In e na ional Jou nal o
En i onmen al Resea ch
and Public Heal h
A icle
Cos -E ec i eness o Two D y Needling In e en ions o
Plan a Heel Pain: A Seconda y Analysis o an RCT
Daniel Fe nández 1, Zaid Al-Boloushi 2,3, Pablo Bellos a-López 1, Pablo He e o 3,* , Manuel Gómez 1
and Sand a Cal o 1


Ci a ion: Fe nández, D.; Al-Boloushi,
Z.; Bellos a-López, P.; He e o, P.;
Gómez, M.; Cal o, S.
Cos -E ec i eness o Two D y
Needling In e en ions o Plan a
Heel Pain: A Seconda y Analysis o
an RCT. In . J. En i on. Res. Public
Heal h 2021,18, 1777. h ps://
doi.o g/10.3390/ije ph18041777
Academic Edi o : Son Nghiem
Recei ed: 25 Decembe 2020
Accep ed: 8 Feb ua y 2021
Published: 12 Feb ua y 2021
Publishe ’s No e: MDPI s ays neu al
wi h ega d o ju isdic ional claims in
published maps and ins i u ional a il-
ia ions.
Copy igh : © 2021 by he au ho s.
Licensee MDPI, Basel, Swi ze land.
This a icle is an open access a icle
dis ibu ed unde he e ms and
condi ions o he C ea i e Commons
A ibu ion (CC BY) license (h ps://
c ea i ecommons.o g/licenses/by/
4.0/).
1Facul y o Heal h Sciences, Uni e sidad San Jo ge, Campus Uni e si a io, Au o . A23 km 299,
Villanue a de Gállego, 50830 Za agoza, Spain; [email p o ec ed] (D.F.); [email p o ec ed] (P.B.-L.);
[email p o ec ed] (M.G.); [email p o ec ed] (S.C.)
2Minis y o Heal h, S a e o Kuwai , Jamal Abdulnasse S ee , Al Solaibeykha A ea 5, Sa a ,
Kuwai Ci y 13001, Kuwai ; [email p o ec ed]
3
Physia y and Nu sing Depa men , Facul y o Heal h Sciences, Za agoza Uni e si y, C/Domingo Mi al s/n,
CP 50009 Za agoza, Spain
*Co espondence: phe e o@uniza .es
Abs ac :
Plan a heel pain is a common cause o oo pain ha a ec s pa ien s’ quali y o li e
and ep esen s a signi ican cos o he heal hca e sys em. D y needling and pe cu aneous needle
elec olysis a e wo minimally in asi e ea men s ha we e shown o be e ec i e o he managemen
o plan a heel pain. The aim o ou s udy was o compa e hese wo ea men s in e ms o heal h
and economic consequences based on he esul s o a published andomized con olled ial. Fo his,
we e alua ed he cos s om he poin o iew o he hospi al and we ca ied ou a cos -e ec i eness
s udy using quali y o li e as he main a iable acco ding o he Eq-5D-5L ques ionnai e. The cos
o he comple e ea men wi h d y needling (DN) was
€
178.86, while he pe cu aneous needle
elec olysis (PNE) was
€
200.90. The quali y o li e o pa ien s imp o ed and was ansla ed in o
+0.615 quali y-adjus ed li e yea s (QALYs) o DN and +0.669 o PNE. PNE p esen ed an a e age
inc emen al cos -e ec i eness a io (ICER) o
€
411.34/QALY agains DN. These esul s indica e ha
PNE had a be e cos -e ec i eness a io o he ea men o plan a heel pain han DN.
Keywo ds:
d y needling; pe cu aneous needle elec olysis; cos -e ec i eness analysis; plan a heel
pain; quali y o li e
1. In oduc ion
Plan a heel pain (PHP) is a common cause o oo pain and discom o ha a ec s he
quali y o li e (QoL) o pa ien s. The equency and incidence o PHP is unce ain; howe e ,
i is es ima ed ha o e he cou se o a li e ime, 10% o he popula ion migh su e om
his condi ion [
1
,
2
]. PHP places a ela i ely la ge bu den on public heal h, being a ai ly
common cause o ou pa ien isi s [
3
] and medical expenses, wi h cos o PHP ea men
es ima ed o be be ween $192 and $376 million in he Uni ed S a es [4].
Clinical p ac ice guidelines ecommend he use o conse a i e ea men o PHP
managemen , such as join and so issue mobiliza ion o sel -s e ching home p o-
g ammes [
5
]. In pa icula , sel - s e ching home p og ammes we e shown o be e ec i e
o add essing PHP [
6
]. Fu he mo e, ecen andomised clinical ials (RCTs) showed
ha he e is an addi ional e ec o educ ion o pain se e i y when sel - s e ching home
p og ammes a e combined wi h manual he apy [
7
]. I was also shown ha d y needling
(DN) is e ec i e o managing PHP, al hough he magni ude o he ea men e ec should
be conside ed agains he equency o mino ansi o y ad e se e en s [8].
DN and pe cu aneous needle elec olysis (PNE) a e wo minimally in asi e ea men
modali ies ha we e shown o be e ec i e o PHP managemen , educing he mean and
maximum pain since he i s ea men session, wi h long las ing e ec s [
9
]. Despi e he
In . J. En i on. Res. Public Heal h 2021,18, 1777. h ps://doi.o g/10.3390/ije ph18041777 h ps://www.mdpi.com/jou nal/ije ph
In . J. En i on. Res. Public Heal h 2021,18, 1777 2 o 9
inc eased use o hese ea men modali ies in ecen yea s in clinical p ac ice, o he bes o
ou knowledge, no p e ious s udy in es iga ed he cos -e ec i eness o PNE and DN on
PHP. Mo eo e , in he case o PHP, we only ound a s udy analysing he cos -e ec i eness
o o he in e en ions, such as he use o oo o hosis [10].
The e o e, he aim o his s udy was o compa e he cos -e ec i eness o wo al e na-
i e in e en ions, DN and PNE, in e ms o heal h and economic consequences.
2. Ma e ials and Me hods
2.1. S udy Design
The p ima y s udy was a andomised con olled ial ca ied ou du ing 2018 and
2019, o compa e he e ec i eness o wo needling in e en ions, conduc ed a he Physical
Medicine and Rehabili a ion Hospi al in Kuwai . The s udy was conduc ed in compliance
wi h he Helsinki Decla a ion o Human Righ s and e hical app o al was ob ained om
he Medical E hics Commi ee o he S a e o Kuwai Minis y o Heal h, wi h e e ence
numbe 642/2017 and egis a ion a Clinical ials.com, numbe NCT03236779, a ailable a
h ps://pubmed.ncbi.nlm.nih.go /30683124/ (accessed on 15 Decembe 2020).
This seconda y s udy used he e ec i eness da a ob ained in he RCT o pe o m a
cos -e ec i eness s udy.
2.2. Pa icipan s
Pa icipan s we e included in he andomised con olled ial i hey ul illed he ol-
lowing c i e ia. (1) Diagnosed wi h PHP in acco dance wi h he Clinical Guidelines linked
o he In e na ional Classi ica ion o Func ion, Disabili y and Heal h om he O hopaedic
Sec ion o he Ame ican Physical The apy Associa ion. (2) Aged 21 o 60 yea s a admission
o he s udy, acco ding o he Kuwai i E hical Commi ee. (3) A his o y o PHP o o e one
mon h, showing no imp o emen s wi h p e ious conse a i e ea men . (4) The abili y o
walk 50 m wi hou any suppo . (5) The p esence o myo ascial igge poin s on plan a
and cal muscles based on an ini ial physical examina ion ca ied ou by a physio he apis
wi h expe ience and aining in myo ascial igge poin s. (6) Accep ing ea men om a
male physio he apis . (7) The abili y o unde s and he s udy and gi e in o med consen ,
as well as ha ing signed he consen o m. The exclusion c i e ia we e—(1) needle phobia;
(2) needle alle gy o hype sensi i i y o me als; (3) he p esence o coagulopa hy o use o
an icoagulan s acco ding o medical c i e ia; (4) he p esence o pe iphe al a e ial ascula
disease; (5) p egnancy; (6) de ma ological disease a ec ing he d y needling a ea; (7) he
p esence o any ch onic medical condi ion ha migh p eclude pa icipa ion in he s udy,
such as malignancy, sys emic in lamma o y diso de s (e.g., heuma oid a h i is, pso ia ic
a h i is, ankylosing spondyli is, sep ic a h i is), neu ological diseases, polyneu opa hy,
mononeu opa hy, and scia ica; (8) ea men o PHP wi h needling o acupunc u e du ing
he las ou weeks; (9) his o y o injec ion he apy in he heel o e he p e ious h ee
mon hs; and (10) p e ious his o y o oo su ge y o ac u e.
2.3. In e en ion Condi ions
The in e en ion condi ions we e es ablished du ing he RCT. All pa icipan s signed
he in o med consen and we e andomised o he DN o PNE g oup in blocks o 10 pa ien s.
Alloca ion was andomly assigned using a compu e p og am (Randomize , h ps://
www. andomize .o g/ (accessed on 14 Janua y 2018)) wi h andom pa ien ile numbe
sequences gene a ed by a hi d pe son no in ol ed in he s udy. Each pa icipan ecei ed
ou indi idual physical he apy sessions consis ing o DN o PNE, once a week, using
speci ic DN needles (Agu-pun , Ba celona, Spain) [
9
]. The du a ion o each session was
app oxima ely 30 min. DN and PNE in e en ions we e pe o med exac ly in he same
way, wi h he only di e ence being ha he needle was connec ed o he PNE equipmen
du ing he PNE p ocedu e (“Physio In asi a” equipmen PRIM S.A. Mad id, Spain) o
add a gal anic cu en o he mechanical e ec o he needle. Du ing he i s session,
all pa ien s we e ins uc ed in a sel -s e ching p o ocol [
7
] ha was pe o med wice a
In . J. En i on. Res. Public Heal h 2021,18, 1777 3 o 9
day. An independen blinded assesso conduc ed all assessmen s a baseline, 4, 8, 12,
26, and 52 weeks o ollow-up. Quali y o li e (QoL) da a we e used o pe o m he
cos -e ec i eness analysis.
2.4. Cos s
The economic e alua ion was made e ospec i ely and om a hospi al pe spec i e.
F om his, di ec heal hca e cos s we e calcula ed, such as he ma e ial used o pe o m
he needling (s e ile gauze, disin ec an , needles), PNE equipmen , and he cos o he
physio he apy and physia is sessions. To assess he cos o PNE equipmen , wo scena ios
we e calcula ed. In one scena io, he o al cos o he equipmen was included in he cos
o he s udy, calcula ing he o al numbe o sessions ha we e ca ied ou in ou s udy
and he o al cos o he equipmen was di ided by he numbe o sessions. In he second
scena io, he a e age numbe o uses ha he equipmen can ha e in a s anda d clinic pe
yea and he amo iza ion o he cos o he equipmen in a sho pe iod o h ee yea s
was calcula ed.
The cos o he physia is and he physical he apy was ob ained om he bulle in
“Cos analysis and pe o mance e alua ion o go e nmen heal h se ices o he Kuwai
Minis y o Heal h” (Financial a ai s, Budge and Con ol Depa men —Cos Accoun ing
Sec ion) [
11
]. Cos s o usual ca e we e no conside ed o compa ison as he pa icipan s
selec ed we e en olled on he basis ha he s anda d ea men o PHP was no e ec i e
(see inclusion c i e ia).
2.5. Ou comes
EQ-5D-5L was comple ed a baseline, 4, 8, 12, 26, and 52 weeks o each pa ien . This
ques ionnai e included i e dimensions—mobili y, sel -ca e, usual ac i i ies, pain/discom o
and anxie y/dep ession, wi h i e le els o se e i y, which made i e en mo e obus han
p e ious e sions [
12
]. To ob ain he quali y-o -li e alue based on he EQ-5D ques ionnai e
da a, he ‘EQ-5D-5L Index Value C osswalk’ ool was used wi h English p e e ence weigh s.
Using he s udy iming, i was possible o ob ain he quali y-adjus ed li e yea s (QALYs), which
was he p e e ed measu e o heal h ou comes o use in echnology app aisals. QALYs we e
es ima ed o each subjec using a ea unde he cu e analysis.
2.6. S a is ical Analysis
The s a is ical analysis was pe o med using IBM SPSS S a is ics (V.25, IBM, Mad id,
Spain) by in en ion o ea , wi h he las obse a ion ca ied o wa d. The dis ibu ion o
he da a was e i ied by he Kolmogo o -Smi no no mali y es and a ac o ial ANOVA
(Bon e oni es ) was pe o med o e alua e he di e ences.
To analyze he unce ain y o QALY and cos s, a p obabilis ic analysis was pe o med
by a ying bo h pa ame e s acco ding o ce ain anges o hei dis ibu ion a iable—
QALY and cos pai s we e boo s apped 1000 imes o achie e 95% con idence in e als [
13
].
To summa ize, his s udy conside ed he p opo ion o boo s ap eplica ions ha ell
below and o he igh o he line o he cos -e ec i eness h eshold. Then, we ep e-
sen ed he inc emen al cos -e ec i eness a io (ICER) in ela ion o possible alues o he
cos -e ec i eness h eshold in he cos -e ec i eness accep abili y cu e (CEAC) [
14
]. To
comple e his sensi i i y analysis, a uni a ia e analysis o o e head cos s was ca ied ou
conside ing ha hey could accoun o up o 30% o he alue o di ec cos s [15].
3. Resul s
A o al o 102 pa ien s wi h an a e age age o 48 yea s we e included in he inal
economic analysis. Pa icipan s we e di ided in wo g oups, wi hou signi ican di e ences
be ween g oups a baseline (Table 1).
In . J. En i on. Res. Public Heal h 2021,18, 1777 4 o 9
Table 1. Demog aphic cha ac e is ics o pa icipan s and o he baseline cha ac e is ics.
DN G oup
N = 51
PNE G oup
N = 51
Gende (male) 15 (29.4%) 15 (29.4%)
Age (yea s) 49.5 (±8.9) 48.1 (±8.8)
Heigh , cm 160.5 (8.2) 161.2 (7.9)
Weigh , kg 87.5 (16.5) 90.8 (15.2)
Body mass index (kg/m2)33.9 (±5.5) 35.1 (±6.4)
Du a ion o symp oms, mon hs 6.0 (6.0) 9.9 (11.5)
Medica ions, n yes (%)
- Neu omodula o s/an iepilep ic 18 (35.3) 22 (43.1)
- Painkille s 16 (31.4) 16 (31.4)
- An i-in lamma o y medica ion 16 (31.4) 17 (33.3)
- Myo elaxan medica ion 9 (17.6) 8 (15.7)
All alues a e means (±s anda d de ia ion) o numbe o pa ien s (%).
All esul s om he o iginal s udy i led “Compa ing wo d y needling in e en ions
o plan a heel pain: a andomised con olled ial” can be ound a h ps://bmjopen.bmj.
com/con en /bmjopen/10/8/e038033. ull.pd .
3.1. Cos s
The DN and PNE ea men cos s e alua ed a e displayed in Table 2. Cos s we e no
compa ed wi h he usual s anda d o ca e cos s as one o he inclusion c i e ia o be en olled
in he s udy was “a his o y o PHP o o e one mon h, showing no imp o emen s wi h
p e ious conse a i e ea men ”.
Table 2. Cos s.
DN G oup Bo h PNE G oup
Sani a y consumables (session) €1.06
PNE equipmen - €2300
Cos o PNE pe session (204 sessions) €12.21
Cos o PNE pe session acco ding o clinic €0.94
Physia is (session) €96.03
Physical he apy (session) €43.65
Cos i s week o ea men €140.74 €146.26 ±€5.64 *
To al ( ou sessions) €178.86 €200.90 ±€22.55
* The a ia ions in he cos o he PNE g oup a e due o he calcula ion wi h o wi hou amo iza ion o he PNE
equipmen .
The cos o sani a y consumables co esponded o he use o glo es, needles, disin-
ec an , and any o he ma e ial associa ed wi h he needling in e en ions. The cos o he
PNE equipmen co esponded o he p ice o he “Physio In asi a” equipmen (PRIM S.A.
Mad id, Spain), wi hou axes. Wi h hese da a, we calcula ed he cos pe session and
asked o eedback om a g oup o expe physical he apis s o closely esemble he eal
alue o he cos o a session wi h PNE in he usual clinical scena io.
To comple e he cos s, i was necessa y o add he cos o he pe sonnel who ca ied
ou he ea men s and hei supe ision. These cos s a e a ailable in he documen “Cos
analysis and pe o mance e alua ion o go e nmen heal h se ices 2013–2014” om he
Kuwai Minis y o Heal h [
11
]. The cos o he physia is and he physical he apy was
In . J. En i on. Res. Public Heal h 2021,18, 1777 5 o 9
conside ed o be he same in bo h g oups. To al di ec cos s o ea men we e
€
22.04 mo e
expensi e in he PNE han in he DN g oup, because o he use o he speci ic equipmen
o p o iding he PNE ea men .
3.2. Quali y o Li e
An imp o emen in QoL was obse ed a weeks 4 and 8 in bo h ea men g oups.
Howe e , he PNE g oup also showed imp o emen s a 52 weeks (Table 3),wi h signi ican
di e ences be ween g oups a 52 weeks (Figu e 1).
Table 3. Mean quali y o li e (QoL) om EQ-5d.
Va iable DN Mean (SD)
DN Mean
Di e ence om
Baseline
PNE Mean (SD)
PNE Mean
Di e ence om
Baseline
Mean Qol
Di e ence
PNE–DN (SD)
QoL (1-0)
Baseline 0.630 (0.230) - 0.669 (0.215) - 0.039 (0.323)
4 h week 0.777 * (0.224) 0.147 0.757 * (0.237) 0.087 −0.020 (0.341)
8 h week 0.721 * (0.232) 0.091 0.737 * (0.230) 0.067 0.015 (0.349)
12 h week 0.641 (0.298) 0.011 0.694 (0.272) 0.025 0.053 (0.370)
26 h week 0.644 (0.287) 0.014 0.722 (0.278) 0.053 0.078 (0.365)
52nd week 0.660 (0.270) 0.034 0.764 * (0.099) 0.099 0.103 ** (0.323)
(±s anda d de ia ion); * di e ence om baseline in means is signi ican p- alue < 0.05; ** di e ence be ween g oups is signi ican .
In . J. En i on. Res. Public Heal h 2021, 18, x FOR PEER REVIEW 5 o 9
To comple e he cos s, i was necessa y o add he cos o he pe sonnel who ca ied
ou he ea men s and hei supe ision. These cos s a e a ailable in he documen “Cos
analysis and pe o mance e alua ion o go e nmen heal h se ices 2013–2014” om he
Kuwai Minis y o Heal h [11]. The cos o he physia is and he physical he apy was
conside ed o be he same in bo h g oups. To al di ec cos s o ea men we e €22.04 mo e
expensi e in he PNE han in he DN g oup, because o he use o he speci ic equipmen
o p o iding he PNE ea men .
3.2. Quali y o Li e
An imp o emen in QoL was obse ed a weeks 4 and 8 in bo h ea men g oups.
Howe e , he PNE g oup also showed imp o emen s a 52 weeks (Table 3), wi h
signi ican di e ences be ween g oups a 52 weeks (Figu e 1).
Table 3. Mean quali y o li e (QoL) om EQ-5d.
Va iable DN
Mean (SD)
DN Mean
Di e ence
om Baseline
PNE
Mean (SD)
PNE Mean
Di e ence
om Baseline
Mean Qol
Di e ence PNE–DN
(SD)
QoL (1-0)
Baseline 0.630 (0.230) - 0.669 (0.215) - 0.039 (0.323)
4 h week 0.777 * (0.224) 0.147 0.757 * (0.237) 0.087 −0.020 (0.341)
8 h week 0.721 * (0.232) 0.091 0.737 * (0.230) 0.067 0.015 (0.349)
12 h week 0.641 (0.298) 0.011 0.694 (0.272) 0.025 0.053 (0.370)
26 h week 0.644 (0.287) 0.014 0.722 (0.278) 0.053 0.078 (0.365)
52nd week 0.660 (0.270) 0.034 0.764 * (0.099) 0.099 0.103 ** (0.323)
(± s anda d de ia ion); *di e ence om baseline in means is signi ican p- alue < 0.05; **di e ence
be ween g oups is signi ican .
Figu e 1. Va ia ion in quali y o li e h oughou he s udy.
Based on he ob ained QoL esul s, ea men wi h DN p esen ed an imp o emen o
+0.615 QALYs while PNE had an imp o emen o +0.669 (di e ence o 0.054) QALYs. The
p obabili y o each al e na i e being cos e ec i e was e iewed using he boo s ap
echnique as a p obabili y sensi i i y analysis.
The cos -e ec i eness a ios o PNE ea men e sus DN inc eased du ing he s udy
pe iod (Table 4).
Figu e 1. Va ia ion in quali y o li e h oughou he s udy.
Based on he ob ained QoL esul s, ea men wi h DN p esen ed an imp o emen
o +0.615 QALYs while PNE had an imp o emen o +0.669 (di e ence o 0.054) QALYs.
The p obabili y o each al e na i e being cos e ec i e was e iewed using he boo s ap
echnique as a p obabili y sensi i i y analysis.
The cos -e ec i eness a ios o PNE ea men e sus DN inc eased du ing he s udy
pe iod (Table 4).

In . J. En i on. Res. Public Heal h 2021,18, 1777 6 o 9
Table 4. Va ia ion o cos -e ec i e a io du ing he s udy.
PNE
Weeks 4 8 12 26 52
% Cos -e ec i e 50% 46% 63% 79% 86%
PNE showed a clea dominance agains DN a 52 weeks, p esen ing e en highe cos s
o he equipmen used (Figu e 2)
In . J. En i on. Res. Public Heal h 2021, 18, x FOR PEER REVIEW 6 o 9
Table 4. Va ia ion o cos -e ec i e a io du ing he s udy.
PNE
Weeks 4 8 12 26 52
% Cos -e ec i e 50% 46% 63% 79% 86%
PNE showed a clea dominance agains DN a 52 weeks, p esen ing e en highe cos s
o he equipmen used (Figu e 2)
Figu e 2. Boo s apped cos -u ili y pai s d y needling (DN) s. pe cu aneous needle elec olysis
(PNE).
The p obabili y ha he PNE ea men a 52 weeks would ha e a be e cos -
e ec i eness a io compa ed o DN was 86%.
The h eshold ha was used o e alua e he implemen a ion o a he apeu ic
al e na i e is usually €25,000. Howe e , in ou s udy, PNE p esen ed an 86% p obabili y
o being mo e cos -e ec i e agains DN a alues much lowe han his h eshold (Figu e
3). Mo eo e , PNE p esen ed an a e age ICER o €411.34/QALY agains DN.
Figu e 3. Cos -e ec i eness accep abili y cu e (CEAC).
The uni a ia e analysis o es ima ed o e head cos s implied an inc eased cos o
€60.27 o he PNE g oup ( o al €261.17) and €53.66 o he DN g oup ( o al €232.52). The
Figu e 2. Boo s apped cos -u ili y pai s d y needling (DN) s. pe cu aneous needle elec olysis (PNE).
The p obabili y ha he PNE ea men a 52 weeks would ha e a be e cos -e ec i eness
a io compa ed o DN was 86%.
The h eshold ha was used o e alua e he implemen a ion o a he apeu ic al e -
na i e is usually
€
25,000. Howe e , in ou s udy, PNE p esen ed an 86% p obabili y o
being mo e cos -e ec i e agains DN a alues much lowe han his h eshold (Figu e 3).
Mo eo e , PNE p esen ed an a e age ICER o €411.34/QALY agains DN.
Figu e 3. Cos -e ec i eness accep abili y cu e (CEAC).
The uni a ia e analysis o es ima ed o e head cos s implied an inc eased cos o
€
60.27 o he PNE g oup ( o al
€
261.17) and
€
53.66 o he DN g oup ( o al
€
232.52). The
In . J. En i on. Res. Public Heal h 2021,18, 1777 7 o 9
esul ing ICER was
€
530.55/QALY, 119.25
€
/QALY mo e han when o e head cos s we e
no conside ed.
4. Discussion
The objec i e o his s udy was o analyze which ea men op ion was mo e cos -
e ec i e o PHP ea men , on he basis ha bo h DN and PNE we e demons a ed o be
e ec i e. Fo his, we conside ed ha a cos -e ec i eness s udy was he bes ool, using
a good e icacy ma ke such as he pa ien QoL and e alua ing all cos s in ol ed a he
heal h cen e. The baseline cha ac e is ics o ou pa ien sample we e homogeneous, and i
was a good s a ing poin o exclusi ely assess he a ia ion due o ea men .
We chose he EQ-5D-5l scale mainly because i was one o he mos used scales, bu
also because i allowed us o make a mo e global assessmen o pa ien heal h s a us.
Compa isons o EQ-5D-5l wi h o he mo e speci ic scales such as he Manches e Ox o d
Foo Ques ionnai e (MOXFQ) concluded ha bo h we e pa icula ly esponsi e o changes
in pain, mobili y and ac i i y, o social in e ac ion ollowing ea men ; bu ‘ he gene ic
EQ-5D may allow compa ison o gene al heal h s a es in he wide heal h communi y’ [
16
].
Howe e , i has a d awback when i comes o ans e ing he da a om he ques ionnai e
o QoL, as cu en ly, he e is no p ede ined c osswalk index o Kuwai i pa ien s. In
communica ion wi h Eu oQol g oup expe s, i was conside ed ha he mos alid op ion
could be o use he B i ish alues.
Ou analysis showed an imp o emen o he QoL in bo h g oups o almos 0.1 poin
on he EQ-5D-5l scale. The esul s ob ained by Rome e al. [
10
] wi h he use o an ac-
commoda i e oo o hosis o unc ional oo o hosis we e 0.07 and 0.09 QALY/yea ,
espec i ely. I we compa e he QALY alues gained wi h DN ea men (0.615) and PNE
(0.669) agains hese esul s, we see ha he e was a conside able imp o emen wi h hese
needling ea men s.
Rega ding cos s, only hose ha mos in luence a clinic, hospi al, o a heal h cen e
we e conside ed in e ms o equipmen and s a . In bo h cases, he cos o he equipmen
was assessed as he consumable ma e ial ha was used and enewed o each pa ien and
session. The p ice o he PNE equipmen migh ha e di e ences depending on he b and
o he coun y whe e i was pu chased. In his case, we only alued he de ice used in his
s udy. To assess he cos o his equipmen o each session as accu a ely as possible, an
a e age o uses pe yea and yea s o amo iza ion was de e mined. On he o he hand, we
also calcula ed he cos in ol ed o each session in case he equipmen was used only o
his s udy (51 pa ien s, 4 sessions o each one; 204 sessions). The cos wi h he a e age o
annual uses and amo iza ion seemed o be he mos ealis ic since his equipmen could
be used in many o he pa hologies.
On he con a y, being among he i s o pe o m cos analyses o his ype o ech-
niques migh lead o ce ain limi a ions, such as he di icul y o assessing he indi ec cos s.
In his s udy, we used as a e e ence he inclusion o indi ec cos s, ep esen ed by a la ge
weigh in he o e all e alua ion o cos s, which migh bias he esul s [
17
]. The use o
RCT da a e ospec i ely did no allow us o ob ain mo e in o ma ion o indi ec cos s and
he e o e we did no include hem o a oid he dis o ion o esul s.
The e we e imp o emen s in QoL wi h bo h ea men s, and he di e ences in cos s
be ween ea men s we e ela i ely low. The cos -e ec i eness ela ionships analyzed a e
he boo s apping indica ed ha he e was a clea ad an age o PNE o e DN a 52 weeks.
These esul s mus be in e p e ed wi h cau ion, aking in o accoun he me hodological
limi a ions o ou s udy, mainly ela ed o he sample size, he lack o s udies ha se ed
as a compa ison and he high a e o d op-ou s. In he la e case, and in he same way as
explained in he published s udy “ei he unde powe ing o he in en ion o ea analysis
may explain he inconsis ency o he esul s in he PNE g oup possibly leading o signi ican
esul s in weeks 12 and 26” [9], also in cos -e ec i eness a io.
In . J. En i on. Res. Public Heal h 2021,18, 1777 8 o 9
Howe e , his s udy also had some s eng hs, as i is he i s s udy o ollow a s ic
me hodology in he cos -e ec i eness analysis o wo needling in e en ions and he da a
we e ex ac ed om a andomized con olled ial compa ing hese needling in e en ions.
This was he i s ime ha a s udy compa ed he ea men cos s o DN and PNE,
which combined wi h he cos -e ec i eness analysis ca ied ou . This could be help ul o
bo h adminis a o s and clinicians o assess he inclusion o new ea men me hods in
hospi als o ehabili a ion clinics.
5. Conclusions
Al hough bo h DN and PNE we e ound o be e ec i e in imp o ing QoL o PHP
managemen , PNE ea men was mo e cos -e ec i e han DN, wi h signi ican di e ences
a 52 weeks. In he compa isons made acco ding o he cos -e ec i eness analysis, his
ansla ed in o an 86% p obabili y ha PNE was mo e cos -e ec i e compa ed o DN a
52 weeks. Conside ing he limi a ions o ou s udy based on he loss o pa ien s om he
p e ious s udy and he lack o eliable indi ec cos s, u he s udies a e needed o e i y
he di e ences in PNE and DN.
Au ho Con ibu ions:
Concep ualiza ion: D.F., Z.A.-B., M.G., and P.H.; me hodology, D.F. and M.G.;
o mal analysis, D.F., Z.A.-B., P.B.-L., S.C., P.H., and M.G.; da a cu a ion, D.F.; w i ing—o iginal
d a p epa a ion, D.F., Z.A.-B., P.B.-L., and S.C.; w i ing— e iew and edi ing, D.F., P.B.-L., P.H.,
and M.G.; supe ision, P.H. and M.G. All au ho s ha e ead and ag eed o he published e sion o
he manusc ip .
Funding: This esea ch ecei ed no ex e nal unding.
Ins i u ional Re iew Boa d S a emen :
The RCT s udy was conduc ed acco ding o he guidelines
o he Decla a ion o Helsinki, and app o ed by he Medical E hics Commi ee o he S a e o Kuwai
Minis y o Heal h, wi h e e ence numbe 642/2017 and egis e ed a Clinical ials.com, numbe
NCT03236779, a ailable a h ps://pubmed.ncbi.nlm.nih.go /30683124/.
In o med Consen S a emen :
In o med consen was ob ained om all subjec s in ol ed in he
RCT s udy.
Da a A ailabili y S a emen :
Da a will be a ailable on easonable eques by email o Daniel
Fe nández ([email p o ec ed]).
Acknowledgmen s:
We would like o acknowledge E a Ma ía Gómez-T ullén and Mohammad
A ian as hei p e ious wo k allowed us o pe o m his seconda y analysis.
Con lic s o In e es : The au ho s decla e no con lic o in e es .
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