Dry Needling and its Use in Health Care – A Treatment Modality and Adjunct
`for Pain Management
`Woehrle J*, Roman G and Russell BE
`Department of Physical Therapy, Midwestern University, USA
`
`Abstract
`Dry needling is used by medical professionals throughout the United States to treat pain and to help patients
`improve quality of life. There are noninvasive mechanisms that are used to treat pain such as heat and cold application,
`other thermal or electrical modalities, stretching to soft tissue, or manual therapy. Dry needling is a mechanism that
`is used to treat muscle trigger points that refer pain to areas within the body. Trigger points can cause irritation to
`skeletal muscle or fascia and affect function. Dry needling is used to reduce pain by achieving a local twitch response
`to release muscle tension, normalize electrical dysfunction of the motor end plates, and assist with return to activities
`or rehabilitation. There are many modalities available for pain management and dry needling is one of many used to
`target soft tissue and manage pain. Using a multimodal approach is an effective method of treatment to consider for
`many musculoskeletal or neuromuscular conditions.
`
`Introduction
`Numerous treatments for pain have been proposed, such as trigger
`point infiltration, dry needling, acupuncture, manual therapy, stretching
`of soft tissue, acupressure, and medications. Trigger point dry needling,
`or intramuscular needling, has become more prevalent and is used by
`medical professionals throughout the United States. Muscle trigger
`points (MTrPs) are found to be involved in the pain process whether the
`pain is in the trunk, neck, arm, or leg. Monofilament needles are used
`with dry needling and are inserted into MTrPs by touching, tapping
`or pricking the tip of the needle into the skin. MTrPs are defined as
`taut bands that are hypersensitive areas in the body and are painful
`upon palpation.[1] MTrPs are classified as either active or latent. When
`palpated, active MTrPs could elicit referred pain, reproducing the
`patient’s symptoms; whereas, latent MTrPs do not cause a pain that will
`reproduce the patient’s symptoms but could be responsible for tightness
`of the muscle.[2,3] Dry needling is used for myofascial pain, lower and
`upper extremity pain, neck pain, back pain, headaches, jaw pain, and
`migraines, among other conditions. The effects of dry needling in the
`treatment of knee osteoarthritis has been well documented.[4-6] Dry
`needling is not used as in traditional Oriental or Chinese medical
`practice, or to inject solutions into MTrPs. Dry needling is used as
`an adjunct for the management of pain and dysfunction in numerous
`neuromusculoskeletal conditions.
`Effects of dry needling
`Many schools of thought and approaches to dry needling have been
`presented as effective ways to treat pain. Various philosophies, theories,
`rationales, and duration of training programs have been proposed,
`within health care, addressing the use of dry needling to treat pain and
`soft tissue irritability. Needling provides a hyperstimulation with an
`analgesic effect that is similar to heat and cold compress causing changes
`of the physiological responses within skin.[7] Pain signals are reduced
`with direct stimulation to the ischemic tight muscle segment allowing
`it to relax when using needling.[1] Opoids and pain gating have been
`implicated in pain control. When using imaging, it has been found
`that changes are noted within the brain after needle treatment.[8,9]
`Using dry needling under infrared thermovision causes a temperature
`increase and short-term vasodilatation response that is similar to the
`pain distribution pattern of the subject.[10] Needle insertion into the
`MTrPs elicits a localized twitch response that could interrupt the motor
`end-plate causing analgesia to the area.[11,12] Dry needling disrupts
`the sensory input to the spinal cord through the mechanical irritation
`of the needle being inserted into the sensitive loci within the MTrPs,
`
`which in turn causes a local twitch response.[13] It has been proposed
`that with needle insertion there is a disruption of nociceptors which
`will elicit a local twitch response within the MTrPs causing a disruption
`of the pain cycle with notable pain relief.[14,15] Pain perceptions
`and reductions in pain could be due to the number of physiologic
`mechanisms that contribute to subjective improvements. Some patients
`may not feel the insertion of the needle while others might note a little
`electrical impulse in the local tissue. The health care provider should
`consider these implications when providing dry needling to MTrPs.
`Dry needling as an intervention
`Using dry needling in combination with various manual therapy
`techniques is considered when treating both MTrPs and non-trigger
`point conditions.[16] Soft tissue interventions such as stretching,
`manual therapy, and exercises to the deep neck flexors are considered
`an effective approach to manage neck pain. Dry needling is also used
`to treat neck pain. Treating neck pain with dry needling to the upper
`trapezius has had positive results in reducing the pain.[17] Using
`a single session of dry needling to the specific MTrPs of the upper
`trapezius, resulted in a decrease of neck pain intensity.[17,18] Treating
`the effects of whiplash with dry needling and exercise has been shown
`to produce positive outcomes with significant reduction in pain, pain
`catastrophizing, and cold hyperalgesia at 6 and 12 months follow-up.
`[19] The temporomandibular joint has associated myofascial pain
`dysfunction and is another area that has had successful outcomes with
`use of dry needling.[20] Treating myofascial pain with dry needling has
`been shown to be an effective way to manage pain, improve mobility,
`reduce sensitivity of MTrPs, and improve the quality of life.[21] Being
`point specific with dry needling seems to produce more effective
`results than non-point-specific dry needling. Using dry needling on
`MTrPs of the hamstrings and gluteal muscles did not show significant
`
`*Corresponding author: Judith Woehrle J, Associate Professor, Midwestern
`University, 19555 N 59th Avenue, Glendale, AZ 85308, USA, Tel: 623-572-
`3921; E-mail: jwoehr@midwestern.edu
`Received July 16, 2015; Accepted August 06, 2015; Published August 10, 2015
`Citation: Woehrle J, Roman G, Russell BE (2015) Dry Needling and its Use in
`Health Care – A Treatment Modality and Adjunct for Pain Management. J Pain
`Relief 4: 194. doi:10.4172/21670846.1000194
`Copyright: © 2015 Woehrle J, et al. This is an open-access article distributed under
`the terms of the Creative Commons Attribution License, which permits unrestricted
`use, distribution, and reproduction in any medium, provided the original author and
`source are credited.
`
`Woehrle et al., J Pain Relief 2015, 4:5
`http://dx.doi.org/10.4172/2167-0846.1000194
`
`Open Access
`
`Pain & Relief
`
` Pain & R
`
`elie
`
`f
`
`f
`
`Journ al o
`
`ISSN: 2167-0846
`
`Short Communication
`
`J Pain Relief
`ISSN: 2167-0846 JPAR an open access journal
`
`Volume 4 • Issue 5 • 1000194
`
`LUMENIS EX1037
`Page 1
`
`
`for Pain Management
`Woehrle J*, Roman G and Russell BE
`Department of Physical Therapy, Midwestern University, USA
`
`Abstract
`Dry needling is used by medical professionals throughout the United States to treat pain and to help patients
`improve quality of life. There are noninvasive mechanisms that are used to treat pain such as heat and cold application,
`other thermal or electrical modalities, stretching to soft tissue, or manual therapy. Dry needling is a mechanism that
`is used to treat muscle trigger points that refer pain to areas within the body. Trigger points can cause irritation to
`skeletal muscle or fascia and affect function. Dry needling is used to reduce pain by achieving a local twitch response
`to release muscle tension, normalize electrical dysfunction of the motor end plates, and assist with return to activities
`or rehabilitation. There are many modalities available for pain management and dry needling is one of many used to
`target soft tissue and manage pain. Using a multimodal approach is an effective method of treatment to consider for
`many musculoskeletal or neuromuscular conditions.
`
`Introduction
`Numerous treatments for pain have been proposed, such as trigger
`point infiltration, dry needling, acupuncture, manual therapy, stretching
`of soft tissue, acupressure, and medications. Trigger point dry needling,
`or intramuscular needling, has become more prevalent and is used by
`medical professionals throughout the United States. Muscle trigger
`points (MTrPs) are found to be involved in the pain process whether the
`pain is in the trunk, neck, arm, or leg. Monofilament needles are used
`with dry needling and are inserted into MTrPs by touching, tapping
`or pricking the tip of the needle into the skin. MTrPs are defined as
`taut bands that are hypersensitive areas in the body and are painful
`upon palpation.[1] MTrPs are classified as either active or latent. When
`palpated, active MTrPs could elicit referred pain, reproducing the
`patient’s symptoms; whereas, latent MTrPs do not cause a pain that will
`reproduce the patient’s symptoms but could be responsible for tightness
`of the muscle.[2,3] Dry needling is used for myofascial pain, lower and
`upper extremity pain, neck pain, back pain, headaches, jaw pain, and
`migraines, among other conditions. The effects of dry needling in the
`treatment of knee osteoarthritis has been well documented.[4-6] Dry
`needling is not used as in traditional Oriental or Chinese medical
`practice, or to inject solutions into MTrPs. Dry needling is used as
`an adjunct for the management of pain and dysfunction in numerous
`neuromusculoskeletal conditions.
`Effects of dry needling
`Many schools of thought and approaches to dry needling have been
`presented as effective ways to treat pain. Various philosophies, theories,
`rationales, and duration of training programs have been proposed,
`within health care, addressing the use of dry needling to treat pain and
`soft tissue irritability. Needling provides a hyperstimulation with an
`analgesic effect that is similar to heat and cold compress causing changes
`of the physiological responses within skin.[7] Pain signals are reduced
`with direct stimulation to the ischemic tight muscle segment allowing
`it to relax when using needling.[1] Opoids and pain gating have been
`implicated in pain control. When using imaging, it has been found
`that changes are noted within the brain after needle treatment.[8,9]
`Using dry needling under infrared thermovision causes a temperature
`increase and short-term vasodilatation response that is similar to the
`pain distribution pattern of the subject.[10] Needle insertion into the
`MTrPs elicits a localized twitch response that could interrupt the motor
`end-plate causing analgesia to the area.[11,12] Dry needling disrupts
`the sensory input to the spinal cord through the mechanical irritation
`of the needle being inserted into the sensitive loci within the MTrPs,
`
`which in turn causes a local twitch response.[13] It has been proposed
`that with needle insertion there is a disruption of nociceptors which
`will elicit a local twitch response within the MTrPs causing a disruption
`of the pain cycle with notable pain relief.[14,15] Pain perceptions
`and reductions in pain could be due to the number of physiologic
`mechanisms that contribute to subjective improvements. Some patients
`may not feel the insertion of the needle while others might note a little
`electrical impulse in the local tissue. The health care provider should
`consider these implications when providing dry needling to MTrPs.
`Dry needling as an intervention
`Using dry needling in combination with various manual therapy
`techniques is considered when treating both MTrPs and non-trigger
`point conditions.[16] Soft tissue interventions such as stretching,
`manual therapy, and exercises to the deep neck flexors are considered
`an effective approach to manage neck pain. Dry needling is also used
`to treat neck pain. Treating neck pain with dry needling to the upper
`trapezius has had positive results in reducing the pain.[17] Using
`a single session of dry needling to the specific MTrPs of the upper
`trapezius, resulted in a decrease of neck pain intensity.[17,18] Treating
`the effects of whiplash with dry needling and exercise has been shown
`to produce positive outcomes with significant reduction in pain, pain
`catastrophizing, and cold hyperalgesia at 6 and 12 months follow-up.
`[19] The temporomandibular joint has associated myofascial pain
`dysfunction and is another area that has had successful outcomes with
`use of dry needling.[20] Treating myofascial pain with dry needling has
`been shown to be an effective way to manage pain, improve mobility,
`reduce sensitivity of MTrPs, and improve the quality of life.[21] Being
`point specific with dry needling seems to produce more effective
`results than non-point-specific dry needling. Using dry needling on
`MTrPs of the hamstrings and gluteal muscles did not show significant
`
`*Corresponding author: Judith Woehrle J, Associate Professor, Midwestern
`University, 19555 N 59th Avenue, Glendale, AZ 85308, USA, Tel: 623-572-
`3921; E-mail: jwoehr@midwestern.edu
`Received July 16, 2015; Accepted August 06, 2015; Published August 10, 2015
`Citation: Woehrle J, Roman G, Russell BE (2015) Dry Needling and its Use in
`Health Care – A Treatment Modality and Adjunct for Pain Management. J Pain
`Relief 4: 194. doi:10.4172/21670846.1000194
`Copyright: © 2015 Woehrle J, et al. This is an open-access article distributed under
`the terms of the Creative Commons Attribution License, which permits unrestricted
`use, distribution, and reproduction in any medium, provided the original author and
`source are credited.
`
`Woehrle et al., J Pain Relief 2015, 4:5
`http://dx.doi.org/10.4172/2167-0846.1000194
`
`Open Access
`
`Pain & Relief
`
` Pain & R
`
`elie
`
`f
`
`f
`
`Journ al o
`
`ISSN: 2167-0846
`
`Short Communication
`
`J Pain Relief
`ISSN: 2167-0846 JPAR an open access journal
`
`Volume 4 • Issue 5 • 1000194
`
`LUMENIS EX1037
`Page 1
`
`
`
`Citation: Woehrle J, Roman G, Russell BE (2015) Dry Needling and its Use in Health Care – A Treatment Modality and Adjunct for Pain Management.
`J Pain Relief 4: 194. doi:10.4172/21670846.1000194
`
`changes in straight leg raise or hip internal rotation; yet, there were
`subjective improvements reported in pain and tightness of the muscles
`following dry needling or sham needling.[3] Using dry needling
`with a multimodal approach for postoperative repair to a humeral
`fracture or rotator cuff repair may have assisted with a faster increase
`in function.[22] The addition of dry needling of the multifidus muscle
`of the low back in the treatment of low back pain has been shown to
`increase multifidus muscle contraction and decrease sensitivity to pain
`in patients who responded to treatment.[23] The use of dry needling
`has been postulated to be a mechanism for the attainment of early pain
`relief in order to facilitate a manual therapy technique and a quicker
`return to function. [24]
`Other modalities used as an intervention for pain relief
`Dry needling and other modalities are available to aide in the
`delivery of pain management. (Figure 1) Thermal modalities change
`responses in tissue temperature and circulation, altering cell membrane
`permeability [25], modulate pain via the gate control theory and
`effect the endogenous opioid system [26]. Modalities are often used
`in conjunction with or in sequence to one another. Moist heat or
`cryotherapy are often used with electrical stimulation or inferential
`current for pain management. For thermal ultrasound, preheating the
`skin with moist heat prior to an ultrasound treatment is thought to
`decrease the time necessary to reach moderate to vigorous heating.[25]
`High volt electrical stimulation with a positive polarity for motor nerve
`depolarization could be used in combination with thermal ultrasound
`for localized trigger point release.[25,27] For managing chronic pain,
`an electrical current is used to depolarize efferent motor nerve fibers
`through high current amplitude, low pulse frequency, and a long pulse
`duration.[25,27] Modality selection depends upon the surface area of
`tissue involvement, the depth of penetration desired and stage of injury
`healing. Dosing parameters unique to each modality must be carefully
`considered, in order to foster the best patient outcome.
`Conclusion
`In review, it is hypothesized that dry needling is an adjunct
`to facilitate a quick response to significantly minimize pain so a
`person could return to function.[24] Practice guidelines have been
`proposed that provide a rationale to deliver the optimal frequency,
`intensity, duration and points of insertion when using dry needling
`for neuromusculoskeletal conditions.[28] Standardization has been
`explored when treating MTrPs in people who have myofascial pain.
`
`Patient/Client
`with pain -
`inhibiting function
`
`Examination Results – Active
`muscle trigger points (MTrPs)
`
`Modalities
`
`Inferential
`Current
`
`Ultrasound
`
`Dry
`Needling
`
`Thermal
`Modalities
`(heat & cold)
`
`Electrical
`Nerve
`Stimulation
`
`Figure 1 : Algorithm illustrating treatment modalities used to address
`MTrPs
`
`Page 2 of 3
`
`[29] There might be a global reduction in pain perception due to the
`physiological responses to pain mechanisms as proposed when using
`other modalities for pain relief. In clinical practice, using dry needling
`as an isolated intervention is atypical. Dry needling combined with
`conventional therapies such as exercises and other modalities should be
`considered, especially if long term effects are desired.[19] Dry needling
`minimizes the pain so that the person is able to focus on performing
`the exercises, or other interventions, that will help restore movement.
`When deciding upon the use of dry needling for pain, a multimodal
`approach should be considered.
`
`References
`1. Simons DG, Travell JG, Simons LS (1998) Travell & Simons Myofascial Pain
`and Dysfunction. (2ndedn) Williams & Wilkins, Baltimore.
`
`2. Mejuto-Vázquez MJ, Salom-Moreno J, Ortega-Santiago R, Truyols-Domínguez
`S, Fernández-de-Las-Peñas C (2014) Short-term changes in neck pain,
`widespread pressure pain sensitivity, and cervical range of motion after the
`application of trigger point dry needling in patients with acute mechanical neck
`pain: a randomized clinical trial. J Orthop Sports Phys Ther 44: 252-260.
`
`3. Huguenin L, Brukner PD, McCrory P, Smith P, Wajswelner H, et al. (2005) Effect
`of dry needling of gluteal muscles on straight leg raise: a randomised, placebo
`controlled, double blind trial. Br J Sports Med 39: 84-90.
`
`4. White A, Foster NE, Cummings M, Barlas P (2007) Acupuncture treatment for
`chronic knee pain: a systematic review. Rheumatology (Oxford) 46: 384-390.
`
`5. Whitehurst DG, Bryan S, Hay EM, Thomas E, Young J, et al. (2011) Cost-
`effectiveness of acupuncture care as an adjunct to exercise-based physical
`therapy for osteoarthritis of the knee. Phys Ther 91: 630-641.
`
`6. Witt CM, Jena S, Brinkhaus B, Liecker B, Wegscheider K, et al. (2006)
`Acupuncture in patients with osteoarthritis of the knee or hip: a randomized,
`controlled trial with an additional nonrandomized arm. Arthritis Rheum 54:
`3485-3493.
`
`7. Melzack R (1981) Myofascial trigger points: relation to acupuncture and
`mechanisms of pain. Arch Phys Med Rehabil 62: 114-117.
`
`8. Wu MT, Hsieh JC, Xiong J, Yang CF, Pan HB, et al. (1999) Central nervous
`pathway for acupuncture stimulation: localization of processing with functional
`MR imaging of the brain: preliminary experience. Radiology 212: 133-141.
`
`9. Bialla G, Solgiu M, Pellegata G, Paulesu E, Castiglioni I, et al. (2001)
`Acupuncture produces central activations in pain regions. Neuroimage 14: 60-
`66.
`
`10. Skorupska E, Rychlik M, Pawelec W, Samborski W (2015) Dry Needling Related
`Short-Term Vasodilation in Chronic Sciatica under Infrared Thermovision. Evid
`Based Complement Alternat Med 2015: 214374.
`
`11. Skorupska E, Rychlik M, Samborski W (2015) Intensive vasodilatation in the
`sciatic pain area after dry needling. BMC Complement Altern Med 15: 72.
`
`12. Kietrys DM, Palombaro KM, Azzaretto E, Hubler R, Schaller B, et al. (2013)
`Effectiveness of dry needling for upper-quarter myofascial pain: a systematic
`review and meta-analysis. J Orthop Sports Phys Ther 43: 620-634.
`
`13. Audette JF, Wang F, Smith H (2004) Bilateral activation of motor unit potentials
`with unilateral needle stimulation of active myofascial trigger points. Am J
`Phys Med Rehabil 83: 368-374. Hong CZ (2006) Treatment of myofascial pain
`syndrome. Curr Pain Headache Rep 10: 345-349.
`
`14. Hong CZ, Simons DG (1998) Pathophysiologic and electrophysiologic
`mechanisms of myofascial trigger points. Arch Phys Med Rehabil 79: 863-872.
`
`15. Fernandez-Carnero J, Fernandez-de-las-Penas C, de la Llave-Rincon AI, Ge
`HY, Arendt-Nielsen L (2007) Prevalence of and referred pain from myofascial
`trigger points in the forearm muscles in patients with lateral epicondylalgia. Clin
`J Pain 23: 353-360.
`
`16. Mejuto-Vazquez MJ, Salom-Moreno J, Ortega-Santiago R, Truyols-Dominguez
`S, Fernandez-de-las-Penas C (2014) Short-term changes in neck pain,
`widespread pressure pain sensitivity, and cervical range of motion after the
`application of trigger point dry needling in patients with acute mechanical neck
`pain: a randomized clinical trial. J Orthop Sports Phys Ther 44: 252-260.
`
`17. Llamas-Ramos R, Pecos-Martin D, Gallego-Izquierdo T, Llamas-Ramos I,
`Plaza-Manzano G, et al. (2014) Comparison of the short-term outcomes
`
`J Pain Relief
`ISSN: 2167-0846 JPAR an open access journal
`
`Volume 4 • Issue 5 • 1000194
`
`LUMENIS EX1037
`Page 2
`
`
`
`Citation: Woehrle J, Roman G, Russell BE (2015) Dry Needling and its Use in Health Care – A Treatment Modality and Adjunct for Pain Management.
`J Pain Relief 4: 194. doi:10.4172/21670846.1000194
`
`between trigger point dry needling and trigger point manual therapy for the
`management of chronic mechanical neck pain: a randomized clinical trial. J
`Orthop Sports Phys Ther 44: 852-861.
`
`18. Sterling M, Vicenzino B, Souvlis T, Connelly LB (2015) Dry-needling and
`exercise for chronic whiplash-associated disorders: a randomized single-blind
`placebo-controlled trial. Pain 156: 635-643.
`
`19. Dıraçoğlu D, Vural M, Karan A, Aksoy C (2012) Effectiveness of dry needling
`for the treatment of temporomandibular myofascial pain: a double-blind,
`randomized, placebo controlled study. J Back Musculoskelet Rehabil 25: 285-
`290.
`
`20. Unverzagt C, Berglund K, Thomas JJ (2015) Dry Needling for Myofascial
`Trigger Point Pain: A Clinical Commentary. Int J Sports Phys Ther 10: 402-418.
`
`21. Arias-Buria JL, Valero-Alcaide R, Cleland JA, Salom-Moreno J, Ortega-
`Santiago R, et al. (2015) Inclusion of trigger point dry needling in a multimodal
`physical therapy program for postoperative shoulder pain: a randomized clinical
`trial. J Manipulative Physiol Ther 38: 179-187.
`
`22. Koppenhaver SL, Walker MJ, Su J, McGowen JM, Umlauf L, et al. (2015)
`Changes in lumbar multifidus muscle function and nociceptive sensitivity in
`low back pain patient responders versus non-responders after dry needling
`treatment. Man Ther 8.
`
`23. Dommerholt J (2011) Dry needling - peripheral and central considerations. J
`Man Manip Ther 19: 223-227.
`
`Page 3 of 3
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`24. Alain-Yvan B (2015) Therapeutic Electrophysical Agents. Evidence Behind
`Practice. (3rdedn) Philadelphia, PA: Lippincott Williams & Wilkins.
`
`25. Belanger, Alain-Yvan. Therapeutic Electrophysical Agents. Evidence Behind
`Practice. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2015.
`Thermotherapy, Chapter 7, Alain-Yvan Belanger Cryotherapy, Chapter 8, Alain-
`Yvan Belanger Transcutaneous Electrical Nerve Stimulation, Chapter 14, Alain-
`Yvan Belanger Ultrasound, Chapter 20, Alain-Yvan Belanger
`
`26. Cameron, Michelle. Physical Agents in Rehabilitation. From Research to
`Practice. 3rd ed. St. Louis, MO: Saunders Elsevier; 2009. Pain, Chapter 3,
`Michelle Cameron Thermal Agents: Cold and Heat, Chapter 6, Michelle
`Cameron Ultrasound, Chapter 7, Michelle Cameron Electrical Currents,
`Chapter 8, Sara Shapiro
`
`27. Michlovitz, Susan, Bellow, James and Nolan, Thomas. Modalities for
`Therapeutic Intervention. 5th ed. Philadelphia, PA: F.A. Davis Company; 2012.
`Cold Therapy, Chapter 2, Stacie Fruth and Susan Michlovitz Therapeutic
`Heat, Chapter 3, Sandy Rennie and Susan Michlovitz Therapeutic Ultrasound,
`Chapter 4, Susan Michlovitz and Karen Sparrow Clinical Electrical Stimulation:
`Application and Techniques, Chapter 10, James Bellow Pain and Limited
`Motion, Chapter 13, Stephanie Petterson and Susan Michlovitz,
`
`28. Gerber LH, Shah J, Rosenberger W, Armstrong K, Turo D, et al. (in press) Dry
`needling alters trigger points in the upper trapezius muscle and reduces pain in
`subjects with chronic myofascial pain. PMR 7: 711-18.
`
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`Citation: Woehrle J, Roman G, Russell BE (2015) Dry Needling and its Use in
`Health Care – A Treatment Modality and Adjunct for Pain Management. J Pain
`Relief 4: 194. doi:10.4172/21670846.1000194
`
`
`
`View publication statsView publication stats
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`J Pain Relief
`ISSN: 2167-0846 JPAR an open access journal
`
`Volume 4 • Issue 5 • 1000194
`
`LUMENIS EX1037
`Page 3
`
`
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