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com
Original paper

Autonomic responses to ultrasound-
guided percutaneous needle
electrolysis of the patellar tendon in
healthy male footballers
Blanca de la Cruz Torres,1 Manuel Albornoz Cabello,1
Paula García Bermejo,1 José Naranjo Orellana2

1
Department of Physiotherapy, ABSTRACT INTRODUCTION
University of Seville. Avicena
Background Ultrasound (US)-guided Techniques involving puncture of the
Street, Seville, Spain
2
Department of Sport and percutaneous needle electrolysis (PNE) is a novel skin are common in physiotherapy. These
Computing, Pablo de Olavide minimally invasive approach, which involves the procedures may use a mechanical stimu-
University, Seville, Spain application of a galvanic current via an lus, as in acupuncture or dry needling,1 2
Correspondence to
acupuncture needle. As in any procedure or apply electrical current as in electroa-
Blanca de la Cruz Torres, involving needling, vagal reactions have been cupuncture,3 stimulation of myofascial
University of Seville, Avicena reported during PNE. trigger points4 or electrostimulation using
street, Seville 41009, Spain; Objective To examine for changes in autonomic galvanic current.5 6
bcruz@us.es
activity during the US-guided PNE technique on Currently, a technique called percutan-
Accepted 29 December 2015 healthy patellar tendons by measurement and eous needle electrolysis (PNE) is also
analysis of heart rate variability (HRV). being used. Ultrasound (US)-guided PNE
Methods Twenty-two male footballers were is a novel minimally invasive approach
randomly allocated to: a control group (11 that involves the application of a galvanic
players), for whom HRV was recorded for current through an acupuncture needle.5 6
10 min, both at rest and during an exhaustive US This technique has mainly been applied to
examination of the patellar tendon and adjacent treat tendinopathies.6–9 Much like acu-
structures; and an experimental group (11 puncture,10–13 this technique is believed
players), for whom HRV was recorded for to influence mechanotransduction in
10 min, both at rest and during application of tendons.5 6 Tendinopathies are one of the
US-guided PNE on the patellar tendon. The biggest challenges in the clinical setting
following HRV parameters were assessed: mean today.14
NN interval, mean heart rate, time domain Similar to any other procedure in
parameters (SDNN, rMSSD, pNN50), diameters of which needling is applied,15 16 mild vagal
the Poincaré plot (SD1, SD2), stress score, and reactions such as paleness, sweating,
sympathetic/parasympathetic ratio. piloerection, and coldness in the skin are
Results There were no differences between common during the US-guided PNE tech-
groups in any baseline measurements, nor were nique in clinical practice. Moreover, vis-
there any significant differences between control ceral effects (eg, nausea±vomiting, pupil
group measurements (baseline vs intervention). The dilation) may appear, especially in associ-
experimental group exhibited statistically significant ation with stronger stimulation, a greater
increases in SDNN/SD1 (p=0.02/p=0.03) and SD2 number of needles, and/or a longer reten-
(p=0.03), indicating increased parasympathetic and tion time. Occasionally, vasovagal reac-
decreased sympathetic activity, respectively. tions may occur, which are clinical
To cite: de la Cruz Torres B, Conclusions US-guided PNE was associated with phenomena mediated by the vagus nerve
Albornoz Cabello M, an autonomic imbalance characterised by greater and characterised by lightheadedness and
García Bermejo P, et al. parasympathetic activity, which could potentially malaise. Exceptionally, vasovagal reac-
Acupunct Med Published
Online First: [ please include
result in a vasovagal reaction. Care should be taken tions may result in brief and reversible
Day Month Year] to monitor for adverse reactions during US-guided loss of consciousness (vasovagal syncope).
doi:10.1136/acupmed-2015- PNE and simple HRV indicators may have a role in Heart rate variability (HRV) is a useful
010993 early detection. tool to analyse imbalances between

de la Cruz Torres B, et al. Acupunct Med 2016;0:1–5. doi:10.1136/acupmed-2015-010993 1
Copyright 2016 by British Medical Journal Publishing Group.

immunocompromise. HRV was recorded changes in RRIs and is considered an indicator of in a seated position. Pacing and Electrophysiology.22 For the metals28. METHODS Conversely. The SS is expressed as the inverse of the diam. recorded for the EG for 10 min. certain drugs (fluoroquinoles.1136/acupmed-2015-010993 . HRV may be a useful unsurmountable fear of needles. the relationship between sym.29 HRV was the sympathetic-parasympathetic ratio (S/PS).17 provide information All subjects signed informed written consent forms to about parasympathetic activity such as the standard participate in this study. The S/PS ratio is expressed as the quotient accepted indications for this technique. which complied with all of Cardiology and the North American Society of the principles set out in the Declaration of Helsinki. both at rest and ively. treatment. applied using a modified electrosurgical scalpel that nique therapeutically but rather to explore the possibility incorporates acupuncture needles (0. Barcelona.7 8 although all of SS and SD1 and it is considered to reflect auto. the transverse dual’s degree of apprehension to the application of an axis (SD1) is a measurement of the short-term electrical current. there are several parameters that. (4) autonomic imbalance characterised by a predomin. During each procedure. time domain. pros- been validated as an accurate tool to assess the status thesis or osteosynthesis in the area of intervention. three US-guided precise applications >37. Acupunct Med 2016.17 HRV has PNE including chronic joint disease. (2) a Personal ically avoided to prevent a tattoo effect of the cath- Psychological Apprehension Scale (PPAS) score odic flow.bmj. Participants only cathodic flow is usable). Isopropyl alcohol was experimental group (EG). Firstly. The pathetic and parasympathetic activity.24 The physiological meaning fasting overnight. the general aim and the number of adjacent RR interval (RRI) pairs of which was to measure the psychological apprehen- that differ by >50 ms in the full register.23 Physiologically. Procedures ences between the adjacent RR intervals (rMSSD). in the early morning and after parasympathetic activity.18–21 Given that vasovagal reactions involve an costeroids or non-steroidal anti-inflammatories)28.27 Subsequently. The patellar tendon was selected because be directly proportional to sympathetic activity at the patellar tendinopathy it is one of the most commonly sinus node.0:1–5. each operator. The HRV methods reaction to needling. and (5) epilepsy. anticoagulants. ically developed medically certified (Directive 93/42/ pathetic and parasympathetic activity (analysed through EEC) device (EPI Advanced Medicine.com Original paper sympathetic and parasympathetic activity. by means of the age ( pNN50). et al.3 mm in diam- of vagal reactions during its use that might need to be eter) of different lengths. USA) with a linear new indices to facilitate the physiological interpret. This is The purpose of this study was not to evaluate the tech. (3) commonly accepted contraindications to at a fixed intensity of 3 mA were performed. did not suffer from any patellar pathology. volunteers were seated to minimise the risk comprising 11 players: a control group (CG) and an of any potential vagal reaction. respect. the Poincaré plot reflects opinion and self-positioning of the subjects. divided by sion of the subjects during electrophysiotherapeutic the total number of RRIs and expressed as a percent. through the negative electrode cathodic flow.Published by group. The intensity can be taken into consideration for safe clinical practice. surgery. GE Healthcare. The local ethics committee at the University of according to the Task Force of the European Society Seville approved the study. difficulty most commonly used for this purpose are based on expressing feelings appropriately and/or allergy to the time domain17 and the Poincaré plot. neoplasia. HRV) during US-guided PNE on the healthy patellar Spain). HRV was recorded for the CG for of the longitudinal axis (SD2) is not as clear but it is 10 min. coagulopathy. which produces modulated galvanic electricity tendons of a group of male amateur football players. and use of and parasympathetic components) under various con. Wisconsin. By contrast. the square root of the mean of the sum of the squares of the differ.bmj. Downloaded from http://aim. We studied a total of 22 members of an amateur male all of which were performed by the same experienced football club divided randomly into two groups. povidone iodine was specif- pathology in the patellar tendon. 2 de la Cruz Torres B. the polarity of the machine is fixed (ie. both at rest and during an exhaustive US thought that it reflects the long-term changes in RRIs examination of the patellar tendon and adjacent struc- and it is considered an inverse indicator of sympa. adjusted by changing either the duration of stimula- tion or the output current (mA) of the device. probe (12 MHz) according to European Society of ation of the Poincaré plot: the stress score (SS) and Musculoskeletal Radiology guidelines. of the autonomic nervous system (both sympathetic cardiac disease. all subjects filled in the PPAS.com/ on January 20. doi:10. 2016 . Finally. tures using a high resolution greyscale US machine thetic activity. an indivi- HRV fluctuations. deviation of the RR intervals (SDNN).527. corti- ditions. This scale evaluates. US-guided PNE technique was applied using a specif- The aim of this study was to assess the changes in sym. Exclusion criteria were: (1) used to prepare the skin. during application of US-guided PNE on the patellar eter SD2 multiplied by 1000 and it is considered to tendon. history of adverse tool to detect these reactions. any contraindications to needling per se including ance of parasympathetic activity.25 Naranjo et al26 recently defined two (Logiq. study participants had healthy patellar tendons and nomic balance—that is.

99 191. cant vasovagal reactions (including syncope).69±19.47 9. heart rate.5±58. rMSSD.66 pNN50 (%) 29.25 0.10±23.30±45. SS.90* rMSSD (ms) 67. ultrasound.0±42.50 32.1±3.com/ on January 20. et al.31±0.82±31.68 24. compared to (ANOVA) with one between-group factor (CG vs EG) baseline values. including age (22.0:1–5.72 kg.85).36±106.15).02±42.7±15. SS.52±3.12 0.2±2. SS Statistical analysis (8.03 77.83 vs 23.97±12.09±40. On the PPAS scale. the EG exhibited statistically signifi- and one within-group factor (baseline vs intervention).53±21.66 118.6±26. p=0. SD2. Jyväskylä. SDNN.25 65. Data were down. respectively. and S/PS p=0. SD1 (67. *p<0.68 40. normal RR interval (RRI).00 7. pNN50. p=0.99. NN interval. (Firstbeat Technologies.37 HR (bpm) 69.8±31.03).5±16. SD2 (131.85 942. SD1.31±15. by means of simple HRV ±6.0 ical practice lies in the avoidance of clinically signifi- ±2. p=0.75±130.72). that this invasive technique should be performed with Table 1 Heart rate variability parameters before and after US examination or US-guided PNE Control group Experimental group Baseline Intervention Baseline Intervention NN interval (ms) 896.bmj. de la Cruz Torres B. Kubios (University of Eastern Finland. Data were analysed with the ±42.70±42.90 vs 89. Acupunct Med 2016.20 vs 76.5±21.87±2.52±16.0±9. SD1.3 measurements.73). S/PS ratio.Published by group. Chicago.78. pNN50. therefore it is important to advise physiotherapists respectively ( p=0. p=0.5±45.02).1136/acupmed-2015-010993 3 . p=0.99. cant elevations in the following three HRV parameters The Games-Howell post-hoc test was used for mul.65 88. SDNN.31±0.3±45.2±171. p=0.54±58.25 vs 0.com Original paper Measurement of HRV Table 1 shows the mean±SD of the study variables The heart rate (HR) monitor Firstbeat Bodyguard (mean NN interval.32.52).57±26.15±171.67* SD2 131.0±12.51).46).97 141.65 ms. the CG and EG scored 22.5±45.29 0. doi:10.45 and 23.46).32 67.51±17. respectively.78 139. and S/PS ratio) at rest (base- to record HR data for 10 min in every session (at rest line measurement) and during US examination or and during US or US-guided PNE).61 vs 181.66 vs 89. PNE.bmj. Statistical Package for the Social Sciences (SPSS) V. quotient of SS and SD1. Kuopio.70 125.46 57. SD1.2±27. which was used to calculate the HRV para.91% vs 24. US. pNN50 (29. divided by the total number of RRIs and expressed as a percentage.00±9.8±130. and body mass index (24. Data were first analysed using a CG measurements taken at baseline and during the US two-factor repeated measures analysis of variance examination (all p>0.97).08 vs 125.53±45. p=0.25 vs 69.7±4. and SD2 (191. The relevance of this finding to clin- ±2.06 Data are mean±SD.67 vs 40.47 vs 24.22 vs 40.50%.35±25.21). p=0.85 vs 98. SD2.08* SS 8. ratio.29. transverse axis of Poincaré plot. rMSSD. during US-guided PNE: SDNN (139. Finland). SDNN (100.00 vs 9. Illinois.28 All variables are expressed as mean±SD.53). Downloaded from http://aim.76±165.4 US-guided PNE technique on healthy patellar tendons ±4. or S/PS ratio (0.73±4.97 vs 125.55.78 ms. application of the US-guided PNE technique in the loaded from the devices to a computer using Firstbeat CG and EG. By contrast. DISCUSSION RESULTS The main finding of this study was a significant There were no significant baseline differences in any increase in parasympathetic activity (in keeping with a demographic variables between the subjects in the CG potential vasovagal reaction) during application of the and the EG.0±35.05. nificance was set at p<0.78±7.32. p=0. Interventions in the control and experimental groups consisted of US examination and US-guided PNE.97 cm. SS.10±3. The normal. SD1 (47. There were no differences Uploader software (Firstbeat Technologies) and all the between the CG and the EG in baseline measurements RRI series were imported into the software package of NN interval (896.41 69.22.76±11.75 S/PS ratio 0.71±15. mean HR.4±25. (SPSS Inc.97 89.1±6.05).37 65.21 p=0. SD of NN interval.28±0. longitudinal axis of Poincaré plot. p=0. Finland) was used pNN50.79±54.25 898. rMSSD (67. mean HR. p=0. rMSSD. SDNN. weight (75.37 bpm. p=0.33 958.52).03 vs 57.10±0. p=0. meters including mean NN interval.95±35. ±0.4±12. 2016 .85). square root of the mean of the sum of the squares of the differences between adjacent RRIs. HR (70.05 baseline versus intervention scores for experimental group only. ity of the data distribution was evaluated using the There were no significant differences between the Shapiro-Wilk test. p=0.77).7±19. number of adjacent RRI pairs that differ by >50 ms in the full register.36±3.23±27. HR.71 5.03).2 of male football players. SD2. height (177.87±33.33 ms.18±0.68±1.0 tiple comparisons.21 SD1 47.22 55.91 34.71.5±3. USA) and statistical sig. percutaneous needle electrolysis.11 SDNN (ms) 99.7±15. stress score (inverse of diameter SD2×1000).23 years.

to avoid serious vasovagal reactions such as syncope.4:188–93. Xu H. 6 Abat F. An experimental study of performance. Kuan TS. In light of lateral epicondylitis: short-term and long-term results.com Original paper due care and one must be fully prepared to attend to Twitter Follow Blanca De la Cruz at @ClinicDraBlanca any adverse reaction. Clinical results after study. Sánchez-Ibáñez JM. Acupunct Med 2014. supervised Specifically. et al. statistically significant increases were its design and drafted the manuscript. Wang Y. beginning with two groups of homogeneous sub. Acupunct Med 2015. regardless of the participants’ attitudes. Minaya-Muñoz F. Contributors BdlCT and MAC conceived the study. Oliveira LP. Dry needling: a literature were attributable to the physiotherapy technique used in review with implications for clinical practice guidelines. the fact that US-guided PNE is a needling technique. Mayoral-del Moral O. pathological conditions19 30–32 in addition to sports 5 Abat F. respectively).0:1–5. it would appear that this peer reviewed.03. de Oliveira LP. et al. subjects in both REFERENCES the CG and the EG scored an average of 23 points on 1 Chou LW. Diesel WJ. appears unlikely that any study subject manifested a sig. Gelber PE.32:446–54. Acupunct Med tial vasovagal reactions during application of the 2015.58:201–5.14:70E–87E. however. lesion with EPI® technique. is likely that subjects were experiencing an autonomic 10 de Almedia Mdos S. In approved the final version of the manuscript. Polidori F. Simple HRV indicators could poten. thetic activity. Hsieh YL. although the changes Ultrasound-guided percutaneous needle electrolysis in chronic were only statistically significant in the EG. which is indicative of decreased sympa. In this context. All authors read and SDNN and SD1 (p=0. Phys the study.4:13. doi:10. HRV based on increased parasympathetic activity that 7 Abat F. Patient consent Obtained. 2015. et al. pathetic activity in both groups. et al. Effect of electroacupuncture versus pelvic floor muscle training plus solifenacin for moderate and nificant degree of apprehension to the needling or the severe mixed urinary incontinence in women: a study protocol. Gelber PE.20 38–40 Some authors have reported an increase in 2014.33:58–64. HRV is muscular injury repair in a mouse model of notexin-induced now being incorporated into evaluation of the physio. In fact.19:252–65.37 and acupunc. thetic activity (detected by HRV). we observed a trend towards and eccentric exercise in the treatment of patellar tendinopathy. Nakajima M. increased parasympathetic tone afterwards. JNO performed data observed in two markers of parasympathetic activity.38–40 In this 8 Abat F. et al. demonstrated. Mourad F.33:7–8. Acupuncture increases the diameter and reorganisation of tially be used as markers for early detection of poten. 2 Liu B. et al. et al. which is important to acknowledge in order Ther Rev 2014. impact on the results.32:178–82. The effect of electroacupuncture on tendon repair in a rat Achilles tendon patients should be monitored for signs of adverse rupture model. externally activity. use for this purpose requires further evaluation. J Man Manip Ther 2006. which is generally followed by Tendons J 2014. a statistically significant increase in SD2 was Competing interests None declared. Needling therapy for the PPAS.23:1046–52.Published by group. Estudio de coste-efectividad de la electrólisis percutánea 4 de la Cruz Torres B. collagen fibrils during rat tendon healing. et al. Acupunct Med 2016.17:7. Muscles Ligaments puncture needling. Trigger point The analysis of HRV has been applied to several dry needling. management and statistical analysis. et al. BdlCT and PGB contributed to the execution of the study. Gelber PE. de Freitas KM. Valles SL. Oi Y. In conclusion. Medina-Mirapeix F. 4 Dommerholt J. autonomic imbalance was elicited by the needling tech- nique per se. Gröbli C. increased parasympathetic activity and decreased sym- 9 Valera-Garrido F.21 34–36 craniosacral therapy. Gelber PE. ultrasound-guided intratissue percutaneous electrolysis (EPI) jects (CG and EG).27 Thus it needle insertion. imbalance with a predominance in parasympathetic Provenance and peer review Not commissioned. technique in patellar tendinosis. which is much less than the threshold of 37. the HRV changes 3 Dunning J. BioMedicine 2014. et al. technique caused a measurable increase in parasympa. which were generally positive. Downloaded from http://aim. reactions such as vasovagal syncope. their potential 14 Minaya-Muñoz F. In this particular study. Consequently. Overall this suggests that the application Ethics approval University Hospital Vírgen Macarena-Virgen of the US-guided PNE technique causes an autonomic del Rocío. Rev Esp Cir Ortop Traumatol ture.18 33 In the field of physiotherapy. tendinopathy at two years follow-up. clinical practice. 2016 . BMC Sports Sci Med Rehabil logical effect of different techniques.21 34 37 Other authors have isoinertial eccentric exercise in the treatment of patellar reported increased sympathetic activity during acu. Valera-Garrido F. Valles SL. US-guided PNE technique. Molecular repair we identified papers on HRV involving therapeutic mechanisms using the intratissue percutaneous electrolysis massage.14:301. Acupunct Med 2015. application of the US-guided PNE 11 Speed C. et al. Acupuncture’s role in tendinopathy: new possibilities. Knee Surg Sports Traumatol Arthrosc 2015.02 and p=0. Guerra Fda R. vasovagal reactions when performing this technique in 13 de Almedia Mdos S. addition.33:51–7.bmj. 12 Inoue M. Effectiveness of the has been translated into techniques designed to reduce intratissue percutaneous electrolysis (EPI®) technique and physiological stress. et al. electrical current that may otherwise have had an BMC Complement Altern Med 2014.com/ on January 20. Butts R. it Acupunct Med 2014.5 myofascial pain: recommended technique with multiple rapid that is considered to indicate apprehension.bmj. Accordingly. A imbalance and this should be borne in mind during hypothesis for the anti-inflammatory and mechanotransduction clinical treatment to avoid potentially serious adverse molecular mechanisms underlying acupuncture tendon healing.1136/acupmed-2015-010993 .

Chatchawan U. Int J a pilot study. Zhao X. Vanderlei LC. Palaniswami M. Rev Iberoam HT7 on heart rate variability: an exploratory study. standards of 31 Lerma C.com/ on January 20. Heart rate variability plot analysis of heart rate variability: effect of endurance and the influence of craniosacral therapy on autonomous training. Spectral analysis of heart rate in integrated circuit design company employees.bmj. Tatsuya H. et al.33:30–5 de la Cruz Torres B. et al. et al. J Altern Complement Med Musculoskeletal Radiology. physiological interpretation.000 consultations with professional acupuncturists. Shogo M. et al. et al. heart failure. Kimura K. Perrey S. Golberg SR. 32 Grieco CR. Med 2015. Effects of massage 2008. Li Y. doi:10. et al. Barcelona: Elsevier España.42:715–20. et al. 26 Naranjo J. Huang Y. Application of the Poincaré plot of Ther 2011. et al. 33 Garrido A. Heart rate 19 De la Cruz B.177: sensation correlates with EEGs and autonomic changes in 271–4. A prospective 30 Guzik P. Férnandez-Domíguez JC. knee. et al. Folia Cardiol Acupunct Med 2001. Heart rate variability survey of adverse events and treatment reactions following by Poincaré plot and spectral analysis in young healthy 34. Bueno A. pain associated with myofascial trigger points. healthy people and cardiac patients. Sarabia E.20:642–8. et al. heart rate variability: a new measure of functional status in 36 Caufriez M. therapy intervention on autonomic nervous system promotion 20 Kitagawa Y. Acupunct Med 2014. Auton Neurosci 2007. Effect of 100 Hz the assessment of autonomic balance in elite soccer players.essr. Tonkin AM. Minaya-Muñoz F.14:53–62. López C. Downloaded from http://aim. Sports Med 2015. eds. Eur J Appl Physiol 2004. Bouhaddi M. Tsai C-N. variability and stress-related parameters in patients with back J Altern Complement Med 2014. Musculoskeletal Ultrasound acupuncture: a systematic review of the Chinese literature for Technical Guidelines. et al.0:1–5. et al.20:507–15. Medina M. et al. Poincaré plot measurement. Bianchi S. et al.18:892–901.91:79–87. Piskorski J. Umeno K. Heart rate variability: breathing exercises on heart rate variability in type 2 diabetes: a follow-up in elite soccer players throughout the season. indexes of heart rate variability capture dynamic adaptations Task Force of the European Society of Cardiology and the after haemodialysis in chronic renal failure patients. Kao M-T.23:72–80.bmj.133:158–69.12(Suppl D):64–7. Kamen P.48:1342–7. J Bodyw Mov 22 Kamen PW. human subjects. SL. Zhong Z. (accessed 1 Sep) 16 MacPherson H. J Integr Med 2014. Fisioterapia 28 Valera-Garrido F. J Altern Complement Med 2014. Clin North American Society of Pacing and Electrophysiology. Heart rate variability. Pérez-Groyas H. Int electroacupuncture on salivary immunoglobulin A and the J Sports Physiol Perform 2015. 2015.XXVIII:257–64. et al.93:1043–65. Quantitative Poincaré 37 Girsberger W.30. indexes of heart rate variability: relationships with 38 Sakai S. Iberoam Fisioter Kinesiol 2011. and clinical use.org/html/img/pool/ 2012. et al. et al. Acupunct Med 2016. 24 Mourot L.19:93–102.15:15–23.2:77–87.10:452–7. Naranjo J.5:208–15. Specific acupuncture other nonlinear variables. 2013.pdf. Auton Neurosci 2013. 2012.25:18–26. Walters S. Perinel P. Hori E. Physiologic effects immediate effects of traditional Thai massage on heart rate of rhythmical massage: a prospective exploratory cohort study. Effect of acupuncture at Psicológica Personal (EAPP) en Fisioterapia. European Society of the years 1956–2010. subjects and patients with type 1 diabetes.43:562–4 2014. De la Cruz B. Somma CT. Eungpinichpong W. Physiol Funct Imaging 2003. Fisioterapia Invasiva. IFMBE Proc variability during trigger point acupuncture. Contribución al studio de los efectos sistémicos 23 Brennan M. et al. Do existing measures of neurovegetativos del masaje terapéutico mediante el análisis Poincare plot geometry reflect nonlinear features of heart rate espectral de la variabilidad de la frecuencia cardiaca. Rev variability? IEEE Trans Biomed Eng 2001. 35 Tbuttagat V. V Knee. Sarabia E. Adverse events following 29 Beggs I. Circulation 1996. 17 [No authors listed]. autonomic nervous system.1136/acupmed-2015-010993 5 . 2005. Lingg G. Poincaré plot disconforts: a pilot study. nervous system regulation in persons with subjective 25 Hoshi RA. Analysis of heart rate variability after three badminton matches. Infante O. Acupunct Med 2015.36:881–6. Escala de Aprensión 40 Huang H. et al. http://www. Br J Sports Med 34 Chuang C-Y. Acupunct Fisioter Kinesol 2005.12:156–61. Are there gender variability at rest and during aerobic exercise: a study in differences? Arch Med Deporte 2011. Krüerke D. Acute effect of 18 Naranjo J. et al. 2016 . The 21 Wälchli C. De la Cruz B. Yoshida S. Saltzwedel G.com Original paper intratisular (EPI®) en las epicondilalgias. Bänziger U. Bychowiec B.32:273–8. 15 He W. Pastre CM. García R. De la Cruz B.33:451–6 27 Albornoz M. Thomas K.Published by group. Two new indexes for 39 Hideaki W. Aust N Z J Med 1995. Rebollo J.

11 of which you can access for free at: http://aim.bmj.com/content/early/2016/01/20/acupmed-2015-010993 These include: References This article cites 38 articles.Published by group.bmj.com Autonomic responses to ultrasound-guided percutaneous needle electrolysis of the patellar tendon in healthy male footballers Blanca de la Cruz Torres. Manuel Albornoz Cabello. Downloaded from http://aim.bmj.bmj.bmj. 2016 Updated information and services can be found at: http://aim.bmj. Sign up in the service box at the top right corner of the online article. Paula García Bermejo and José Naranjo Orellana Acupunct Med published online January 20. Notes To request permissions go to: http://group. 2016 .com/ on January 20.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.com/subscribe/ .com/content/early/2016/01/20/acupmed-2015-010993 #BIBL Email alerting Receive free email alerts when new articles cite this article.