Dry Needling Treatment – How it Works

Dry Needling Treatment – How it Works

Dry Needling Treatment Explained
by Logan Swisher SPT

How is Dry Needling treatment applied?

Dry needling treatment has become an increasingly popular treatment technique performed by certified health care providers. It refers to the insertion of a very thin needle into muscles, ligaments, tendons, subcutaneous fascia, and/or scar tissue for the management of numerous musculoskeletal pain syndromes.

Trigger points

There are several advantages to the technique documented in the literature which include an immediate reduction in local and /or widespread pain, restoration of range of motion and normalization of chemical imbalances with active myofascial trigger points. A trigger point is a hyperirritable spot often referred to “a knot” in the muscle or fascia which can cause pinpoint pain in the or refer to another area in the body. Trigger points can further be divided into active and latent trigger points. Active trigger points commonly have spontaneous local and referred pain while latent trigger points do not cause spontaneous pain unless they are stimulated by pressure.

How are trigger points formed?

The exact mechanism of trigger point formation is not well understood but it is thought that it starts as the development of tight muscle fibers or taut bands which may or may not be painful. This is possibly due to chemical reaction dysfunction at the cellular level of muscle fibers. Trigger points are thought to develop following low-load repetitive tasks, sustained postures or rapid loading and unloading of muscles. Initially taut band formation is a normal physiologic, protective and stabilizing mechanism associated with damage or potential muscle damage. Active trigger points produce constant pain signals to the brain which can alter movement patterns and lead to disuse. Trigger points have also been seen to cause decreased blood flow and oxygen to the affect muscle which further decreases the muscles ability to function properly.

Differences between dry needling treatment and manual trigger point release

The main difference between dry needling and manual trigger point release is the specificity dry needling provides. Dry needling latent trigger points can lead to their inactivation and prevent the formation of active trigger points as well as reduce the pain signals they produce. It is rarely a stand-alone treatment and is generally considered another instrument assisted manual therapy technique. Dry needling can be very useful in facilitating a rapid reduction of pain and return to function.

How it is applied at Physical Therapy First

Here at PTFirst we will perform a comprehensive exam and work with you to decide if dry needling is a good option for you. We pride ourselves on taking a multimodal approach to reducing pain and improving function so you can return to the activities that are important to you.

Can Physical Therapy help my Headache?

By Maureen Ambrose PT, DPT, OCS


Headaches are a common complaint for many people, and most assume that it is just normal part of life. Some may experience headaches multiple times per week or even daily. Patients often report that headache medication may help reduce the severity of the symptoms, but does not eliminate them entirely or stop them from coming back.  If this is true for you, it may be a sign that your headaches are related to dysfunction in your neck. Both tension headache and the various forms of migraine headaches will likely have a musculoskeletal component.


The term “cervicogenic headache” indicates that although pain is felt in the head, the root cause of the symptoms related to the neck (cervical spine). Common root causes of head and facial pain include:

– Altered cervical spine alignment

– Forward head posture

– Muscle tightness or trigger points in the following muscles (see figure above)

– Upper Trapezius

– Suboccipitals

– Sternocleidomastoid

– Splenius capitus and Splenius cervicis

– Shallow breathing pattern using the neck muscles

– Jaw clenching or grinding


 Now, what about those who just attribute their headaches to work-life stress? While it may be true that the headache feels worse during times of stress, it could be related to some of the root causes listed above. During a stressful meeting, do you resort to a shallow breathing pattern and overwork the neck muscles? Or, while concentrating on work, are you holding tension in your jaw or facial muscles and clenching? Each of these, over time and with repetition, has the potential to create trigger points in the neck muscles that can lead to referred pain in the head and face.

Physical Therapy for headaches begins with an exam of your neck alignment, posture, muscle strength, and breathing pattern. Treatment involves postural correction and neck strengthening, releasing trigger points, correcting breathing patterns, and improving postural and muscle awareness. If you feel that these factors could be a cause of your headaches, Physical Therapy First can help identify and treat these issues.


There are times when the headache is more than “cervicogenic,” and the following red flags from The Amercian Migraine Foundation indicate the need for medical attention:

  1. Thunderclap Headache: very severe headache that reaches its maximum severity immediately (within a couple of minutes). Thunderclap headaches require emergent medical evaluation.
  2. Positional Headache: headache that substantially changes in intensity in association with changes in position – e.g. standing from lying or vice-versa.
  3. Headaches Initiated by Exertion: headache starting while coughing, sneezing, and/or straining.
  4. New Headaches: especially if older than 50 years of age, or if there are medical conditions that make worrisome headaches more likely (e.g. cancer, blood clotting disorder).
  5. Substantial Change in Headache Pattern
  6. Constant Headache Always in the Same Location of the Head
  7. Worrisome Neurologic Symptoms: about 1/3 of people with migraine have neurologic symptoms (“migraine aura”) that typically precede onset of a migraine headache. Commonly, aura symptoms consist of slowly spreading visual symptoms sometimes accompanied by tingling of the face and upper extremity. These symptoms resolve within 60 minutes. If these symptoms have immediate onset (as opposed to a slow progression of symptoms), last longer than 60 minutes, or do not completely resolve, medical attention is required. Medical attention is also required if other symptoms are present, such as weakness of one side of the body, change in level of consciousness, significant difficulty walking, or other symptoms that worry you.
  8. Headache that never goes away
  9. Systemic symptoms: including fever, chills, weight loss, night sweats


(1)Travell JG, Simons DG. Myofascial Pain and Dysfunction, The Trigger Point Manual, Vol. 1. Baltimore. Williams and Wilkins. 1993

(2) American Migraine Foundation

Does Dry Needling really work?

A Dry Needling Study
by Logan Swisher SPT


Myofascial pain syndrome is caused by myofascial trigger points or highly localized and irritable spots in muscle. Recently dry needling has been used as an instrument assisted technique to address myofascial trigger points. Research in the effectiveness of dry needling has been limited by the difficulty of providing a true control or sham treatment. This study took advantage of a planned total knee replacement to allow for needling vs no needling while a patient was under anesthesia to allow for a true randomized clinical trial. Trigger points are common in lower extremity muscles in patients with hip and/or knee osteoarthritis. Most patients experience the greatest amount of pain in the first month following a total knee replacement.


40 total participants

-20 participants in the true dry needling group

-20 participants in the sham dry needling group


This study was a double-blind, placebo-controlled, randomized clinical trial. Several hours prior to their total knee replacement surgery, patients were examined by experienced physical therapist for the presence of trigger points. The participants placed into the dry needling group received dry needling for 20 insertions of the intended site while under anesthesia. The participants in the sham dry needling* group did not receive any treatment for their trigger points. Patients gave a baseline and follow up measurements at 1, 3- and 6-months following surgery using the visual analog scale (VAS), need for postoperative analgesics, and the western Ontario and McMaster Universities Osteoarthritis Index Questionnaire (WOMAC).


There was a significant improvement in VAS values with the dry needling* group in the first month as compared to the sham dry needling* group. It was also found that the use of analgesic medications was significantly lower in the dry needling* group.

Dry Needling – Clinical Application:

This study demonstrated dry needling* of trigger points in the lower limbs allowed patients to reach the same degree of pain reduction in 1-month as the subjects with the placebo intervention achieved in 6-months.  The use of dry needling* also significantly reduced the need for post surgical analgesic medications which is always a postoperative goal. While this study was limited to surgical patients, ti was a well-designed study which suggests dry needling* would be beneficial for many patients with muscle pain. Here at PTFirst we can incorporate the use of dry needling, other manual techniques and modalities to reduce muscle pain associated with surgery, injury, and/or overuse.

Dry Needling Article:

Mayoral, O., Salvat, I., Martín, M. T., Martín, S., Santiago, J., Cotarelo, J., & Rodríguez, C. (2013). Efficacy of myofascial trigger point dry needling* in the prevention of pain after total knee arthroplasty: A randomized, double-blinded, placebo-controlled trial. Evidence-Based Complementary and Alternative Medicine : ECAM, 2013, 694941-8. doi:10.1155/2013/694941

A Manual Therapy and Home Stretching Program in Patients With Primary Frozen Shoulder Contracture Syndrome: A Case Series

Frozen Shoulder : A Case Series
By Brianna Hurt, SPT

Lirios Dueñas, PT, PhD, Mercè Balasch-Bernat, PT, PhD, Marta Aguilar-Rodríguez, PT, PhD, Filip Struyf, PT, PhD, Mira Meeus, PT, PhD, Enrique Lluch, PT, PhD


Frozen shoulder is a common musculoskeletal disorder that is characterized by a progressive loss of both active and passive mobility of the glenohumeral (shoulder) joint. Muscle strength deficits in external and internal rotation are also common with this condition. Typically, frozen shoulder is thought to follow 3 phases (painful, stiff, and recovery) into a full recovery without any type of treatment. However, recent systematic reviews have found that improvements in mobility and function decrease with time, with the possibility of limitations being present for multiple years.

When managing persons with frozen shoulder, it is important to consider the level of tissue irritability (high, moderate, and low) and adapt treatment strategies based on this. Manual therapy techniques can be used to help restore normal tissue extensibility of the shoulder and help improve range of motion. To restore mobility, improving shoulder rotation should be emphasized over forcing full flexion.

The purpose of this case series was to describe outcomes after the application of manual therapy and a home stretching exercise program for persons with frozen shoulder.

Frozen Shoulder Case Description

Eleven patients diagnosed with frozen shoulder were included in the study. One physical therapist performed all of the baseline measurements and follow up assessments. Measurements were taken before the intervention period, after the 3 month intervention period and at 3 and 6 months after the intervention period. A second physical therapist conducted all of the manual therapy techniques.

Baseline measurements included shoulder pain and disability, range of motion and muscular strength. For the treatment sessions, patients received a 12-session treatment program with treatments lasting 60 minutes, scheduled once a week over 12 weeks. The intervention program consisted of manual therapy techniques based on tissue irritability and shoulder mobility and home stretching exercises.


For the shoulder pain and disability outcome measures, 8 out of the 11 patients showed improvements in pain by 9 months posttreatment and all but one patient improved in their shoulder disability at posttreatment. For range of motion, there were improvements in shoulder flexion, abduction and external rotation at posttreatment in up to 9 patients. For strength measurements, 8 of 11 patients had improvements in shoulder flexion and internal rotation strength at posttreatment, however, none of the patients had improvements in external rotation strength.


When treating patients with frozen shoulder, a multimodal manual therapy approach along with a home stretching program based on tissue irritability and specific shoulder mobility impairments should be used. This approach results in reduced shoulder pain, improved range of motion and increased strength.

Physical Therapy First Approach to Frozen Shoulder Treatment

Here at Physical Therapy First, a complete evaluation is conducted and based on those findings a specific treatment plan is designed that best addresses our patient’s needs. Treatment plans typically include advanced manual therapy joint mobilization techniques, soft tissue mobilization, stretching, therapeutic exercises and providing our patients with a unique home exercise program to maximize outcomes. We offer individualized home exercise routines that can be updated and followed by patients on a user friendly app.  Patients at Physical Therapy First can also benefit from a variety of modalities as well as myofascial trigger point dry needling treatment to muscles as indicated.  Our goal is to provide quality patient care and as this study suggests, a manual therapy approach with home stretching can be used to improve pain, mobility, strength and function in those with frozen shoulder.

Original Article

Dueñas L, Balasch-Bernat M, Aguilar-Rodríguez M, Struyf F, Meeus M, Lluch E. A Manual Therapy and Home Stretching Program in Patients With Primary Frozen Shoulder Contracture Syndrome: A Case Series. Journal of Orthopaedic & Sports Physical Therapy. 2019;49(3):192-201. doi:10.2519/jospt.2019.8194


by Maureen Ambrose PT, DPT, OCS


Cold Laser Therapy, Low power laser therapy, Soft Laser, Photobiomodulation


Low-Level Laser Therapy (LLLT) uses low powered light energy from a laser to stimulate changes in injured tissue.  LLLT penetrates through the skin and can be used treat many musculoskeletal conditions. It is often called “cold-laser” because the wavelength used does not create heat or increase cell temperature.

Instead, it works by stimulating a photochemical reaction in the target cells. A small laser emits non-thermal photons of light into the skin. Cells in the target tissue absorb the light, and use the light as energy to increase cellular activity. This activity can increase local blood flow, decrease inflammation, and desensitize pain receptors. All of these effects can result in an accelerated healing process.


The depth of penetration into the target tissue can be up to a few centimeters depending on the wavelength and power of the laser.

  • Sprains and Strains
  • Osteoarthritis
  • Rheumatoid Arthritis
  • Tendonitis
  • Tendinosis
  • Myofascial pain
  • Chronic pain
  • Trigger points.

Specific Conditions:

  • Temporomandibular Dysfunction (TMD/TMJ)
  • Carpal Tunnel Syndrome
  • Adhesive Capsulitis
  • Achilles Tendonitis
  • Lateral Epicondylitis (Tennis Elbow)
  • Acute neck pain
  • Headaches


Treatment involves a small handheld device being placed over the skin of the injured area for 30 seconds -2 minutes. The therapist and patient wear protective eyewear while the laser is in use. Multiple sites may be treated in the same region or around the body in one session. Typically, results can be achieved in a series of short treatments.

Advantages over other treatments include:

  • Painless
  • Non- invasive
  • Non-surgical
  • Requires no recovery time
  • Patients can avoid taking medication

Contraindications include:

  • Pregnancy
  • Epilepsy
  • Performing over cancerous lesions, the thyroid, and over the eyes.

While research continues to be ongoing to determine the exact mechanism of LLLT, many patients benefit from reduced pain, healing effects, and shorter recovery times.


Hashmi, Javad T. et al. “Role of Low-Level Laser Therapy in Neurorehabilitation.” PM & R : the journal of injury, function, and rehabilitation 2.12 Suppl 2 (2010): S292–S305. PMC. Web. 1 Mar. 2018

Marovino T. Cold Lasers in Pain Management. Practical Pain Management. Sep/Oct 2004. 4(6):37-42.



The Application of Blood Flow Restriction: Lessons From the Laboratory

By Brianna Hurt, SPT


Blood flow restriction (BFR) is the use of a pneumatic cuff that is placed and inflated at the most proximal portion of the upper and/or lower limb, which causes arterial blood inflow to be reduced and largely occludes venous return. BFR in combination with low load resistance training has been demonstrated to increase muscle size and strength similar to that observed in traditional high load resistance training.

BFR training is effective across a variety of populations with the most common protocol of repetitions being one set of 30 reps followed by three sets of 15 reps, reaching a total of 75 repetitions. While there are some concerns related to BFR training including, increased risk of blood clots, muscle damage, and negative effects on the cardiovascular system, these concerns have been unsupported in research studies. When applying BFR safe practice should be used in order to minimize risks of these concerns by individualizing factors such as cuff width, cuff type and the pressure that is being applied.

Applications in Clinical Medicine

BFR can be used for several clinical conditions, including but not limited to postoperative care, joint replacements, patellofemoral pain, and muscle injuries. For postoperative patients, BFR in combination with neuromuscular electrostimulation or with low load resistance exercise, is shown to improve muscle atrophy and strength loss. Patellofemoral pain is a common condition among active individuals. The use of BFR training with this condition allows for low loading of the quadriceps in order to strengthen without aggravating symptoms.


BFR training is an effective alternative to traditional high load resistance training and can be beneficial during rehabilitation. When using BFR, safety is important so the appropriate width, material and pressure should be used based on the individual. The same absolute pressure should not be used for each individual in the clinic setting.

Kevin T. Mattocks; Matthew B. Jessee; J. Grant Mouser; Scott J. Dankel; Samuel L. Buckner; Zachary W. Bell; Johnny G. Owens; Takashi Abe; and Jeremy P. Loenneke, Phd

The effects of taping and foot exercises on patients with hallux valgus

by Logan Swisher, SPT


Hallux valgus, also known as a bunion or hammer toe, is a foot deformity that causes a bony sometimes painful bump at the base of the big toe. Per year this affects over 3 million people in the US. The cause of bunions is not well understood but factors such as gender, footwear and heredity are known to play a role in the development of hallux valgus. Conservative treatment which can include physical therapy is usually the first step in addressing this diagnosis.


20 total female participants

-10 in the study group (exercises and taping)

-10 in the control group (exercises only)


Subjects were split into a study group which involved both daily exercises and taping or the control group which only involved daily exercises for 8 weeks. At the start of the study each participant had the angle of their hallux valgus measured, their intensity of foot pain measured by the visual analog scale (VAS) and their ability to walk determined by the walking ability scale (WAS). Subjects in the control group were asked to perform the exercises 2 times a day and the subjects in the study group were asked to perform the 2 times a day and wear tape for 10 hours a day. All subjects were re-evaluated at the end of the 8 week period.


At the end of 8 weeks, both groups showed improvement in: resting pain, walking pain and their ability to walk. However, the study group (which received taping) demonstrated a greater improvement in all three areas than the exercise only group.

Clinical Application:

The results of this study indicate that the combined approach of exercises and taping is more effective in reducing pain and improving walking ability as compared to exercise alone. Here at PTFirst, we will provide an in-depth evaluation which will address multiple factors contributing to your hallux valgus. This could include strength, range of motion, gait and shoe wear. Our therapists will then design an individualized program to conservatively manage and treat your hallux valgus with the goal of keeping you as active as possible without being limited by pain.

Article: Bayar, Banu & Erel, Suat & Simşek, Ibrahim & Sumer, Erkan & Bayar, Kilichan. (2011). The effects of taping and foot exercises on patients with hallux valgus: A preliminary study. Turkish Journal of Medical Sciences. 41. 403-409. 10.3906/sag-0912-499.

Plantar Fasciitis a Clinical Study

by Logan Swisher, SPT


Plantar fasciitis is the inflammation of the plantar fascia and a very common cause of heel pain. The plantar fascia is a thick band of tissue that runs from the heel bone to the toes and supports the arch of the foot. The pain is usually most noticeable when first standing up and walking or after walking, running, or standing for long periods; and may decrease after light activity. Plantar fasciitis can be a very frustrating diagnosis due to the fact that most people have to be on their feet at sometime during the day which further exacerbates their symptoms.


66 total participants

-32 in dry needling group

-34 in the steroid injection group


This study was a single-blind, randomized clinical trial. The participants placed into the dry needling group received dry needling for 30 seconds of the intended site. The participants in the steroid injection group received an injection at the intended site and the needle was immediately withdrawn. Patients gave a baseline measurement using the visual analog scale (VAS) and were followed up with at 3 weeks, 6 weeks, 3 months, 6 months and 1 year.


Baseline visual analog scale (VAS) scores to rate pain were taken in both groups before treatment. When scores were retested at 3 weeks, the dry needling and the steroid group both improved, although the steroid group demonstrated greater pain relief. This trend continued until the 3 month follow-up where the steroid began to demonstrate a gradual increase in pain. The dry needling group continued to demonstrate a gradual decrease in the VAS score at every follow-up. In conclusion, the steroid group got more effective short term relief while the dry needling group more significantly lowered their VAS score overall and were able to maintain their decrease over a 1 year follow up.

Clinical Application – Plantar Fasciitis:

This study demonstrated that steroid injections can make a rapid improvement in plantar fasciitis pain peaking at 3 weeks while dry needling showed a gradual decrease in pain that lasted up to the 1 year follow up. Here at PTFirst, we will work with you and your doctor to find the optimal treatment combination to reduce your pain. If dry needling does not interest you as viable treatment option we have many other treatments which include manual therapy, stretching, exercise, ultrasound and taping among others.

Article treatment of plantar fasciitis:

Rastegar, S., Baradaran Mahdavi, S., Hoseinzadeh, B., & Badiei, S. (2018). Comparison of dry needling and steroid injection in the treatment of plantar fasciitis: A single-blind randomized clinical trial. International Orthopaedics, 42(1), 109.

The optimal desk ergonomics setup for your computer

by Logan Swisher, SPT

Finding the optimal desk setup

Many of us spend hours of our workday in front of a desk/computer. While some people have no difficulty with this, others find that their desk set up contributes to their pain. Proper desk ergonomics can help you stay comfortable at work and reduce the risk of pain from static postures.


  1. Start with feet flat on the ground. A footrest may be used if you cannot reach the ground.
  2.  Maintain a 90°-120° angle at the knees and hips. There should be a small distance (two fingers width) between the back of the knees and the front of the chair.
  3. You should be seated all the way back in the chair with lumbar support from either the chair or towel roll.
  4. Shoulders should be relaxed and elbows bent between 90°-120°.
  5. Wrist position should be in neutral and forearms should be supported by the arms of the chair or desk.
  6. Screen should be at eye level or slightly lower with a 10°-20° screen tilt backward.
  7. Screen distance is recommended to be an arm length (20’’-30’’) or a distance where you can comfortably see the screen without changing your posture.
  8. Remember to take frequent breaks when working in a position for an extended time. If possible, try to alternate between a seated and standing desk.


Before making any permanent changes, try household items like towels, pillows and boxes to find the best setup. Here at PTF we will work with you to optimize your desk setup so you can reduce your pain and maximize your efficiency.

Effect of Laser Therapy on Chronic Osteoarthritis of the Knee in Older Subjects

By Sidney Jones, SPT


Osteoarthritis (OA) is a common degenerative joint disease that is usually associated with pain, limited range of motion, muscle weakness, difficulty with activities of daily living and impaired quality of life. The knee is the most common joint in the body affected by osteoarthritis. Low-level laser therapy has been studied and used for pain control, anti-inflammatory effects and its healing efficacy. The purpose of this study was to determine the effects of adding low-level laser therapy (LLLT) to an exercise training program on pain severity, joint stiffness, physical function, isometric muscle strength, knee range of motion, and quality of life in older subjects with knee OA.


Men and women between 60-72 years old with chronic osteoarthritis according to the American College of Rheumatology (ACR) criteria grades II & III and knee OA according to the Kellgren-Lawrence grade. Participants also had to have the ability to stand independently and willingness to participate in the study.

Methods – laser therapy treatment

Group1: 18 subjects 7 males & 11 females were treated with a laser dose of 6 J/cm² over 8 points around the knee. Each point received energy of 6 J/point for 60 seconds.

Group 2: 18 subjects 6 males & 12 females were treated with a laser dose of 3 J/cm² on 9 points around the knee. Each point received energy of 3 J/point for 50 seconds.

Group 3: 15 subjects 5 males & 10 females participated as the control group. Procedure was identical but without emission of energy.

Exercise Training Program

All participants in each group participated in the same exercise training program for 30 to 45-minute sessions 2 times a week for 8 weeks. The program included stretching the quadriceps, hamstrings, adductors, and calf muscles. Strengthening exercises included knee extension, straight leg raises and quadriceps setting. All participants were instructed to practice these exercises as a home program.

Each participant was evaluated pre and post 8 weeks of physical therapy interventions on:

  • Pain intensity with Visual Analogue Scale (VAS)
  • Physical function with Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC).
  • Knee range of motion, active knee flexion range of motion was measured with long arm universal goniometer.
  • Isometric strength of knee flexor and extensor muscles was measured using Handheld Dynamometer


The best improvements in VAS, WOMAC pain, knee range of motion and physical function were seen in patients who were treated with 6 J/cm² then 3 J/cm² and then placebo group. Mean values for WOMAC significantly reduced, which means improved physical function. Isometric strength of the quadriceps and hamstring muscles increased significantly in each group after interventions. The largest increase in isometric strength of the quadriceps and hamstring muscles and knee flexion range of motion was seen in patients who received 6 J/cm² followed by 3 J/cm² and then the placebo group. Mean values of knee flexion range of motion increased significantly after physical therapy interventions in each group with significant differences among the 3 groups.

Discussion about adding laser therapy

The current study suggests that adding LLLT to exercise training program could be an important modality for treating older adults with OA than exercise training alone. The active laser groups either 6 J/cm² or 3 J/cm² had a significant reduction of pain intensity in VAS and WOMAC, increase in physical function, increase in isometric quadriceps and hamstring muscle strength, and increase in range of motion after treatment of knee OA.


Adding LLLT to an exercise training program is more effective than exercise training alone in treatment of patients with chronic knee OA and the rate of improvement may be dose dependent, as with 6 J/cm² or 3 J/cm².

PTF Approach to adding laser therapy 

Here at Physical Therapy First, we perform a complete evaluation and based on those findings we design a treatment plan that best addresses our patient’s needs. Our goal is to provide quality patient care and as this study suggests, multiple interventions can and should be used to treat knee osteoarthritis simultaneously. At Physical Therapy First, laser therapy and strengthening are options along with several other interventions such as soft tissue mobilization, stretching and providing our patients with a home exercise program to maximize outcomes.

Original Article about Laser Therapy

Youssef, E. F., Muaidi, Q. I., & Shanb, A. A. (2016). Effect of Laser Therapy on Chronic Osteoarthritis of the Knee in Older Subjects. Journal of Lasers in Medical Sciences,7(2), 112-119. doi:10.15171/jlms.2016.19