Oldies but Goodies – The trigger point strikes … out!

Over this holiday season we are posting the most read articles from the last five years.  Here is the second.

The trigger point strikes … out!

John Quintner and colleagues recently published a controversial review in Rheumatology. We asked him to present their position in blog form. I expect it to stir some intriguing emotions in many of you and we welcome comments and alternative perspectives. In anticipation, and with tongue almost completely in cheek – remember to avoid the ad hominem mistake and the straw man mistake. Here is the post from Dr Quintner et al.

“The study of fallacies … should attune the student to the omnipresent dangers to which we are exposed as a consequence of imprecise expressions – vague, ambiguous, or misdefined terms – or of unarticulated assumptions and presuppositions [1].

The 1980s was a watershed decade for me. I had a long-standing interest in what was then called Physical Medicine, and my most valued textbooks were those written by James Cyriax, Allen Stoddard and John Bourdillon. At that time the Australian epidemic of repetitive strain injury (“RSI”) – a diagnosis applied to primarily upper limb (forearm and wrist) symptoms, the cause of which was attributed to keyboard and other occupational overuse – was raging. I was forced to admit that my training and subsequent experience as a rheumatologist did not help me to understand the clinical phenomena associated with “RSI” that I encountered daily. By chance I came upon the first edition of The Trigger Point Manual by Janet Travell and David Simons [2]. Could their theory of “myofascial pain” arising from “trigger points” fill the large gap in my understanding of these complex clinical problems? These authors expanded upon an earlier publication by Travell and Rinzler [3] in which patterns of “pain referral” from specific muscles were illustrated. However, as they did not publish the evidence upon which they based their patterns, it appeared to me that the illustrations were based on little more than inspired guesswork. Nonetheless, taken at face value, the hypothesis for Myofascial Pain Syndrome (MPS) advanced by Travell and Simons seemed quite convincing: myofascial trigger points (MTrPs) were the sites of tissue damage, and resided within taut bands located in the culprit muscles. In hindsight, this is an excellent example of circular reasoning! Many of the MTrPs (marked with an X), together with their respective patterns of pain “referral”, were impressively displayed. Treatments such as cold spray administered to the skin followed by gentle stretching of the involved muscle was said to be helpful, if not curative (page 63). In addition, insertion of “dry” needles into the MTrPs followed by stretch of the involved muscle was recommended, as were ischaemic compression (page 86) and massage (page 87). But when I met the late Bob Elvey, he completely changed my way of thinking about these clinical problems. Bob’s mantra was that “muscles protect nerves.” He introduced me to the dynamics of the nervous system and I came to understand that peripheral nerves of the upper limb had evolved to be able to adapt to the various changes in limb position and length and that they were vulnerable at certain anatomical points along their course. His pioneering work on methods of assessing the mechanosensitivity of peripheral nerve trunks has greatly enhanced the clinical examination of the upper limb. In addition to these important clinical insights, I became aware of the large mechanical forces that could potentially be generated within the cervical spinal canal by the maintenance of fixed head/neck postures being adopted by those who performed repetitive manual work. On a closer reading of The Trigger Point Manual, I discovered that the authors had made at least three fundamental epistemological errors that cast considerable doubt upon their theory of MPS. These three errors are not directly related to MTrPs, which are in any event yet to be validated, but rather to poor diagnostic reasoning. Firstly, they implied that pain of peripheral nerve origin could be diagnosed only with accompanying clinical evidence of neurological deficit (page 22), as defined by loss of muscle power and wasting, loss of myotatic reflexes, and diminished sensibility in the distribution of the relevant peripheral nerve, thus enabling the clinician to distinguish such pain from that said to arise from MTrPs. Travell and Simons did not appear to appreciate that pain of peripheral nerve origin could be present without such clinical evidence. Secondly, they believed that a normal conventional electrodiagnostic examination effectively ruled out the possibility of peripheral nerve pain (page 22). Such an examination does not provide any information as to the state either of the small diameter nerve fibres responsible for nociceptive input or that of the nerve interstitium. Thirdly, they announced in Table 3.2 (page 63) that taut bands within muscles that contained MTrPs could entrap peripheral nerves in the vicinity. The existence of such bands had never been demonstrated and it was therefore highly speculative and erroneous to attribute nerve entrapment to such a mechanism. Other weaknesses in their theory included the somewhat metaphysical concepts of “latent trigger points,” “secondary trigger points,” “satellite trigger points” and even “metastasising trigger points”. To further confuse matters, it was later shown that “experts” in MPS diagnosis could not agree as to the location of or even the presence of individual MTrPs in a given patient. The mind-boggling list of possible causative and perpetuating factors for MTrPs was completely devoid of scientific evidence and therefore lacked credibility. But at least any of a myriad of factors could be drawn upon to exempt from blame those well-meaning therapists who were finding that the recommended treatment regimen was ineffective. Finally, those who became “dry needlers” appeared to be unaware that when justifying their assault on MTrPs they were following the “like cures like” tenet of homeopathy. In their parlance, physical therapists (including physicians) were obliged to create a lesion in muscle tissue in order to cure (“desensitise”) a lesion (for which there was no pathological evidence). Meanwhile there were important developments on the “RSI” front. Taken together, our work and that of Milton Cohen’s group in Sydney provided scientifically credible and testable hypotheses for “RSI” [4,5]. But that is for the next installment. Early in the 1990s, Milton and I decided to challenge myofascial pain theory. At the time, another concern of ours was that the fibromyalgia construct was also logically and epistemologically flawed. In our 1994 paper we deconstructed the MPS hypothesis of Travell and Simons, found it wanting, and offered scientifically credible explanations for the observed clinical phenomena [6]. The pioneering studies of nerve inflammation conducted by Geoffrey Bove and the publication by Geoff, together with Alan Light, of the “nervi nervorum” hypothesis [7] attracted our interest and culminated in an alliance with Geoff that has continued. In brief, Geoff’s studies have had two major impacts on how we think about pain felt in muscles or other deep structures. Firstly, he confirmed the presence of nociceptors with multiple receptive fields that branch within the nerve sheaths and extend to other deep tissues (nervi nervorum) [7]. The implication of this finding is that activity in a receptor in one structure such as the nerve sheath, could be perceived in another, such as the muscle. Secondly, he showed that inflammation of nerves has profound effects on these same axons, the nociceptors to deep structures. These effects include ongoing activity and abnormal mechanical sensitivity [8, and others]. The implication of this finding is that this activity will be perceived by the brain in the area of the receptive fields mapped for the deep structure nociceptors, not in the area of the problem. Both of these mechanisms are critical to the concepts being discussed, because they encourage consideration of a number of plausible neurobiological explanationsfor ‘muscular’ pain. (see Figure 1).

trigger point

Figure 1. Proposed hypothesis for the development of focal muscle sensitivity and possible alteration in muscle texture with a proximal neural cause. Inflammation affecting a peripheral nerve (red spot) results in spontaneous and mechanically evoked afferent and efferent action potentials in small caliber sensory neurons innervating non-cutaneous structures, and decreased sympathetic discharge (-). These processes may cause reflex motor discharge sufficient to cause a palpable contraction (?), which combined with clinical phenomena associated with neurogenic inflammation (+), could explain the clinical phenomenon that has become known as a “trigger point.”

However our challenge to the MPS theorists failed to evoke a response, which we thought surprising, given that we raised serious doubts about their construct. Not only was the MPS/MTrP literature expanding in volume but also the editors of journals that published papers based on MPS theory appeared reluctant to countenance any criticism of the authors. But this subsequent literature was also notable for its failure to acknowledge that the underlying hypothesis was flawed – no one has ever succeeded in demonstrating nociceptive input from putative myofascial trigger points. All subsequent “research” simply assumed the truth of what started out – and remains – as conjecture. Early in 2013, Milton, Geoff and I joined forces and decided that another paper was needed to refute the MTrP dogma. The three most prominent North American pain journals did not accept our offerings. Eventually our paper was published online, with open access, in Rheumatology [9]. Now we are left with a major challenge – how to explain the pain previously attributed in error to MTrPs. We hope that in our latest paper we have pointed the way towards a theoretical model that will explain the clinical phenomena by incorporating our knowledge of the mechanisms of referred pain and tenderness, along with the well-documented clinical findings of nerve trunk allodynia, and the experimental evidence derived from studies of nerve inflammation. I gratefully acknowledge the assistance of Geoff Bove and Milton Cohen when preparing this article.

About John Quintner

John QuintnerJohn Quintner is a retired physician in Rheumatology and Pain Medicine who is currently a volunteer with Arthritis and Osteoporosis WA. He is now interested in contributing to pain education for health professionals and consumers. John has long been active as an iconoclast in the field of pain theory and practice. The prime targets have been myofascial pain theory and the North American fibromyalgia construct. His skeptical approach has been well balanced by Milton Cohen’s critical analytical skills. Most of John’s useful ideas have come to him whilst “in the zone” atop his long-cherished bicycle.

References

[1] Toulmin S, Rieke R, Janik A. An Introduction to Reasoning, 2nd ed. New York: Macmillan Publishing Co., 1979.

[2] Travell JG, Simons DG. The Trigger Point Manual. Baltimore: Williams and Wilkins, 1983.

[3] Travell J, Rinzler SH. The myofascial genesis of pain. Post-Grad Med 1952; 11: 425-434.

[4] Elvey RL, Quintner JL, Thomas AN. A clinical study of RSI. Aust Fam Physician 1986; 15: 1314-1312.

[5] Cohen ML, Arroyo JF, Champion GD, Browne CD. In search of the pathogenesis of refractory cervicobrachial pain. A deconstruction of the RSI phenomenon. Med J Aust 1992; 156: 432-436.

[6] Quintner JL, Cohen ML. Referred pain of peripheral neural origin: an alternative to the “Myofascial Pain” construct. Clin J Pain 1994; 10: 243-251.

[7] Bove GM, Light AR. The nervi nervorum. Missing link for neuropathic pain? Pain Forum 1997; 6: 181-190.

[8] Bove GM, Ransil BJ, Lin HC, & Leem JG. Inflammation induces ectopic mechanical sensitivity in axons of nociceptors innervating deep tissues. Journal of Neurophysiology 2003; 90: 1949-1955.

[9] Quintner JL, Bove GM, & Cohen ML (2014). A critical evaluation of the trigger point phenomenon. Rheumatology PMID: 25477053

Comments

  1. For those that might have missed it:

    “We contend that a far more parsimonious interpretation of the meta-analysis is that dry needling is not convincingly superior to sham/control conditions and possibly worse than comparative interventions. At best, the effectiveness of dry needling remains uncertain but, perhaps more likely, dry needling may be ineffective. To base a clinical recommendation for dry needling on such fragile evidence seems rash and risks exposing patients to an unnecessary invasive procedure.”

    Dry needling for myofascial pain. Does the evidence make the grade?
    July 4, 2014 by BiM
    http://www.bodyinmind.org/dry-needling-myofascial-pain/

  2. You’re welcome to observe me in clinic if you want. Would you like to do that?

    John Quintner Reply:

    Thank you for the offer. But I am not sure who you are, what are your qualifications, or where your clinic is situated. However, a list of your publications will suffice for the time being.

  3. John Quintner says:

    Graham, the proponents of “dry needling” have been inhabiting such an alternative world for some years. They may have convinced themselves that “dry needling” is effective, but proof of efficacy has not been forthcoming in the critically reviewed scientific literature.

    Please listen to the final few minutes of the talk by Neil O’Connell. This is a wake-up call for all of us working in the area of pain medicine.

    As for “dry needling”, to borrow Andre Gide’s quotation of an old Arab proverb – “the dogs bark but the caravan (of science) moves on.”

  4. If all manual techniques have similar effects on the nervous system, shouldn’t we then choose the one with the least risk associated with it, and the one that promotes the least amount of dependency?

    I am growing tired of the tool in the toolbox and I it just “works” mentality.

    Patients experiencing temporary transient reductions in pain shouldn’t be used to justify techniques that fail miserably according to the guiding scientific principles.

  5. There’s also the “false god” … It’s called the p-value
    It is “false” when used in “selective outcome reporting”

    This conference “pain and physiotherapy” sheds a light on some reasoning errors being made: like cherry picking studies that favour ones argument (reading only the abstracts!) and more

    “Neil O´Connell. ‘Effectiveness in chronic pain: Peeking under the evidence bonnet’
    O´Connell is member of the editorial board of the Cochrane Pain, Palliative and Supportive Care (PaPaS) review group.

    graham yates Reply:

    And I don’t think Physiotherapy comes out of his findings for effectiveness at all well

    Marcel Reply:

    That’s why the only logical, ethical (and honest; towards our patients) way is being rigorously critical.

    Which may actualy be harder than many dare to admit, not least because it involves self criticism, (like identifying confirmation bias)
    a common one: judging pubmed publications on p-values and abstract conclusions only.

  6. John Quintner says:

    Andrew, who are these “gods of science”? Apollo? Asclepius?

    In any case, I cannot see that divine intervention will prevent the practice of “dry needling” of “myofascial trigger points” from falling into disrepute.

    Here is a devastating commentary that you may not have seen: http://www.fmperplex.com/2013/02/14/travell-simons-and-cargo-cult-science/

  7. Thanks for the links .. seems like a real case of my science is bigger than yours. For me as a clinician with an open who has trialled many different techniques over years I remain unconvinced that needling is ineffective. Not to say that its a miracle cure but just another stimulus hoping to elicit a response ( bottom up) within a particular context (top down) . Done skilfully this seems to have the ability to create change in a relatively harm free efficient manner. Should the gods of science show that there is a clear case of me deluding myself and my patients i will happily stop.

  8. What are the risks of DN,…

    DN practitioners cannot rule out that the skin they are going to penetrate and damage might be a pre melanoma stage type of tissue
    (the stage before being visible),

    They cannot rule out the “taut band” they believe to palpate might be a
    developing sarcoma,

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4015162/

    Do needle practitioners give informed consent to their patients about the risks of infection?
    Hepatitis B was named in 60% of the cases in this review:

    “A cumulative review of the range and incidence of significant adverse events associated with acupuncture”:
    http://aim.bmj.com/content/22/3/122

    graham yates Reply:

    Or if you rub someones back and they have bony metasteses you might fracture, or if you leave the house you might get hit by a car.
    Presumably the hep B relates to countries where they reuse their needles.If you use disposables this is not an issue, unless I have hep B, cut myself shaving and drip blood onto their open wound for example.Should we be worried about this?.

    Marcel Reply:

    Is that the type of explanation people get when the needling practise
    causes serious complications like:
    “Pneumothorax complication of deep dry needling”
    http://aim.bmj.com/content/early/2014/09/19/acupmed-2014-010659

    graham yates Reply:

    This report is showing adverse events to be very low, much lower than other medical procedures.Also if you take away the Hep B which would not be a factor for single use needles then it is tiny.Your probably as likely to nave someone fall off your bench, or stroke out when asked to look up at the ceiling.
    Of course good practice is important in all medical professionals and I have never needled over a rib myself as I don’t think I need to.
    What about the misery many physical therapists and doctors create for their patients by telling them their back is like that of a ninety year old or their discs have worn out, or they have leg length discrepancies, not to bend, keep your back straight, mind your back,you have a weak core, only I can fix you, better give up the golf,your riddled with arthritis.
    I bet these iatrogenic effects are very common indeed.

  9. John Quintner says:

    Hi Graham. I think you are “clutching at straws”.

    graham yates Reply:

    Why am I clutching at straws?.I have given you a few of many studies that show positive effects when a needle penetrates the skin.I am happy to believe you that Travel and Simons got it all wrong, but that doesn’t mean it doesn’t work.
    Take expectation and classical conditioning, two strong forms of placebo medicine. If someone has an opiate on Monday,Tuesday,Wednesday and Thursday and are given (unknown to them ) saline on Friday 100% will have pain relief, according to Benedetti.
    If someone has perceived benefits from exercise, manipulation, acupuncture or stretch in the past for a problem they will likely have benefits again. This isn’t just cortical either as Benedetti shows, it goes for Parkinsons – deep in the brain.
    Mary O’Keefe’s meta-analysis showing little difference between psychological and physical therapies states that the reason there is little difference is because successful outcomes are mediated by changes in cognitive and psychological factors (fear , catastrophising, self efficacy) and that clinician support, empathy and the ability to motivate and encourage may well be the keys to success for both therapies.
    If one study gives the practitioner no opportunity to engage meaningfully with a patient the outcomes will likely be poor.Similarly if given snake oil but with empathy, care, presence and attention, the outcomes will likely be good.
    I believe a needle penetrating the skin may offer help on its own, but it is the therapeutic encounter that is important.
    What I find difficult to tolerate currently is that acupuncture has been singled out, when almost everything in physical therapy is not what it says on the tin.
    I find this scoffing at another practitioners work insulting, especially when they cannot show what they do on a daily basis has any hard evidence.
    Tell me exactly how massage or stretch works therapeutically.Isometrics v eccentrics?, especially eccentrics itself not conforming to theory of actin/myosin cross bridging.Hot v cold (appears to be placebo), knee replacements(not the degree of damage prior to surgery, but quad strength,depression,female,obesity most important), sham surgery having similar outcomes to real, people feeling pain when given sham electric shocks etc etc
    This is why we are not providing “bang for the buck” as K O’ Sullivan puts it so nicely.We have the model wrong.But try and sell that to your patient and still be called a “professional”.

    John Quintner Reply:

    “I believe a needle penetrating the skin may offer help on its own, but it is the therapeutic encounter that is important.”

    Who could argue against the importance of the therapeutic encounter?

    But the rationale of expecting benefit to accrue from needle penetration of the skin continues to elude me.

    As I remarked above, when submitted to critical analysis, most if not all of the studies of “dry needling” are flawed and therefore likely to be worthless.

    Finally, Shah et al. (2015) concede: “To date, the pathogenesis and pathophysiology of MTrPs and their role in MPS remain unknown” and that “It remains unknown whether the nodule is an associated finding, whether it is a causal or pathogenic element in MPS, and whether or not its disappearance is essential for effective treatment.”

    They also pose a number of rather embarrassing questions for researchers to answer:

    1. What is the etiology and pathophysiology of MPS?

    2. What is the role of the MTrP in the pathogenesis of MPS?

    3. Is the resolution of the MTrP required for clinical response?

    4. What is the mechanism by which the pain state begins, evolves and persists?

    5. Although the presence of inflammatory and noxious biochemicals has been established, what are the levels of anti-inflammatory substances, analgesic substances, and muscle metabolites in the local biochemical milieu of muscle with and without MTrPs?

    6. How does a tender nodule progress to a myofascial pain syndrome?

    7. Which musculoskeletal tissues are involved, what are their properties, and how do these change with treatment?

    Will ethical therapists now stop needling, at least until these questions are properly answered? Will those who run courses in “dry needling” now admit that their teaching has been based upon flawed theory and many conjectures?

    Reference: Shah JP, Thaker N, Heimur J, et al. Myofascial trigger points then and now: a historical and scientific perspective. PM R 2015; available at http://dx.doi.org/10.1016/j.pmrj.2015.01.024

    graham yates Reply:

    Hi John I promise this is my last attempt. What if in an alternative world although the theory for acupuncture was found to be absolute nonsense(no trouble with that idea I would guess), but they found that beyond doubt it was effective. Would you then still want a stop to the practice?

  10. All they know is that the mind plays some part in pain. They can’t actually do anything with that knowledge. They can’t actually cure pain. So to cope with their lack of efficacy, they form multi-disciplinary clinics, prescribe Lyrica and core strengthening, and use phrases like “manage the symptoms” and “improve functional capacity”.

    When you actually learn how to make pain vanish, get back to me and we can compare notes.

    John Quintner Reply:

    EG, thank you for your most kind invitation. But if by chance I should happen to make such a monumental breakthrough in pain medicine, I would much prefer to share it with the rest of the world than to compare notes with one who promises much but delivers nothing.

  11. Hi Graham,

    Under the term ‘placebo’, you mentioned a number factors involved in therapeutic alliance, but didn’t mention expectation. Some degree of alliance is required, but not sufficient for rapid change. However positive expectation is necessary for deep, rapid change. The client must be made to expect complete recovery.

    Re: hypnosis, Mark Jensen once said something to me which was helpful. He said that a trance state is not necessary for most chronic pain patients – just start talking. In practice I found this to be true. Nowadays I don’t do any inductions, even though the process itself tends to create a light trance state.

    I find patients are much more open to mental healing techniques than doctors and therapists. Generally doctors/therapists think of hypnosis as a dinky side interest suitable only for smoking cessation. If only they knew.

    John Quintner Reply:

    Well, judging from this review article, you can be assured that some of them (i.e. “doctors and therapists”) do know about and practice these techniques: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4759289/

  12. graham yates says:

    Hi Marcel I am not a statistician but is it not the case that every (therapeutic) encounter we have will have a placebo response( a strong therapeutic alliance-listening,validating,caring,empathising,coaching) or a nocebo response (your broken and only I can fix you).My words and behaviours can literally change someone else’s neuroimmune function. this is whether I use acupuncture, massage, surgery or pain education.If I delivered pain education in an angry,bored or uncaring manner it would likely have no positive effect.
    We should celebrate the placebo response, for without it we would be in big trouble.What we need to know more about is how we best harness and utilise it.
    On another note many of the famous psychology research studies, have failed replication- the pencil between your teeth making you happier, the power pose making you more assertive and the priming of students with words that suggest being old and them walking slower out of the classroom all failed to show the same results. I am not suggesting we stop researching, but I looked again more fully at dry needling on pubmed and found the vast majority of studies to be positive in their outcomes. I am noticing on the twitter world that many physical therapists are calling dry needling snake oil/pseudoscience. I do not accept this.The understanding may be wrong, as the understanding is probably wrong for most things we do, but if it shows benefit I don’t really care that much.
    I also practice hypnotherapy, which I studied as I wanted a top down approach and it has great research findings for chronic pain.However there is a lack of acceptance for its use because i believe “serious” researchers/practitioners cannot believe something as whacky as hypnosis could possibly work.But also, and very much so with hypnosis, what is going on when someone is hypnotised?.
    Lots of theories and arguments, which I will keep abreast of, but I will still use it in the mean time as I think it gives me another valuable tool in my practice.

    Marcel Reply:

    A recent publication in: J Orthop Sports Phys Ther. 2017 Jan; showed no benefit (CEBM Level of Evidence 1b)

    “Contribution of Dry Needling to Individualized Physical Therapy Treatment of Shoulder Pain: A Randomized Clinical Trial.

    Conclusion Dry needling did not offer benefits in addition to personalized, evidencebased physical therapy treatment for patients with nonspecific shoulder pain. Level of Evidence Therapy, level 1b.”
    https://www.ncbi.nlm.nih.gov/pubmed/27937046?dopt=Abstract

    graham yates Reply:

    Hi Marcel
    Here are a few of the studies that are positive for “dry needling” that I pulled off the first 2 pages of PUBMED when using dry needling and chronic pain as key words.
    To me there seems to be enough positive studies that I could have continued to add to, that shows benefits in outcomes. If it were ineffective would they not mostly show little or no effect, rather than the great majority showing positive results.
    By showing only one negative study are you not guilty of finding what you want to find in order to make your case.i am happy to look at all the literature and make my own choice.
    https://www.ncbi.nlm.nih.gov/pubmed/27537209
    https://www.ncbi.nlm.nih.gov/pubmed/27297448
    https://www.ncbi.nlm.nih.gov/pubmed/27274427
    https://www.ncbi.nlm.nih.gov/pubmed/26640708
    https://www.ncbi.nlm.nih.gov/pubmed/26118519
    https://www.ncbi.nlm.nih.gov/pubmed/26064172
    https://www.ncbi.nlm.nih.gov/pubmed/25661462
    https://www.ncbi.nlm.nih.gov/pubmed/25322743

    On the matter of individualized physical therapy for the treatment of shoulder pain its worth looking at this
    https://www.youtube.com/watch?v=QPxhK1SawgA
    He (Chris Littlewood) shows that orthopaedic testing of the shoulder only allows you to draw the only conclusion that all the tests made you sore (they do not aid diagnosis) and the best treatment for rotator cuff tendon pain is to exercise into the painful arc (only one exercise normally into abduction).This is from a man who has only studies shoulders.Manual therapy too has a long way to go!.

    Marcel Reply:

    Graham,

    Here’s some critique on your collection

    https://ptthinktank.com/2015/08/03/what-are-the-issues-with-therapeutic-or-trigger-point-dry-needling-9-considerations-to-ponder/

    John Quintner Reply:

    Marcel, here is another interesting study that may convince the “dry needlers” that the evidence base supporting their practice is rapidly shrinking: https://www.ncbi.nlm.nih.gov/pubmed/28017188

    Graham Yates Reply:

    Hi John
    I interpret that as positive for d.n.
    Ok no better than pressure but both effective.
    Manual therapy is no better than CBT for chronic pain.Does that mean physical therapy has no place for treating chronic pain?.
    After all CBT is only listening and talking on the part of the therapist!.

  13. John Quintner says:

    I hope that more and more clinicians are now questioning the practice of “dry needing” and the theory behind it.

    As we agreed above, waiting for a solid evidence base to support “dry needling” is going to be a long wait.

    Meanwhile, fashions in physical treatment could well change and we will then be discussing the next “big thing”.

  14. The p-value alone doesn’t say anything:

    Evolution of Reporting P Values in the Biomedical Literature, 1990-2015

    JAMA. 2016;315(11):1141-1148. doi:10.1001/jama.2016.1952
    http://jamanetwork.com/journals/jama/fullarticle/2503172

    “There is increasing concern that P values are often misused, misunderstood, and miscommunicated.1- 6 Moreover, there is mounting evidence from diverse fields that reporting biases tend to preferentially select the publication and highlighting of results that are statistically significant, as opposed to “negative” results.6- 12 Such biases could have major implications for the reliability of the published scientific literature.”

    Misleading p-values showing up more often in biomedical journal articles

    Stanford Medicine news march 2016
    https://med.stanford.edu/news/all-news/2016/03/misleading-p-values-showing-up-more-often-in-journals.html

    “The p-value does not tell you whether something is true. If you get a p-value of 0.01, it doesn’t mean you have a 1 percent chance of something not being true,” Ioannidis added. “A p-value of 0.01 could mean the result is 20 percent likely to be true, 80 percent likely to be true or 0.1 percent likely to be true — all with the same p-value. The p-value alone doesn’t tell you how true your result is.”

    “The p-value does not tell you whether something is true.
    For an actual estimate of how likely a result is to be true or false, said Ioannidis, researchers should instead use false-discovery rates or Bayes factor calculations.”

    A major problem with the p value: the lack of replicability by Dr. Cumming. He is proponent of using confidence interval and abandoning p value altogether. The video demonstrates it well: https://www.youtube.com/watch?v=5OL1RqHrZQ8

  15. Geoffrey Bove, co-author says:

    We should all remember that most biomedical science studies with inherent low risk are presented as either thumbs up (YAY!) or thumbs down (NAY!) based on the almighty but arbitrary statistically significant convention of “p < 0.05." This means that if we did the experiment 100 times, we would expect that the result we are reporting would come up the same way 95 times, and the other way 5 times. This give us confidence that the answer is correct. But it is not perfect. In the case of acupuncture and dry needling research, we can look at it another way, using the same conventions. If 100 studies are performed, 5 of them will give positive results, even if "really" the results are negative. If one chooses to "cherry pick" these results — well, they can cite 5 papers with positive results. There are many hundreds of papers and so… we can make the argument either way unless we consider the literature as a whole. Just sayin'.

    graham yates Reply:

    When I put “dry needling, chronic pain, meta-analysis” into pubmed I seem to get lots of favourable or equivocal findings. I cannot see that this should tell us to stop needling. Also are you saying that acupuncture per se is meaningless or is it just the theory you don’t like?.If TCM is OK are you then agreeing there are some meridian lines running through the body?.
    I know its basic but I find the beauty of dry needling is you find an area of soreness, needle it and seem to get a decent response(alongside a manual therapy session).Now I don’t audit myself to know if I am a victim of cognitive dissonance, but I feel the problem with research is that they are very quick to throw the baby out with the bath water.
    According to recent meta-analysis, physical therapy isn’t that great for chronic pain,and neither are psychological therapies(O’Keefe study 2016).
    Also recent evidence that research is far more positive when being paid for by a company with vested interests, makes you feel slightly circumspect when looking at any research findings

    John Quintner Reply:

    Graham, I don’t think there ever was a baby in this particular bath.

    Every study of “dry needling” that I have read has begged the question as to whether “myofascial trigger points” actually exist as pathophysiological entities.

    In my opinion, most, if not all, of the studies are worthless.

    Why not just offer the manual therapy session without resorting to needle penetration? Your outcomes are likely to be the same.

    graham yates Reply:

    There is a difference between “how” something works and” if “it works.I am interested in if it works as I am a hands on therapist.If you tell me that it is definitely ineffective then I would hold my hands up and drop it as a technique.However that is not what I am reading.If studies are worthless then we need more studies. I follow pain neuroscience education but it means I honestly cannot say to a patient what exactly is causing their pain, is it their fall, lack of sleep, poor diet, sick parent etc. I have to operate in that world.I also cannot say why massage , manipulation and stretch works,or indeed if but I still do it.If it all comes down to talking I might as well send everyone for CBT, who have spent years studying that model.
    As Panksepp shows every drug class for mood was found by serendipity not science.We need to explore, make mistakes.Things are messy in the field of chronic pain and we need new tools.So keep questioning and help us to improve outcomes, but don’t throw things out before they are categorically disproven

    Marcel Reply:

    Graham,

    Kaptchuk et al 2008 demonstrates the dominant factor of effectiveness is “patient-practitioner context”.in a placebo acupuncture trial for IBS.

    “Factors contributing to the placebo effect can be progressively combined in a manner resembling a graded dose escalation of component parts. Non-specific effects can produce statistically and clinically significant outcomes and the patient-practitioner relationship is the most robust component.”
    “The proportion of patients reporting adequate relief showed a similar pattern: 28% on waiting list, 44% in limited group, and 62% in augmented group”
    https://www.ncbi.nlm.nih.gov/pubmed/18390493

    Doesn’t that raise questions?

  16. graham yates says:

    I practise “dry needling” or “modern acupuncture”. I am happy to stop treating with needles if they have no benefit. The problem seems to be that the literature is confusing with many studies showing benefits and more powerful when part of integrated pain management programme (plus exercise/ manipulation).
    However is it not true that we really do not understand the mechanisms of massage, manipulation, mirror box therapy,cryogenic therapy etc , etc. This is because we do not understand the nervous, immune and hormonal systems fully.
    The problem then is do we stop doing what we do as practitioners, whilst we wait for a solid evidence base, which it seems is going to be an awful long time coming, or do we give as high quality care as possible using tools that are well researched like the therapeutic alliance, education and exercise as well as our favoured techniques(remembering + 60% psychotherapeutic outcomes are dependent on the therapeutic alliance and whether the practitioner believes in their method of treatment).
    As affective neuroscientists such as Jaak Panksepp and Richard Davidson are showing, it is not just about cognition and behaviour, but emotion is now the big player.

    John Quintner Reply:

    Graham, I can see that you are faced with a dilemma.

    In our letter to the Editor of the Journal of Bodywork and Movement Therapy [Quintner et al. 2015] we presented a detailed analysis of the contrasting views and positions on this topic.

    From this, readers draw their own conclusions as to the scientific validity of the MPS/TrP construct upon which the practice of “dry needling” of TrPs is based.

    I agree with you that waiting for a solid evidence base to support “dry needling” will mean a long wait. But my prediction is that, like waiting for Godot, it will never come.

    As you point out, there are better (i.e. rational and well researched) therapeutic options that are worthy of consideration.

    Quintner JL, Bove GM, Cohen ML. Response to Dommerholt and Gerwin: Did we miss the point? J Bodyw Mov Ther 2015; 19: 394-395.

  17. John Quintner says:

    Thanks for your support.

    There cannot now be many physical therapists who are unaware that the practice of “dry needling” is indefensible on both logical and scientific grounds.

    In my opinion, it is surely time for the leaders of the relevant professions to condemn the practice of “dry needling” as quackery and the theory behind it as bogus.

    Andrew Reply:

    Hello I would like to study the scientific evidence showing that dry needling is ineffective . Please help with links etc ? Thanks

    John Quintner Reply:

    Andrew, may I suggest that a close reading of our paper would be a good place to commence your study?

    Soula’s comment (see above) is also deserving of serious consideration.

    But let me make my position quite clear.

    The reality of clinical phenomena attributed to MTrPs is not in dispute; however, the pathophysiological explanation favoured by Travell, Simons and their followers has been called into question (and that is being kind).

  18. John Quintner, Thank you for your outstanding work.

    There is a thing I like to add: the hypothetical MtP are supposed to be caused by ischaemia or hypoxia according to the main authors (defending the hypothesis like J.D.) Now what surprises me is that no dry needling physio seems to be alarmed by that! If one has ischaemia in the most important muscle in the body (the heart) everyone would agree that is a pretty serious condition, which is not going to be solved by sticking needles in it. What surprises me even more is the fact no
    one (who accepts the ischaemia hypothesis) rules out thrombosis which would be a probable cause for very localised (hypothetical) ischaemia,
    if thrombosis is a hypothetical cause then wouldn’t be needling ie. lesioning such an area be potentialy harmfull?
    Next to that is that ischaemia probably would present itself with different symptoms: “Physiological and anatomical studies show that irreversible muscle cell damage starts after 3 h of ischemia and is nearly complete at 6 h.” ref. “The pathophysiology of skeletal muscle ischemia and the reperfusion syndrome: a review.” https://www.ncbi.nlm.nih.gov/pubmed/12453699

    Kind regards
    Marcel

  19. Brilliant!

  20. Seems Dr. Quintner also rejects the existence of paragraphs? Thank you for posting this thought-provoking summary!

    John Quintner Reply:

    Matt, I accept that paragraphs do exist and apologise for their omission from this blog.

    But we continue to deny the existence of “myofascial trigger points” as promulgated by Travell, Simons, et al.

    Notwithstanding our best efforts to convince physical therapists otherwise, there is evidence that some researchers are still pursuing these mythical lesions, even when they are said to lie deep within the confines of the pelvis: https://clinicaltrials.gov/ct2/show/NCT02795026

    Soula Reply:

    Would it be a huge ask for health professionals to acknowledge and embrace the possibility that responses to all forms of treatment are to varying degrees contextually determined? I can now better understand the effects of my various treatments over the years. When I look back, I don’t believe that any of them have helped ‘fix’ my chronic pain. Rather the ‘aagh’ and ‘ooh’ responses to massage, physio, alexander technique etc, as well as the nerve blocks, the local anaesthetics, my two stimulation implants (that are brilliant pain scramblers) are merely different ways of changing my response to being in pain. And, I would add, a glass of wine, my morning coffee, my art practice, viewing a great sunset etc., have all been valuable ways for me to better manage my pain.

  21. Vicente Miralles Liborio says:

    Congratulations for this post and the research publicated in “Rheumatology “, both very interesting and really usefull.

    The idea of the “neuritis model” to explaing some aspects of MPS is really interesting, besides the secondary hiperalgesia for the question of the patterns of “pain referral”.

    Thank you so much for the post and greetings from Spain.