.083	75.27 ± 5.405	24.13 ± 13.596
Lateral flexion	28.53 ± 6.468	42.20 ± 8.678	13.67 ± 8.174

Note: NRS — Numeric rating scale. M — Mean, SD — Standard Deviation.

 

Hypothesis test

Based on the normality test result, the data of both groups were found to be normally distributed (p > 0.05), so paired sample t-test and independent sample t-test and were conducted.

Based on table 3, the NRS score significantly decreased before and after the intervention in both groups, with a p-value of 0.000 (p < 0.05). This indicates that there were significant reduction of tenderness in both groups.

 

Table 3. Numeric rating scale mean difference test of 1st treatment and 2nd treatment groups

Data group	Before	After	t	p
1st treatment group
M	6.60	2.53	8.792	0.000
SD	1.993	1.246
2nd treatment group
M	6.93	3.60	7.906	0.000
SD	1.387	1.805

Note: M — Mean, SD — Standard Deviation.

 

Based on table 4, the rotation ROM significantly increased before and after the intervention in both groups, with a p-value of 0.000 (p < 0.05). This indicates that there were significant increase of cervical rotation in both groups.

 

Table 4. Mean test of rotation range of motion of 1st treatment and 2nd treatment groups

Data group	Before	After	t	p
1st treatment group
M	56.87	78.73	–7.176	0.000
SD	10.433	6.170
2nd treatment group
M	51.13	75.27	–6.875	0.000
SD	18.083	5.405

Note: M — Mean, SD — Standard Deviation.

 

Based on table 5, the lateral flexion ROM significantly increased before and after the intervention in both groups, with a p-value of 0.000 (p < 0.05). This indicates that there were significant increase of cervical lateral flexion in both groups.

 

Table 5. Mean test of lateral flexion range of motion of 1st treatment group and 2nd treatment group

Data group	Before	After	t	p
1st treatment group
M	28.53	41.00	–7.377	0.000
SD	6.457	5.305
2nd treatment group
M	28.53	42.20	6.476	0.000
SD	6.468	8.678

Note: M — Mean, SD — Standard Deviation.

 

Based on table 6, there is no significant difference was found in the mean difference between groups, where p = 0.251 (p < 0.05). Meanwhile, it shows that the value of 4.07 (1st treatment group) > 3.33 (2nd treatment group). This indicates that dry needling and unilateral down glide can produce a greater decrease in tenderness than IASTM and unilateral down glide in patients with upper trapezius MPS.

 

Table 6. Differential test of mean difference in numeric rating scale between two groups

Variable	1st treatment group	2nd treatment group	t	p
M	4.07	3.33	1.172	0.251
SD	1.792	1.633

Note: M — Mean, SD — Standard Deviation.

 

Based on table 7, there is no significant difference was found in the mean difference between groups, where p = 0.630 (p > 0.05). Meanwhile, it shows that the value of 24.13 (2nd treatment group) > 21.87 (1st treatment group). This indicates that IASTM and unilateral down glide can produce a greater cervical rotation ROM improvement than dry needling and unilateral down glide in patients with upper trapezius MPS.

 

Table 7. Mean difference test of rotation range of motion difference between two groups

Variable	1st treatment group	2nd treatment group	t	p
M	21.87	24.13	–0.488	0.630
SD	11.801	13.596

Note: M — Mean, SD — Standard Deviation.

 

Based on table 8, there is no significant difference was found in the mean difference between groups, where p = 0.661 (p > 0.05). Meanwhile, it shows that the value of 13.67 (2nd treatment group) > 12.47 (1st treatment group). This indicates that IASTM and unilateral down glide can produce a greater cervical lateral flexion ROM improvement than dry needling and unilateral down glide in patients with upper trapezius MPS.

 

Table 8. Mean difference test of lateral flexion range of motion difference between 1st treatment and 2nd treatment groups

Variable	1st treatment group	2nd treatment group	t	p
M	12.47	13.67	–0.444	0.661
SD	6.545	8.174

Note: M — Mean, SD — Standard Deviation.

 

DISCUSSION

The effect of Dry needling and Unilateral down glide on reducing tenderness and increasing cervical Range of Motion in upper trapezius myofascial pain syndrome

Based on the Paired sample t-test, unilateral down glide and dry needling significantly reduce tenderness and increase cervical ROM in upper trapezius MPS.

The combination of dry needling with mobilization in the form of unilateral down glide is one way to maximize the therapeutic effect in cases of MPS upper trapezius. In this study, unilateral down glide was performed in a supine lying position by pushing laterally down (down) on the C3–C4 segment to facilitate gliding motion on the cervical facet joint with a grade 3–4 intensity dose. The thrust causes the contralateral side to have a gapping facet, while the ipsilateral side has a gliding facet.

Cervical mobilization with the unilateral down glide technique can produce mechanical effects in the form of stretching the facet joint ligament capsule, especially in the C3–C4 facet joint segment. The stretch effect can improve ROM lateral flexion and cervical rotation. In addition, the mechanical effects that occur in the C3–C4 facet joint can reflexively affect the muscle spindle of the upper trapezius muscle because it has the same nerve segment. This can have an impact on improving cervical ROM.

Dry needling intervention is applied to the upper trapezius muscle using pistoning techniques and palpation techniques in the form of pincer and pull. Dry needling of the superficial region (upper trapezius) involves the insertion of a 0.25 × 50 mm needle into the tissue. In the pistoning technique, the needle is inserted and then partially raised and lowered several times on the TrPs or around them.

This study found that the number of samples experiencing latent TrP was more dominant than active TrP, where pain was felt when pressure or compression applied to the upper trapezius muscle. Also there were several samples with referred pain to the neck and head area. This study discovered that whereas lower tension levels lead to fewer LTRs, higher muscular tension is correlated with more frequent LTRs (> 3 times), also there were some samples that did not produce LTR. Following several dry needling sessions, samples with decreased muscle tension also shows lower LTR. According to the observation, this occurs because LTR will drop as muscular tension does, especially after the third intervention.

Based on the narrative review in 2017, stated that the presence of LTR during dry needling is confirmation that the needle hits the TrP, but LTR is considered to have little correlation to dry needling, not even needed to manage MPS. Therefore, LTR is not an important consideration for the success of dry needling [13].

Static student activities, continuously for a long time will trigger upper trapezius muscle tension so that it can have the opportunity to develop MPS [14]. This is in line with research that the presence of MTrP in the upper trapezius muscle is the cause of cervical ROM limitations, this condition was found in students who experienced soreness and limited movement when looking down, turning their heads to the left or right [15].

According to a 2014 study, the group that had dry needling had significantly greater cervical ROM in all directions than group that did not receive treatment. This occurs because dry needling will deactivate the TrP in the upper trapezius muscle, resulting in a reduction in muscular tension via the LTR. The mechanical consequences of dry needling, including as disruption of contraction nodes, local stretching, and decreased overlap between actin and myosin filaments, can also be responsible for the ROM changes [16]. Based on observations by researchers, patients who experienced a decrease in tenderness and the greatest increase in ROM were patients who initially had the highest NRS values and fairly limited ROM. Based on the physiological review of upper trapezius MPS, it can be concluded that during the intervention the patient’s body responded well, this can be seen from the number of LTR following dry needling, which is declining and signifies upper trapezius muscle tissue recovery.

Based on information obtained from the patient, this intervention provides an effect in the form of comfort while sleeping, but sometimes causes soreness that is felt after dry needling lasts more than 24 hours. However, after these effects disappear, patients can feel more comfortable in their activities, this is characterized as a feeling of “lighter” in the shoulder area, which also marks a decrease in pain and upper trapezius spasm.

The effect of Instrument Assisted Soft Tissue Mobilization and Dry needling on reducing tenderness and increasing cervical Range of Motion in upper trapezius myofascial pain syndrome

Based on the Paired sample t-test, unilateral down glide and IASTM significantly reduce tenderness and increase cervical ROM in upper trapezius MPS.

Unilateral down glide in this sample group is the same as in treatment group 1, which is carried out in a supine lying position by pushing laterally down (down) on the C3–C4 segment to facilitate gliding movements in the cervical facet joint with a dose of grade 3–4 intensity. The thrust causes the contralateral side to have a gapping facet, while the ipsilateral side has a gliding facet.

In this study, IASTM uses stroking with a technique that is parallel or in the same direction as the upper trapezius muscle fibers through the help of a device for 3 minutes. The biggest goal of IASTM is to eliminate scar tissues and promote the return of normal function after soft tissue regeneration. Microvascular and capillary hemorrhage, along with localized inflammation, may occur as a result of the use of IASTM which produces pressure and frictional force on the soft tissue. Inflammation reactivates the healing mechanism by removing scar tissue and releasing adhesions, while increasing blood flow and nutrient supply to the injured area and fibroblast migration [17].

IASTM increases tissue extensibility by reducing soft tissue limitations, and when applied will produce heat effects from tool/instrument friction. This process can affect tissue viscosity where there is a decrease in tissue viscosity. Physiologically, a decrease in tissue viscosity can increase ROM. In addition, based on hypotheses related to the nervous system, IASTM application in the form of mechanical pressure will stimulate intrafascial mechanoreceptors. This condition will change the proprioceptive input sent to the central nervous system and ultimately improve the tension in the tissue-related motor units [17].

A study reported that IASTM can produce significant improvements in lateral flexion ROM and cervical rotation, as well as increase pain pressure threshold values and reduce pain compared to ischemic compression upper trapezius trigger point conditions in badminton players [9]. This is in line with the research which shows that although IASTM is as effective as dry needling in improving ROM, pain scale, and neck disability, IASTM is more effective in increasing active cervical contra-lateral flexion (ACLF) in active trigger point upper trapezius [18].

Based on information obtained from interviews with patients, IASTM can provide a direct sensation of relaxation in the patient’s muscles, so that it can also have an effect in the form of comfort during sleep. This is felt after the administration of IASTM, the patient feels sleepy. In addition, patients with relatively low ROM values at first shows the biggest increase in ROM.

The difference effect between Dry Needling and Unilateral Down Glide vs. Instrument Assisted Soft Tissue Mobilization and Unilateral Down Glide on reducing tenderness and improving cervical Range of Motion in upper trapezius myofascial pain syndrome

Based on the independent sample t-test, with values of p = 0.251 for pain, p = 0.630 for cervical rotation, and p = 0.661 for cervical lateral flexion shows that there is no significant difference between the Dry Needling and Unilateral Down Glide groups with IASTM and Unilateral Down Glide groups in terms of decreasing tenderness and enhancing cervical ROM in upper trapezius MPS. However, the mean difference of 1st group NRS was greater than the 2nd group and 2nd group shows bigger mean difference in ROM than 1st group.

Several factors might explain why the 1st group shows a more significant change in NRS compared to the 2nd group. First, Dry needling directly targets trigger points, this causes deactivation and destroys TrP, which will elicted LTR. LTR will facilitate an increase in local blood supply and release in contractile tissue so as to have an effect in the form of decreased muscle tension and pain. Second, dry needling can trigger the release of endogenous opioids and neurotransmitters that modulate pain, this will significantly reduce pain.

On the other hand, IASTM affects the soft tissue by creating microtrauma that will increase blood and nutrient supply to the injured area and fibroblast migration. This increases tissue extensibility. However, the effect of mechanical pressure may not directly destroy the main source of pain, the trigger point, unlike dry needling which directly targets the deactivation of the pain point.

This study shows the 2nd treatment group experienced a greater gain in cervical ROM than the 1st treatment group. The reach of IASTM is wider than dry needling which only targets trigger points, while IASTM will target a wider range of upper trapezius muscle fibers. IASTM pressure along the tight upper trapezius muscle fibers will release muscle fibers and promote tissue healing by removing scar tissue, releasing adhesions, and fibroblast migration so as to increase tissue extensibility. This then decreases muscle tightness and has an impact on reducing pain and increasing ROM lateral flexion and cervical rotation.

CONCLUSION

Conclusions and recommendations

It can be concluded from this study that there is no superior group between both groups. The dry needling and Unilateral down glide interventions are more influential in reducing pain, while IASTM and Unilateral down glide interventions are more influential in increasing cervical ROM in upper trapezius MPS.

Combining both therapeutic interventions leads to increase cervical ROM and greater pain reduction compared to single interventions. Physiotherapists are advised to implement both techniques for MPS management and students should maintain consistent stretching routines to prevent MPS. Further longitudinal research is suggested to obtain more precise and comprehensive findings.

Recent findings

According to this study, some samples with higher levels of muscle tension might produce more LTR, which is > 3 times. While samples with less muscle tension will produce fewer LTR. Researchers also discovered that the discomfort experienced during a dry needling puncture will increase as muscle tension diminishes. According to the observations, this occurs because LTR will drop as muscular tension does, particularly following the third intervention.

Patients who initially presented with high NRS pain scores and the most restricted ROM experienced the greatest reductions in pain and the gains in ROM. LTR decreases in the dry needling treatment group indicating muscle tissue repair. Along with to significantly reducing pain and improving range of motion, the IASTM treatment group also directly provided a feeling of relaxation, which may have an impact on comfort during sleep.

Research limitations

Age and activity differences between the first and second treatment groups could be a contributing cause to the variation in study findings. Age and activity level influence how the body responds to an intervention and therefore affect NRS and ROM measurement results. In addition, the use of pain medication by patients may introduce potential bias into the study.

ADDITIONAL INFORMATION

Author Contributions. All authors confirm their authorship according to the international ICMJE criteria (all authors contributed significantly to the conception, study design and preparation of the article, read and approved the final version before publication). Special contributions: Nurhalim L.I. — writing — original draft; Nugraha R. — conceptualization, writing — original draft, writing — review & editing; Sudaryanto — conceptualization, formal analysis; Hasbiah, Erawan T. — supervision.

Funding. This study was not supported by any external funding sources.

Disclosure. The author declares no apparent or potential conflicts of interest related to the publication of this article.

Ethics Approval. The authors declare that all procedures used in this article are in accordance with the ethical standards of the institutions that conducted the study and are consistent with the 2024 Declaration of Helsinki. The study was approved by the Local Ethics Committee of the Health Polytechnic Ministry of Health Makassar (Makassar, Indonesia) (Protocol No. 0136/M/KEPK-PTKMS/II/2025, dated February 7, 2025).

Informed Consent for Publication. The study does not disclose information to identify the patients. Written consent was obtained from all patients / legal representatives for publication of all relevant medical information included in the manuscript.

Data Access Statement. The data that support the findings of this study are available on reasonable request from the corresponding author.

About the authors

Rahmat Nugraha

Health Polytechnic Ministry of Health Makassar

Author for correspondence.
Email: rahmatnugraha@poltekkes-mks.ac.id
ORCID iD: 0009-0003-9342-8785

Bachelor of Physiotherapy, Lecture

Indonesia, Makassar

Latifa I. Nurhalim

Health Polytechnic Ministry of Health Makassar

Email: rahmatnugraha@poltekkes-mks.ac.id

Student

Indonesia, Makassar

Sudaryanto Sudaryanto

Health Polytechnic Ministry of Health Makassar

Email: rahmatnugraha@poltekkes-mks.ac.id

Bachelor of Physiotherapy, Lecture

Indonesia, Makassar

Hasbiah Hasbiah

Health Polytechnic Ministry of Health Makassar

Email: rahmatnugraha@poltekkes-mks.ac.id

Bachelor of Physiotherapy, Master of Health Science, Lecture

Indonesia, Makassar

Tiar Erawan

Health Polytechnic Ministry of Health Makassar

Email: rahmatnugraha@poltekkes-mks.ac.id

D.Sc. (Med.), Bachelor of Physiotherapy, Lecture

Indonesia, Makassar

References

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