Guía Docente 2020-21


Id.: 30387
Programme: GRADUADO EN FISIOTERAPIA. PLAN 2009 (BOE 15/10/2011)
Subject type: OBLIGATORIA
Year: 3 Teaching period: Segundo Cuatrimestre
Credits: 6 Total hours: 150
Classroom activities: 57 Individual study: 93
Main teaching language: Inglés Secondary teaching language: Castellano
Lecturer: Email:


The subject Physiotherapy in Clinical Specialties II aims to provide the students with basic knowledge for the treatment of myofascial pain syndrome in order to be applied for different populations and pathologies. This subject aims to develop students´ competences in order to allow them to integrate specific myofascial pain treatment techniques along with the rest of the techniques studied during the Physiotherapy Degree. In this subject, teaching methodology combines master classes that provide basic knowledge that the student has to handle, together with methodologies that improve clinical reasoning and problem solving skills so that the student can integrate and apply his/ her clinical knowledge more effectively.

All this theoretical content and clinical reasoning will be coordinated with workshops to allow students to develop their practical skills, as well as with activities oriented to help students to communicate with their patients in this specific area of knowledge.


General programme competences G01 Ability to analyse and summarise information from several sources with the aim of providing effective physiotherapy care based on the primary treatment of the patients/ users.
G02 Solve problems that arise day-to-day both creatively and efficiently, in order to ensure the highest levels of quality of professional work.
G03 Ability to organise and plan physiotherapy duties.
G04 Use of information and communication technologies to meet the needs of patients/ clients and for the design, application and evaluation of treatments.
G08 Ability to apply acquired knowledge.
Specific programme competences E17 Know and apply the theoretical bases and the development of physiotherapeutic methods and procedures.
E18 Have the ability to assess from the perspective of physiotherapy, the functional status of the patient/ user, considering their physical, psychological and social aspects.
E19 Understand and apply the manual and instrumental assessment methods and procedures in Physiotherapy and Physical Rehabilitation, as well as the scientific evaluation of its usefulness and effectiveness.
E22 Identify the most appropriate physiotherapy treatment in the different processes of alteration, prevention and promotion of health as well as in the processes of growth and development.
Regulated profession competences P07 Design the physiotherapy intervention plan according to criteria of adequacy, validity and efficiency.
P08 Execute, direct and coordinate the physiotherapy intervention plan, using suitable therapeutic tools and attending to the individuality of the user.
P09 Evaluate the evolution of the results obtained with the treatment in relation to the established objectives.
P10 Prepare the discharge report of physiotherapy care once the proposed objectives have been met.
P19 Communicate effectively and clearly, both orally and in writing, with users of the healthcare system as well as other professionals.
Learning outcomes R01 To know the physiopathology of myofascial trigger points and the clinical characteristics of myofascial pain syndrome
R02 Identify and properly assess myofascial pain
R03 Properly prescribe and use the different conservative and invasive techniques for myofascial pain treatment
R04 Recognize and identify the different activating and perpetuating factors of myofascial pain syndrome as well as to carry out an adequate proposal to eliminate these factors
R05 Know the indications and contraindications, therapeutic effects and existing evidence about new trends in dry needling


In order to ensure a good understanding of the subject, the student must have good palpating skills and functional anatomy knowledge.

The student will be best able to take advantage of this subject and improve clinical integration skills if he/ she has attended the following subjects:

Clinical Interview Workshop

Physiotherapy Evaluation

Specific physiotherapy intervention methods II (locomotor)

General physiotherapy procedures II

Physiotherapy in clinical specialties I



The subject will be structured in the following parts:


Part 1. Theory. The objective will be to provide students with the theory and background of myofascial pain and invasive therapies, allowing them to understand the main concepts and promote critical and clinical thinking


Part 2. Practical workshops. In these workshops, students will work in pairs and will have the opportunity to practice conservative and invasive approaches in the selected MTrPs


Part 3. Special seminars will be organized with the objective to show some innovative uses of traditional dry needling approaches, as well as linking them to the clinical practice (volunteers may attend this seminar to be treated). This seminar is used as an opportunity to show how we face a patient and how GDPR and Informed consent must be done


Another part in the subject, transversal to all parts will be to develop a video about a topic from a list proposed by the lecturers

Subject contents:

1 - Myofascial Trigger Points (MTrP) and Myofascial Pain Syndrome (MPS)
    1.1 - Introduction and characteristics of Myofascial Trigger Points (MTrPs) and Myofascial Pain Syndrome (MPS)
       1.1.1 - The concept of Myofascial Trigger Point (MTrP) and Myofascial Pain Syndrome (MPS)
       1.1.2 - Integrated Hypothesis
       1.1.3 - Current theories about MTrP: analysis of the different theories from the available scientific evidence
       1.1.4 - The nature of MTrP
       1.1.5 - Characteristics of MTrP
       1.1.6 - Classification of MTrP: active and latent
    1.2 - MPS diagnosis and assessment
       1.2.1 - Diagnostic criteria of MTrP
       1.2.2 - MTrP Exploration
       1.2.3 - The MPS: differential diagnosis
       1.2.4 - Patient Assessment
    1.3 - Activating and perpetuating factors
    1.4 - Conservative treatment of MPS
    1.5 - Invasive treatment of MPS
       1.5.1 - Mechanisms of action of superficial and deep dry needling
       1.5.2 - Evidence-based dry needling
       1.5.3 - Indications and contraindications of dry needling. Areas of risk.
       1.5.4 - Dry needling needles: characteristics and dimensions
       1.5.5 - Considerations prior to dry needling
       1.5.6 - Considerations during dry needling treatment
       1.5.7 - Legal considerations about dry needling
2 - Conservative and invasive treatment of myofascial trigger points
    2.1 - Diacutaneous Fibrolysis
    2.2 - Infraspinatus Muscle
       2.2.1 - Activating and perpetuating factors
       2.2.2 - Referred pain patterns
       2.2.3 - Conservative treatment
       2.2.4 - Algometry practice
       2.2.5 - Superficial and Deep Dry Needling
    2.3 - Gastrocnemius Muscle
       2.3.1 - Activating and perpetuating factors
       2.3.2 - Referred pain patterns
       2.3.3 - Conservative treatment
       2.3.4 - Deep dry needling of gastrocnemius muscle. Flat and pincer needling
    2.4 - Sternocleidomastoid muscle
       2.4.1 - Activating and perpetuating factors
       2.4.2 - Referred pain patterns
       2.4.3 - Pincer palpation. Identification of the taut band and the MTrP. Provocation of LTR
       2.4.4 - Conservative treatment
    2.5 - Extensor digitorum communis muscle
       2.5.1 - Activating and perpetuating factors
       2.5.2 - Referred pain patterns
       2.5.3 - Conservative treatment
       2.5.4 - Deep dry needling of Extensor digitorum communis muscle
    2.6 - Quadratus lumborum muscle
       2.6.1 - Activating and perpetuating factors
       2.6.2 - Referred pain patterns
       2.6.3 - Conservative treatment
    2.7 - Iliopsoas muscle
       2.7.1 - Activating and perpetuating factors
       2.7.2 - Referred pain patterns
       2.7.3 - Conservative treatment
    2.8 - Quadriceps muscle
       2.8.1 - Activating and perpetuating factors
       2.8.2 - Referred pain patterns
       2.8.3 - Conservative treatment
       2.8.4 - Deep dry needling of quadriceps
    2.9 - Scaleni muscles
       2.9.1 - Activating and perpetuating factors
       2.9.2 - Referred pain patterns
       2.9.3 - Deep dry needling of scaleni muscles
    2.10 - Gluteus medius and minimus muscle
       2.10.1 - Activating and perpetuating factors
       2.10.2 - Referred pain patterns
       2.10.4 - Conservative treatment
       2.10.5 - Deep dry needling of gluteus medius and minimus
    2.11 - Trapezius and levator scapulae muscles
       2.11.1 - Activating and perpetuating factors
       2.11.2 - Referred pain patterns
       2.11.3 - Conservative treatment
       2.11.4 - Deep dry needling of trapezius muscle
3 - New trends in dry needling
    3.1 - Percutaneous electrolysis
    3.2 - Dry Needling for Hypertonia and Spasticity (DNHS technique)
    3.3 - Percutaneous Neuromodulation

Subject planning could be modified due unforeseen circumstances (group performance, availability of resources, changes to academic calendar etc.) and should not, therefore, be considered to be definitive.


Teaching and learning methodologies and activities applied:

Teaching-learning methodologies will change depending on the unit:

1 - Introduction to Myofascial trigger points (MTrPs).

The methodology of Unit I will consist of master classes in order to present the theoretical content of the subject. The classes will be very interactive and the student will have participate in differents activities that the lecturer will propose.


Students will be asigned to a group the first day, and they will start working in the different activities from the first day as a group. Groups will be the following:

Group 1. Head and neck pain.

Group 2. Superior spine, shoulder and arm pain.

Group 3. Forearm and hand pain. 

Group 4. Lower back and anterior thorax pain. 

Group 5. Lumbar spine, gluteus, pelvic and abdominal pain. 

Group 6. Hip, thigh and knee pain. 

Group 7. Leg, ankle and foot pain.


Students will have to present their group works although they won´t be considered for the final score of the subject


2 - Conservative and invasive treatment of myofascial trigger points. 

The methodology of Unit II will consist of theoretical-practical demonstrations. After them, the students will have the opportunity to practise these skills and competences with a partner. Both students will perform both roles: physio and patient. The lecturers will supervise the students in pairs. 


3 - New trends in dry needling.

The methodology of Unit III will be based on theoretical-practical seminars in which new trends of dry needling will be shown.


Complementary, students will be guided during their group works, as these will be evaluated with a 30% of the total subject score. They will have to present a video about a topic previously agreed with the lecturer. 



Student work load:

Teaching mode Teaching methods Estimated hours
Classroom activities
Master classes 16
Other theory activities 4
Practical exercises 5
Practical work, exercises, problem-solving etc. 4
Debates 2
Workshops 19
Assessment activities 1
New trends in dry needling seminars 6
Individual study
Tutorials 9
Individual study 48
Group cousework preparation 20
Practical exam preparation 16
Total hours: 150


Calculation of final mark:

Written tests: 35 %
Group coursework: 30 %
Final exam: 35 %
TOTAL 100 %

*Las observaciones específicas sobre el sistema de evaluación serán comunicadas por escrito a los alumnos al inicio de la materia.


Basic bibliography:

Simons DG, Travell JG, Simons LS. Dolor y disfunción miofascial. El manual de los puntos gatillo. Extremidades inferiores. Madrid: Editorial Médica Panamericana; 2006.
Simons DG, Travell JG, Simons LS. Dolor y disfunción miofascial. El manual de los puntos gatillo. Mitad superior del cuerpo. Madrid: Editorial Médica Panamericana; 2006.
Valera Garrido F, Minaya Muñoz F. Fisioterapia invasiva. Barcelona: Editorial Elsevier España, S.L. 2016. 2ª edición. ISBN: 9788491130994
Valera Garrido F, Minaya Muñoz F. Advanced Techniques in Musculoskeletal Medicine & Physiotherapy. Editorial Elsevier. ISBN 10: 070206534X ISBN 13: 9780702065347.
Mayoral del Moral O, Salvat Salvat I. Fisioterapia Invasiva del Síndrome de Dolor Miofascial. Editorial Médica Panamericana.ISBN-10: 8498351030; ISBN-13: 978-8498351033

Recommended bibliography:

Dommerholt J, Huijbregts P. Myofascial trigger points. Pathophysiology and evidence-informed diagnosis and management. Editorial Jones and Bartlett; 2010.
Graven-Nielsen T, Arendt-Nielsen L, Mense S. Fundamentals of Musculoskeletal Pain. IASP Press.
Butler DS, Moseley GL. Explicando el dolor. Noigroup Publications.
Hong CZ, Simons DG. Pathophysiologic and electrophysiologic mechanisms of myofascial trigger points. Arch Phys Med Rehabil. 1998;79(7):863-72
Shah JP, Phillips TM, Danoff JV, Gerber LH. An in vivo microanalytical technique for measuring the local biochemical milieu of human skeletal muscle. J Appl Physiol (1985). 2005;99(5):1977-84.
Chen JT, Chung KC, Hou CR, Kuan TS, Chen SM, Hong CZ. Inhibitory effect of dry needling on the spontaneous electrical activity recorded from myofascial trigger spots of rabbit skeletal muscle. Am J Phys Med Rehabil. 2001;80(10):729-35
Chen Q, Bensamoun S, Basford JR, Thompson JM, An KN. Identification and quantification of myofascial taut bands with magnetic resonance elastography. Arch Phys Med Rehabil. 2007;88(12):1658-61
Hsieh CY, Hong CZ, Adams AH, et al. Interexaminer reliability of the palpation of trigger points in the trunk and lower limb muscles. Arch Phys Med Rehabil 2000;81:258-64
Rha DW, Shin JC, Kim YK, Jung JH, Kim YU, Lee SC. Detecting local twitch responses of myofascial trigger points in the lower-back muscles using ultrasonography. Arch Phys Med Rehabil. 2011;92(10):1576-80
Sikdar S, Shah JP, Gebreab T, Yen RH, Gilliams E, Danoff J, et al. Novel applications of ultrasound technology to visualize and characterize myofascial trigger points and surrounding soft tissue. Arch Phys Med Rehabil. 2009;90(11):1829-38
Ballyns JJ, Shah JP, Hammond J, Gebreab T, Gerber LH, Sikdar S. Objective sonographic measures for characterizing myofascial trigger points associated with cervical pain. J Ultrasound Med. 2011;30(10):1331-40
Lucas K. Latent myofascial trigger points: their effects on muscle activation and movement efficiency. 2004.
Lucas KR. The impact of latent trigger points on regional muscle function. Curr Pain Headache Rep. 2008;12(5):344-9
Lucas KR, Rich PA, Polus BI. Muscle activation patterns in the scapular positioning muscles during loaded scapular plane elevation: the effects of Latent Myofascial Trigger Points. Clin Biomech (Bristol, Avon). 2010;25(8):765-70
Audette JF, Wang F, Smith H. Bilateral activation of motor unit potentials with unilateral needle stimulation of active myofascial trigger points. Am J Phys Med Rehabil. 2004;83(5):368-74, quiz 75-7, 89
Hong CZ, Chen YN, Twehous DA, et al.: Pressure threshold for referred pain by compression on the trigger point and adjacent areas. J Musculoske Pain 4(3)m-79, 1996
Gerwin RD, Dommerholt J, Shah JP. An expansion of Simons\' integrated hypothesis of trigger point formation. Curr Pain Headache Rep. 2004;8(6):468-75
Simons DG, Hong CZ, Simons LS. Endplate potentials are common to midfiber myofacial trigger points. Am J Phys Med Rehabil. 2002;81(3):212-22
Shah JP, Danoff JV, Desai MJ, Parikh S, Nakamura LY, Phillips TM, et al. Biochemicals associated with pain and inflammation are elevated in sites near to and remote from active myofascial trigger points. Arch Phys Med Rehabil. 2008;89(1):16-23
Shah JP, Gilliams EA. Uncovering the biochemical milieu of myofascial trigger points using in vivo microdialysis: an application of muscle pain concepts to myofascial pain syndrome. J Bodyw Mov Ther. 2008;12(4):371-84.
Chen Q, Basford J, An KN. Ability of magnetic resonance elastography to assess taut bands. Clin Biomech (Bristol, Avon). 2008;23(5):623-9.
Ballyns JJ, Turo D, Otto P, Shah JP, Hammond J, Gebreab T, et al. Office-based elastographic technique for quantifying mechanical properties of skeletal muscle. J Ultrasound Med. 2012;31(8):1209-19
Maher RM, Hayes DM, Shinohara M. Quantification of dry needling and posture effects on myofascial trigger points using ultrasound shear-wave elastography. Arch Phys Med Rehabil. 2013;94(11):2146-50.
Turo D, Otto P, Shah JP, Heimur J, Gebreab T, Zaazhoa M, et al. Ultrasonic characterization of the upper trapezius muscle in patients with chronic neck pain. Ultrason Imaging. 2013;35(2):173-87
Hsieh YL, Kao MJ, Kuan TS, Chen SM, Chen JT, Hong CZ. Dry needling to a key myofascial trigger point may reduce the irritability of satellite MTrPs. Am J Phys Med Rehabil. 2007;86(5):397-403
Hsieh YL, Yang SA, Yang CC, Chou LW. Dry needling at myofascial trigger spots of rabbit skeletal muscles modulates the biochemicals associated with pain, inflammation, and hypoxia. Evid Based Complement Alternat Med. 2012;2012:342165
A.Mauro, “Satellite cell of skeletal muscle fibers,” The Journal of Biophysical and Biochemical Cytology, vol. 9, pp. 493–495, 1961
M. Reznik, Current Concepts of Skeletal Muscle Regeneration, Williams
Domingo A, Mayoral O, Monterde S, Santafé MM. Neuromuscular damage and repair after dry needling in mice. Evid Based Complement Alternat Med. 2013;2013:260806
Langevin HM, Bouffard NA, Badger GJ, Churchill DL, Howe AK. Subcutaneous tissue fibroblast cytoskeletal remodeling induced by acupuncture: evidence for a mechanotransduction-based mechanism. J Cell Physiol. 2006;207(3):767-74
Hong C-Z. Consideration and recommendation of myofascial trigger point injection. J Musculoskel Pain 1994;2:29-59
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. Eur J Pain. 2009;13(1):3-10
Kietrys DM, Palombaro KM, Azzaretto E, Hubler R, Schaller B, Schlussel JM, et al. Effectiveness of dry needling for upper-quarter myofascial pain: a systematic review and meta-analysis. J Orthop Sports Phys Ther. 2013;43(9):620-34
Couto C, de Souza IC, Torres IL, Fregni F, Caumo W. Paraspinal stimulation combined with trigger point needling and needle rotation for the treatment of myofascial pain: a randomized sham-controlled clinical trial. Clin J Pain. 2014;30(3):214-23
Garvey TA, Marks MR, Wiesel SW. A prospective, randomized, double-blind evaluation of trigger-point injection therapy for low-back pain. Spine. 1989 Sep; 14 (9): 962-4.
Hong C-Z. Lidocaine injection versus dry needling to myofascial trigger point. The importance of the local twitch response. Anm J Phys Med Rehabil 1994 Jul-Aug;73 (4):256-63.
Ga H, Choi JH, Park CH, Yoon HJ. Acupuncture needling versus lidocaine injection of trigger points in myofascial pain síndrome in elderly patients-a randomised controlled trial. Acupunct Med. 2007 Dec: 25 (4): 130-6
Venancio Rde A, Alencar FG, Zamperini C. Different substances and dry-needling injections in patients with myofascial pain and headaches. Cranio. 2008 Apr; 26 (2): 96-103.
Venancio Rde A, Alencar FG, Jr., Zamperini C. Botulinum toxin, lidocaine, and dry-needling injections in patients with myofascial pain and headaches. Cranio. 2009 Jan;27(1):46-53
Ay S, Evcik D, Tur BS. Comparison of injection methods in myofascial pain syndrome: a randomized controlled trial. Clin Rheumatol. 2010;29(1):19-23
Ong J, Claydon LS. The effect of dry needling for myofascial trigger points in the neck and shoulders: a systematic review and meta-analysis. J Bodyw Mov Ther. 2014;18(3):390-8
Ga H, Choi JH, Park CH, Yoon HJ. Dry needling of trigger points with and without paraspinal needling in myofascial pain syndromes in elderly patients. J Altern Complement Med. 2007;13(6):617-24
Srbely JZ, Dickey JP, Lee D, Lowerison M. Dry needle stimulation of myofascial trigger points evokes segmental anti-nociceptive effects. J Rehabil Med. 2010;42(5):463-8
Hong C-Z. Persistence of local twitch response with loss of conduction to and from the spinal cord. Arch Phys Med Rehabil 1994;75:12-6.
Hong C-Z, Torigoe Y, Yu J. The localized twitch responses in responsive bands of rabbit skeletal muscle fibers are related to the reflexes at spinal cord level. J Musculoskel Pain 1995;3:15-33
Cummings M, Ross-Marrs R, Gerwin R. Pneumothorax complication of deep dry needling demonstration. Acupunct Med. 2014
Cummings M. \'Forbidden points\' in pregnancy: no plausible mechanism for risk. Acupunct Med 2011;29(2):140-2
Xie YM, Xu S, Zhang CS, Xue CC. Examination of surface conditions and other physical properties of commonly used stainless steel acupuncture needles. Acupunct Med. 2014;32(2):146-54
Hong C-Z, Kuan T-S, Chert J-T, Chen S-M. Referred pain elicited by palpation and by needling of myofascial trigger points: a comparison. Arch Phys Med Rehabil 1997;78:957-60
Martín-Pintado Zugasti A, Rodríguez-Fernández AL, García-Muro F, López-López A, Mayoral O, Mesa-Jiménez J, et al. Effects of Spray and Stretch on Postneedling Soreness and Sensitivity After Dry Needling of a Latent Myofascial Trigger Point. Arch Phys Med Rehabil. 2014

Recommended websites:

Seminarios Travell y Simons
Técnica DNHS
Trigger Points Maps
Sociedad Científica Fisioterapia Invasiva Neurmusculoesquelética

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