Trigger Point Dry Needling for Lateral Epicondylitis

Today’s guest post is from Ann Wendel on trigger point dry needling and the effect of dry needling for lateral epicondylitis. Dry needling is gaining more popularity and becoming another great option when dealing with trigger points. Ann went through Myopain Seminar’s dry needling certification. I have had the pleasure to get to learn from some of the instructors of the trigger point program, including Katie Adams, and definitely recommend them if this is of interest to you.

Trigger Point Dry Needling

 

 Trigger Point Dry NeedlingDry Needling is a physical therapy modality used in conjunction with other interventions to treat myofascial pain and dysfunction caused by trigger points. Myofascial trigger points (MTrP’s) are defined as hyperirritable nodules located within a taut band of skeletal muscle (Simons et al., 1999). Palpation of a MTrP produces local pain and sensitivity, as well as diffuse and referred pain patterns away from the affected area. Painful MTrP’s activate muscle nociceptors that, upon sustained noxious stimulation, initiate motor and sensory changes in the peripheral and central nervous systems. (Shah et al., 2008).

Trigger point dry needling can be used to achieve one of three objectives. First, trigger point dry needling can confirm a clinic diagnosis by relieving the patient’s pain or symptoms of nerve entrapment. Second, inactivation of a MTrP by needling can rapidly eliminate pain in an acute pain condition. Third, inactivation of the MTrP through needling can relax the taut band for hours or days in order to facilitate other therapeutic approaches such as physical therapy and self stretching (Dommerholt and Gerwin, 2006).

Universal precautions are always followed when utilizing dry needling in patient care. During the procedure, a solid filament needle is inserted into the skin and muscle directly at the myofascial trigger point. The trigger point is penetrated with straight in and out motions of the needle. The needle can be drawn back to the level of the skin and redirected to treat other parts of the trigger point not reached in the first pass (Dommerholt and Gerwin, 2006). During this procedure, it is essential to elicit twitch responses in the muscle. The local twitch response (LTR) is an involuntary spinal reflex contraction of muscle fibers within a taut band during needling. Research shows that biochemical changes occur after a LTR, which correlate with a clinically observed decrease in pain and tenderness after MTrP release by dry needling (Shah and Gilliams, 2008).

Trigger Point Dry Needling for Lateral Epicondylitis

Trigger point dry needling is an effective treatment modality for numerous acute and chronic musculoskeletal issues. One condition that responds favorably to dry needling is lateral epicondylitis. Therapists know that this problem has usually become chronic by the time the patient seeks treatment, and progress is usually frustratingly slow for both the patient and the therapist.

When dry needling is incorporated into the treatment plan, results are often seen after 2 or 3 visits. The entire forearm is easily treated with the patient supine on the treatment table, and multiple TrP’s can be treated in a matter of minutes. After a thorough history and physical exam, the therapist assesses the forearm for taut bands and trigger points. Muscles commonly involved in symptoms of lateral epicondylitis include: triceps, brachioradialis, extensor carpi radialis longus (and sometimes brevis), extensor digitorum, anconeus, and supinator. As always, the therapist should screen the neck and shoulder region for MTrP’s. Muscles that may refer pain to the lateral epicondyle include: supraspinatus, infraspinatus, teres major and scalenes.

The needling treatment is completed when all LTR’s are eliminated or the patient requests to stop the treatment. The needle is discarded in a sharps container and hemostasis is applied to the area to decrease bruising. The therapist provides manual therapy with a local stretch to the taut band, myofascial release and therapeutic stretch. The patient is taught a self stretch for home, and the treatment can be concluded with ice or heat to the area. The patient is instructed to stretch the area throughout the day and apply heat/ice as needed. It is not unusual to have some increased soreness at the needling site that may last for up to 48 hours. After 48 hours, most patients report a significant decrease in pain, increase in range of motion and some return of strength.

In conclusion, trigger point dry needling can be used in conjunction with other interventions to treat myofascial pain. At the current time, each state has made its own ruling with regard to the physical therapist’s ability to utilize dry needling. The therapist would be best served by reading the State Practice Act for the state in which they practice to determine their ability to use this modality. I went through 100 hours of classroom and practical training in dry needling and successfully passed both a written and practical exam to become a Certified Myofascial Trigger Point Therapist through Myopain Seminars. I highly recommend this course and I find dry needling to be a very effective part of my practice.

Mike’s Thoughts

Great article Ann, thanks.  Dry needling is something I have been exploring and integrating into my practice.  I’d love to hear form others about their experiences as well, so please comment below.  What works?  What technique do you use?  What diagnoses respond best?

Here is a video from Youtube for the extensor pollicis brevis.  This technique is more aggressive in nature, utilizing and “in and out” pattern of needling rather than just different needles.  Different groups teach it differently:

YouTube Preview Image

Dry NeedlingAnn is a graduate of Myopain Seminars program, which is great, but I also recommend Dr. Ma’s Integrated Dry Needling approach.  They are both different models.  Myopain is based on the trigger point theories of Janet Travell.   Dr. Ma’s Integrative Dry Needling, Orthopedic Approach™ is a contemporary dry needling therapy developed by Dr Yun-tao Ma and based on the works of Dr Janet Travell, Dr Chan Gunn, clinical evidence, evidence-based research and Dr Ma’s own 40 years of clinical and research experience and neuroscience training.

Click the below links for more information:

References

  • Dommerholt, J. and Gerwin, R., Trigger Point Needling Course Manual, The Janet Travell, MD Seminar Series, 2006
  • Shah JP, Gilliams EA. Uncovering the biochemical milieu of myofascial trigger points using in vivo microdialysis: an application of muscle pain concepts to myofascial pain syndrome. J Bodyw Mov Ther. Oct 2008;12(4):371-384
  • Simons, D.G., Travell, J.G., Simons, L., 1999. Myofascial Pain and Dysfunction: The Trigger Point Manual. Williams & Wilkins, Baltimore.

About the Author

Ann Wendel, PT, ATC, CMTPT holds a B.S. in P.E. Studies with a concentration in Athletic Training from the University of Delaware, and a Masters in Physical Therapy from the University of Maryland, Baltimore. She is a Certified Athletic Trainer (ATC) licensed in Virginia, a Licensed Physical Therapist, and a Certified Myofascial Trigger Point Therapist (CMTPT). Ann received her CMTPT through Myopain Seminars and utilizes Trigger Point Dry Needling as a treatment modality for many pathologies, including lateral epicondylitis.

 

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226 Responses to “Trigger Point Dry Needling for Lateral Epicondylitis”

  1. I am concerned when you state “Therapists know that this problem has usually become chronic by the time the patient seeks treatment, and progress is usually frustratingly slow for both the patient and the therapist.” and then suggest patients typically only need 2-3 sessions of dry needling to eliminate painful trigger points. There is significant literature to support that chronic issues are characterized by being in a state of central sensitization, which is a central phenomenon not peripheral. In patients in this state, there is often a strong association with maladaptive psychological factors and pain that is disproportioate, non-mechanical and unpredictable. Are you stating that the pain is likely instead due to peripheral trigger points and sticking needles in them will eliminate the pain? By what neurophysiological mechanism would you attribute the decreased pain?

    • Hi Joe,
      Thanks for your interest in the article. When I stated “results are often seen after 2-3 visits” I did not mean to suggest (as you stated) “patients typically only need 2-3 sessions of dry needling to eliminate painful trigger points.”
      I stated that results (meaning decreased pain, increased ROM, increased functional use of the hand)are OFTEN seen after several visits. This has been my experience.
      Thank you for also pointing out the issue of central sensitization. I did not go into that in this article, since it was a blog post (not a journal article) and there is a need to be concise. If you are interested in research regarding trigger point dry needling and central sensitization, please email me directly, as I have plenty of articles I can share with you. Myopain Seminars covers central sensitization and chronic pain in minute detail, and we took a written exam on over 300 pages of research articles which cover this topic in depth.
      Finally, I never “stick needles in patients.” I utilize an effective physical therapy modality as part of a comprehensive treatment plan. If you are interested in the immediate effects of dry needling for pain control, I would direct you to Karl Lewit’s work on “The Needle Effect.”
      Thank you for your interest,
      Ann

  2. I have often heard that dry needling and accupuncture are different, yet to me they seem very similar. You are sticking needles into the body and expecting some change in pain response. Is the main difference the selection of where to insert the needles and trying to elicit the LTR? Can you compare and contrast the differences and what different biological mechanisms and responses are happening in the tissues.

    • Kory,
      I am not a licensed acupuncturist and have never taken acupuncture courses, so I have no formal training in how and why acupuncturists use solid filament needles to effect a change in pain.
      What I can say, based on my training and discussions with licensed acupuncturists is that one difference between trigger point dry needling and acupuncture is in the selection of where to insert the needles (trigger point vs. meridian) and that the type of dry needling I learned through Myopain Seminars is done to elicit the local twitch response to effect change in the physical and biomechemical conditions in the muscle tissue.
      You may see further research available to the public here:
      http://myopainseminars.com/resources/

      • Ann,

        Thank you for the response back and clarifing the differences between acupuncture and dry needling. Thank you for taking the time to answer these questions in regards to dry needling, to help with further understanding of the biological processes in play when performing this technique.

        With dry needling does one have to elicit the LTP for it to be effective and get the physical and biomechanical conditions you refer to in the muscle tissue. (sorry I have not had the opportunity to review all the articles you pointed to at the myopainseminars site) If that answer is in there can you shorten my search by directing to which article :)

        • Short answer is yes, the LTR confirms that the needle is in the Trigger Point, which is what makes it an effective treatment.

          • Do all trigger points elicit a LTR if a needle is placed into them and can only a trigger point elicit a LTR with needle placement?

            I appoligize for the questions and very much appreciate your time and answers, but dry needling is a very interesting technique to me especially noting the response that you get with patients.

  3. Thanks for the resonse…My email is joseph.brence@physiocorp.com …Please send over the articles which examine dry needling as an effective modality for those in central sens. Thanks!

  4. Joe,
    I will do my best to get the information to you today/tonight. It may be tomorrow, due to treating patients today.
    Thanks,
    Ann

  5. What continues to perplex me about those who propose treatments directed towards the myofascial trigger point (MTrP) is that they never seem to acknowledge the lack of evidence supporting that such an entity exists as it has been traditionally described (see the systematic review by Lucas et al, Clin J Pain, 2009;25:80-89). If these things can’t be reliability detected via a normal clinical exam, then of course the validity of the underlying construct is seriously in question. Furthermore, any treatment mechanism that is hypothesized to “inactivate” an MTrP falls within the realm of wild speculation rather than firm scientific plausibility.

    When this lack of established reliability of the MTrP construct is evaluated in the light of recently published research on acupuncture (I know they’re not the same, but they are similar enough to at least consider the established mechanisms of acupuncture), which shows that the effects are driven primarily by placebo, then I think it’s time to re-evaluate what exactly inserting needles into patients is actually doing.

    A study just published in last month’s highly regarded IASP publication Pain by White et al entitled “Practice, Practitioner, or Placebo? A Multifactorial, Mixed-Methods Randomized Controlled Trial of Acupuncture” incorporated real acupuncture, sham acupuncture and mock electrical stimulation. First of all the real acupuncture was no more effective than the sham treatment, which is consistent with prior research. However, what did have a significant effect on outcome was both the patients’ beliefs of the treatment’s veracity AND, independently of that, some “unknown characteristic” of the treating clinician.

    Is it possible that undergoing a long and arduous training to insert needles into painful areas of patients’ bodies might impart to the clinician this as yet ill-defined and elusive practitioner characteristic(s) that apparently serves to heighten already established placebo effects? If this is the case, given that MTrP’s have not been validated as a real clinical entity, shouldn’t our research efforts be geared towards identifying what that practitioner characteristic(s) may be, so that we might develop therapeutic interventions that are less invasive and more rigorously scientifically plausible?

    I think so.

  6. John,
    Your comment is interesting, and it is also based on a false comparison. Trigger Point Dry Needling is most emphatically not the same as acupuncture (although some acupuncturists are trained to do trigger point dry needling). When citing research to disprove a treatment modality, one should quote discrediting research on the actual modality in question, not a completely different modality. The only similarity between trigger point dry needling and acupuncture is that the same instrument (a solid filament needle) is used. The study you cite, regarding acupuncture, is as useful in this conversation as a study comparing a plumber and an auto mechanic because they both use a wrench.
    If you would like to provide some information about who you are and how to reach you (you are not signed into Mike’s blog and no identifying information can be found for you), I would be happy to communicate the research via email.
    Thanks for the interest,
    Ann

  7. Ann,
    I acknowledged that the interventions are different, but there are obvious similarities, the most obvious being the insertion of a needle into a patient. My point is that there are effects outside of the local, peripheral effects (DNIC?) that cannot be discounted, and may actually be more influential than the proposed peripheral effects, which is what the results of the White study suggest. Yet, you replied above that central sensitization was covered in great detail during your training. If this is the case, then certainly you’d appreciate the presence of patient beliefs, expectations and practitioner characteristics in the ultimate outcome.

    However, you’ve failed to address the issue of diagnostic accuracy of MTrPs. Based on what you’ve written above, it appears you use a palpatory examination of painful “taut bands” in muscles. The systematic review by Lucas et al that I cited found that these methods were unreliable in detection of MTrPs, which, as you know, causes us to question their validity. Your brief description of your examination in the lateral elbow pain scenario states the following: “…the therapist assesses the forearm for taut bands and trigger points…”. So, from this we infer that you use a palpatory examination, which must involve stimulation of receptors in the skin. Yet, you have not ruled out possible neurological effects at the level of the skin at the moment you make physical contact with the patient.

    I’m not trying to disprove any treatment modality, I’m trying to get those who use them to adequately defend them. Thus far, I’ve yet to find any dry-needler or other practitioner who subscribes to MTrP-based interventions to provide a scientifically-based rationale that justifies their use.

    • John,
      Since you have not provided your email addressed as I asked, I have no way to share the research with you.
      I have a feeling that it really doesn’t matter what research I send you (you seem to have your own worldview); but, I will send it anyway.
      Since you brought it up (“I’ve yet to find any dry-needler or other practitioner who subscribes to MTrP-based interventions to provide a scientifically-based rationale that justifies their use”)I can’t imagine who you might possibly have talked to? It certainly wasn’t another graduate of Myopain Seminars, as we have been taught and tested on over 300 pages of research, much of it from studies done at NIH by both physical therapists and neurologists.

      I’m not interested in debating with you about why your view is right and mine is wrong. If you want to review some of the research, see http://myopainseminars.com/resources/
      and I’m happy to discuss it with you after you have read all of the studies.

      Ann

      • John, I will say that acupuncture and dry needling are not the same. Acupuncture does not consider trigger points, dry needling does. So the article you reference really isnt relevant to the topic.

        • Mike,
          Perhaps I haven’t been clear enough that the reason I cited that study was to demonstrate how important patient beliefs, expectations and practitioner characteristics are during the clinical encounter and any resultant outcome. Not all placebo is created equal. The level of veracity that a patient assigns to a treatment has a large impact on the outcome. How well the practitioner “sells” the treatment may be what drives this.

          Juxtaposed to a treatment modality that currently lacks a strong explanatory basis, particularly in terms of affecting MTrPs, I think the study is very relevant to this discussion.

        • My hospital, Bates County Memorial Hospital, recently purchased your Shoulder exam and treatment DVD. In viewing it, we felt a bit overwhelmed by the note taking all the while trying to attend to the info.

          Do you have any outlines available for your DVD programs to help us with ready reference info.

          Thanks

  8. Ann,
    The link you provided has alot of antedoctal pieces. It does have a 1997 article published in “Pain” which examined the interexaminer reliability of detecting tps. This article was included in the the 2009 systematic review which John provided. The conclusion of this higher level of evidence, is that there is no evidence to support that interexaminer reliability of tps exists…

    • I believe I stated that I would email you directly in order to share the articles. Since I have been treating patients and working all day, I have not yet had a chance to do so (they are not on my computer, since as you know, even if one pays $30.00 for an article, one does not have the right to share it, and I will need to email you the titles and abstracts so that you can find the articles yourself).

      If you cannot wait until tomorrow for the articles, then I suggest that you do your own search and find them, as you seem to be highly motivated to prove yourself right.

      I am aware that it is a game to many people to go to different blogs and make inflammatory and aggressive comments. I am not interested in playing this game with anyone who comments on this thread. I really don’t believe that you are interested in learning about trigger point dry needling; but, rather, interested in showing off how “smart” you are and how well you attempt to discredit research.

      Yawn. You are boring me.

  9. I am not attempting to make inflammatory and aggressive comments. I am holding you accountable to support a practice which I have not seen be scientifically validated and which could potentially pose more harm than good. I am not interested to read antedoctal reports. I want to see scientific evidence to validate that this is an effective modalitiy of treatment. The vision of the APTA for 2020 is to moveforward and I am afraid that our profession will not unless we ensure that we are truly practicing evidence-based medicine.

  10. Ann,
    I have no interest at all in debating worldviews, personalities or motivations, but I am very interested in discussing the current state of the evidence regarding the validity of the MTrP construct. I’ve provided a reference to a high quality systematic review of the literature that was published in 2009. In it the authors concluded:

    “No study to date has reported the reliability of trigger point diagnosis according to the currently proposed criteria. On the basis of the limited number of studies available, and significant problems with their design, reporting, statistical integrity, and clinical applicability, physical examination cannot currently be recommended as a reliable test for the diagnosis of trigger points.”

    I’ve seen nothing since its publication that refutes the findings of this review. If you’re aware of some more recent research that validates the physical findings that you briefly described above, then I would be very interested in reading it. If it’s published in a reputable journal, you should be able to provide a link to the Pubmed citation here. As a clinical faculty in major university PT program, I have access to the university library, so I can retrieve the article myself.

    I realize that this line of questioning is pointed and challenging, and I very much regret that you find it boring. I hope that you or perhaps one of your colleagues at Myopain Seminars will bear with me and the other questioners and help us to advance our understanding of the science behind the methods we use to treat patients.

  11. Mike,

    You asked these questions:

    [quote] What works? What technique do you use? What diagnoses respond best?[/quote]

    What I find peculiar is that PT’s in general avoid asking the most important questions…how and why.

    Being from Canada where dry needling has become the latest “big thing” I have indeed invested the time to read the literature on this topic and have been woefully under-impressed. The literature generally leads one to placebo rather than treatment as the primary “effect”. Jware and Joe Brence are most certainly on point with their queries and comments.

    If PT’s continue to avoid asking the important questions we will marginalize ourselves into oblivion.

    Anne’s “boredom” with the questions is unfortunately representative of the PT profession as a whole from what I gather

    • Glen,
      You misunderstand me. My boredom is with arguing for the sake of arguing, and goading people who have already promised to get back to someone via email! I am most definitely NOT bored with discussing the research behind physical therapy practice, nor am I bored with legitimate questions, such as Kory’s, which I quickly answered above.

      I have already stated that the reason I have not yet posted the additional research is that I was seeing patients all day (I had no idea this post was going live today, as I sent it to Mike 6 months ago). Since I did not know the post was going live, I did not have my research binder in front of me at work, and was unprepared to post the links to articles.

      I find it very interesting that everyone who is commenting can’t wait a few hours until I get home from work, and can provide you with exactly what you are asking for…….am I missing something here? I’m unsure why this has turned into such an attack……I am more than willing to share the research, I’m not trying to avoid the question, I just simply can’t give you the information right now!

  12. I think my question regarding the validity and reliability of the MTrP construct is not only legitimate, but it is essential to any further discussion about any empirical, anecdotal or even controlled clinical trials reporting outcomes as a result of any treatment method that bases it’s mechanisms of action on the presence of these as a real clinical entity.

    I have discussed this issue on many occasions with numerous clinicians who have made fantastic claims of empirical results with a variety of methods directed at MTrPs, but none of these people have provided a scientifically sound argument for their existence in terms of reliability and validity.

    Kory’s question above about the elicitation of the LTR with needle insertion begs the question of whether this muscular response is specific to an MTrP, or does it occur in normal subjects as well? If the LTR is elicited in normal subjects, then you’ve developed a diagnostic test with high sensitivity, but unacceptably low specificity, i.e. it does not provide diagnostic utility if everyone has displays an LTR when you stick a needle in their muscle.

    Is there some measurable characteristic of the LTR that makes it different in patients with pain? Is it the quality of the pain evoked?

  13. Let me preface my comment by stating 1) I’ve never done any dry needling 2) I’ve never seen it done

    You’re going round and round over two separate entities.

    One:
    It seems some of the debate is focusing on reducing the relevance of this particular intervention hinging on lack of inter-rater reliability in determining trigger points. From a palpatory perspective this is probably true… from a local twitch response this is probably not true. I’d be willing to bet observing whether a twitch does or does not happen is reasonably reliable. (No, I have no clue, but I’d like to think our observational skills might be more reliable than our palpatory skills.)

    If a particular technique has a foundation in which palpatory inter-rater reliability is poor, but the actual desirable response of observing a twitch is also required because this solidifies the location is bang on… then you are actually using an intervention that depends on more than just the weak palpatory component as a foundation for the delivery location for dry needling.

    Second:
    I think it is reasonable to ask questions on the mechanism and how pain sciences come into play with this particular intervention. I think you all might find value in the below particular article. Realize… it’s talking theory. I highly doubt there is any proof that the proposed theory is accurate or correct. It was published in 2011, and I do think it may answer your “scientific” questions, John & Joe. I have a feeling it will try to explain the science.

    http://www.ingentaconnect.com/content/maney/jmt/2011/00000019/00000004/art00006

    Of course, I’m an “outcomes” girl and instead I’m one who LOVES to see the actual outcomes – pain and functional improvements. Theories mean little to me if outcomes are poor.

    I think Mike Reinold has worked hard create a respectful learning environment with his blog. I also think we should all remember this as we pursue our agendas.

    Selena

  14. I must say that we do not truly understand the human body as much as we sometimes think we do. I would just challenge everyone to not discredit something that we dont understand.

    If you watch the video above of dry needling, it is pretty much exactly what our docs do when giving an injection for epicondylitis (i.e. “wet” needling). They dont just inject a steroid, they poke around. In essence you cause trauma that stimulated the bodies own natural ability to heal. The classic work by Travel and Simons has shown that injecting a saline is just as effective as a steroid, which tells you something – is it the drug or the needling.

    Acupuncture is completely different and based on meridians. Any research on acupuncture has nothing to do with dry needling.

    Sometimes as a profession we get away from our true value – making people feel better. Patients dont come to see you because you are doing the most evidence-based practice, they simple want to feel better.

    If dry needling makes someone feel better, great we succeeded. Our goal is to make people feel better.

    The discussion about trigger points is never ending, you can debate it all day. But how can you discredit so may people (both patients and clinicians) that have had great clinical success treating trigger points because:

    1) there isnt any evidence (lack of evidence does not mean lack of efficacy, realistically true clinical studies are hard to control)
    2) A couple of studies show something (there are flaws in every study that make the results not applicable to everyone)

    Are all these people wrong? Why do people feel better?

    Trust me, I am as evidence based as anyone, but my outcomes have been greatly enhanced once I started to open my mind and listen to what other people were having success with on their patients.

    So for stuff like this, the clinician has two choices – 1) give the patient (i.e. the consumer) what they want – to feel better, or 2) resist because there isn’t enough evidence to satisfy you.

    I know what I am doing…

    • Mike,
      You state: “If you watch the video above of dry needling, it is pretty much exactly what our docs do when giving an injection for epicondylitis (i.e. “wet” needling). They dont just inject a steroid, they poke around. In essence you cause trauma that stimulated the bodies own natural ability to heal. The classic work by Travel and Simons has shown that injecting a saline is just as effective as a steroid, which tells you something – is it the drug or the needling.” and then go on to state that acupuncture is very different than dry needling because of the theoretical constructs. Isn’t the intervention the same? We have no reliable way in determining that an active trigger point exists in painful individuals and as Kory eludes, how do we know that we are eliciting a LTR in a trigger point and not healthy muscle tissue? The one thing we can say, is that in both cases we are putting needles into skin.

      I feel that providing evidence-based practice is vital for our profession to move forward. I do believe that maximizing placebo effects within clinical practice (within ethical limitations as highlighted by Bialosky) is also important, but I do not believe that dry needling is necessary to do this. We already have ultrasound and laser.

      As “so-called” evidence-based professionals, we should be able to provide evidence on what we do. We should question if and why things work. If we don’t, we our practice will make as much sense as this video: [removed by editor]

      • Thanks Joe, appreciate your enthusiasm here. I am going to edit your reply and take out the link to the video. I get what you are saying but I dont want this use this website to poke fun at others.

        Joe, the intervention is not the same, that is what Ann is trying to tell you. Acupuncture does not specifically attempt to treat soft tissue or trigger points. It is based on meridians. They are very different. You cant compare acupuncture research to dry needling. They only thing they share is a needle – the location, technique, and rationale are different.

        I am not disagreeing with you and agree there needs to be more research, I am just advising you to not knock what you don’t understand. I am not referring to the acupuncture vs dry needling debate, just in general. I am sure there are many things you do that are not 100% evidence-based. We cant all be 100% evidence based all the time. Research takes time to conduct. You can wait for 100% validation all the time, but you may be behind the times!

        When something is becoming popular it is because there are perceived benefits. All I am saying is dont discredit something for lack of efficacy without exploring. You dont have to agree or participate, but I would caution you to not discredit without full info.

        I would imagine that if there were the internet many years ago, someone would have debated that the world was still really flat. You dont want to be that guy. Your comments dont go away on the internet! Heck, we all laugh at dry needling in 10 years, but I would never be embarrassed about trying to provide the best outcomes for my patients.

        • Mike,
          Not all acupuncture is based on the meridian theory. A recent text written by de las Penas et al entitled “Tension-type and Cervicogenic Headache: Pathophysiology, Diagnosis, and Management (2010) refers to the use of tender point identification as a criterion for needle placement.

          So really, often the only difference is depth of penetration.

    • Hi Mike,

      Great discussion here. Wondering your thoughts on “wet” needling. Do you think that it is a little counter productive to induce a healing response with the needle just to put an anti-inflammatory on it with the cortisone? Do you also feel that the only reason that MD’s inject something is so they can be reimbursed for the procedure?

      I was trained through the KinetaCore system and really find that treating centrally (i.e. corresponding spinal level) first will clear up some of the issues prior to treating the periphery. I use it on most of my patients chronic and acute and have found good results across the board.

      Its nice to see that others are opening their eyes to this technique. I hope that it continues to gain traction so that more patients can benefit.

      Thanks for helping to get the information out there.

      Ian

  15. Here is a list of research regarding trigger points and their treatment with dry needling. If you would like me to send you a copy of the Word document I typed this into, let me know and I will do that.

    Research:
    http://bit.ly/zkaPjq Interrater Reliability in Myofascial Trigger Point Evaluation
    Dry Needling in Orthopedic Physical Therapy Practice
    Mense S. Muscle Pain:mechanisms and clinical significance. Dtsch Arztebl Int. March 2008;105(12):214-219
    Shah JP, Gilliams EA. Uncovering the biochemical milieu of myofascial trigger points using in vivo microdialysis:an application of muscle pain concepts to myofascial pain syndrome. J Bodyw Mov Ther. Oct.2008;12(4):371-384
    Gerwin RD, Dommerholt J, Shah JP. An expansion of Simons’ integrated hypothesis of trigger point formation. Curr pain Headache Rep. Dec 2004;8(6):468-475
    Lewit K. The needle effect in the relief of myofascial pain. Pain. 1979;6:83-90
    Chen Q, Basford J, An KN. Ability of magnetic resonance elastography to assess taut bands. Clin Biomech (Bristol, Avon) Jun 2008;23(5):623-629
    Mense S. How do muscle lesions such as latent and active trigger points influence central nociceptive neurons? J Musculoske Pain. 2010;18(4):348-353

    • Ann,
      The Gerwin study is the only one you cite that addresses reliability, and it was included in the systematic review by Lucas et at that I cited above. It met only 4 of 9 quality criteria. The Gerwin article actually contained a smaller (n=10) and a larger study (n=25). The kappas reported in the smaller study were moderate to high for several of the criteria, but not LTR, where they were low. In the larger study, the authors didn’t even report kappas, but only mentioned that they were low for all the criteria.

      The Chen et al MRE study is interesting and I’ll have to take a closer look at when I get a chance. Aside from the shear small size of the study (n=8) it obviously commits a blatant tautological error by having a single examiner make a determination of a diagnosis of “myofascial pain syndrome” via a palpatory examination of taut bands, and then performing an MRE to confirm the single examiner’s findings. This is not to mention that the clinical relevance of these abnormalities using this technology and their relationship to MTrPs remains largely speculative at best.

      The rest of the citations do not address the essential question of validity and reliability of the MTrP construct.

      So, I remain unconvinced that anyone has provided evidence that they exist, and therefore that any intervention thus far devised is treating something that cannot be reliably identified.

      Mike, I will echo Glen’s question below, and remind you that for over a century chiropractors have evoked the “subluxation” theory to justify manipulating patient’s spines and other joints. The science has pretty well established that this theory is hogwash (although most chiros remain doggedly devoted to it), but many patients continue to be committed to this intervention as the only method of relieving their pain. They’re “sold” on it, and many because they are convinced that they have a bone out of place that some expert is needed to put back in place. This is where the slippery slope of inadequate explanatory models can take us. I don’t think we, as PTs, want to go there, do we?

  16. Mike,

    Two choices you say? Regarding your choice number one “give the patient what they want”; do you see any potential pitfalls with this logic?

    • Glen, I should clarify – when I said give the patient what they want, i wasnt referring to dry needling. I was referring to their “want” to feel better. I dont care how you do it, i think my job is to make people feel and function better.

  17. Better question is how do we legalize dry needling in NY???

  18. Steven,
    That is in the process of taking place. If you are interested, contact Jan at Myopain Seminars, he’s involved in the effort. Also, keep in mind that you can take the courses to become certified, and then use only the manual TrP release until dry needling is approved in NY.
    Cheers,
    Ann

  19. Ann~

    Do you have a contact for anyone addressing the TDN issues in PA?

  20. Mike you stated: “The classic work by Travel and Simons has shown that injecting a saline is just as effective as a steroid, which tells you something – is it the drug or the needling.”

    Isn’t there the potential for a third option? Namely placebo effects and therapist-patient interaction. Obviously placebo effects are always in play with all treatment interventions, it is unavoidable. But in medicine should we not try to determine if the physiological changes are more from the operation of the procedure or from the interaction with the therapist-patient and placebo effects. It would be pretty hard to get a medication past the FDA without that science behind it. In the PT profession I think we have been down this road with other treatment interventions, raising more caution and less enthusiasm may be warranted if we are to be doctoring profession. You are correct that not all treatments can be evidence based 100% of the time, but scientific plausibility has to be there. Acupuncture has not been able to pass the scientific plausibility and placebo only effect test. If Dry Needling truly is different and the only thing that differentiates it is LTR with injecting into a trigger point. Then we need to know is a trigger point the only thing that can elicit a LTR and are all trigger points a causation of some underlying pathological condition? If a LTR can be elicited in normal tissue then we have no way of knowing if we are in a trigger point or not. And if all trigger points are not a causation of some underlying pathological condition, how do we know which ones to treat?

    Mike you also stated: “Sometimes as a profession we get away from our true value – making people feel better. Patients dont come to see you because you are doing the most evidence-based practice, they simple want to feel better.

    If dry needling makes someone feel better, great we succeeded. Our goal is to make people feel better.”

    While I’m sure no one disagrees that we want our patients to feel better. But as professionals we also have a PT Code of Ethics to uphold while trying to get patients to feel better. I think 4A and 6C need to be reread and evaluated closely when we embark on new treatments that may not have much science behind the plausibility of their supposed effects. There are many patients that believe they feel better after receiving various non-scientific treatments. But I hope we all agree we should not offer them, just because a patient might feel better. If this is the case then I am very concerned about my profession moving out of the medical community and into a non-medical community.

  21. I would like to take the opportunity to reply to some of the comments made in response to Ann’s blog. I do not find the responses and inquiries to be boring and welcome the opportunity to provide some more background information. I agree that the “resources” on the Myopain Seminars website do not provide scientific support for the concepts Ann described. Since about 2007, publishers rarely give permission to post studies on commercial websites. I guess I should clarify that on the site.

    John, while I am glad to see that you consider the literature on trigger points [TrPs], I do think that basing your opinions on the article by Lucas et al without considering the rest of the scientific literature would be a mistake, as there are many issues with the study by Lucas et al

    Lucas et al used a newly devised measurement tool to assess the reliability of the physical examination of TrPs. I find it remarkable that the authors of this seemingly authoritative review did not establish the validity and reliability of this tool. Checking the face validity of a new test via consultation with methodology experts is an important step toward developing a reliable evaluation tool, but hardly meets the criteria to determine its reliability. Without actually studying a new assessment tool against existing valid and reliable tools, its validity and reliability cannot be accurate determined, which makes the entire study rather questionable.

    One item on the test is of particular interest and questions whether “the test was performed by examiners representative of those who would normally perform the test in practice.” Two papers were criticized as the evaluators were considered experts in the field. Three other papers were mentioned for using “representative examiners.” Interestingly, these latter papers included Dr. Chang-Zern Hong of Taiwan, who is without any doubt one of the world’s foremost experts on myofascial pain and TrPs. Another paper “acceptable” to Lucas et al was prepared by Bron and colleagues, who are established TrP experts in the Netherlands. Dr. Bron’s doctorate dissertation was on TrPs in the shoulder region (see Bron, C, De Gast, A, Dommerholt, J et al 2011. Treatment of myofascial trigger points in patients with chronic shoulder pain; a randomized controlled trial BMC Medicine, 9, 8; Bron, C, Dommerholt, J, Stegenga, B, Wensing, M & Oostendorp, RA 2011. High prevalence of shoulder girdle muscles with myofascial trigger points in patients with shoulder pain. BMC musculoskeletal disorders, 12, 139). It should be noted that Lucas et al did recognize that Bron’s interreliability paper is a valid paper, which demonstrates that experienced physical therapists reliably can agree on the identification of TrPs in the shoulder (see Bron, C, Franssen, J, Wensing, M & Oostendorp, RaB 2007. Interrater reliability of palpation of myofascial trigger points in three shoulder muscles. J Man Manipulative Ther, 15, 203-215).

    Lucas et al did not address the question how interrater reliability studies should be performed if papers by experts in the field are downgraded. I agree that some of the earlier TrP reliability papers were troublesome, because the examiners were not experts in the field and therefore they were not able to reliably assess TrPs, or because researchers used poor methodology. For an detailed review of the various interrater reliability studies see McEvoy, J & Huijbregts, PA 2011. Reliability of myofascial trigger point palpation: a systematic review. In: Dommerholt, J & Huijbregts, PA (eds.) Myofascial trigger points: pathophysiology and evidence-informed diagnosis and management. Boston: Jones & Bartlett).

    All experts in these studies conduct workshops, teaching other clinicians how to perform TrP assessments and treatments. If the experts are criticized for conducting reliability studies, what would be the basis for their teaching? It is hard to imagine that Lucas et al would be interested in attending courses taught by clinicians who have not conducted any such studies, which brings up the question how they determined that they “had experience in the diagnosis and treatment of myofascial pain syndrome…”

    Nevertheless, lessons can be learned from the systematic review by Lucas et al. I agree that there is an obvious need for reliable criteria to evaluate patients for the presence of TrPs. More research is indeed needed to establish the difference and relevancy of active versus latent TrPs and their exact location. Studies need to be conducted with patients and with healthy controls.

    I agree with Lucas et al that TrPs should not be considered as an exclusive diagnosis for patients presenting with pain. However, TrPs frequently are part of the picture and as such, they can and should be included in the assessment and treatment. It makes little sense to focus exclusively on TrPs without consideration of other pertinent issues, such as psychological aspects, arthogenic restrictions, postural deviations, and placebo, among others, but it remains nearly impossible to determine which objective parameter would be the primary problem. As Patrick Wall stated, “if pain is a puzzle, we should not throw away pieces of the jigsaw just because we are obsessed with a preconceived single solution”]. Once Lucas et al have established the validity and reliability of their assessment tool, it would be prudent if they would conduct another reliability study of the palpation and examination of TrPs using their own validated criteria.

    When John states that “I’ve seen nothing since its publication that refutes the findings of this review” I wonder where you looked as high-quality research on TrPs has exploded during the past decade. I must admit that I am surprised that “as a clinical faculty in major university PT program” you apparently have not researched the TrP literature, before you posted here. You stated that “what continues to perplex me about those who propose treatments directed towards the myofascial trigger point (MTrP) is that they never seem to acknowledge the lack of evidence supporting that such an entity exists.” It is tempting to turn that around and state that “what continues to perplex me about those who oppose treatments directed towards the myofascial trigger point (MTrP) is that they rarely seem to study the overwhelming evidence supporting that such an entity exists, before showing everyone who reads this blog and its comments, that you really are not familiar with the scientific literature, but I won’t do that.

    For example, researchers at the US National Institutes of Health have not only visualized TrPs, they have analyzed the immediate vicinity of active and latent TrPs and found that active TrPs are characterized by the presence of multiple inflammatory mediators, such as CGHRP, substance P, norepinephrine, interleukins, TNF-alpha, etc. Questions were raised about the local twitch response. Of interest is that after eliciting a LTR, the concentrations of these chemical nociceptive substances was reduced to near-normal values minutes after the stimulation. There are several studies of the relevancy of LTRs. See for example

    Chen, JT, Chung, KC, Hou, CR et al 2001. Inhibitory effect of dry needling on the spontaneous electrical activity recorded from myofascial trigger spots of rabbit skeletal muscle. Am J Phys Med Rehabil, 80, 729-735.
    Dexter, JR & Simons, DG 1981. Local twitch response in human muscle evoked by palpation and needle penetration of a trigger point. Arch Phys Med Rehabil, 62, 521.
    Hong, CZ 1994. Lidocaine injection versus dry needling to myofascial trigger point. The importance of the local twitch response. Am J Phys Med Rehabil, 73, 256-63.
    Hong, CZ 1994. Persistence of local twitch response with loss of conduction to and from the spinal cord. Arch Phys Med Rehabil, 75, 12-6.
    Wang, F & Audette, J 2000. Electrophysiological characteristics of the local twitch response with active myofascial pain of neck compared with a control group with latent trigger points. Am J Phys Med Rehabil, 79, 203.

    In other studies the NIH researchers confirmed that active TrPs have a very restricted blood supply, which supports the findings of a European study that in the core of TrPs the oxygen saturation is about 5%-15% of normal. See for example

    Brückle, W, Sückfull, M, Fleckenstein, W, Weiss, C & Müller, W 1990. Gewebe-pO2-Messung in der verspannten Rückenmuskulatur (m. erector spinae). Z. Rheumatol., 49, 208-216.
    Shah, J, Phillips, T, Danoff, JV & Gerber, LH 2003. A novel microanalytical technique for assaying soft tissue demonstrates significant quantitative biomechanical differences in 3 clinically distinct groups: normal, latent and active. Arch Phys Med Rehabil, 84, A4.
    Shah, JP, Danoff, JV, Desai, MJ et al 2008. Biochemicals associated with pain and inflammation are elevated in sites near to and remote from active myofascial trigger points. Arch Phys Med Rehabil, 89, 16-23.
    Sikdar, S, Ortiz, R, Gebreab, T, Gerber, LH & Shah, JP 2010. Understanding the vascular environment of myofascial trigger points using ultrasonic imaging and computational modeling. Conf Proc IEEE Eng Med Biol Soc, 1, 5302-5.
    Sikdar, S, Shah, JP, Gebreab, T et al 2009. Novel applications of ultrasound technology to visualize and characterize myofascial trigger points and surrounding soft tissue. Arch Phys Med Rehabil, 90, 1829-38.

    Patients with a hypersensitive TrP in the upper trapezius muscle exhibited significantly enhanced somatosensory and limbic activity and decreased activity in the dorsal hippocampus compared with control subjects. Using functional magnetic resonance imaging, Niddam et al. showed that pain following the insertion of a needle into a trigger point combined with electrical stimulation is mediated through the periaqueductal gray in the brainstem. See for example

    Niddam, DM, Chan, RC, Lee, SH, Yeh, TC & Hsieh, JC 2007. Central modulation of pain evoked from myofascial trigger point. Clin J Pain, 23, 440-8.
    Niddam, DM, Chan, RC, Lee, SH, Yeh, TC & Hsieh, JC 2008. Central representation of hyperalgesia from myofascial trigger point. Neuroimage, 39, 1299-306.

    TrPs are not a placebo or made up phenomenon and have been identified not only in humans, but in dogs, rabbits, horses, rats, etc. using objective scientific methodologies. See for example

    Macgregor, J & Graf Von Schweinitz, D 2006. Needle electromyographic activity of myofascial trigger points and control sites in equine cleidobrachialis muscle–an observational study. Acupunct Med, 24, 61-70.
    Chen, JT, Chen, SM, Kuan, TS, Chung, KC & Hong, CZ 1998. Phentolamine effect on the spontaneous electrical activity of active loci in a myofascial trigger spot of rabbit skeletal muscle. Arch Phys Med Rehabil, 79, 790-794.
    Chen, JT, Chung, KC, Hou, CR et al 2001. Inhibitory effect of dry needling on the spontaneous electrical activity recorded from myofascial trigger spots of rabbit skeletal muscle. Am J Phys Med Rehabil, 80, 729-735.
    Hong, C-Z & Yu, J 1998. Spontaneous electrical activity of rabbit trigger spot after transection of spinal cord and peripheral nerve. J Musculoskelet Pain, 6, 45-58.
    Hou, CR, Chung, KC, Chen, JT & Hong, CZ 2002. Effects of a calcium channel blocker on electrical activity in myofascial trigger spots of rabbits. Am J Phys Med Rehabil, 81, 342-9.
    Kuan, TS, Chen, JT, Chen, SM, Chien, CH & Hong, CZ 2002. Effect of botulinum toxin on endplate noise in myofascial trigger spots of rabbit skeletal muscle. Am J Phys Med Rehabil, 81, 512-20.

    Of course, when the blood supply is insufficient, the pH will drop. The same NIH researchers measured the pH in the immediate vicinity of active TrPs to be 4.5, which is more than sufficient to activate acid sensing ion channels (ASICs; especially ASIC-1a and ASIC-3) and transient receptor potential vanilloid (TRPV) receptors, which in turn contribute to mechanical hyperalgesia and central sensitization, because of the subsequent release of several
    nociceptive substances, such as calcitonin gene related peptide (CGRP), adenosine triphosphate (ATP), bradykinin (BK), serotonin (5-HT), prostaglandins (PGs), potassium, and protons. As you may know, ATP is one if the most important activating substances of muscle nociceptors by binding to P2X3 receptors. To save you time in going through many studies, you may want to consider reading Dommerholt, J 2011. Dry needling — peripheral and central considerations. J Manual Manipul Ther, 19, 223-237.

    Joe questions whether TrPs contribute to central sensitization and the answer is absolutely. Central sensitization is the mechanism of referred pain from trigger points, which Travell and Simons
    described for most musculoskeletal muscles. The mechanisms of muscle referred pain have been described in detail by Hoheisel, Mense, Arendt-Nielsen, and Graven-Nielsen, among others, and
    involve sensitization and an expansion of receptive fields. There are many studies of TrPs and central sensitization. Dry needling is one of the most effective methods to alter central sensitization. Stimulation of muscle tissue, i.e., TrPs, is much more effective than stimulation of cutaneous tissue. TrPs are peripheral sources of persistent nociceptive input, which can excite muscle nociceptors. Nociceptive input from muscle is particularly effective in inducing
    neuroplastic changes in the spinal dorsal horn and likely in the brainstem. Dry needling may be instrumental in reversing such neuroplastic changes by removing a constant and intense nociceptive input source. Yes, there is plenty of literature to support this notion as well. A sensitized muscle nociceptor has a lowered stimulation threshold into the innocuous range and will respond to harmless stimuli like light pressure (allodynia) and muscle movement (mechanical hyperalgesia). Unfortunately, most data are derived from animal studies as there are only few human research on muscle nociceptor activation.

    You may be familiar with the many studies of Arendt-Nielsen from Denmark. His lab has published many scientific studies of for example latent TrPs and they concluded through many lines of research that latent TrPs are also nociceptive active. In other words, latent TrPs do contribute to central sensitization even though a person may not yet experience significant pain. See for example

    Ge, HY, Serrao, M, Andersen, OK, Graven-Nielsen, T & Arendt-Nielsen, L 2009. Increased H-reflex response induced by intramuscular electrical stimulation of latent myofascial trigger points. Acupunct Med, 27, 150-4.
    Ge, HY, Zhang, Y, Boudreau, S, Yue, SW & Arendt-Nielsen, L 2008. Induction of muscle cramps by nociceptive stimulation of latent myofascial trigger points. Exp Brain Res, 187, 623-9.
    Wang, Y-H, Ding, X-L, Zhang, Y et al 2009. Ischemic compression block attenuates mechanical hyperalgesia evoked from latent myofascial trigger points. Experimental Brain Research, 202, 265-270.
    Xu, YM, Ge, HY & Arendt-Nielsen, L 2010. Sustained nociceptive mechanical stimulation of latent myofascial trigger point induces central sensitization in healthy subjects. J Pain, 11, 1348-55.
    Zhang, Y, Ge, HY, Yue, SW, Kimura, Y & Arendt-Nielsen, L 2009. Attenuated skin blood flow response to nociceptive stimulation of latent myofascial trigger points. Arch Phys Med Rehabil, 90, 325-32.

    Glen, I can’t agree more with you when you state “If PT’s continue to avoid asking the important questions we will marginalize ourselves into oblivion.” I can assure you that PTs who successfully pass the certification examinations of Myopain Seminars have been pushed to ask those important questions with a very extensive review of the scientific literature. In Canada, the prevailing model of dry needling is Gunn’s radiculopathy model. The most recent scientific outcome study was published in 1980.

    Joe, you mentioned that “the vision of the APTA for 2020 is to move forward and I am afraid that our profession will not unless we ensure that we are truly practicing evidence-based medicine.” Of interest is that during the past year, the APTA conducted a very detailed study of the validity of dry needling and its underlying principles, and just last week published its findings in a supportive resource paper. Based on the independent review (independent in the sense that non-dry needlers and scientists without a vested interest in dry needling and trigger point stuff completed the study), dry needling will be included in the next edition of the Guide to Physical Therapy Practice.

    I hope to have provided you with some food for thought.

    Jan Dommerholt
    President, Myopain Seminars

    • Thanks for your response Jan. I appreciate your professionalism and willingness to engage in discussion. I also appreciate the references, which like Kory, I am reading through. I do not have access to the Acupuncture journal you cited, but I assume that that article is irrelevant since a journal promoting accupuncture wouldn’t publish a competing and different science.

      I want to begin my comments based upon this comment you made:
      “Joe questions whether TrPs contribute to central sensitization and the answer is absolutely. Central sensitization is the mechanism of referred pain from trigger points, which Travell and Simons
      described for most musculoskeletal muscles. The mechanisms of muscle referred pain have been described in detail by Hoheisel, Mense, Arendt-Nielsen, and Graven-Nielsen, among others, and
      involve sensitization and an expansion of receptive fields. There are many studies of TrPs and central sensitization. Dry needling is one of the most effective methods to alter central sensitization.”

      From my understanding of modern neuroscience and the descriptions of central sensitization in article published in high impact journals, central sensitization is a phenomenon with several mechanisms, all of which are synaptic, none of which have anything to do with muscle, at all. Do you have biopsy or cadaveric studies which demonstrate that trigger points are muscle tissue? Or are we assuming based on how they look on ultrasound imaging? It is the assumption of those in clinical neuroscience that if trigger points exist, then they more likely to be in nerves, not muscles (because only nerve cells are long enough to span the distance between cord and surface of organism where sore spots are palpable) and central sensitization will travel from cord to periphery, not from periphery to cord.

      By definition, pain is 100% of the time an output from the brain. This can be based upon an input from the periphery, with or without nociception (as Bas stated). An input is not necessary. I have a difficulty understanding the concept that pain can travel from one muscle to another and that peripheral input from trigger points causes central sensitization. To those who understand the neuromatrix, this is logically impossible.

      How can you say that dry needling is one of the most effective ways in controlling central sensitization? I am baffled by this comment. Individuals in this state are extremely hypersensative in undefined regions and can experience pain based upon variables such as environmental contexts, beliefs, past experiences, etc. Would you argue that dry needling can affect this central process and we are incorrect in assuming psychological variables have more of an influence than the periphery while in this state?

  22. All very interesting. I wonder if you have any literature that would specifically address the following questions from Kory:

    If Dry Needling truly is different and the only thing that differentiates it is LTR with injecting into a trigger point. Then we need to know is a trigger point the only thing that can elicit a LTR and are all trigger points a causation of some underlying pathological condition? If a LTR can be elicited in normal tissue then we have no way of knowing if we are in a trigger point or not. And if all trigger points are not a causation of some underlying pathological condition, how do we know which ones to treat?

  23. Hi Kory,

    With regard to the LTR’s, the following studies referenced above by Jan explain the LTR, the active and latent TrP, and the research behind the changes that occur in tissue after stimulation/LTR measured by in vivo microdyalysis technique.

    As Jan stated, “Researchers at the US National Institutes of Health have not only visualized TrPs, they have analyzed the immediate vicinity of active and latent TrPs and found that active TrPs are characterized by the presence of multiple inflammatory mediators, such as CGHRP, substance P, norepinephrine, interleukins, TNF-alpha, etc. Questions were raised about the local twitch response. Of interest is that after eliciting a LTR, the concentrations of these chemical nociceptive substances was reduced to near-normal values minutes after the stimulation. There are several studies of the relevancy of LTRs. See for example:”

    Chen, JT, Chung, KC, Hou, CR et al 2001. Inhibitory effect of dry needling on the spontaneous electrical activity recorded from myofascial trigger spots of rabbit skeletal muscle. Am J Phys Med Rehabil, 80, 729-735.
    Dexter, JR & Simons, DG 1981. Local twitch response in human muscle evoked by palpation and needle penetration of a trigger point. Arch Phys Med Rehabil, 62, 521.
    Hong, CZ 1994. Lidocaine injection versus dry needling to myofascial trigger point. The importance of the local twitch response. Am J Phys Med Rehabil, 73, 256-63.
    Hong, CZ 1994. Persistence of local twitch response with loss of conduction to and from the spinal cord. Arch Phys Med Rehabil, 75, 12-6.
    Wang, F & Audette, J 2000. Electrophysiological characteristics of the local twitch response with active myofascial pain of neck compared with a control group with latent trigger points. Am J Phys Med Rehabil, 79, 203.

    I would also again mention that the Shah and Gilliams article from 2008 (which I referenced in my earlier list) does a very nice job of detailing the LTR, as well as describing how the local biochemical milieu of active TrP’s in the UT differ from a remote, uninvolved site in the gastrocs. (i.e. the tissue around the TrP has been shown to be biochemically different than tissue around latent TrP’s and normal tissue). Of particular interest – in that same study they found that although none of the subjects in the “active” group had TrP’s in the gastrocs, the analyte concentrations of the “active” group were significantly higher than in the latent and normal groups, hypothesized to be related to central sensitization, and leading to questions about what makes individuals susceptible to possibly widespread elevations of biochemicals.

    The development of chronic pain and central sensitization is fascinating to me. It is very complex and affected by many, many factors. I personally am happy to be able to assist these patients in regaining some normalcy in their lives after they have suffered for many years without relief from many other techniques, including medications, surgeries, injections, psychotherapy, physical and occupational therapy, pain management, alternative healing modalities, etc. I am happy to know that there are others out there who are as motivated to seek out the research and work with these patients who are often passed off as being “malingerers” or told that “it is all in their heads.” As we all work together to find the best solutions, our patients will surely benefit.

    I want to thank everyone for the interesting discussion, and wish you all the best as you participate in the care of patients who are in pain. I am happy to address further questions via email, and you can contact me through my website http://www.prana-pt.com.

    Best Regards,
    Ann

  24. Ann and Jan, thank you for the reply and the references in regards to LTR. I will read these with interest as I see I need to understand the mechanisms at play with LTR.

    Just trying to wrap my mind around what is going on biologically. I have felt what I thought was LTR in my shoulder when getting a flu shot in the past when the muscle twitched upon insertion of the needle by the nurse. Maybe this was not an actual LTR, because I was not having any problems or pain with my shoulder or anywhere at the time that would lead me to think I had a TrP causing any pathological problem. (It was a little sore after the shot, but I think the immune response from the vaccine and sensitization of the nervous system was mostly at play then :) )

    I have also felt muscle twitches in my arms or legs at various times at rest. I use to think these and LTR might be the same, but if I’m understanding you correctly, they are not. So again I appreciate your time and references so I can understand the mechanisms at hand better.

    I realize that I may be over cautious and falling behind on valuable treatment interventions, but as a new graduate in the early 90s I used many of Richard Don Tigny’s treatment techniqes for SI problems. Many patients felt better with them. Somewhat shamfully now, I understand that there were other mechanisms in play for them to get better and not as I believed and was taught at the time. I’m just trying to avoid being reminded in a blog post similar to what John Childs posted over at EIM Blog in regards to a Blast from the Past in another 15 years from now that I chased another rabbit hole. (http://blog.myphysicaltherapyspace.com/2012/01/a-blast-from-the-past.html)

    • Kory,I do share your concerns about chasing another rabbit hole. By nature, I am a very skeptical person and agree that many interventions may have a positive outcome without anyone having any idea why they would work. I have studied cranio-sacral therapy, had some interesting results, but I do not comprehend the mechanisms, am troubled by the lack of research, etc., and therefore refer patients who insist on being approached with CST to other PTs in my community. What I found attractive in TrP research that the initiators of this field of study (Janet Travell and David Simons) always challenged researchers to prove them wrong. I worked closely with David Simons for many years and was always impresses with his relentless search for facts to improve the scientific basis of our understanding of TrPs, I do not see that in many other parts of our profession. I am very well versed in the myofascial pain literature and the chronic/persistent pain literature and came to the conclusion that this is one of the best supported topics and approaches. Of course, there are always many more questions that answers, but that is part of the excitement. If you have an opportunity to read the reviews I publish of the myofascial pain literature (I prepare a quartely column for the J Musculoskeletal Pain), you may be pleasantly surprised about my at times very critical commentaries. Much research makes little sense, but if you take the time to work your way through the literature, I hope you would come to the same conclusion I came to. Of interest perhaps is that several years ago our colleague David Butler was very skeptical about TrPs and dry needling as he frequently voiced on his interactive discussion site on niogroup.com. In response, I invited him to speak at our Focus on Pain conference. I will never forget that during a lecture of Jay Shah (one of the NIH researchers I mentioned before), that David turned to me and stated “I had no idea that this body of research existed.” When he returned to Australia, he corrected his previous statements and admitted that he had expressed strong opinions without knowing what he was talking about. We have remained professional friends and have nothing but respect for each others contributions.

      Our course participants receive a 380-page syllabus with scientific articles about mechanisms, pathophysiology, etc, and are expected to critically analyze these. Our theoretical exam is quite challenging and includes much of the pain sciences others have referred to.

      BTW, the flu shot may have hit a latent TrP and caused a twitch response. The twitching in your arms and legs is likely not the same as LTRs.

  25. “Central sensitization is the mechanism of referred pain from trigger points, which Travell and Simons described for most musculoskeletal muscles”

    I could not believe reading this. Really?!?
    The whole concept of pain being an experience produced by brain activities, based on input from a variety of nervous structures, including the periphery, but NOT requiring it, leads to me to say that the above quote is at best “poorly stated”. At worst, it is a serious deviation from the present wealth of neuroscientific evidence about pain.

    It behooves us to appreciate how much our own confidence in our techniques and the trust of the patient in us, can drive the beneficent outcomes of our interventions. As soon as we acknowledge that, we then must examine the most likely and plausible explanation for what we observe.

  26. Shannon Murphy, PT, MPT Reply January 17, 2012 at 12:41 pm

    A few thoughts on all of the above:

    Trigger points have indeed been scientifically visualized, believe that video ultrasound of both the trigger point and LTR elicited by needling was shown during the Myopain seminars; since few clinicians have access to diagnostic ultrasound in the clinic, however, palpatory skills become the default. In time, perhaps that will change.

    Kory – your interest in learning more about the science behind LTRs and MTrPs in general is helpful and encouraging. And the desire to avoid a repeat of past dissapointments is a sign of personal growth – who among us doesn’t have some prior conviction that we don’t seriously regret as our new, more enlighted selves? I think I have sufficient, evidence-based research at this point to say that Sun-In and mall-bangs were not as unquestionably cool as my 8th self once unfailingly believed…. And regretfully, there are probably truths that we know & believe today that will get reconsidered tomorrow. Politicians get lambasted for “flip-flopping” over their career records – but I’m not sure that change and evolution over time are bad things.

    As to central sensitization – I need to re-read the above very carefully to figure out what we’re arguing about; the MTrP piece is simply that sustained noxious stimuli have an end result of increasing system gain / sensitization. I’m not sure how that premise is at odds with the current state of neuroscience and pain research.

    At the end of the day, I think Ann’s piece was a solid contribution to public education on the scope of physical therapy and treatment concepts. The insider debate on trigger-point theory and dry needling remains one that I expect will play out over time and research – but you always need two voices in a conversation, so the dissent is a natural piece of the process. Glad the post has drawn so much commentary.

    • My concern with the MTrP is not as much if they can be visualized with US imiging as to clinical usefullness of the them. (I just sent the many references to my librarian to get them, so I appoligize I have not had the opportunity to read them as of yet).

      My examples of concern with this are: Herniated discs are easily viewed on MRI’s but we know that a large percent of the normal population walk around with them on a regular basis with no problems. We also know that discs can herniate and return to a more normal state on their own over time. Also they can be cut out surgically and the segments fused and no change in the patients status after all of that. McKenzie method was once thought to “push” the disc back into place. We now know that is not the case. Another example was we used to think heel spurs were the cause of “plantarfasciitis”, but we realize now they are a normal occurance and have no correlation with the symptoms and cutting them out is probably going to make it worse.

      So even if MTrP are there, with what accuracy can we say that is a source of the problem or is it a normal occurance in many people? And would MTrP reduce on their own over time as a part of normal course of healing or does my treatment have a direct response on reducing them or are other interactive placebo responses in play.

      • Kory,

        To figure out whether a TrP is clinically relevant requires a detailed examination considering motor and sensory aspects. TrPs can be relevant in acute injuries and treatment with manual techniques or dry needling can quickly resolve the problem. This may be relevant for acute sports injuries. I have seen soccer players with so-called hamstring pulls or groin pain, which resolved game side and they were able to continue playing. Nearly everyone has latent TrPs and it is a fair question to consider whether they should be considered. Many latent TrPs are probably irrelevant, but once patients come in with particular pain problems, these TrPs can be relevant. As I mentioned before, latent TrPs are commonly sources of nociceptive input and while they may not be the primary target, based on recent scientific evidence, we do recommend to include these in the treatment. The initial focus is however, on active TrPs, which spontaneously cause the patient’s familiar pain.

        There are quite a few studies supporting the clinical application of TrPs. See for example:

        Bron, C, De Gast, A, Dommerholt, J et al 2011. Treatment of myofascial trigger points in patients with chronic shoulder pain; a randomized controlled trial BMC Medicine, 9, 8.

        Fernández De Las Peñas, C, Alonso-Blanco, C, Cuadrado, ML, Gerwin, RD & Pareja, JA 2006. Myofascial trigger points and their relationship to headache clinical parameters in chronic tension-type headache. Headache, 46, 1264-72.

        Fernández De Las Peñas, C, Campo, MS, Carnero, JF & Page, JCM 2005. Manual therapies in myofascial trigger point treatment: a systematic review. J Bodyw Mov Ther, 9, 27-34.

        Fernández De Las Peñas, C, Ge, HY, Arendt-Nielsen, L, Cuadrado, ML & Pareja, JA 2007. Referred pain from trapezius muscle trigger points shares similar characteristics with chronic tension type headache. Eur J Pain, 11, 475-482.

        Fernández De Las Peñas, C, Simons, D, Cuadrado, ML & Pareja, J 2007. The role of myofascial trigger points in musculoskeletal pain syndromes of the head and neck. Curr Pain Headache Rep, 11, 365-72.

        Fernandez-Carnero, J, La Touche, R, Ortega-Santiago, R et al 2010. Short-term effects of dry needling of active myofascial trigger points in the masseter muscle in patients with temporomandibular disorders. J Orofac Pain, 24, 106-12.

        Fernández-De-Las-Peñas, C, Alonso-Blanco, C, Fernández-Carnero, J & Miangolarra-Page, JC 2006. The immediate effect of ischemic compression technique and transverse friction massage on tenderness of active and latent myofascial trigger points: a pilot study. J Bodyw Mov Ther, 10, 3-9.

        Hidalgo-Lozano, A, Fernández-De-Las-Peñas, C, Alonso-Blanco, C et al 2010. Muscle trigger points and pressure pain hyperalgesia in the shoulder muscles in patients with unilateral shoulder impingement: a blinded, controlled study. Experimental Brain Research, 202, 915-925.

        Hidalgo-Lozano, A, Fernandez-De-Las-Penas, C, Calderon-Soto, C et al 2011. Elite swimmers with and without unilateral shoulder pain: mechanical hyperalgesia and active/latent muscle trigger points in neck-shoulder muscles. Scandinavian journal of medicine & science in sports.

        Hidalgo-Lozano, A, Fernández-De-Las-Peňas, C, Díaz-Rodríguez, L et al 2011. Changes in pain and pressure pain sensitivity after manual treatment of active trigger points in patients with unilateral shoulder impingement: A case series. J Bodyw Mov Ther, 15, 399-404.

        Rodriguez Blanco, C, Fernández De Las Peñas, C, Hernández Xumet, JE et al 2006. Changes in active mouth opening following a single treatment of latent myofascial trigger points in the masseter muscle involving post-isometric relaxation or strain/counterstrain. J Bodyw Mov Ther, 10, 197-205.

        Ruiz-Saez, M, Fernandez-De-Las-Penas, C, Blanco, CR, Martinez-Segura, R & Garcia-Leon, R 2007. Changes in pressure pain sensitivity in latent myofascial trigger points in the upper trapezius muscle after a cervical spine manipulation in pain-free subjects. J Manipulative Physiol Ther, 30, 578-83.

        Affaitati, G, Costantini, R, Fabrizio, A et al 2011. Effects of treatment of peripheral pain generators in fibromyalgia patients. Eur J Pain, 15, 61-9.

        Alonso-Blanco, C, Fernandez-De-Las-Penas, C, Morales-Cabezas, M et al 2011. Multiple Active Myofascial Trigger Points Reproduce The Overall Spontaneous Pain Pattern in Women With Fibromyalgia and are Related to Widespread Mechanical Hypersensitivity. The Clinical journal of pain.

        • Jan, thank you for the reply back. I appreciate your responses to help clarify the mechanisms at hand with Dry Needling.

          You stated: “To figure out whether a TrP is clinically relevant requires a detailed examination considering motor and sensory aspects.”

          So there is actual specific muscle weakness or sensation loss that is clinically detectable with the MTrP that are relevant, if I’m understanding your response correctly? I can see plausibility that there could be muscle weakness since the MTrP is in the muscle. Not sure if manual muscle testing would be able to detect this though. Is there some other method you use to test the muscle weakness? I am a bit confused on sensory loss and how that equates with a MTrP. I think of sensory loss as related to a specific peripheral nerve or dermatome region not a muscle that has a MTrP. I’m guessing you use monofiliment or pain pressure threshold to measure this?

          You also stated:”TrPs can be relevant in acute injuries and treatment with manual techniques or dry needling can quickly resolve the problem.”

          When you refer to acute sports injuries are you referring to something that has actual tissue damage and would undergo an inflammatory response as part of it’s normal healing? By “resolve the problem”, do you mean the healing/inflammatory response goes through all phases of healing (chemical inflammatory response, proliferation, remodeling) immediately to allow the athlete back into competition?

          Last question from your response to help with my understanding: “Many latent TrPs are probably irrelevant, but once patients come in with particular pain problems, these TrPs can be relevant.”

          Why would a latent TrP be irrelevant if I have no pain, but all of sudden become relevant if I experienced pain? What mechanism is in play that changes the TrP from irrelevant (not producing nociceptive input) to relevant (produce nociceptive input)?

  27. Hey Everyone,
    Can anyone compare and contrast the courses offered by Myopain Seminars program and others such as Kinetacore or the Spinal Manipulation Institute, etc.? Is one superior to the other, if so then why? I have heard about dry needling for quite some time now. It is not within my state’s practice act at this time but in time I am hoping it will be. Thank you. -Jeff

    • Jeff – I can not comment on Kinetacore or the Spinal Manip Inst’s dry needling course specifically, but I have attended a Spinal Manip Inst course in the past and was pleased. I also like that Dunning is publishing more and more lately, showing efficacy in his techniques.

      I have total respect for Myopain, but have not gone through their dry needling classes. I correspond with a few myopain instructors and students and they have taught me a lot. I respect them a ton and the only reason I havent attended more of their classes is my hectic schedule.

      Dr. Ma’s course is interesting. He has many years of experience in the technique and sits on some prestigious boards. There is an entire day of the 3-day seminar that is dedicated to efficacy, though myopain really drives this home even more. I have attended a Dr. Ma seminar and was classmates from actual acupuncturists and myopain students. His technique is different. My lab partner was a long time acupuncturist and she was excited about using dry needling as a technique in addition to her traditional acupuncture treatments. She said they were completely different techniques and rationale.

  28. “the MTrP piece is simply that sustained noxious stimuli have an end result of increasing system gain / sensitization.”
    Thanks for your post. The above quote brings me to the following (in addition to what Kory states):
    how does one know that the TrP is an ongoing noxious stimulus? And NOT the result of a painful state? In other words: defense versus defect?
    This is of course accepting that they are reliably found by manual exam (and not US or other imaging) in clinical situations and reliably correlated with the painful state of the patient.

    How can one tell whether they are defect or defense?
    And how can their (peripheral) treatment change all the aspects of persistent pain as Ann stated? Is it really the needle?

  29. Kory,

    TrPs inhibit full muscle function and while muscle weakness is not specific, regular muscle testing can point into the direction of TrPs. For example, asking the patient to stand on one leg can point one to weakness in the glut medius. Of course, there may be many reasons why that patient presents with a positive Trendelenburg, but when the muscle is weak, the next step would be the check the muscle for the presence of taut bands and TrPs. Once these TrPs are treated, muscle strength return usually immediately. In other words, TrPs can inhibit normal muscle activation.

    “Sensory” does not necessarily imply a loss of sensation. I used the term “sensory” in the sense that the patient with active TrPs c/o pain. IN the glut med example, the referred pain pattern of the glut med and glut min mimics a radiculopathy. If that same patient with weakness in these muscles c/o pain down their leg, the sensory complaint would point a clinician toward these muscles. The referred pain patterns described by Travell as early as 1952 with variations described by others in later years (i.e., Dejung et al in Switzerland published a book with slightly different patterns) become a guide to which muscles are likely to harbor active TrPs.

    Regarding acute injuries, I am not referring to muscle tears, etc., but to acute muscle spasms, that I believe are often misinterpreted on the sideline of a sports event as a muscle tear. A team physician or physical therapist should be able to assess the nature of the sudden pain. If that athlete presents with taut bands which upon evaluation (palpation) presents as the source of the sudden pain, it is reasonable to treat it as a TrP. If that athlete would have a real tear rather than a muscle spasm or contracture, he/she would not respond well to the needling. In that sense, dry needling can also be used as a diagnostic tool.

    Nearly everyone has latent TrPs. There is some speculation why that may be the case. Recent NIH research showed that contractures are already present within muscle before these can be palpated as TrPs (see Ballyns, JJ, Shah, JP, Hammond, J et al 2011. Objective sonographic measures for characterizing myofascial trigger points associated with cervical pain. J Ultrasound Med, 30, 1331-40). This and other studies suggest that these contractures occur on some kind of “sliding scale” ranging from non-palpable contractures within muscle (visible only on high-quailty sonography) to latent to active TrPs. There is some emerging evidence that the more contracted the muscle fibers are, the more sensitization occurs, presumable because the capillary blood flow becomes more and more restricted, causing a more significant lack of oxygen, a lower pH, etc.

    It all makes perfect sense and is supported by outstanding research from the NIH, and several other highly regarded labs around the world (Germany, Denmark, Taiwan, etc).

    Moving on,

    Jan

    • Jan, thank you for your responses and time. I take from your final statement “Moving on” that my questioning is moving into the annoying catagory, I appoligize for that as that was not my intent.

      As I evaluate things I like to utilize the “5 Whys” as my questions-asking method to explore the cause/effect relationships underlying a particular problem. I am about 3 Whys into it, so I will not continue with my last 2, as I do not want to offend someone or take away from their valuable time. :)

      Again I appreciate your time, answers to this point and references you have provided to allow me further study into Dry Needling.

  30. Well I see that this discussion is going to become circular quite fast.

    I will part with two points:

    1) Based on the literature I have read (much of the work Jan Dommerholt listed) along with my developing understanding of pain physiology, I remain quite skeptical about the requirement to jab my patients with needles, into debatable “trigger points” that may… or may not be clinically relevant.

    I have had the opportunity to observe dry needling and based on the patient-therapist interactions I have witnessed, I just do not think you can seperate the non specific effects from the specific treatment effects. I think Jware put it best when he stated:

    “Is it possible that undergoing a long and arduous training to insert needles into painful areas of patients’ bodies might impart to the clinician this as yet ill-defined and elusive practitioner characteristic(s) that apparently serves to heighten already established placebo effects?”

    I challange anyone to dispute this.

    Secondly, I agree with Mike Reinhold when he states “Our goal is to make people feel better”. I also agree with Selena in that I am an outcomes guy as well (I also like to see my patients feeling better and functioning better). My only caution on that would be the potential for nocebo effects when we impart tooth fairy science upon our patients. Again as Jware highlighted, millions of patients “feel better” with the subluxation as the back drop explanation. Yet I am not sure having millions of people walking around convinced that their bones just move out of place like that is helpful.

    It seems much of the science behind the effects of spinal manipulation are being revealed now (ie; bones are not put back in place). I loathe the fact that years ago I left my patients with the impression that their bones randomly moved out of place and required my skills to fix the problem.

    I think I’ll hold off on informing my patients that they have trigger points causing their pain and then subsequently jabbing them with needles. Seems a little too invasive(for me)based on where the literature stands right about now.

  31. It is very interesting to read the opinions of Ann and John Ware. In fact, I have answered all the questions asked by John in my course.

    As I emphasized in the course that all models work and clinically effective, each model represents partial truth, all models share the same physiological mechanisms, any scientific researches that support any particular models in fact support every model, while any researches which disprove or falsify any model only disprove
    the theory of that models, not clinical practice of that model. For example, we disprove meridian, and Luke disproves Trigger points, both models are clinical effective, but they need to change model theories.

    That is why I am integrating all the models together into one model because they all share the same physiology. TCM acupuncture is different from dry needling because they have different theories which have been developed in completely different history and background thus the trainings for using both models are different.

    If you read my textbook, you should see this. Also sometimes we do not understand what placebo is (good explanation is in my first book). Again Luke’s research find many problems with Trigger points theory that I completely agree and Luke’s researches does not falsify the clinical practice of trigger points which is an empirical not scientific model. Of course science develops because of disagreement.

    This is why in my course I emphasize, if you remember, that scientific philosophical thinking is important. Both John and Ann need widen their thinking.

    Dr Yun-tao Ma,
    Director,
    American Dry needling Institute
    http://www.DryNeedlingCourse.com

    • Who’s Luke?

      By your reasoning, Dr. Ma, we should then eschew the scientific method for emperically-based clinical practices like trigger point dry-needling.

      I find that position very dubious.

      I suspect that by attending your course I’d acquire an understanding of this elusive concept you refer to as “scientific philosophical thinking”?

      [deleted by editor]

      I’ll stick with real science and keep my brain within my cranial vault- but thanks anyway.

  32. Shannon Murphy, PT, MPT Reply January 18, 2012 at 2:13 pm

    Glen -

    While I recognize that you are speaking figuratively, it seems fair to clarify that no one is requiring anyone to jab anything into anyone. Dry needling is just one option among many others. Personally speaking – I needle and find it effective… but also go days without needling anyone. It’s a tool, not a theology.

    Kory -

    I don’t think your line of questioning is annoying or being perceived as such. But I think Jan is expressing that he’s put sufficient research & response out there for the time being. We’re all “busy”, but Jan really takes over-extended to a new level. At any rate … caution, analysis, and seeking a deeper understanding of topics aren’t bad qualities. Unless you are “that” guy trying to figure out what he wants at Panera while everyone else waits to get their selection of choice. Don’t be that guy.

    Bas-

    Determining defect vs defense – well, I think chickens & eggs are always difficult to sort out. I think MTrPs are generally both the product of a noxious state, as well as then an ongoing source of noxious input themselves … I don’t think you have to put trigger points, more than any other dysfunction, into a strict box of cause or effect. Relevant clinical example and apropo to the original article upon which this debate was started (bear with me):

    I have been seeing a woman for R shld issues for about 6 wks – repetitive injuries over time, most recently fall over summer, came in with presenting complaint of severe shooting headaches and pervasive aching R shld. Her upper traps, levator scap and supraspin were wicked tender to palpation, full of nodules, and sustained pressure to UT that replicated her HA pattern. Dry needling to all the same muscles resolved HA frequency by about 80% after first visit. Did repeat DN at another future visit to “clean up” residual sx, but generally more put more effort in addressing the underlying “issue” – compensatory mechanics following from pain and injury. Worked on nuanced exercise for neuro-reed, taping, bracing with substantial improvement.

    Patient was off schedule over holidays, returned with new aching and occasssional shooting pains into anterior chest and post scap. Palpation to anterior scalene replicated symptoms, but did not needle – to be honest, it’s not my favorite to do and I generally try manual release first. Again, significant relief after 1 session. Revisiting home exercises revealed a serious ‘morphing’ of technique and a propensity for UT & supraclavicular compensation. Re-trained, no further symptoms of that nature since.

    I am seeing her now intermittently to check exercise technique and treat residual arthritic sx–saw her last night, in fact. While doing some general soft tissue work to R shld, I noticed a patch on her L elbow – a piece of the Flector patch that she sometimes uses on the R shld. Asked her about it, and she confessed to recent onset L elbow pain – states she didn’t want to mention b/c she feels self-conscious about ‘falling apart’ and being ‘too young for this *$&!’. I played off, said “OK – well, keep an eye on it and maybe we’ll take a look at it a bit more if still bothering you next week”. Meanwhile, I sit her up and recheck various things from spinal/scap alignment standpoint and notice a significant increase in tonicity of the L supraspin, lesser degree UT/levator. She acknowledges doing more with the L arm to decrease overuse of her dominant R arm, which was something I counseled her to try. Palpation was tender and reminiscent of the former presentation on the R, although I deliberately didn’t sustain pressure since I had a theory and didn’t want to bias her reaction. Asked her if she was amenable to a quick round of needling to keep the L from escalating – she agreed. Got several LTRs and extinquished with DN, f/b stretching. Had patient sit up who immediately noticed a looser perception in her neck. As we get ready to wrap up for the evening, she cocks her in a confused canine fashion
    and says: “Wait- my elbow doesn’t hurt”

    Swear to the heavens.

    I laughed a little and explained my theory that the tightness in L shld might have been the source of, or at least a contribution to, her elbow pain. Now – she probably has some forearm stuff, and restricted radial head stuff, and so on – and none of that is invalid, and we’ll probably look at it down the road. But it seemed like a heaven-sent case in point and incredibly timely for this discussion.

    For me, education in dry needling has refined my assessment skills- regardless of whether I choose to needle. I can only speak to the Myopain program, but it has been a fully worthwhile experience.

    PS: Icing on cake: the patient is also licensed in traditional Chinese acupuncture.

  33. Shannon Murphy, PT, MPT Reply January 18, 2012 at 2:21 pm

    (PS: Kory – The Panera thing was a joke, BTW! My emoticon didn’t go through -? )

  34. Kory, I do share your concerns about chasing another rabbit hole. By nature, I am a very skeptical person and agree that many interventions may have a positive outcome without anyone having any idea why they would work. I have studied cranio-sacral therapy, had some interesting results, but I do not comprehend the mechanisms, am troubled by the lack of research, etc., and therefore refer patients who insist on being approached with CST to other PTs in my community. What I found attractive in TrP research that the initiators of this field of study (Janet Travell and David Simons) always challenged researchers to prove them wrong. I worked closely with David Simons for many years and was always impressed with his relentless search for facts to improve the scientific basis of our understanding of TrPs, I do not see that in many other parts of our profession.

    I am very well versed in the myofascial pain literature and the chronic/persistent pain literature and came to the conclusion that this is one of the best supported topics and approaches. Of course, there are always many more questions that answers, but that is part of the excitement. If you have an opportunity to read the reviews I publish of the myofascial pain literature (I prepare a quartely column for the J Musculoskeletal Pain), you may be pleasantly surprised about my at times very critical commentaries. Much research makes little sense, but if you take the time to work your way through the literature, I hope you would come to the same conclusion I came to. Of interest perhaps is that several years ago our colleague David Butler was very skeptical about TrPs and dry needling as he frequently voiced on his interactive discussion site on noigroup.com. In response, I invited him to speak at our Focus on Pain conference. I will never forget that during a lecture of Jay Shah (one of the NIH researchers I mentioned before), David turned to me and stated “I had no idea that this body of research existed.” When he returned to Australia, he corrected his previous statements and admitted that he had expressed strong opinions without knowing what he was talking about. We have remained professional friends and have nothing but respect for each others contributions.

    Our course participants receive a 380-page syllabus with scientific articles about mechanisms, pathophysiology, etc, a textbook and 5 other syllabi and are expected to critically analyze these. Our theoretical exam is quite challenging and includes much of the pain sciences others have referred to.

    BTW, the flu shot may have hit a latent TrP and caused a twitch response. The twitching in your arms and legs is likely not the same as LTRs.

    Agree with Yun-Tao Ma; we teach based on the same theoretical basis of pain sciences, although our needling approach is different. As Dr. Ma and I discussed over dinner last year in Dublin, Ireland, our dry needling approaches are very complimentary.

    Thanks to Shannon for correctly interpreting my “moving on” comment. All the best to all.

  35. To everyone:

    I must say that this has been one of the most enjoyable discussions I have seen on this website! This is what the internet is for!

    There have been some very interesting comments and questions, all of which are well deserved. I agree that there are many aspects of dry needling that we still dont understand and these questions need to be asked, research, and answered.

    I have learned early in my career not to discredit anything just because I dont understand. I used to be more skeptical of everything (perhaps the bostonian in me…). I pride myself of not only being evidence-based but also contributing to our body of evidence through research myself.

    But i also made a self discovery that probably made the biggest impact on my career – what I do isn’t about me – it is about the patient and our strive to provide an exceptional service.

    It is very similar to Joe Erhmann and his “insideout coaching.” The players are not there to serve the ego of the coach, the coach is there to help the athlete grow.

    This is when I entered professional sports and my objectives changed. My new goal was to do everything I can to help my athletes minimize injuries and enhance human performance. Now all of a sudden a budget, insurance company, a billing department, referral source, or any other outside factor had absolutely no influence on how I treated. To my initial disappointment, another outside factor that also didnt always matter was efficacy.

    I still base everything I do off efficacy, but if a patient/athlete feels that they need ESTIM to perform at their optimal level, I educate them on what ESTIM does but I would never deny them that treatment. I can educate but realistically someone can understand your point but still perceive something different. Who am I to deny them of that? I am here for them, not me.

    I get a sense from the group against trigger points and dry needling that they are more concerned about what they think rather than what the patient thinks.

    How can we ignore Shannon’s great story? Is the patient lying? Is the patient crazy? Is it a placebo effect? As a clinician, don’t you want to explore why that was so effective and learn how you can offer that same great experience to someone in your clinic?

    Despite an amazing amount of research that is becoming more and more of a focus everyday, we are clearly at an early stage in our understanding of trigger points, dry needling, etc.

    I would just simply say to both sides that we need to not be on either extreme end of a spectrum. Like Dr. Ma states, there are flaws in all the theories and mechanisms of action. But we clearly don’t know everything.

    I used to also discredit things immediately if I didn’t think they had enough efficacy. Now, even if there isn’t efficacy (again lack of efficacy is not the same as research saying no efficacy), if the anecdotal experience are strong enough I am open to trying anything to help my patients. There are many things I tried and thought were a bunch of bull@#$%! I tried and moved on. Knocking it without trying it is shortsighted. If you tried it and think it is bull@#$%, then go ahead and criticize!

    In regard to questions ethics, which I have seen alluded to here, that to me is a bit excessive. I see dry needling as a technique with potential to have a positive impact on our outcomes and patient satisfaction. I would never be embarrassed or worried about my ethical decision to try to help someone. Add to this that the APTA has released a white paper in support of dry needling (http://www.apta.org/StateIssues/DryNeedling/ResourcePaper/) with comments such as:

    “Preliminary research supports that dry needling improves pain control, reduces muscle tension, normalizes biochemical and electrical dysfunction of motor endplates, and facilitates an accelerated return to active rehabilitation.”

    In the APTA’s review of 154 articles on dry needling they found:

    “Of the 23 RCTs, again using a rating scale from 0‐5, with 5 indicating the highest level of quality and highest level of support for dry needling, the median quality of the research was 4; the median support of dry needling was 3.”

    • I just want to take a moment to thank several people:
      Mike, thank you for the opportunity to guest post. I enjoyed writing about one of the techniques I use as part of a patient’s whole plan of care. I am excited by the level of interest in the research, and I hope that the references I provided will give folks a good place to start their review of the literature.
      Jan, thank you for providing your thoughts and sharing the research. I feel very well prepared to discuss the science behind the techniques I use thanks to the education I received from Myopain Seminars. My first exposure to the term central sensitization was during our pain science lectures. I finally understood the mechanism of ongoing pain from your statement that “chronic pain is not prolonged acute pain.” I knew this in part from my clinical experience; but, the research explained it to me and in turn allows me to explain it to my patients, who have often been told they are exaggerating or making things up.
      Dr. Ma, thank you for taking the time to read the article and comment. I look forward to reading your materials and learning more about your techniques.
      I would encourage everyone to keep reading, researching, asking questions and working with a collaborative attitude. If there is anything I have learned after nearly 20 years in this field, it is that ideas and techniques come and go; but, what lasts is an inquisitive and open mind, a kind heart, a good deal of humility and the passion to help others resume the activities that give meaning to their lives.
      Be well!
      Ann

  36. Mike,

    From what I gather from your last comment, you feel that so long as the patient improves (both from a pain perspective as well as functionally), it really is no business of ours how they improve?

    Respectfully, we disagree completely.

    I wonder what your thoughts then would be about say….visceral manipulation?

    http://www.sciencebasedmedicine.org/index.php/visceral-manipulation-embraced-by-the-apta/

    Is this how we want our profession potrayed going forward? One that embraces anything so long as “it works”.

    It’s articals like this one (with a wide readership) when I refer to marginalizing ourselves into oblivion.

  37. There is a big gap between the research about trigger points, outcome studies and what actually happens in the patient’s brain (where the pain experience occurs and where the pain experience changes, improves or worsens). Assigning positive effects to technique without considering a) the skin that is needled FIRST, and b) the influence of all the other aspects of the neuromatrix, is blatantly premature.

    I can not get past this:
    “Knocking it without trying it is shortsighted. If you tried it and think it is bull@#$%, then go ahead and criticize!”

    Have you tried faith healing? Snake oil? Past-lives regression therapy? Releasing memories from fascia (MFR)?
    All of these have been or are tauted as “helpful” and “effective” at some time or other, yet I feel fully able and capable to criticize them, without trying them first.
    That “try it first” is similar to post-modernist thinking where both sides of ANY argument or issue are given equal value.

    There has been no study posted where it has been clearly demonstrated that the cutaneous structures HAVE been considered in dry needling, and found a non-issue. As long as that has not been done, any TrP “evidence” is tainted.

  38. BTW, that last paragraph applies to most any manual or therapeutic interaction that has contact with the human skin. Including MFR, CST or ortho-manipulative techniques – it is not limited to needling.

  39. Glen and Bas, trust me when I say I agree with you two. But, I think we are getting a little carried away. Dry needling isn’t as pseudo-science based as your reference to visceral manipulation or faith healing. And the APTA does not endorse visceral manipulation, as the article you referenced might suggestion. They Women’s Health section ran an ad, that is it.

    I don’t embrace anything just to please patients, I base my practice on efficacy first. In fact, I contribute to our professional body of knowledge and actually research and publish myself, which most people in this discussion can’t say.

    You guys are taking this WAY too far, you cant honestly compare dry needling to faith healing?

  40. Wow, great discussion guys. I am going to close this discussion. I want to keep this website is about sharing, learning, and growing together. It is great to ask questions and stimulate thought, and it is OK to disagree. Doing so makes us all take a step back think.

    Appreciate everyone’s input!

  41. Per the request of many readers, I am re-opening this discussion. Let’s keep it clean and professional. I will just flat out delete any comments that are offensive or belittling. Let’s discuss, debate, and share!

  42. Hi Jan,

    In regard to your comments about our systematic review, I feel I can offer some clarification.

    At the time we decided to conduct a systematic review on the reliability of palpation for the identification of trigger points, there was no accepted quality appraisal tool for the specific evaluation of reliability studies.

    For this reason, all other systematic reviews of reliability studies had been prepared by authors who had devised their own ‘tool’, but had provided very little information about how the tool was developed. We therefore decided to go to much greater lengths to devise a quality appraisal tool for the specific evaluation of reliability studies.

    We took the other tools into consideration and also compared our tool to QADAS, which is the accepted quality appraisal tool for studies of diagnostic accuracy. The experts we used to help develop the tool were also involved in the development of the STARD criteria for reporting studies of diagnostic accuracy.

    The tool we used to evaluate the quality of the reliability studies was not some ‘ad hoc’ tool we made up, and this is important for readers to understand. Also, remember that this systematic review was subjected to editorial and blinded peer-review by those at the Clinical Journal of Pain. We would have welcomed your formal response in the journal with critical feedback to help progress the scientific literature on this topic.

    Jan, your reasoning that our ‘entire study is questionable’ on the basis that our simple quality appraisal tool was lacking ‘reliability’ needs to be likewise applied to the practice of trigger point diagnosis and treatment. Without reliability, the practice is questionable.

    I’m pleased to say that our quality appraisal tool has been published in the Journal of Clinical Epidemiology and has also been subjected to a study of its reliability – and this paper is currently in the review process. We are happy with the results, which I will not pre-empt any further here.

    For interest, I would also like to mention the systematic review by Myburgh et al. which was published shortly before ours (it turns out that ours and theirs were under peer review at the same time).

    This European group, completely independently of us, decided to undertake a systematic review of trigger point diagnosis. They used a different quality appraisal approach and came to the conclusion that:

    “None of the trigger point criteria were found to have a high level of evidence supporting their reproducibility during manual palpation. However, the trapezius, gluteus medius, iliocostalis lumborum, and quadratus lumborum muscles were supported by moderate evidence for certain trigger point criteria…

    However, when considering the level of association required, it became evident that only local tenderness (trapezius) and pain referral (gluteus medius and quadratus lumborum) showed the required value of 0.4 or higher.”

    Myburgh et al. A systematic critical review of manual palpation for identifying myofascial trigger points: Evidence and clinical significance. Arch Phys Med Rehab; 89: 2008.

    All this is a moot point regarding your criticism, however.

    We did not use our quality appraisal tool to exclude any studies in the systematic review that we prepared on trigger point identification. There were so few studies that we decided to include them all and provide a critique of each one in a systematic manner.

    The quality scores we applied were used to make comment on the quality of papers in this field and to help researchers design better studies in the future. None of our quality criteria are contentious.

    Your criticism of our paper does not, therefore, make our “entire study rather questionable” as you suggest. In fact, you have misrepresented our quality appraisal tool by stating that it was used to “assess the reliability of the physical examination of TrPs”.

    It was used to evaluate the quality of papers reporting on the reliability of trigger point identification – which is very different from what you have implied…by error?

    I also note your criticism of our study on the basis that one of the quality criteria we use are that raters should be representative of those who would normally carry out the test in practice.

    I believe that you may have a misunderstanding.

    You and I are in agreement that tests should be reliable. My stance, and that of my co-authors, is that tests should be reliable when performed by those people who are performing them on patients. If experts are reliable, and these experts are different from the majority of those people performing the tests on a daily basis, then it is of more interest to know how reliable the ‘everyday’ practitioner is – and not just the expert.

    If experts are shown to be reliable, then this reliability can only be generalised to other experts with the same training. If the purpose of a study was to demonstrate that experts were reliable, and only experts were used in the study, then the study would not be downgraded.

    If, however, the study was being used to claim that ‘trigger point identification is reliable’ (which has been used to mean ‘reliable in general’) yet only expert raters were used, then these findings would not be applicable to the ‘everyday’ practitioner.

    By example, if specialist radiologists with years of training in the identification of breast carcinoma by MRI were reliable, we would not expect their reliability to be generalised to all radiologists.

    I do not believe that this criticism of our quality appraisal tool has merit, and it does not detract at all from the findings of our systematic review.

    If experts are reliable, then of course that is the first and proper step to demonstrate. Next, however, comes the need to demonstrate that students who graduate from courses teaching trigger point identification are as reliable as the experts – otherwise, why are they being remunerated for identifying trigger points on patients and applying precise interventions, such as dry needling?

    You need to be able to reliably identify a very discreet area of muscle tissue if you are to apply a very precise intervention such as a thin needle. If the reliability is not there, then the treatment cannot be specific.

    I would welcome a series of studies that show ‘everyday’ practitioners of trigger point therapy can reliably identify trigger points in all the muscles they say that they can identify them in.

    Jan, you also comment that ‘examiners in the early reliability studies were unreliable because they were not experts’ – which highlights the exact issue that led us to undertake our systematic review in the first place.

    If only experts are reliable, then what is everyone else doing? We do, however, make this generous statement about the ‘expert’ studies in our review:

    “Nevertheless, these studies provide estimates of reliability that might constitute a benchmark of what could, or should, be obtained in conventional practice.”

    Your comment that earlier studies were troublesome because non-experts were used doesn’t address the later studies in which experts were used – and in particular the Gerwin et al. study published in 1997.

    This paper has been used to sell the idea that trigger point identification is reliable – in fact, if you look at the citations of this paper, it has been cited as a positive study far more than any other reliability study on trigger points.

    What is not mentioned by those who cite this study is that it was not a study of identifying the exact location of a trigger point, but a study of identifying if a muscle had a trigger point in it.

    This is very different.

    Two expert clinicians may have agreed that a muscle had a trigger point in it, but may have identified different areas of that muscle.

    So, let’s be clear about this. These experts had some agreement about which muscles had trigger points in them, but this can’t be used to claim that experts can reliably identify the exact location of a trigger point for an exact intervention such as dry needling.

    In addition, we’re not sure, but it would seem, that localised tenderness and referred pain were what contributed to the reliability observed in this study, and not the palpatory findings, such as taut band.

    We do discuss all this in our review.

    The other major issue we have is with the difference between ‘tenderness’ and ‘trigger points’.

    If you remove the palpatory criteria for trigger point identification, such as taut bands, palpable nodules, and twitch responses, then reliability improves – but when you remove these features, you are no longer identifying trigger points, but tenderness – and tenderness is not a diagnosis or an entity.

    We comment on this in our review, but I quote Myburgh et al. here from the conclusion of their systematic review (note the emphasis on local tenderness and referred pain only),

    “Moderate evidence for the reproducibility of trigger point palpation of the trapezius for local tenderness and the gluteus
    medius and quadratus lumborum for pain referral has been shown. However, generally poor conceptual clarity and inconsistent designs render the evidence in this area of study weak.”

    Jan, I don’t think you would try to persuade others to disregard the findings of our systematic review on the basis that we are not trained through your system or that we have ‘dubious’ experience.

    I’m sure you would prefer people to read both our review and the one by Myburgh et al. and let them come to their own conclusion.

    I think your comments here have not represented our review correctly, and I wouldn’t want people to disregard our review on the basis of your criticisms here, which I believe I have clarified.

    We agree that there is an obvious need for reliable criteria to evaluate patients for the presence of TrPs. I believe that this is a requirement and not a bit of evidence that is ‘nice to have’.

    Right now, across the world, there are practitioners who believe that they are reliably identifying trigger points. They believe this because they have been told so. They believe this because an ‘expert’ told them that the Gerwin paper proves it.

    They then insert a needle and believe that they are applying a very specific intervention – and that if it is not precise it will not work.

    Right now, there are practitioners who are applying these needle treatments and who believe that they are specifically effective – and yet do not know the attributable effect of the exact placement of the needle over and above a non-specific effect.

    Right now there are practitioners paying for and undertaking courses.

    If the needles are necessary because they need to be precisely inserted, then the identification of the trigger point must be equally reliable and accurate as performed by those who insert the needles.

    Similarly, if I were to recommend a patient to receive trigger point therapy with dry needling, then I would want to know that the treatment was necessary and provided a superior outcome.

    As a pain researcher, I am interested in the biochemistry of pain, referred muscle pain, DNIC, sensitisation etc etc – but none of this – even 300 papers on the topic – helps me know if practitioners can reliably and accurately identify trigger points, if they can accurately insert the needle into the trigger point, and if this leads to a superior outcome compared to other interventions.

    Jan, you maintain that “TrPs frequently are part of the picture and as such, they can and should be included in the assessment and treatment”. I don’t want theory – I’m just interested in knowing if all this is really necessary.

    How do you know that trigger points, not tender points, are frequently part of the picture, and that they can be reliably and accurately assessed with palpation, and that they can be accurately treated and assessed for improvement?

    Good evidence about this excludes studies in which patients were assessed for trigger points by one practitioner. Good evidence also demonstrates that reliability exists for more than just the exact location of trigger points in the ‘trapezius’.

    I do hope that these studies are underway or have been completed by your group – we definitely need some more definitive answers – on that I’m sure we both agree.

    I admit that I have been focussed for the last year on the reliability of radiologists reporting knee MRI, and have not kept completely up to date on the reliability of trigger point identification – so I would be appreciative if you could bring me up to speed here on any new developments.

    Kind regards,
    Nicholas Lucas

    • Lucas,

      Your points as a researcher perspective are well taken in regards to limitations in the internal and external validity on current literature about reliability issues on TrP physical examination. I have two conclusive comments as below responding comments you made. Hope you can clarify for readers or discussion participants in this interesting threads.

      1. I appreciate the fact that your team uses accepted quality of appraisal tools (equivalent to QUADAS) to evaluate physical examination aspects of TrP on current literature ( up to 2008). Your group and Myburgh group all had similar conclusion indicating more valid methodological studies are needed for future studies. Myburgh group also presented there were mild to moderate reliability on the a few muscles even though the distribution of values are somewhat wide.

      Poor inter-rater reliability definitely minimize external validity to be able to generalize or replicate the method or examination process since the assessment of TrP heavily depends on palpatory examination plus subjective examination to comprehend characteristics of TrP clinical presentation. We may have some more of gold standard (high tech) to identify TrP in the future though. I strongly feel that investigators in studies might have done preliminary process to standardize examination process to identify TrP prior to collecting data. However, I would not agree that expert level rater than rater’s standardization in exam process requires to improve reliability as you stated in your post. One of study that you mentioned is Gerwin’s study which actually demonstrate better inter-rater reliability after going through standardization process. This process might have changed the reliability issues.

      This issue is very common in literature utilizing any procedures requiring palpation even though intra-rater reliability is acceptable. In clinician’s perspective, what do you think about how the reliability concern would change when studies uses more cluster tests rather than single test to improve statistical power? This method would reflect more pragmatic clinical practice we perform. I think this way there is more room to improve limitations for future studies.

      2. In regard to the identification of specific spots to test of its outcome (i.e. use of dry needling), I do not think that this inter-rater reliability issue matters when one clinician (intra-rater reliability) treat a patient (N=1). I am not sure whether you understand how the needle direction change in mutidi-directional dimensions which requires throughout muscle layers (in trigger points).

      To evaluate efficacy of treatment is up to outcome changes in clinical findings of patient’s clinical presentation with conformation of changes in abnormal physical variables and response. If it was not aimed to the specific area, we would not be successful to clear TrPs. In clinical practice, we always use a test-retest approach to see at least clinically meaningful changes after the any procedure.If outcomes are unsuccessful, require to refine skill sets (identification and target treatment) to get to better outcomes. Otherwise, we need to be more clinical reasonable to accept or reject clinical hypothesis generations of primary dysfunction.

      In general, treatment outcome also help to make decent diagnostic decision. We observe and see this very frequently in any type of injection studies. Nowadays, image guided injection studies helps to minimize the errors. I recognize that a few studies now in DN used image guidance.

      I think that this is really healthy and sounds reasonable discussions between researcher and clinician perspective.

      Sincerely yours,
      Kwon Jung

      • Francis,
        Thank you for commenting – I have always learned from my interactions with you regarding research and clinical practice, both in the lab section of the course work and in other communications we have had. For the benefit of the group, I would like to share a video clip of a diagnostic US showing the LTR. This video was sent to me by Dr. Carel Bron last year when I was preparing a lecture on dry needling for the physical therapists and physicians at my place of employment last fall.

        http://bit.ly/y55oPQ

        If nothing else, some of the readers here may be interested to “see” the LTR from the point of view of a diagnostic test. Dr. Bron also has several other videos on his You Tube channel that show the LTR. (One of these was the one Mike used in the initial posting of my article).

      • “In regard to the identification of specific spots to test of its outcome (i.e. use of dry needling), I do not think that this inter-rater reliability issue matters when one clinician (intra-rater reliability) treat a patient (N=1).”

        How do you propose we teach the identification of Trps then? If we cannot detect them with interexaminer reliability during the education process (i.e. the myopain courses), how can we accept that any clinician will then clinically be able to find them when applying the skills in the clinic? Are the majority of PTs utilizing dry needling using ultrasound guided imaging to place the needles?

        • Joe,

          I think you raised fair questions about “reliability issue” and “TrP education process.” Your Questions are related to “diagnostic accuracy” and “reproduction of examination.”

          As I briefly mentioned in my earlier post to Lucas, I suggest composites of battery test (multiple cluster tests)to increase likelihood of ratio to get acceptable post-test probability which will help us to make better diagnostic decision making. There are many similar studies adapting multiple clusters to rule in a target condition.

          As Gerwin’s study demonstrated, standardized process (step by step) will help to minimize the errors. Some of similar articles used a body mapping to identify a local area of TrP or pain distribution to be able to reproduce patient’s similar signs and symptoms. This would be great direction for future studies.

          As a clinician, I am always to strive to get to some degree of “Pattern recognition” based on my own prevalence as well as inductive probability thoughts process (detailed steps) with continuing test and retests (as well as confirmation of my hypothesis). Refining skill sets to clinical mastery level would be optimal when we are consciously incompetent. I think that TrP aspect of management also greatly apply here.

          Sincerely yours,
          Kwon Jung

  43. I would like to say thank you to Mike for re-opening this thread and in particular for the opportunity for Nick Lucas to respond to the issues surrounding reliability. It is refreshing to find the level of expertise displayed here being involved in public debate, something which happens all to rarely within the profession.

    Thank you ladies and gentlemen for your time and effort, it is appreciated.

    regards

    ANdy

  44. I’ve been following this debate with interest and will offer a few thoughts of my own if that’s OK with Dr Reinold.

    First, I’d like to say that I don’t do dry needling and I don’t think much of the trigger point conceptual model or the needling approaches now popular in physical therapy. Dr Lucas covered the issues with this theoretical model pretty well. I have no interest in learning dry needling, though I did attend an introductory course by KinetaCore given by the chief instructor Mr Edo Zylstra on the topic so I feel I understand the basics of the rationale and supporting literature. I can imagine wanting to learn dry needling at some future date if there were compelling evidence that this approach could produce better outcomes in my patients than the noninvasive manual therapy and exercise approach I currently use, which is supported by basic science plausibility (a science-based standard) as well as published randomized controlled trials (an evidence-based standard). I’ve seen no indication that such evidence exists, however, to merit the expense of training, the risk (however small) of invasive needling, and the regular use of it to maintain proficiency. Until I have compelling evidence otherwise, it represents in my view a more invasive mode of care that has less research evidence to support it so therefore is of little interest to me personally.

    Second, I have every confidence that practitioners such as Ms Wendel or Mr Dommerholt or Dr Reinold have their patients’ interests at heart and strive to provide effective, safe, and appropriate medical care to the best of their ability. I may disagree with some of their methods, but I don’t think there’s any reason to think dry needling as practiced by physical therapists is in any way dangerous or inappropriate. I’m almost certain it compares favorably to the risk/benefit profile of an extended course of NSAIDs for example. I am reasonably sure we agree on most major clinical principles since we share a common profession and treat similar populations of patients. I have no desire to dictate to them how to practice and I’m sure they feel the same way about me, though I do feel we have a responsibility to each other as professionals to question each other closely and challenge our decisions and rationales for doing what we do in clinical medicine.

    Third, dry needling is likely here to stay. Pain treatment continues to suffer from rampant practice variation and the lagging adoption of modern neuroscience. A lack of understanding of modern pain physiology continues to plague good discussions and the understanding of clinical problems. As a result, for example, there is a large amount of literature published on the phenomenon of so-called “muscle pain”. Of course we now know that pain doesn’t come from muscles, it comes from the brain. But we still have a large number of researchers who are very interested in the component of the pain experience that is both nociceptive in nature and arising from the nerve tissue in and around muscles – stating it this way should give you an idea of how incomplete this approach has the potential to be. I suppose they will continue to publish on why they feel nociception from nerve tissue in and around muscle (as opposed to in and around other tissues and as distinct from the many other aspects of the pain experience) is very important. No doubt much of this research advances our understanding, and I don’t begrudge them for publishing in their area of interest. I’m sure if enough people are interested in needling and publish enough studies on various trigger point models and link it somehow in some way to some of the neurophysiology of pain in some patients, there will be a case to be made, whether strong or weak, that dry needling is an option. That’s probably where we are now, from a literature perspective. Certainly these folks are not writing prescriptions for homeopathy (that’s just water) or cutting their patients’ backs open for spinal surgery, or using thrust manipulation of the neck for in a chiropractic subluxation model or telling parents not to vaccinate their children. So, as a Physical Therapist, there are probably larger threats to my patients’ collective health than a group of people in my own profession I probably agree with on 90% of practice issues who happen use needling in their practice alongside manual therapy, exercise, lifestyle changes, and other interventions supported by relevant evidence and provided in a biomedical, non-acupuncture, science-based paradigm. So some perspective on this is helpful in my view. Whether you agree with dry needling or not we are all on the same team, so to speak. Doesn’t mean we shouldn’t argue and push each other, though, more on that later.

    With all that said, there is a familiar and disappointing pattern to the debate that I’d like to review in the hope that we can all collectively do better next time – and this of course includes me as well, as I’m by no means immune to getting caught up in a debate about something I feel strongly about.
    More on that in my next entry if Dr Reinold will allow me…

  45. Having been a regular forum participant in professional venues for physical therapy, strength and conditioning, and medicine since 2002, I’ve seen a wide variety of discussions and responses over the years. I don’t suggest this makes me more qualified necessarily to point out errors in thinking and reasoning other people make, this is just my perspective on this issue and the wider question of online debate within our profession. I think several mistakes were made in the context of this discussion that hampered understanding, and it may be useful to look at them in some detail.

    First Mistake: Treating honest questioning of an approach or rationale as an “attack” or that it is “discrediting” or “bashing” a method. Here’s something I’m particularly tired of hearing. Any profession that claims to be based in science should not only encourage rigorous questioning and debate but seek it out as part of our ethical responsibility to each other and to society. Any science-based practitioner should refrain from taking questioning personally and focus on the issue at hand while not confusing what we do with who we are. Someone who questions me closely about what I do is helping me refine my thinking and explore in detail my rationale for my decisions – this is not an attack on me or on my chosen decision but an opportunity for growth and learning.

    Second Mistake: Argument from empiricism – “I do what works”. Our personal experience and clinical expertise, while often valuable in clinical care and a consideration in evidence-based medicine, is unreliable and prone to bias. Regression to the mean, placebo, expectancy and multiple other “nonspecific” effects are common in medicine and we need to be aware of them and consider them in our clinical observations. Such a purely empirical approach inevitably ignores much settled science on nonspecific effects, and reveals that such scientific considerations as prior plausibility or relevant basic science have been ignored with little more than a hand wave. As a profession based in science we can do better than this, and we should hold each other to a higher standard.

    Third Mistake: Reference bombing, a form of argumentum verbosum or “proof by verbosity”. Mr Dommerholt’s citation of multiple references is, in my opinion, an example of just such a technique. This approach seeks to overwhelm participants or opponents with such a large volume of citations that they cannot challenge the argument since to do so would involve reading through every listed article to attempt to determine if they support the points made. Now, I am sure Mr Dommerholt provided those references in good faith and with the intention of honestly supporting his points. The participants actually did a very good job of reviewing several of his cited references in detail. However, as Dr Lucas pointed out, none of the citations actually supported the key points being made about trigger point diagnosis and reliability. Volume can’t make up for accuracy or applicability. Using references is important but in a discussion like this you should choose them carefully and ensure the point you are making is supported by the citation.

    There might be a few more things that are relevant I could bring up but I wanted to put this out there first for consideration and discussion.

  46. Dr. Silvernail

    As usual, very well said!

  47. Jason,

    I had decided to “move on” as I am quite busy and do not really have time to continue these discussions online. You accuse me of bombarding this conversation with references to “proof by verbosity”. I am sorry you feel that way as that was most definitely not my intention. Apparently I did not communicate that as well as I should. After reading the comments made by others, it was very clear that several contributors were not at all familiar with the recent scientific literature on TrPs,but nevertheless, had strong opinions opposing TrP work. Comments were made that there is a lack of evidence supporting that such an entity (TrP) exists. I provided MRI, sonography and other evidence of TrPs. I figured that since some contributors had apparently not taken the time to read recent TrP literature, but had outspoken opinions nevertheless, it would be a good opportunity to give them references just in case they would be inclined to learn something about the topic. Some of the contributors asked for references and assured us that they are on the faculty of major universities with access to libraries. No intent to bombard anyone. No intent to deny the need for clinical validation of TrPs either. I replied to several entries in one comment which resulted in a long story with indeed quite a few references. It was my understanding that this was requested: “If it’s published in a reputable journal, you should be able to provide a link to the Pubmed citation here.”

    When I re-read the many comments, several other issues were raised beyond clinical validity, but nearly every time an issue was addressed by Shannon, Ann, me, or others, the argument was turned around and another issue was introduced. I am not convinced that it was always the next logical honest question. When Kory asked about clinical issues, I replied, which he appreciated. Although I did not reply to NIcholas’ comments (as I had moved on…),I do appreciate his perspective on his study and his review of my criticism. I learned a thing or two, which were not clear to me when I read his study a few years ago. Kory and some others seemed interested in learning more.

    I cannot say that about all other contributors. Some seemed more concerned about voicing their preconceived belief systems that TrPs don’t exist, which goes against their own conviction that they are so scientifically inclined. It seemed to me that these contributors deny the very nature of the scientific process. If they had read any of the many recent book chapters and papers about TrPs, they would have known that I and others always acknowledge what we do know (based on science), what we do not know.], and what research is still needed. In the preface of one of my books, my co-editor (the late Dr. Peter Huijbregts) and I stated that the most important chapter in the book was “Myofascial Pain Syndrome: Unresolved Issues and Future Directions’ and in that chapter, many issues are raised that need much more research.
    This week I am meeting with several scientists to further develop research studies about the issues raised in this blog. To suggest that PTs who incorporate TrPs in their practice have no scientific focus may apply to some, but based on my experience of teaching thousands of PTs all over the world, the vast majority of our students express a strong desire to practice evidence-informed physical therapy.

    You interpreted the comments as “honest questioning of an approach.” I respectfully doubt that all questioning was all that honest. The fact that Mike had to edit several entries seems that confirm that not all questioning by some individuals was all that honest.

    PTs who have completed my courses do not just practice what works. They have been introduced to an extensive review of pain sciences, which includes the literature of input from muscle noiciceptors, a notion that Melzack included when he presented his neuromatrix at the Focus on Pain conference our group used to organize. Fact is that current high-level scientific evidence does provide a basis for TrP therapy including dry needling. If I had just stated that, the next comment would have been about the lack of references. I too have participated in many online discussions and I have learned that it is better to provide the references upfront rather than having to reply many times afterwards.

    Fact is also that dry needling does work. The past weekend I taught a dry needling course in Montana. I demonstrated dry needling on a course participant who hqd not been able to swallow for months. After the demonstration during which I needled the SCM muscle, she could swallow without any problem. Another PT suffered from suboccipital headaches, which completely disappeared after needling only the oblique cap inferior. Two weeks ago, I needled a patient in Wyoming with a four year history of severe and disabling shoulder pain. She had been treated by many clinicians. After I treated her pectoralis minor, rhomboids and serratus anterior, her pain was gone. The next day, she called me to state that she could not believe that her pain was still gone. She could not remember what it was to live without pain. Every case was treated based on the current scientific evidence, which I will not quote here as you will likely criticize me again.

    This is not about volume making up for accuracy or applicability. The research is here. Yes, there are many questions left. Some PTs may feel more comfortable waiting until everything has been proven scientifically before learning more about a therapeutic approach, but I do not know too many aspects of our field that are so well supported that there are no more questions.

    Obviously, I did not address every issue that was raised. Bas for example stated that “There has been no study posted where it has been clearly demonstrated that the cutaneous structures HAVE been considered in dry needling, and found a non-issue. As long as that has not been done, any TrP “evidence” is tainted.” Well, I could post studies that considered cutaneous vs muscle in dry needling, but why bother? Those studies have been completed as far back as 1997. Besides, the statement itself is non-sensical. It is impossible to not consider the skin and the fascia when using dry needling and yes, I have written book chapters about that relationship. But I will not reference those either.

    I agree with Andy, that “It is refreshing to find the level of expertise displayed here being involved in public debate, something which happens all to rarely within the profession.” For those of you who are interested, I would suggest to start with Mense and Gerwin’s Muscle Pain books (which I did reference earlier). They may open your eyes and as long as you are willing to approach the world with open eyes, you too will conclude that TrP therapy is very much based on current science.

  48. I am a professional musculoskeletal clinician with extensive experience in dry-needling. I used to treat many professional musicians from the Melbourne Symphony Orchestra, most of whom had lateral and medial epicondylitis.

    MDNT (myofascial dry-needling therapy) worked brilliantly on all, in fact for a number of them it was the only manual therapy application that worked.

    MDNT is highly effective, safe, and produces minimal post treatment pain in the hands of a knowledgeable and skilled practitioner.

  49. Peta

    Thank you for sharing your personal experience. However without being disrespectful, for this interesting discussion to continue you on a more science and evidenced based level, we need more than anecdotal stories. Thetoads nothing to the argument that hasn’t already been said and quite frankly do nothing to support the use of dry needling.

    Also thanks to all the other great contributions from both sides of the discussion, I continue to enjoy it. But please, can we keep future comments to those that add some actual science based reasoning. I would hate for our profession to be displayed as just relying on anecdotes by everyone on the web looking at this.

  50. Mr. Dommerholt,
    You’ve impugned my integrity by suggesting that my questioning here was anything less than honest, and I request and expect a public apology.

    This is an ad hominem attack, and you should know that. You can’t possibly know what my motivations are for asking questions here about trigger points, so to suggest that I’m dissembling in some way due a “belief system” is unbecoming of a fellow physical therapist colleague, to say the least.

    You have just added additional fodder to Dr. Silvernail’s excellent post above describing how *not* to undertake a scientific debate.

    My post that was edited had nothing to do with the truthfulness or “honesty” of the content. Apparently a couple of discussants misconstrued my reply to Dr. Ma as somehow “offensive” because I made reference to him being a non-native speaker of English, and I used a Western idiomatic phrase that may have bee lost on him for that reason. This was after Dr. Ma told me I needed to “widen my thinking”.

    I said from the onset of this discussion that I was unconvinced by the evidence that MTrPs as operationally defined and clinically diagnosed lack sufficient reliability studies to support their existence as such. Based on Dr. Lucas’s clear explication of his study and reference to the similar findings of Myburgh et al, I think I stand on firm ground in that questioning.

    Again, you should apologize for this unfounded challenge to my integrity.

    • John, several people who read your offensive comment in the direction of Dr. Ma, interpreted it as a racial slur. Racial slurs are by definition dishonest, and I do not think I have to apologize to you believing that racism is dishonest. I did not see an apology from you to Dr. Ma.

      If indeed, you are an honest contributor, I’d be glad to apologize. Your own racial comment made me believe otherwise.

      • I have nothing to apologize for. The remark I made was totally without reference to race and was in no way intended to belittle or denigrate Dr. Ma. However, it was intended to ridicule his suggestion that I need to widen my thinking by espousing his version of “scientific philosophical thinking”.

        I attack ideas, not people, and certainly not their race. To suggest otherwise is inaccurate and reeks to me of political correctness.

        Pulling the race card is also another effective way to deflect the argument away from its merits and demonize your opponent.

        Keep this up, Jan, and Jason will have to re-write his post on how to have a scientific debate.

  51. Correction:
    In the 2nd to last paragraph, the first sentence should read: “I was unconvinced by the evidence that MTrPs as operationally defined and clinically diagnosed possess sufficient reliability studies…”

  52. Jan stated:

    “Fact is also that dry needling does work.”

    I would dispute the accuracy of this statement. I am sure you have considered the various non-specific effects that are at play with the results you describe?

    I do not think anyone will dispute the outcome you see. I am however quite certain that it is hardly a “factual truth” to suggest the underlying mechanism is in fact the needle into the specific location required (ie dry needling).

    I am sure I am just nit-picking over word choice here, but blanket statements like that always stand out to me….like a flashing beacon in need of clarification.

  53. After following this discussion for the last week and a half I thought I would add an interesting link to another thread that makes for interesting reading, it corresponds with this post and many of the comments made here. http://bit.ly/wpsbrr

    It is a long thread so here are some of the comments to focus on: 116, 130, 133, 134, 139,144, 147, 148, 155, 159, 162, 163

    At the end of the day decide for yourself and ask if this discussion was really all about science based treatment and bettering the PT profession. I dare say it was not.

  54. Hello Mr Dommerholt-
    I hope you’re not upset by my post, I did take great pains to state “… I am sure Mr Dommerholt provided those references in good faith and with the intention of honestly supporting his points” in my previous entry. As John Ware correctly notes above, we cannot determine other people’s motivations and my assumption here is that you are motivated only to engage in an honest debate about what we do professionally. As someone who also runs seminars on these methods, I complement you on your participation as that’s not something we often see by those who stand to profit from the adoption of a particular method – they frequently stand on the side of important clinical debates and I’m glad to see you here. I agree that you have not denied the need to establish important concepts like reliability of TrP diagnosis, but I do think we have a different opinion of the strength of evidence and a different opinion of the value of this TrP construct as it exists now.

    My comments on mistakes of argumentation was not aimed at any one particular participant but a general statement of the way the debate proceeded.

    My comment on empiricism was also not aimed at you, but was a general statement that applied to the overall discussion. In fact I think Dr Reinhold best exemplified this concept, I hope I’m not out of line saying that on the blog he hosts! I have no problem with empiricism if the concepts and treatments remain firmly grounded in basic science, which is of course the issue several folks have with dry needling in the first place. Sue Blackmore once said something along the lines of “free will is an illusion – doesn’t mean it doesn’t exist, but it doesn’t exist in the way that we thought that it did”. I feel the same way about these clinical concepts. Many people in the manual therapy community have been talking about the importance of “joint pain” for years with all sorts of studies about stiffness of the joint, and innervation for nociception, and the effect of these nociceptors on reflexive nervous system behavior, etc. I don’t deny these facts exist, but I question the relevance of those facts of the “joint dysfunction” construct to clinical treatment. Just as many have published similar background information on “muscle dysfunction”, such as those you helpfully posted for review. I don’t doubt such dysfunction exists, but I question its relevance to clinical treatment and its use to drive our clinical decisions – such as dry needling. It’s not my position that TrPs and joint dysfunction don’t exist – I think they may not exist in the way that we sometimes think they do, and the neurophysiology of pain makes that pretty clear, in my opinion.

    On whether dry needling works in the clinic- I must say, your seminar anecdotes are disappointing. I would think we can do better in 2012, as I write this entry. I am a manual therapist and if you asked me “does manual therapy work for musculoskeletal conditions” my first move would not be a story at a seminar (of course, I have plenty of those also, don’t we all?),but a very brief citation list of randomized trials and other published evidence to support my position. If you asked me about knee osteoarthritis for example I could cite Deyle 2000 and Deyle 2005 as well as a clinical practice guideline and discuss briefly why, given what we know about the pathophysiology of osteoarthritis (for an excellent review I recommend Brandt 2008) exercise and manual therapy makes sense. If we’ve discussed the scientific rationale of TrPs and dry needling enough already, maybe it’s time we turn to any clinical evidence of efficacy. Do you have a short list of a few randomized trials or other clinical outcome studies on dry needling you could share for consideration? Right now the ratio of anecdote to evidence is a bit high for my comfort level. Peta’s contention that it “worked brilliantly on all” and your above anecdotes are certainly not something we can do much with from a discussion standpoint.

    I’d also note a book called “Muscle Pain” appears curiously named given what we all should know by now about the neurophysiology of pain. There really isn’t any such thing as “muscle pain”, “joint pain”, “bone pain” etc, since pain a perception in the brain not reliant on any particular connective tissue. These old ways of describing clinical problems are really an obstacle to good understanding of these issues from both the clinician and patient point of view. There really is a difference between nociception and pain and exactly which connective tissue the nociceptive driver of interest resides in and around may not be as important as we imagine it is.

    I look forward to that short list of clinical efficacy papers if you’re willing.

    Thanks-

    • Jason,

      just a few comments.

      1. I do not know how well you know the myofascial pain literature and whether you can judge the strength of the scientific evidence. If you have indeed reviewed the many clinical papers I cited before, and many others I did not cite, and you still believe that there is no strong evidence, than I would agree with you, that we disagree.

      2. I thought I had given a lot of references citing scientific evidence and believed I had “discussed the scientific rationale of TrPs and dry needling enough already” and therefore figured that a few anecdotes would do no harm. Funny that Peta provided an anecdote and questioned me when I did the same.

      3. Your points about joint pain and muscle pain are intriguing, but I do not agree with you entirely. I do not question that pain is a perception. In fact, I teach this in every workshop I conduct. I am aware of the differences between pain and nociception. I am also aware of the presence of many nociceptive receptors in muscles, such as acid sensing ion channels (ASIC-1a and ASIC-3) and transient receptor potential vanilloid (TRPV) receptors, purinergic receptors, NMDA and AMPA receptors, BK1 and BK2 receptors, etc. Are you telling me that these receptors are irrelevant in the total pain science picture? Are you telling me that nociceptive input from these receptors would not lead to an expansion of receptive fields, a release of inflammatory mediators, wind up and indeed sensitization? Do you think that PT researchers like Kathleen Sluka are not studying pain mechanisms when she explores ASIC receptors? I do not really understand why you do not seem to believe that nociceptive input is part of the overall pain science. I am not asking you to explain that to me.

      4. Asking me for more papers is kind of funny. Why don’t you read first what I already suggested. Maybe in a year or so, we can communicate again.

      I am not upset by your post, but I am done with contributing to this discussion.

  55. Dolph

    Thank you for linking to Soma Simple. For those not aware, it is a great forum of open science debate specifically looking for plausible science and evidence to account for and support treatment ideas around manual therapies.

    I’m not sure what your post intends but I suggest people read the whole thread. Also search around, there are some great threads on various topics. Be prepared to debate though with more than just anecdotes and personal quotes like ‘I know it works’.

    I can assure you that the intentions of people on the forum is the progression of our profession, there is no hidden agenda. The posts you mention clearly just highlight the frustration with anecdotes, poor scientific understanding and garbage that seems to be rife in our profession.

  56. I find these online discussions very interesting. So much can be “read into” each post with our written language and our human nature and bias quickly takes over, often in not the best way. I will self admit upon reading Jan’s latest opening sentence on January 24th realized I could “read” lots of things into that sentence. Another interesting behavior is how each of us posting pick and choose which response and posters we reply back with comments to and those we let go and avoid (maybe on purpose or maybe by accident).

    Jan, I understand you are quite busy (as I am sure everyone that took time to post on this blog is and I’m not going to try and come up with any criteria to quantify who is more busy). So I thank you for your past inputs, along with all of those that have brought valuable insight to the science of what may or may not be going on with Dry Needling and MTrPs. I agree with Fletch, personal anecdotal stories offer very little if anything to the scientific discussion. Peta, Jan, and others keep sharing stories of patients that get better to make a statement to the fact dry needling works. I can also give a personal story of a patient with 10/10 back pain and unable to bend forward, she had a strong desire to receive ultrasound because this had helped her pain in the past. I noticed at the end of the treatment that I had accidently pulled the machine to far from the wall and unplugged the machine during treatment. When the patient got off the table she reported pain less then 1/10 and able to reach down to her toes. In this case I don’t think many would want to say that it is fact unplugged ultrasound works for any reason that should be utilized regularly in a clinical setting. Don’t miss interpret my stating this story to say Dry Needling is the same as my unplugged ultrasound story was. It is just an example to why we need to be very careful of the slipper slope with anecdotal stories. I am also concerned with how some of these stories seemed to get sensationalized (intentionally or unintentionally). Jan are you saying the individual in Montana was on a feeding tube when you state: “not been able to swallow for months”? If this was the case and they were able to instantly get off a feeding tube after Dry Needling that is remarkable. I hope a swallow study was done to ensure this person did not aspirate any of the material they started to swallow.

    I will share one interesting thought about one of the articles that was provided for the rest of us to get up on the latest research regarding Dry Needling and MTrP. It is from Xu, et al (2010). What I took from it was not necessarily from the abstract or conclusion but from the methods section. They took 12 healthy individuals with no signs or symptoms of musculoskeletal pain. They were able to find latent MTrP or a nonMTrP in all 12 subjects in the finger extensor muscle. What struck my interest is that ALL the subjects had these latent MTrP in the one muscle they picked to test, finger extensor muscle. While this was not a large study based on the number of people tested, but 12 out of 12, makes me wonder does everyone in the world walk around with these MTrP in every muscle in the body? And if so, I go back to how important are they and how would I ever discern which ones are important from a treatment standpoint? I still don’t understand this detailed motor and sensory examination of all the muscles would be done considering 600+ muscles in the body.

    Social science research has shown us that our bias increases the more time and money we have invested into something. Many of those that have posted for support of Dry Needling have lots of time and money invested into this procedure. As PT’s and scientist’s we need to guard against this and factor in placebo and belief systems, regression to the mean, and the therapist/patient interaction more. When we open our eyes up to this it can be like the Wizard of OZ and choosing to step from behind the curtain and move past sleight of hand and see that method is not the trick.

    • Kory,

      After all I have written here, it is just plain embarrassing that you zoom in on a few little patient stories, as if that tells the whole story. Yes, I have invested a lot in studying pain sciences. And yes, I do teach many courses, write many book chapters, and do research. But as I just read some comments by your buddy Barrett Dorko, I may be bright, but I apparently don’t get it at all. Your comments about the Xu et al study once again shows that you really have no understanding of the scientific basis. You may be bright yourself, but I am not sure that you get it all either.

      To all, it has been fun, but I am done. Thanks to Mike for making this all possible.

      • Jan,

        I’m not sure what the embarrassing part is? I just simply asked questions to comments and stories that are pointed out and replied from my point of view. I did not mean to imply that any of these should be viewed as the whole story; I apologize if it came across as such.

        Thank you for your observation of my lack of understanding of “scientific basis”, I will continue to improve my understanding of the literature. Constructive criticism and self reflection is helpful, and I will be the first to publicly admit I am far from getting it. Again I thank you for the many references and your participation in this discussion.

        Kolbs’ Experiential Learning Theory defines learning as “the process whereby knowledge is created through the transformation of experience. Knowledge results from the combination of grasping and transforming experience”, based on that definition I can state I have learned much from this discussion experience I hope it can continue.

  57. I am just curious, since the research for TrPN is no good (according to some people) and anecdotal evidence is unreliable and then there is the placebo affect, what would your preferred method of treatment be? Obviously it must take all of these things into account, right?
    I ask because there has been so many comments on science and research I want to know what methods actually have been validated scientifically and have good patient outcomes.

  58. Mr Dommerholt-
    Sorry to see you leave the discussion. A few responses back numbered for clarity.

    1. You’re right, you don’t know how well I know the “myofascial pain” literature, and we do disagree on the strength of the overall clinical construct.

    2/4. My question about efficacy papers was an attempt to sort what you felt were the most critical efficacy papers for the TrP and/or Dry Needling construct/approach. Your previous response to Dr Zimney about “quite a few studies” on clinical efficacy included narrative review papers and a few on selected clinical findings like mouth opening or pressure pain sensitivity which have an uncertain relationship to clinical outcomes. I only saw one randomized controlled trial (Bron et al 2011) which I will review. I bring this up only because the manual therapy world (itself no stranger to struggling with unreliable assessments and construct validity) has been through a similar research wringer. The standard really has become (for better or worse) RCTs of a comparison intervention for clinical treatment testing. If I presented you manual therapy evidence consisting of better reported tolerance to joint mobilization or neck rotation without any relevant patient-centered outcomes or a 6 month to one year outcome endpoint, you should rightly declare that my treatment choice rested on thin ice indeed – and that is for a noninvasive treatment! I felt that in order for you to be so confident of the evidence behind TrP treatment in general and dry needling in particular, you must have some strong clinical evidence that these treatments perform better for the problems we see in clinic than competing noninvasive treatments such as exercise or manual therapy. I figured that you already cited them in your long lists and I missed it or that there were others that you hadn’t brought up. Given that we’ve seen what’s on offer based on your last entry, I suppose I will stand by my original post here.

    That original position is essentially that there is some evidence published for the TrP construct, that the scientific basis in terms of validity and reliability is under some question (as Dr Lucas explained) and that there are a few efficacy studies but few (none? I must check Bron 2011) that show this invasive treatment of needling is of significant benefit over competing noninvasive interventions. In which case we circle right back around to where we came from. Those who like to needle can find a rationale if they look hard enough, those who are looking for a side by side appraisal to compare interventions will not likely find convincing evidence.

    3. I took pains to explain that I don’t in any way doubt the presence of nociceptors in muscle (thanks for listing them) or that nociception is relevant to pain. Of course it is. My skepticism centers on the supposed importance of the “particular connective tissue around those relevant nociceptors” and whether the connective tissue itself is at fault. Now you seem to argue (please correct me if I’m wrong, I don’t want to misrepresent your position) that muscle is responsible for a special kind of nociception. You’re not alone in thinking your favored connective tissue is so important – in the case of many manipulative therapists, osteopaths, and chiropractors, its the facet joint that is supposedly got special nociceptive relevance. To those who would have us focus on fascia (did I see your Myopain Seminars teaching fascia manipulation too in a recent ad?), its the fascia that has such important nociceptive relevance. To those advocating decompression traction and spine surgery, it’s all about the disk – -what about all that great disk evidence? Everyone clamoring that they’ve got the secret – and the secret is to pay attention to their particular favored connective tissue of the body they like – that oh by the way they sell a procedure, medical device, or seminar on for those interested . We can’t all be right, now can we?

    Shall I suggest you go off and read the disk literature, the joint literature, and the fascia literature and come talk to me in a year, or would you find that dismissive and rude?

    Out of a degree of frustration with these connective tissue approaches, I wrote a post called “Enough is enough” that the good folks at Body in Mind picked up a while ago – you can find it here if you’re interested: http://bodyinmind.com.au/jointhead-diskhead-musclehead-fasciahead/

    I think these pain problems are complex (since the issue is the brain not the muscle) and the literature seems to indicate that these are multifactorial problems that don’t suggest simple solutions – you clearly have a grasp of the pain literature so I know we are on the same page here with this complexity.

    At the end of the day, I would think we need to see much better evidence than we have to date to justify the risk, cost, time investment, and effort to learn how to do invasively with needles what the literature seems to suggest I can do just as well with education, exercise, and manual therapies. You are going to use needling, I am going to use manual therapy and exercise, we both think we have more literature support than the other person and we are going to agree on 90% of clinical topics and argue online about the other 10%.

    By way of context, we have real issues with genuine pseudoscience in our profession rather than a simple disagreement on needling – see the post at Science Based Medicine here: http://www.sciencebasedmedicine.org/index.php/visceral-manipulation-embraced-by-the-apta/

    Here’s part of that 90% of clinical life I’m sure you and I can agree on….

  59. Jason,

    That was simply one of the best written pieces I have read in quite some time.

    Thanks for that…it was spot on.

  60. I find it amazing how much the SOMA groupie’s just keep stroking each others ego!! I also find it amazing that they are so hung up on research based treatment because PT like any other profession needs a balance. Science is important but to disregard everything else is a mistake. At the end of the day you can make the best widget in the world but if no one buys it or uses it it doesn’t matter.

    If the patient walks away feeling better/fully recovered that is what matters the most.

    But when you have PT’s commenting on this site who are so radical and outspoken they get cease and desist orders from other blogs they comment on you know that no matter what your argument is you will never convince them.

    Regards-Dolph

  61. Dolph, thanks for your comment. It is exactly your statement,:

    “At the end of the day you can make the best widget in the world but if no one buys it or uses it doesn’t matter.

    If the patient walks away feeling better/fully recovered that is what matters the most.”

    as to why some of us raise and try to wave a big cautionary flag to that sort of thought process in PT. Is PT just another widget? Are we no better then a product bought off the shelf at WalMart? I like to think not. As a profession we should hold ourselves to higher public standard and ethical level not to just see who can sell the most widgets. I think that only degrades this profession.

    As I have stated before, we can’t just be content with getting people better. We need to continue to get people better based on sound science and evidence. If not we are no better then a shaman. I think Jason was very clear on this point in his post. Some of us will choose to do Dry Needling others of us will not, it does not make either therapist better or less then the other. I don’t understand either why people get upset when we debate the 10% of our practice that we don’t agree upon.

    I would have to disagree with your comment about “no matter what your argument is you will never convince them”. I believed in TrP and treated them very aggressively for many years as that is what I learned in PT school and at many con ed courses. But through reading and discussing both ends I did change my mind about them and not as convinced they need to be treated as I once did. Just as I used to think I was putting a left on left pelvic rotation back into place with manual techniques, I have been convinced that is not the case.

    Mike, I do want to personally thank you for allowing this discussion to take place on your site. You have been a gracious host, and I enjoy and appreciate the work you do for the profession in putting out the content on this site and in the literature. Seeing comments like Dolph’s I understand you may need to close the discussion again, so I wanted to have an opportunity to thank you publicly.

    • I am all game for open debate but when people read the comments that you and others have posted on SOMA Simple about faking to be nice and how the ring leader Dorko has you doing his bidding it is hard to take you seriously. We have offensive comments from Bas, we have you leaving smiley faces to look nice and then we have the comments trashing Mike. You have people making fun of the person who wrote the article, playground bullies comes to mind. You wonder why more debate doesn’t take place it because people don’t like getting trashed by the fringe group Soma Simple and the fact that you keep kissing up to Mike for allowing you to continue the debate makes me laugh.
      Thankfully I am helping expose the Soma group and hopefully it will raise awareness as to the tactics used and how it actually hurts the debate and the PT profession. In case you want to read their comments and missed my link here it is again-http://bit.ly/wpsbrr

      It is a long thread so here are some of the comments to focus on: 116, 130, 133, 134, 139,144, 147, 148, 155, 159, 162, 163

  62. http://bit.ly/wpsbrr

    It is a long thread so here are some of the comments to focus on: 116, 130, 133, 134, 139,144, 147, 148, 155, 159, 162, 163

  63. Dolph,
    I began this conversation on Mike’s site and linked it to a SomaSimple discussion on dry needling. I welcome anyone to check out this discussion on somasimple and actively engage. I hope that everyone sees that we are asking legitimate questions regarding a new intervention. These questions must be asked and discussed so that we can truly deliver evidence-based interventions. I agree that there may be a preconcieved bias regarding an intervention such as this but that doesn’t mean that our minds can’t be changed—just show us that it is superior to the non-invasive interventions. I agree that we need to avoid bullying in these discussions, but asking difficult and necessary questions is not bullying.

    For us to take so much time to add to these discussion boards indicates that we all truly care about the health and welfare of our patients. We all share that commonality. In a further discussion with Ann elsewhere, we found that our treatment approach and philosophies are very similar minus this intervention.

    We must continue to search for truth and engage in discussions with each other such as this. I also think that it is important for those who perform alternative therapies to present them, but understand that doing so may open up debates such as this.

    • Guys, I have to admit, Dolph has some good points. You may not be trying to be confrontational but most people reading perceive it this way.

      Acting as the mediator, I love the discussion, great minds, and challenging questions – we need that. Everyone involved has added significant value to this discussion. I learned a lot from everyone on both sides!

      But there have been times that there has been some emotion and some negative comments. That isn’t good for the discussion.

      Confrontational discussions actually hurt us as I bet there are 100′s of other people that would have liked to join in on this discussion but didn’t want to get belittled by taking a side. That defeats the whole purpose of the discussion, in my mind and on my website at least.

      I have no problem with disagreeing, that is common and needed to push our profession forward. Obviously there are many areas that still need to be researched in our profession, including dry needling. Discussions like this push us to research all of these excellent questions.

      • I agree Mike. Much of this information is new to me, and I have plenty questions about pain, nocioception, and current neurophysiology research. I am however hesitant to ask for fear of being subjected to the same ridicule that participants of this debate, Mike included, were over at the SOMA website. The brilliant minds who contributed on these two sites have opened my eyes to new ideas, while at the same time closed my mouth to questioning their practice and concepts. I think some people like Jason did a fantastic job staying relatively neutral in emotion while strong in opinion. I would love to hear more about current neurophysiology of pain speficially how it pertains to manual therapy that isn’t dry needling. Perhaps if Mike would allow we could have a guest post over on this website that would again stimulate such energetic and intellectual debate.

        Sincere thanks to everyone who has contributed, and of course Mike for hosting.

  64. I have found this debate educational on several levels not least the social dynamics of blogs.

    I have learned a number of things I did not previously know about dry needling, I have also been made aware of some of its weaknesses.

    I would like to have seen Jan address Nick Lucas’s response to his criticism but it seems that is no longer likely, I think that is a pity.

    At some perceived risk of making myself vulnerable I will sum up where I find myself with this debate at this time.

    Up fron I have some conceptual difficulty with some aspects of trigger point theory. While I do not doubt that “something” is there but I remain unclear quite as to what, other than pain, is induced if a particular point is pressed. I struggle – no in fact I disagree as I think Jason did above, that it is appropriate to talk in terms of muscle or myofascial pain. I accept Jans point that the nociceptors are intimately coupled with pain perception but it seems too often that the language extends or encourages a thought process that suggests not only that they are coupled but that they are synonymous. It does not agree with the current state of understanding regarding pain and as such is a form of syntax which despite its ubiquity should be encouraged into disuse. Otherwise confusion is perpetuated through our language not only with each other as professionals but with the wider population and in particular patients. In doing so it creates a paradigm of (mis)understanding that can perpetuate pain and its sequelae long after it should have been abolished by natural healing process or by appropriate intervention. Indeed it is this kind of (mis)understanding that encourages patients to be continually looking for an intervention which will provide a mechanical fix, whether muscle, joint or a.n.other, to problems which are often, if not always, multifactorial. To assume such a simplicity is tempting and whilst often effective is, in my opinion insufficient and misses the fundamental understanding that pain is in the brain, by treating other tissues we are addressing pain by proxy and that state of removal will by necessity reduce effectiveness to a greater or lesser degree depending upon the choice of tissue targeted. I am not suggesting that we should not target other tissues but we should seek to select which in some sort of order of efficacy in addressing the patients primary compliant- that of pain. Hence I would have no difficulty per se with a needling intervention but I am left wondering if I could do the same thing more efficiently by other means. This thought process may come to a screeching standstill given that we do not seem to have a clear understanding of the patho-aetiology of trigger points. SHould some particular pertinent information come to light I am quite willing to consider needling as the most efficient way to intervene in any theoretical order of efficacy.

    regards

    ANdy

    (conflicting interests – I am a member of Soma Simple, I am not a “groupie”, I attempt to think and have some sort of independent opinion all be it one informed by many other sources of information)

  65. Andy, I have to say I really liked your post and it is refreshing to see what having an open mind can bring to the debate.

    Regards

  66. There seems to be some science behind and emerging evidence for trigger point dry needling. However, if you are treating a patient with lateral elbow pain, why not start with a less invasive intervention that is supported by high quality research?

    http://www.ncbi.nlm.nih.gov/pubmed/17012266

    When high quality research exists should that not be our baseline intervention? If the patient does not respond then perhaps we can attempt additional interventions.

    • Bill i would say that dry needling, as with anything, would fall into the category of an adjunct treatment. I think you would do it within the scope of the entire treatment program including manual interventions included in your reference. I see it as a way of potentially enhancing what we already do, not replacing. Just my opinion.

  67. Well, that’s the concern we all should have with these “adjunctive” modalities. The question is “do they” enhance what we do, and if so, to what degree, and at what risk and at what cost? These are the same questions we should be asking about any medical treatment.

    This could be dry needling, or low level laser therapy, or decompression traction machines, or the latest electronic gizmo that uses electrical stimulation.

    One thing that encourages me about what i’ve seen from dry needling is that people are apparently using it in a greater context of physical therapy treatment: heavy on education and exercise for self management, small numbers of visits, low cost care, and often the use of manual therapy approaches which have randomized controlled trial support. That in no way changes the concern over risk v benefit or cost v benefit, but does provide some useful context to the whole discussion, in my view.

    At the end of the day we are left with Bill’s very relevant concern and the issue of whether someone is invested with dry needling such that they are using this invasive procedure as a first line of treatment when better evidence for less invasive care exists in many cases.

  68. Yes, it’s me, “Dorko the ring leader” demanding that the others here from Soma Simple do my bid… sorry, I couldn’t keep a straight face.

    Come on,has Dolph ever even MET any of that crowd? They want a “ring leader” like they want an extra eye. Well, maybe Jason (ha,ha).

    I’d find the characterization of this group hostile, inaccurate and insulting if it weren’t so funny.

    I began serious questioning of this concept in a blog post about two months ago, and I’m glad it’s still alive. It will serve as a useful and illustrative blog post very soon.

  69. If we can have nonspecific low back pain treated with a nonspecific lumbopelvic manipulation and achieve a good patient outcome can we have nonspecific shoulder pain treated with nonspecific dry needling and achieve a good outcome? Just wondering.

  70. Of course you can. But then why not just hire a grocery clerk, train them minimally, offer them a tiny raise and then have them do it? Why would they care anything about the deep model? They get paid the same and the patient gets “better” anyway.

    But the word “conservative” in this context means “potentially harmless.” See where I’m going with that?

    Many don’t seem to know why they went to school, and they’re in charge of treating our loved ones. I find that unacceptable.

    The meaning of that crack by Dolph escapes me entirely.

    • Why not just go to a message therapist to do Simple Contact it would be far cheaper, you wouldn’t need a script and since their is very little research behind Simple Contact we wouldn’t have to worry about harming the PT profession with procedures that aren’t scientifically proven? Who know’s it could just be the placebo affect of having a therapist put their hands on the patient? Right or am I mistaken?

  71. Comments from Barrett Dorko on Somasimple, a.k.a. the ring leader coaching Joe and Kory.
    #117 Joe, I see that both you and Kory have been after this.
    Good luck getting any actual answers to your questions and/or starting a fruitful discussion with any “experts” here.
    #121 I’d suggest you toughen your stance and questioning. Point out their lack of relevant response.
    Try the “stabbing Tinker Bell” gambit.
    #123 Yes. Just now read this. Excellent, as always.

    Faries are only implied however. Think it will be enough?
    #131 It has been my experience (I know, not worth much) that as soon as somebody says they’re “treating patients” you may as well forget about getting a straight answer out of them.

    This was alluded to repeatedly.

    You guys have done a wonderful job – you’re also, well, you know.
    #134 I see Jan Dommerholt as arrived to rescue Anne. Well spoken (written) fellow for sure yet; he misses the mark completely.
    #135 I’ve had a couple of bad experiences with him.
    You’re right, he’s very bright and he doesn’t get it at all.
    #140 I agree. I’m hoping you guys will stay. Referencing the threads here about MTrPs might be a good idea.
    A SIMPLE synopsis of the situation might help clarify the issues
    I’m going to stay out of it there.
    #142 Thanks for sticking with this Kory (and the others). I know it’s hard.
    This very thread is a perfect example of what PTs without a rational theory will do when questioned.
    They run away.

    • Dolph,
      You are adding nothing constructive to this discussion. I do not appreciate the personal attack on myself. I posed questions to individuals who perform dry needling on trigger points. At no point did I personally single out individuals. I instead questioned theories and interventions. I do not appreciate you singling me out by stating I am following Barrett’s lead simply because we both share a common understanding of trigger points and dry-needling. If you would like to engage in science-based discussion with me then I am cool with it but do not voice erroneous assumptions.

      • Joe, I apologize to both you and Kory I should not have singled you out in that post but rather just posted the clips without directly referencing you.

        On a total separate note have you ever been dry needled? I am guessing not, but you should consider giving it a try sometime you might be surprised as to how effective it is. I know the insertion of the needle is considered invasive but really the needle is so thin that it really isn’t even noticeable.

        Let me know your thoughts-Dolph

  72. Yeah, what gives here, Mike? Dolph is allowed to ramble on endlessly with his overt hostilities and assumptions about why others are here to comment on the topic at hand. He wanders off topic, he questions motives and he takes comments out of context.

    That’s not only an offense to the individuals whose motives he continues to impugn, but to the process of scientific debate.

    So, who’s making the offensive comments now?

  73. P.S.
    Dolph’s comment about Simple Contact was so completely ignorant and vacuous that it alone is an offense to rationality.

  74. I for one stand by everything said on Soma Simple and then so helpfully posted here.

    Dolph thinks it reveals something hidden yet it was (and is) all publicly stated.

    I really don’t see his point.

  75. Mr Ware,

    Since Dry needling is no good or has yet to really be proven by research, please show me the research that has been done on Simple Contact. If you are going to argue that the lack of scientific research is going to ruin the PT profession then since you hold Simple Contact in high regards should it not be held to the same standards as you would hold dry needling to?

    I am being serious about this so please do not take it any other way.

  76. Dolph,
    You obviously have no idea what Simple Contact is or what scientific model it’s based on. If you did, you wouldn’t be comparing it to massage.

    You make yet another (among several now) erroneous assumption that I’ve argued that the lack of scientific research will be the ruin of PT. I’ve never made any such argument.

    I also never said or meant to imply that dry needling was “no good”. My argument from the onset of this thread and many other conversations about the myofascial trigger point concept is that it has dubious validity. Unless and until the purveyors and supporters of this method can show that MTrPs can be reliably identified in a clinical examination, then I will continue to question any intervention that makes this- what is now- a leap of faith, and justify it by citing positive outcomes.

    This is how bloodletting remained all the rage into the late 19th century. It did turn out to be no good for almost everything.

  77. Dolph,
    I’m not sure what you are trying to expose with your comments. I am fully aware, as I’m sure everyone is, that anything posted on an internet discussion board is open for the world to read. That is why I will attach my full name with my posts as I don’t have anything that I am concerned would be exposed to anyone. I do thank you for being “Exhibit A” as to why I feel the need to try and be extra kind in my posts as compared to just direct questions. Invariable someone will come along and see it as a personal attack as compared to a challenge of ideas and discussion spirals downward from there. This leads to the frustration that Chris expresses, and that is unfortunate.

  78. I do want to try and open back up discussion based on the very good question by Arthur Veilleux.

    Some PTs point to Dry Needling as another tool in the tool box. I wonder do we need another tool in the tool box; or do we just need to understand better the tools we already have? And if we have another tool in the tool box, how do we explain it to patients?

    I see patient confusion when it comes to spinal manipulation as an example. A subluxation theory based chiropractor tells them they need a manipulation to realign their subluxation, most PTs are hopefully explaining very differently. The patient seeing that chiropractor and receiving a manipulation are led to believe they have to have the manipulation to get better. A patient seeing a PT (hopefully) is instructed to see that a manipulation technique can potentially create a neurophysiological reflex that may help reduce a pain state and lead to resolution of pain. In the chiropractic case, the patient most likely is limited in self-efficacy as they have to rely on someone else fixing them as they will not get better unless someone can fix the subluxation. In the PT explanation of manipulation the patient can decide if they want a manipulation or they may choose to just do some form of movement exercise or receive some other form of manual therapy all of which can lead to resolution of pain. I think we can see the difference.

    I do not want to be misinterpreted in saying a false assumption that anyone here that uses Dry Needling is saying it has to be done to get resolution of pain, because I don’t know in what context it is explained to patients. I would be interested in how it is explained to patients by those that use it.

    I know when someone raises the voice of caution it can be annoying. I was reminded of this during my state Physical Therapy association board meeting this morning. Some people on the board are very strict that parliamentary procedure is followed perfectly. While this can seem annoying (I will admit I started to feel that way this morning), it is for very good reason. It allows the rule of the majority with respect for the minority. Its object is to allow deliberation upon questions of interest to the organization and to arrive at the sense or the will of the assembly upon these questions. That is all I’m trying to do (along with others that raise questions about Dry Needling and MTrPs) with these questions. I hope fruitful discussion on these thoughts and others can continue.

  79. I am sure many of you especially the Soma folks will be glad to hear that I am done posting. I feel that I have made my message clear and don’t want to ramble on endlessly and wander from the topic at hand as stated by John Ware. After all it will just hurt the debate and not encourage thoughtful responses or thinking.

    Kind Regards,

    Dolph

  80. I see some similarity in the development of dry needling and spinal manipulation within our profession. Not that many years ago manipulation was looked at with suspicion, it was what the Chiro’s did and it was wrapped up in subluxation woo. There were few physical therapists using it, but all that has changed. Now we have clinical prediction rules and validation studies that help us grocery clerks to decide what treatments to offer our patients.

    If diagnosing pathology is unnecessary for treating spinal pain and a classification based approach can produce good outcomes for patients perhaps reliably diagnosing trigger points is unnecessary and that there is a class of patient that will have a good outcome when a needle is inserted into soft tissue. I believe there are some clues as to who these patients are, but much more needs to be done to understand this better. I find it plausible that there is a neurophysiological response to dry needling, as there is to spinal manipulation, that can fit within a deep model of pain.

    I hope that our researchers get interested in dry needling. Perhaps in 3 – 5 years we will know if this treatment a boon or a bust.

  81. “Pathology”? What pathology?

    “Class of patient”? What class?

    “…a good outcome when a needle is inserted into soft tissue.” Do you mean as opposed to when it is inserted into hard tissue?

    You find a neurophysiologic response “plausible”? How can it be avoided?

    “3-5 (more) years”? Why not yet?

  82. Ouch, Barrett. Bitter?

  83. Classic. Instead of answering these questions you characterize the questioner in a negative personal manner.

    Thanks for the display.

  84. Sorry, Barret. I mistook your legitimate questions for something else. My bad.

    Pathology? That is the point, right? We don’t need to know if a patient does or does not have pathology, ie tissue insult, to provide relief if they are classified in the manipulation class. That is not to say that a worker twisting and lifting can not sustain tissue insult.

    Class? I am sure many if not most of those here are familiar with the work of Delitto, Flynn, Fritz, Cleland and others who have developed the classification based approach. If not, there is plenty research out there to read.

    Sorry, I don’t understand the soft tissue, hard tissue question. Can you rephrase it for me?

    Of course, there is a neurophysiological response. I was just stating the fact. At the very essence of our being it is the only response. There are varying degrees to this response. Variable outcomes to the response. The skill comes form understanding what stimulus will produce the best outcome.

    It is here now. And it is receiving a lot of attention. Questions remain. Research is slow. We will see.

  85. Arthur,
    In the August issue of JOSPT Barrett and Jason Silvernail had an editorial published titled “Manual Magic: The Method is not the Trick.” If you haven’t seen that conversation with the authors of the lead editorial in the May issue entitled: “Moving Past Sleight of Hand”, then I think reading it might help you understand better where Barrett’s questions are coming from.

    The issues you raise about tissue pathology and neurophysiological effects sound very similar to what Mintken et al were trying to pinpoint in their effort to make a clearer delineation between mobilization and manipulation. As you can see in the response from Barrett and Jason, the authors of this editorial failed to account for a more plausible explanation for the effects of manipulation, which they described thus: “…aside from speed, what additional distinctions would you cite? If, in fact, the effect of manual care (manipulation included) can be assigned to the consequent neurophysiologic change, what is the significance of speed aside from its drama?”

    In light of the Bialosky study (cited in the Dorko/Silvernail article) finding the association between expectation and outcomes from a spinal manipulative intervention, isn’t it safe to assume that there are contextual factors in the therapeutic relationship that we may be ignoring in some of our outcomes research studies? Isn’t it possible that making a leap to some isolated biochemical and physical change within the “soft tissue”, i.e. MTrPs, as an etiological factor in persistent pain is akin to our prior fascination with joint nociception as a driver of persistent spinal pain?

    If we look at the full body of the research into pain, we know that (not so) simply providing LBP patients detailed pain physiology education can result in significant (albeit not likely clinically meaningful)improvements in physical performance, such as forward bending and SLR (Moseley et al Clin J Pain. 2004 Sep-Oct;20(5):324-30). We also know that patients with phantom limb pain can achieve very significant improvement in pain by visualizing movement of the mirror image of their intact limb.

    My concern with adding yet another “peripheralist” tool to the PT toolbox is that it may be just another manifestation of our profession continuing to ignore what we know, or at least should know, about the totality of the pain experience.

  86. Arthur,

    If you mean by pathology “something that requires healing and/or repair” then I know what you’re talking about. No such a thing has been identified within the context of “trigger point” speculation. The word “insult” in relation to tissues is new to me. What exactly are you talking about? (I know what it means for me to be insulted personally BTW. Who doesn’t?)

    Please don’t use the word “class” when referring to “classification.” I am not personally convinced that the research on classification relates well to clinical reality. That’s not bitterness, it’s my take on what I’ve read, know and have experienced the past 40 years.

    When you say “soft tissue” what tissue are you referring to? What isn’t included?

    You’re suggesting that one day we’ll be able to predict who will react in what way and to what degree to a stimulus surrounded by an undeniably variable context. The chaotic, fractal nature of the nervous system insures that we will do this well just as soon as the seismologists begin to predict earthquakes. Did you hear about [link broken] here in Ohio?

    As yet, the best we can do is design buildings that can withstand them – and so it is with the human body.

  87. The funny thing about our profession is this drive for evidence based practice. Well, we cannot agree whether stretching is to be performed before exercise, after exercise, or even at all. Evidence also suggests that PT is no more effective than manipulation or rest for acute spine pain. What about mobilization with movement?!! Or SCS?!! Or craniosacral?!! MFR?!! Should QL be trained as a spinal stabilizer or should it be pliable and have minimal tone? Point is- we use a LOT of modalities that have little to no evidence to back them up. If you want evidence- become a researcher!! OR find what works for you. Do TpS exist?!! Are you kidding me?!! More like finding which are central and which are satellite TpS!! I am very interested in IMS and hope that our state practice acts reflect our level of professional knowledge and care. Thanks for the post Ann!!

  88. Thanks for commenting.

    What you’ve said made no sense to me.

  89. Dr Seth wrote: “we use a LOT of modalities that have little or no evidence to back them up”

    Speak for yourself, I try to use modalities, techniques, treatments that have evidence to support their use. As Jason commented earlier, there is evidence to back up lots of what we do. Equally there evidence against some of what we do. This is the beauty of research; it allows our profession to develop…. well some of our profession.

  90. Dr. Seth also writes: “Do TpS exist?!! Are you kidding me?!!”

    No, not at all.

    He also writes: “If you want evidence- become a researcher!! OR find what works for you.”

    Is he seriously suggesting that people who aren’t researcers don’t understand evidence?

    Dr. Seth? Care to answer?

  91. Barrett, you have an interesting tone to your comments. I am all in favor of disagreeing and debating, not sure why you just lunge yourself out there at people.

    This seems to be the Soma Simple vibe.

    If you don’t agree with people and feel strongly about something (you, in fact, seem to feel you are 100% positive you are right and everyone else is wrong) than why don’t you take a different and more positive approach and educate us. This would make a positive impact on our profession, as you guys seem to be arguing the integrity of our profession so much.

    I am sure you are brilliant and know much more than I on the topic. I would love to learn from you, but your approach makes it challenging.

  92. The comment about pathology was in reference to low back pain and the classification based approach. Patients who fall into the manipulation classification would expect a good outcome whither or not pathology was present.

    I do not think of a TrP as pathology – something in need of healing or repair. The model I currently use is that they are the result of spontaneous electrical activity in the muscle, associated with taut bands and localized tenderness. Trp’s are a local, peripheral contribution to the experience of pain.

    Barrett, I disagree that our understanding on the nervous system is beyond our useful prediction, at least in a general way. We predict learning, motor development, response to exercise, skill development and other nervous system changes. I think that one role of physical therapists is to understand these systems, apply our knowledge and problem solving skills to individuals to reduce pain and improve function.

    John, do I understand what you mean by ignoring contextual factors in the therapeutic relationship? These the non specific factors regarding expectations, patient-therapist relationship and maybe even placebo, right? Plus pain, fear, catastrophizing, etc. This is very important in obtaining good outcomes, and should be part of patient education and PT interaction. However, I do not think that dry needling need distract physical therapists from using this knowledge in helping patients.

    @ Diane. I don’t believe that the TrP’s are occurring in the skin, even with all its thickness and innervations. I say this because I can see the depth of the needle and can judge where I am in the body. I include this description:

    A small gauge needle is inserted into the body and passes through the skin. Usually there is little to no pain reported at this level. Moving the needle deeper a thicker slightly more resistant barrier is often encountered; the superficial fascia. Additional fascial layers may also be encountered. I proceed into the muscle belly where I attempt to elicit a local twitch response but stay alert for any reaction or comment by the patient that might guide the needling technique. This is the area where the strongest sensations are reported by the patient. As I proceed I may reach the underlying bone. In the gluteal area is common to insert a needle 4-5 cm.

  93. Mike,

    I take exception to several of your assertions, and instead of simply saying, “You’d probably be better off not telling me how to behave,” I will explain why.

    You say, “(you, in fact, seem to feel you are 100% positive you are right and everyone else is wrong).”

    Citing an example here of how it is you’ve concluded that MY feelings are evident would be nice. Of course, my numerous posts elsewhere regarding my uncertainty and its importance in practice would be easily posted in opposition. You’re turn.

    I have spent many years watching our colleagues mistreat patients. This mistreatment is a direct result of two things – willful ignorance and an absence of consequence. These therapists seem uninterested in any form of education and coddling them has resulted in a form of practice quite appropriately ridiculed and dismissed. I doubt that I have to tell you who has paid the price for this.

    You have conflated negativity with directness. For the patients and the profession I choose the latter path.

    • Again, negative tone and no relevant addition to the discussion… I’m a sponge and have expressed my interest in learning from you. You’re turn – add something meaningful to the discussion and teach me something!

  94. Should be “your turn”

  95. Arthur you stated: “Trp’s are a local, peripheral contribution to the experience of pain.” This is where I get stuck when I reason through treatment of MTrP with Dry Needling. Let me use another case example. If you don’t think they are similar let me know why, so I can correct my reasoning process. Mike, I think you will be able to add in since my example is one of your specialties, so let me know where I am going wrong.

    Baseball player has an MRI that shows they have a small labral defect in their shoulder. We know this MRI tells us they are like most baseball pitchers, whether they have pain or don’t have pain. Most all of them have labral defects. The labral defect could be a “local, peripheral contribution to the experience of pain” (along with lots of other tissues in the shoulder); c-fibers and/or a-deltas could send nociception based on mechanical, chemical or temperature stimuli that upon evaluation of the brain neuromatrix produce pain. We would conservatively, first treat them with mobility and strengthening activities. Many of these will get better (decrease pain and improved function secondary to decrease pain) with this course of treatment. Once they are “better” we realize we did nothing to the labral defect, it would appear on the MRI exactly the same as prior to the PT.

    Don’t MTrP produce nociception in the same method as a labral defect? So in this case we did not need to do anything to the “local, peripheral contribution to the experience of pain” to allow the patient better, correct? I do understand the patient had a change the neural representation of the shoulder “map” in the brain (through exercise and movement) that no longer is perceived as a threat and thus no longer in need of producing a pain response. Would we be in agreement to say we don’t need to do anything to a MTrP (like the labrum defect) in order for a patient to get “better”? Why do we have to get rid of the MTrP but not the labral defect?

  96. Kory,

    This is interesting.I look forward to hearing some responses to your question.

  97. I see what you are saying kory but not sure if that is a great comparison. I don’t know if I am right but, yes many overhead athletes have labral tears, but I don’t think the labral tear itself is the source of symptoms. It’s more what the labral tear does (decrease static stability) that leads to symptoms.

    I am admittedly naive in this area, help me out. If someone comes in and says my neck hurts and I have a bad headache. They can’t rotate their neck fully. I palpate and find taut bands that are sensitive to palpating and reproduce the patient’s symptoms. I then do manual techniques to the area (and maybe dry needling :)…) and the patient has less pain, more function (can rotate better), and is happier.

    Perhaps we can debate what happened but what am I missing here? What would you guys do for this patient that only includes things completely backed up by evidence? I am all for enhancing what I do, what would everyone recommend?

  98. Well said Mike.

    I see what you are getting at with the comparison. However in the case of MTrP’s I can both palpate the tissue in question and receive feedback form the patient that can guide treatment. I am unable to palpate a labral tear and believe that patient feedback is less specific. I feel that I am more reliable in judging a MTrP than a labral tear in being a contribution to the experience of pain.

    Do treat MTrPs yourself or ignore them or feel they are just a figment?

    • Arthur, if I’m understanding your last question correctly do I treat, ignore or think they are make believe.

      Are they a figment, no when I push somewhere and the patient says it hurts and it feels tight, there is probably something there. I just can’t peel back the skin to see what it is. Diane Jacobs provides this potential insight to what might be going on as an alternative description: http://humanantigravitysuit.blogspot.com/2011/07/why-i-dont-buy-idea-that-trigger-points.html

      Also I am inclined to think of Abnormal Impulse Generating Sites (AIGS) when I palpate something like this.

      Do I treat MTrP, not really. I treat the patient with manual techniques and movement based exercises. When they get resolution of the pain, if they still have MTrP they don’t seem to care and nor do I. Just like a patient with labral defect doesn’t care as long as it doesn’t hurt and they understand why they don’t hurt anymore.

  99. Mike, if you want to stick needles in someone’s neck that is up to you . You are right this is a debate of what is happening and how we explain it to our patients. You asked: “What would you guys do for this patient that only includes things completely backed up by evidence?” I can’t speak for others only myself, but my guess is my manual techniques may not look much different from yours (just I don’t stick needles into someone, alright promise that is the last needle joke in this post). Again just because it cannot be completely backed up by evidence doesn’t mean that the body of evidence and scientific plausibility doesn’t help direct us in our practice. I pick many of my shoulder exercises to do on patients based on your evidence from 2009 article. My concern with MTrP and Dry Needling is for me (and yes I know plenty will disagree with me and I am still reading through the list of articles given to me) is that the body of evidence isn’t strong enough one way or another to add another treatment option. Maybe it’s because I don’t see any value in hoarding every treatment technique out there and just want to simplify things.
    Probably one of my bigger concerns is also the potential explanation of MTrP and dry needling, is it along the line of subluxation and manipulation? Let me explain my comparison. We thought we were palpating rotations in the spine and pelvis and we thought our techniques put those alignment issues back in place. “Your neck is out of alignment and you need me to do a manipulation to put that back in place so you don’t have pain anymore.” We know many patients to this day feel they need to get their spine adjusted monthly in order to maintain their health, good luck convincing them otherwise. This current practice works for them. My concern with the question of validity and reliability of palpating MTrP is also under question as the subluxation theory had been. Again I’m not saying I don’t or anyone else doesn’t feel something, it is a question is it clinically meaningful enough to base a treatment based on concerns with reliability (see Jason’s post on Enough is Enough previously listed and my question of how come some tissues may produce nociception and it is not a problem yet MTrP are). “You have a MTrP and I need to do Dry Needling to reduce that MTrP so you don’t have pain anymore.” Again I do not know if this is how it is explained (obviously in a little more detail then I gave but I hope my general point is received) or not, as I don’t do it, so you or others that do it can help answer that.
    Some might say, “What differences does it makes how you explain it as long as it works, the patient doesn’t care”. With an incorrect explanation we have developed a false expectation within that patient and also have taken some self-efficacy away from the patient in them thinking someone else has to fix me. I think in the long run this is making some patients much worse, especially if they have central sensitization issues. It is going to be very hard for them to see pain is in the brain if they are convinced they just need to get rid of all the MTrP in the periphery.
    Pain issues are extremely complex and multifactorial and educating patients appropriately on this is important. My concern is we just need to be cautious when we add another peripheral tool to the tool box. Again, I don’t want to be taken as saying I do it right and you do it wrong. I just want people to consider it a little further than “it works, so I do it” and a few posts have seemed to allude to that. Other posts alluded more to Dry Needling being used in a larger clinical decision making model as it should be. Another concern is those that are taking enough time to read and post here are not the majority of our profession (I get concerned most don’t take this much time to read and contemplate what they are doing). Many of those posting and reading here are probably out their teaching that majority and I hope that majority is hearing more than “it works”. I understand more than that is being taught; I’m just not sure the majority is hearing more than “it works so I got another tool in my tool box”.

    • Kory, this is a great response, thanks! I really liked your first points. If you are happy with your current techniques, then yes why add a new one to your bag of tricks, especially one that isnt yet completely understood or proven to be effective.

      My point of view has always been that I am striving to be the best and provide the best service to my patients. While I feel like I do a good job now, I always wonder if I could do better! I don’t mind trying something new that doesnt have research if I think that it has some plausibility. But I usually dont adopt first, I’ll let others try it out and get feedback. Then when a number of people I trust recommend something, I listen. This is what happened to me with dry needling.

      As I use it more, I will definitely make the decision if it is worth keeping in my bag of tricks or not (and will be sure to update everyone!). I hope it is, because I am always looking to enhance my outcomes. Dont get me wrong, I am not a huge dry needler, but I want to explore if there are some real specific situations where it will enhance my outcomes.

  100. It seems to me that having a “bag of tricks” in and of itself may be problematic for the patient in what it implies:

    THERAPIST: We didn’t have much luck with “x” and “y” interventions, so I’m now going to try “z” because there is some evidence that it helps people with your problem. [Therapist proceeds to provide complicated biomedical descriptions of the patient's "pathology".]
    PATIENT [thinking to himself: Wow, I must have a really difficult problem since my therapist is trying so many different things on me. And what were those things he said were in my muscle/joint/ligament?] Oh, OK.

    If MTrPs turn out to be as elusive and irrelevant as I suspect they are, then it won’t be the first time that the biomedical mindset resulted in the medicalization of persistent pain.

    • John that is an interesting way of describing our clinical skills. Maybe I shouldnt have said bag of tricks or other similar phrases, like toolbox. Or perhaps people take this phrase to aggressively.

      Do you just do one thing with every patient you treat (i.e. just stretch one person or just perform one exercise with someone) or do you use a combination of techniques and exercises? That is what people refer to as their “bag of tricks” etc. You can take that phrase however you want but my “bag of tricks” is the combination of techniques i use to maximize my results as quickly and safely as possible. As one would assume sometimes combining two techniques is more effective than just performing one.

      Its not that one failed and now i am moving on and trying the next one. That is a pretty simplistic view of what people say when they say “toolbox.”

      Would rather have chocolate, peanut butter, or the way better option of a Reese’s Peanut Butter Cup?!

  101. But what happens if they do turn out to be important? Since there isn’t an agreement whether or not they are a factor in peripheral pain, why such strong opposition? In my practice I plan on being equipped with multiple manual “tools” to treat pain and MSK dysfunction-partially bc I feel it makes me a better more dynamic therapist, but mostly because there doesn’t seem to be a superior method. If you can suggest one-please do so I can learn. My personal belief is that if there is no definitive “best” manual intervention for dealing with pain decreased function then I might as well try to learn as many good ones as I can. Is that wrong? Ideally there would be a method that is completely proven to work but since there’s not I don’t see a problem in being open to different ideas-especially ones that are so well accepted by experienced clinicians (the Janda approach for instance respects MTrPs and treats them with needling.)

    • Shannon Murphy, PT, MPT Reply February 1, 2012 at 4:48 pm

      A few thoughts –

      1) I don’t know that the existence of MTrPs is a point of valid contention with US, MRE and histological research confirming that yes – there is something aberrant going on. But the question of relationship, relevance, correlation & causation IS fair… and what (I think)we’re really debating.

      2) Moving away from an exclusive discussion of pain might help. Can we agree that tender, taut, grissly tissue is often associated with neuromuscular dysfunction of some sort? Without hashing over the specific definition of this term or that, regions with concentrations of bands & MTrPs don’t function properly – timing, sequence, amplitude of response, etc. I understand it as muscle inhibition. I don’t know if her research is held in esteem or disregard, but PT colleague Barbara Headley has written about EMG findings in this area. Agree that all this addresses correlation more than causation. Does tissue overload (e.g. sustained eccentric loading) lead to chemical changes and MTrPs which further disorder gross muscle and regional function and signal the nervous system to overattend to the area that went offline? Or does it happen in the opposite direction? I’m sure there’s some law of quantum physics that states both can be equally true.

      3) As to needling – the issue of inter-rater reliability is probably not going to get resolved. Human factors & palpation are variable and both sides are likely to always have evidence for their perspective and against the other. But the goal of needling, as I’ve learned & experienced, is to elicit an extinguish a local twitch response. As far as I know and understand, the LTR phenomenon is exclusively associated with MTrP stimulation. So – if you get an LTR, you’ve got an MTrP. The palpation part is just a screen. And no, you don’t always “have” to needle to either elicit or eliminate an MTrP. But it can be more precise and efficient than other techniques. Think SEAL TEAM 6 vs enlisted forces. The Navy is great. But for the right mission at the right time – Seals kick A.

      3a) Now the LTR is a unconscious reflex that I think falls clearly in the realm of neurologic phenomenon. I don’t think anyone debates that. I think what is possibly being mis-ascribed is an idea that people who treat soft tissue are doing so in a way and mentality that is completely dimwitted and divorces periphery from centricity. (did I just make up the word centricity? anyhow – parallel structure of central:peripheral) I don’t think that’s the case at all. I just think that you can bring the whole system back online in a variety of ways. I use that analogy of ‘reboot’ in a lot of contexts, including needling.

      4) In terms of determining when to use needling over another technique, I don’t think any study or classification system is ever going to make treatment completely algorhythmic. I use it selectively but successfully – defined, in my world, as normalizing bad behavior as efficiently as possible.

      5) In terms of finding the right number of tools for a toolbox – what? Based on the number of seemingly identical socket sets owned by my husband, I didn’t think there was an upper limit.

      At any rate, I *hope* this bridges some of the debate on both sides. I don’t claim to be an authority on anything beyond my own experience, so take that for what it’s worth. And to Kory’s point – yes, we’re all preaching to the choir. The profession is probably not being marginalized by those taking the time to involve themselves in it. Passion trumps apathy. But diplomacy should reign supreme.

    • Well said Shannon and Chris

  102. Shannon-
    For my part, for a those in a doctoral-level profession, I think science should reign supreme. Far more so than ‘diplomacy’. I think we should ask for and expect direct questioning of all of our methods without complaining about “tone” or becoming offended with plain speaking.

    Chris-
    What about all that great disk evidence from the 80s and early 90s? Remember the “high intensity zone” of the disk? How about IDET, remember that was supposed to just revolutionize spinal pain? I’m old enough to remember this process of getting all excited by fads in the connective tissue – it has never worked out before. First it was joints out of place, then disks were deranged, and now people want me to believe that it’s all about the muscle knot. “Look, they said – here it is on this imaging study. Wow check this out – we can study it.” Guess what? The fads come and go, and every one of these approaches has failed us. “But THIS TIME, this time with this TrP thing, this time we’ve got it. ” “Just wait for the research,” they say. You’ll see, this will turn out to be the next big thing, and you don’t want to be left behind do you?”. You know what, Chris? I’ve heard this story before, and I can’t pretend I haven’t. I get that you want us to not throw away what might be a promising treatment – I like where you’re going with that concept. But those of us who have been around a while or who have read the history of physical medicine can’t help but be a little jaded to “the next big thing” – especially when it seems to ignore the strides we’ve made in understanding the neuroscience of pain. I’m not suggesting we throw things out – I’m suggesting we are more careful about what we pick up in the first place. I think there’s a difference.

    All-
    I think the concept of a “bag of tricks” or a “toolbag” should be downright embarrassing for any doctoral level healthcare professional. The fact that we use this language expresses how little we understand about the physiological phenomena we see in clinical problems. With all that we now should know about painful problems, this is just an embarrassing situation.

    I read the first five chapter’s of David Butler’s The Sensitive Nervous System and it totally changed my clinical life. I immediately stopped doing 50% of what I had been doing in physical therapy. How could I not have?
    The origins of pain are simple (I didn’t say “easy”). Mechanical deformation, chemical irritation (including thermal), central sensitization, and ectopic discharge. These basic facts have been well known in neuroscience for some time.
    Those with central sensitization (think Fibromyalgia as an example) are a bit more difficult to help than most due to the disorder of pain processing that is present.
    However, for most of the time for most of us in clinical life, we are dealing with pain whose origin is mechanical deformation of the relevant nervous tissue – mechanical pain. The only treatment that really makes sense for mechanical pain is movement – this really shouldn’t be that hard for us as a profession. Maybe that’s passive movement such as what Maitland recommends, to include manipulative therapy. Maybe that’s primarily active movements and loading positions such as recommended by McKenzie. Maybe that’s the use of gentle progressive recoordinative movement such as recommended by Feldenkrais or Hanna. Maybe that’s the use of inherent ideomotor movement as recommended by Barrett Dorko. Or gentle movement of skin and the body positioning recommended by Diane Jacobs. Even mechanical traction might have a place, and I do sometimes still use that. These aren’t ‘tools’ they are approaches designed to relieve the underlying problem and all of these can be defended based on what we KNOW TO BE TRUE about mechanical origin pain. For those interested, find references here: http://www.somasimple.com/forums/showthread.php?t=8686

    I’m not interested in poking my patients with needles, scraping their skin with metal or plastic tools, zapping them with lasers or electricity, or doing god knows whatever fad treatment is next on the horizon. Why not? Because they don’t help the mechanical origin of their symptoms, that’s why. I’m not interested in any “tool” that doesn’t involve movement – because I understand the origin of the problems that I see in clinic. We all should by now. This is the sort of frustration that lead me to write the “Enough is Enough” post that got picked up by Body In Mind (posted above).

    For Dr Reinold’s neck pain example – if after my examination and differential diagnosis process I determined they had mechanical neck pain, I would treat them with movement – probably manual therapy and exercise. This approach has randomized trial support by Walker 2008, Hoving 2002, Hurwitz 2002 and several others. By the way, analysis of both the Hurwitz and Walker trials showed that the addition of thrust manipulation didn’t improve outcomes, so I probably wouldn’t use thrust manipulation. For anyone to choose needling first for mechanical neck pain, they would have to directly and deliberately choose a more invasive treatment with less supporting evidence that does not directly address the underlying origin of pain (since it doesn’t involve movement). In what possible system of clinical reasoning does this make sense?

    I get that most Dry Needlers are already physical therapists and they probably are already doing movement-based treatment. I get that it probably is low risk (depending on where you stick the needle I suppose). I get that, as Shannon notes, these are already our colleague doing more or less right by their patients. But that doesn’t change our responsibility to ask the hard questions of each other – especially questions of risk vs benefit to our patients.

    • Wow Jason! You really have a way with explaining things that just makes sense.

      I agree you have to look at the true source of pain: is it mechanical, thermal, chemical and so forth. The brain is interpretting whether or not there is a threat and that’s when pain can show up.

      I don’t doubt that needling may help ease the symptoms but not sure if it has any effect on the true cause.

      I feel if you try to go and treat pain you need to have an appreciation of the nervous system and how it may be affected by the stimulus that starting everything.

      Pain comes from the brain. You may step on a tack but it is your brain that says ” hey, this hurts, get away” in order to protect us from further damage.

      I think a large percentage, but not all of the pts coming to us are mechanical pain. Think of the person who “throws there back out” shoveling. They usually come in so guarded with their mvmt that they are afraid to bend their spine at all. If you show them slight mvmt such as hip hinging for example this may settle down their anxiety and start to allow more mvmt w/o pain. Just an example , not an end all be all of treatment. First you relax their fears that the pain is severe so the damage must be severe. Then doing some gentle novel movements may further reduce pain. could you in theory use needling to reduce the symptoms? Maybe, but did it treat the symptom or origin?

      The point I am getting at is if you listen to whant Jason says about the true origins of pain, as decribed in The sensitive Nervous System, you might want to do other things first to reduce the pain. Needle is at the end of the day an invasive treatment compared to other forms.

      I have taken some trigger point courses at in the past and remember feeling like this was the missing tool. Learning more about the neuroscience of pain left me second guessing myself.

  103. Jason,

    One of the finest posts I have ever read. Thank you for this.

  104. That post by Jason is indeed a tough act to follow, but I’ll take a stab at it.

    I highly recommend the readers of this thread take a look at this week’s contribution from Body in Mind, Lorimer Moseley and Neil O’Connell’s site where they mostly discuss the pain literature that’s relevant to PT (http://bodyinmind.org/moral-dilemma-in-treatment-of-whiplash/). This topic comes from Esther Williamson, who recently completed a huge study for her PhD that included 599 participants who had whiplash injuries. What she and her co-investigators found was that the strongest predictor of a delayed outcome was the patient’s expectation that they wouldn’t get better.

    In the thread I referenced she is taking this finding to the next level by questioning the current methods of treating conditions like whiplash, and suggesting that our medical systems may be contributing to rather than preventing chronicity. In her words:

    “We need to think carefully about the treatments we provide, avoiding treatments for which there is little evidence of benefit (even if that means providing less treatment) or passive treatments that encourage patient dependence.”

    I’m very confident that I if I polled purveyors of the MTrP construct that I would get a resounding affirmative to the presence of these things in post-whiplash patients. I know that I have felt twangy sore spots on many patients after a whiplash injury.

    Problem is, if you familiarize yourself with the extant literature in pain science, much of it coming from PTs, you’ll see an emerging pattern that tends to discount the use of passive interventions for the patients who are not improving as you’d normally expect.

    Yet, PTs continue to search in vain for some holy grail, some peripheral culprit, to justify acquiring some highly specific skill to perform on the awaiting, passive patient.

    As Chris admitted above, “I feel it makes me a better more dynamic therapist…”. Nothing against Chris or anyone else wanting to be a more dynamic therapist, but our longings for dynamism and a “skill-set” shouldn’t overshadow what the science and the evidence is telling us.

    It’s telling us to be more circumspect before we adopt new treatments that threaten the autonomy and self-efficacy of the patient.

  105. Finally, fantastic posts! Thanks so much everyone.

    Jason:
    You do verbalize your thoughts well and reading your posts has enhanced my knowledge – so you have succeeded and made a nice impact on this discussion.

    You have experienced a few “trends” in rehab come and go, that is a great perspective. You could absolutely be right concerning trigger points, we’ll find out one day I am sure!

    I do think the whole “toolbox” concept is being blown way out of proportion. You said “I would treat them with movement – probably manual therapy and exercise.” That is your bag of tricks and you know what, that is exactly what I would do. Perhaps our “manual therapy” component would differ slightly, but I bet by not much, though saying we do “manual therapy” is like saying we do “physical therapy” on a patient.

    Perhaps we call it our “clinical skill set” instead of “bag of tricks” if that makes everyone feel better about our profession. Forgive my casual tone when making comments like “bag of tricks.” You are right, we are better than that, I just dont get bent out of shape over comments like that because I know people reading this know that I dont consider my clinical skills to be “tricks.”

    John Feil:
    Great comments and well said.

    John Ware:
    I think your post is one of the best so far and absolutely makes sense. Thanks!

    All of this research on pain makes sense. I still really dont think we know as much as we think we do and I am sure a decade or two from know this whole discussion here will probably be pretty silly, on all sides!

    Call me crazy, or unscientific, or heck even a bad apple for our profession, but I still don’t feel comfortable intentionally NOT performing a manual therapy technique on a patient that is in pain and not functioning that I know is going to help reduce their pain and get them back to their level of function. I get it, pain is their problem, but pain is in the brain… OK, then what do I do?

    I ask in sincerity and plead ignorance. I want to understand more.

    As John Feil states, maybe we just need to get them moving and gain confidence in moving again. That makes sense. Does manual therapy help relax them and ease them into this state? I would say it would. I dont care if you rub a tool, press with your thumb, stick a needle, or anything else. None of it is probably doing exactly what we think it is doing. But does it help the person achieve some level of a parasympathetic response so that we can work on the true source of the pain? I think it may.

    Maybe we somehow combine everyone’s perspectives here and all come out ahead? Or am I just too optimistic :)!?!

  106. Hi Mike,

    Here is an article which looks at the current pain science and the application part. There are many books, videos and studies in the “recommended reading” list. I wrote it for the strength and fitness industry.

    http://bretcontreras.com/a-revolution-in-the-understanding-of-pain-and-treatment-of-chronic-pain/

    Jason helped edit it, if that helps. And I learned almost everything from somasimple. For your amount of knowledge and curiosity, you will pick it up in no time.

  107. Wow-
    Thanks so much for the responses and especially for providing links and resources.

    I did like your post Jason and certainly respect the opinion of the “SOMA group,” even if it teeters on the border of pessimism at times.

    Before I leave to begin exploring this new information, would you, or others agree with this summarization:

    -New concepts of pain neurophysiology have brought old interventions and techniques under question, and produced new manual concepts that MAY be beneficial to our patients (haven’t seen any RCTs on ideomotor movement or gentle movement-although I can’t say I have been looking for them.)

    -One of these old interventions is Needling and MTrPs. While it hasn’t been disproven, its theoretical foundation may not coincide with new pain research. That said, it doesn’t mean it can’t still be a viable option as adjunct to exercise and movement, but it should not be considered as a superior manual technique until we can definitively agree on MTrPs as a cause of pain, and then definitively agree if needling eliminates them and produces greater outcomes.

    -Since, in my opinion, we are considered specialists in movement dysfunction and pain, it is our obligation to pursue current concepts of movement impairments and it’s connection with pain physiology-similar to the work of Sarhmann and Cook, as well as the pain research you presented in your posts. By doing so, it may be likely that we place less of a priority on peripheral soft tissue techniques. We need not throw these by the wayside and ignore the outcomes we have been able to achieve, but maybe de-emphasize them in light of current science and (hopefully) better manual interventions.

    I think this thread has shed just as much light on MTrPs and Needling as it has on the complexities of our profession. Much thanks to everyone.

  108. Chris,

    Your admission that you haven’t looked for RCTs about various movements and their effect upon the origin of mechanical deformation doesn’t surprise me, but it certainly justifies my bent toward a pessimistic view of our profession’s notion of appropriate practice. I presume you haven’t given this much thought either, but that’s just a presumption and I am perfectly willing to admit I am wrong.

    Looking for “causes” is like looking into a black hole. You aren’t going to find them. It makes as much sense as looking for a “source.” Both of these tactics are frought with peril. We need only seek to understand origin.

  109. First, I would like to apologize to Dr Jan Dommerholt. I repeatedly used the title “Mr” when speaking to him here in an attempt to be polite, I had not realized he had a doctoral degree, which I discovered when I went to his website. I in no way meant any disrespect to him and had I known, I would have referred to him as Dr Dommerholt. Sir, you have my apology, I meant you no disrespect and did not intend to be rude.

    Second, it’s often helpful to put some of these things into perspective in terms of seminar costs. Let’s look at the cost of the training as well.

    The McKenzie Method is a good comparison. This method uses progressive movement and loading positions in an established clinical reasoning process to resolve mechanical pain. It includes education about the origins of pain (chemical vs mechanical vs central sensitization) and has a certification program as well as a seminar series. There are randomized controlled trials and systematic reviews that show benefit for this treatment in the lumbar spine. I am in no way affiliated with the McKenzie Institute nor I am certified through their system. I have found their approach of use in numerous patients and I think, since they are using movement, this is a valid approach for mechanical pain from a basic science perspective as well as their considerable published research base (primarily in the low back).

    McKenzie Institute USA Courses
    Part A Lumbar Spine two days online, 3 days in person, $650
    Part B Cervical and Thoracic Spine two days online, 3 days in person, $650
    Part C Advanced, 4 days, $690
    Part D Extremities, 4 days, $690
    Part E Advanced Extremities, 2 days, $400
    Certification Exam $500

    Myopain Seminars Courses
    (dry needling only – not listing the fascia or manual trigger point courses)
    IMT-1, Foundations, 2.5 days, $750
    IMT-2, Head, neck and face (yikes), 2.5 days, $750
    IMT-3, Low back and pelvic pain, 2.5 days, $750
    IMT-4, Extremity Pain, 2.5 days, $750
    IMT-5, Review and Certification, $1200

    KinetaCore Seminars Courses
    TriggerPoint Dry Needling(TDN) – not listing the FMS/SFMA or “functional myofascial cupping” courses.
    TDN 1, 3 days, $1250
    TDN 2, 3 days, $999
    Pelvic Floor TDN (double yikes), 1 day, $250

    Costs are as of the official websites in February 2012. I would say the ratio of cost to evidence and cost to plausibility of these seminars gives us all something to think about. Especially when compared to an existing, well respected, well-referenced, plausible education program such as that offered by the McKenzie Institute.

  110. And this written about poking with reference to that linked above:

    http://humanantigravitysuit.blogspot.com/2012/02/projector-or-movie-screen.html

  111. This is from “another” blog site…I find it is direct and to the point:

    “The denouement of that movie begins with the pulling back of the curtain. This is done, of course, by Toto, Dorothy’s instinct and the whole reason for that trip to Oz, according to me anyway.

    Diane Jacobs’ latest blog post should be read by everyone who normally reads Range of Motion and I get an average of 200 views in the first 18 hours anytime I post.

    This bit of blogging has now grown close to 300 replies and 7000 views. All about a method I have never used (or intend to) and a theory that has increasingly been called into question.

    Diane’s writing and the link in that article make the reasoning that precedes the needling even more suspect and I’d love to see someone defend it in light of this new evidence.

    Let me add this: Abductive reasoning, explained in detail here, also precludes the possibility that things are as the purveyors of dry needling say they are. Once again, I’m not talking about the results they claim.

    Remember the Wizard’s initial attempt to hide his true nature? He said, “Pay no attention!”

    It didn’t work then and it’s not going to work now.

    Over to you.”

  112. For those that may require a reference to the above

    http://www.youtube.com/watch?v=NZR64EF3OpA

    By continually ignoring the “why” (ie science) of what we do…and primarily focusing on the “outcome” of the “tools in our tool box”….will we be exposed by the mounting pain sciences?

    My guess is soon enough.

  113. Should credit the author of the above (no edit function here):

    http://www.somasimple.com/forums/showthread.php?t=12373

  114. Ok, I cannot resist and will add a few more comments, actually, I have a few questions.

    On Somasimple.com I have been described as “he’s too married to his own research and teaching to even begin to understand what Jason, Kory and others are talking about. He is now leaving, chest puffed out trailing his peacock feathers”. Mr. Dorko described me as “he’s very bright and he doesn’t get it at all”. Others stated “he misses the mark completely”. Mr. Dorko even mentioned that “he should get credit for upsetting Jan as well should remember that this guy is REALLY easy to upset.”

    Let’s assume that these descriptions are correct, although I seriously question whether anyone who knows me would agree that I am really easy to upset. As other contributors apparently feel that they are getting it, maybe they can explain the one issue I really do not understand.

    I have read all the links that were provided and agree with 90+% of what has been written here and in the links. I understand that many of you believe that including a bottom-up approach is not indicated partially based on recalled hypotheses about disk pathology, etc. I also sense that many of you believe that a top-down approach is the only sensible pain management approach. And that is where I do not quite follow the debate.

    In my courses we spend a lot of time on current pain science studies and papers. Course participants get a syllabus with almost 400 pages of current pain science articles, which include articles by Woolff, Moseley, and many others. About 65% of our theoretical exam focuses on pain sciences. I may not get it at all according to some, but I do believe that I am quite up-to-date on the pain science literature.

    In one of those articles “A pain neuromatrix approach to patients with chronic pain” (Manual Therapy (2003) 8(3), 130–140), Lorimer Mosely mentions “Broadly speaking, any strategy that has an inhibitory effect on nociceptive input is probably appropriate in the short term unless it simultaneously activates non-nociceptive threatening inputs.”

    I believe that I do attempt to practice evidence-informed physical therapy. I also believe that trigger points are sources of persistent nociceptive input and following Moseley’s comment, I do not see any reason why I should not include applying an inhibitory technique to reduce nociceptive input. I also believe that trigger points are part of the pain science literature, which is consistent with Melzack’s neuromatrix. Yes, I do realize that in one publication in which the neuromatrix was presented in an abbreviated fashion, he did not specifically mention trigger points in his diagram (but did so in the body of the text). I believe that trigger points are physiologic phenomena and in that sense quite different from anatomical structures.

    My first question: why do you maintain that trigger points would not meet Moseley’s notion of nociceptive input? There are many studies that provide support for this notion.

    My second question: if trigger points are sources of persistent nociceptive input, why would I deny the patient what Moseley suggested?

    In my courses, trigger point therapy is very much taught in context of current pain sciences. We do acknowledge placebo effects of the needle. We do emphasize that dry needling is not indicated if it is experienced as a threatening input and therefore no longer therapeutic.

    One comment on the cost of our courses compared to other types of courses. Trigger point dry needling carries certain risks, not the least, pneumothorax. To enable a safe learning environment, much supervision is required. We – and the folks at Kinetacore – have a very high instructor-student ratio and I do think it is fair to pay our instructors a reasonable honorarium for not seeing patients on clinic days, and reimburse them for travel, lodging and meals.

    Jan Dommerholt

    • Jan, you are a genius. Couldn’t have put it better myoself.

      Dry-needling is here to stay, like it or not. It is incredibly effective, as you find more and more people researching, the evidence will shine through.

  115. Jan,
    Great questions. I actually just wrote a post for “The Manual Therapist” today about pain (check it out http://www.themanualtherapist.com/2012/02/guest-post-all-about-pain-by-dr-joe.html). I agree that, if one can detect tps reliably, and they can confidently state that it is the cause of nociceptive input, then inhibition would be treatment of choice so summation does not occur. I am not sure invasive measures are necessary though and there are reliability issues with tp detection, but in theory, you hold a valid argument.

    Once the individual is in a state of central sensitization, I believe any peripheral input could actually make symptoms worse. Using a recently validated, neurophysiological approach for the classification of pain, individuals in central sens. have hypersensitivity to peripheral stimuli (thermal/tactile/sharp&dull). At this point, pain is not localized and is disproportionate to the actual degree of injury. Psychological factors are also highly at play here. At this point, pain has become a central process and peripheral techniques, via any means could potentially make symptoms worse. Graded exposure and psychological pain coping strategies are likely more justified (at least from my understanding of pain literature).

    With this stated, I am glad to hear the efforts to incorporate pain sciences into any course.

    • Joe,

      I agree that invasive procedures are not at all necessary, but that does not mean that they should never be considered. In a state of sensitization, dry needling could be problematic, but generally speaking, it rarely is. Dry needling does not exclude graded exposure, psychological pain coping strategies, etc. Some patients are indeed hypersensitive to invasive procedures and temporarily the patient may experience more pain. Nearly every patient can distinguish this increase in pain and along with the pain education, most patients feel much better 1-2 days later.

  116. Jan,

    Thanks for the questions.

    I’m still working through all the articles you gave me. I have only gotten through about a third of them. So I understand I have more to learn about MTrP.

    I will explain my concerns while trying to answer your questions, and yes were talking about the 10% of differences we have (and it may not even be that much)and I hope all that are reading along understand this.

    This is something that I am currently working through over at SomaSimple.com, so please come and join in the conversation as I try to look at emergent systems and the complexity that comes with them, I greatly appreciate all that add to this.(http://www.somasimple.com/forums/showthread.php?t=12378)

    “An emergent nervous system has the capacity to produce an output of pain.

    Pain thus will have properties of the tenets of emergent systems.

    Tenets of an emergent system:
    1) They are nonlinear in nature. Even if some of the constituent parts in isolation are linear, once they are put into the emergent system they fall under the property of that emergent system and will become nonlinear.
    2) No single constituent part can be responsible for the emergent system. The sum of the parts is always less then the product of the whole emergent system.”

    I see MTrP as potentially one of those constituent parts that add nociception from the left side of Melzack’s Pain Neuromatrix. But unless you change the whole culture/context of the pain experience I don’t think that we can expect long term change of a patient’s pain experience. We may make some good short term improvements, but I’m concerned we will not see long term change with chronic pain. Considering the IOM report on Relieving Pain in America stating there are 116 million Americans in Chronic Pain, these long term improvements need to be looked at seriously. (One of the studies you shared with me – Hong 1994 showed that pain was decreased but effects tended to decrease with time). How do we get so this does not decrease over time. I understand the study was not a long term study, so longer use of Dry Needling may be able to make these changes. Does Dry Needling after a series of treatments make sure MTrP never return? I’m not sure that has been shown. The best I understand at this time is: no specific intervention targeted toward nociception input on a large scale is going to change around, long term, a persistent pain patients unless you can surround that person with a new culture/context of understanding pain. I think this potential can only be done through Pain Neuroscience Education, and it may not be able to either.

    There may be times that Dry Needling may be beneficial in treatment of pain, but I’m concerned that there may be times that it may be detrimental to the long term treatment of pain. For example if the patient’s concern is stuck in the tissue (and this is perpetuated with a therapist treatment focused on those tissues) as a root cause, adding a treatment that decreases self efficacy (this would be any external passive treatment) does not, in my opinion, help them move into a new culture/context of what is happening with the situation even if you reduce the nociceptive input.

    I’m glad to hear how much pain science education is contained in your training course. I hope all Dry Needling courses do this. As for me this is a central theme that needs to be understood by therapists. I realize some (maybe yourself, maybe not) will disagree with me, but I think we need to first and foremost think about treating pain by changing the culture/context the patient understands pain, not MTrP or any constituent part that provides nociceptive input. I think there is a difference, for therapists and patients to understand. I’m not saying you are not teaching this, my bigger concern is the average PT hearing and understanding this.

  117. I’m with Kory here. Changing the context is extremely important and if at some point the patient is shown a needle that’s a big problem. The therapist may overcome this, but the work required to do so must include information we don’t actually possess.

    I object to Jan saying, “I understand that many of you believe…” Belief isn’t necessary for an informed opinion.

    Claims made regarding the immediate resolution of chronic symptoms are never a good idea. I don’t think I need to say more about that.

  118. I think Jan makes some good points.The question is why not trigger point if nociceptive input can affect pain?

    I guess the problem is how do we know for sure it it is the trigger point that is contributing to the pain or not? Maybe it is the muscle imbalance. bad posture, movement dysfunction,and so forth. And everyone can come up with a sensible theory for all these. And mind you they all have excellent results too.

    As Louis Gifford rightly says “It is important to note that we are full of dysfunctions whether we are in pain or not. If we are in pain it is easy to find something wrong relevant to a precise tissue model but which may not be relevant at all to the patients state”.

  119. Since when are all theories sensible?

    If we’re driven toward method by theory wouldn’t it be a good idea to choose the one with the best defense?

    NO ONE is arguing results here.

    The point (pun intended) is method. And if a method requires tortured theory and additional work by the therapist in order to create a non-threatening context it should be called into question. If is something other than conservative (read potentially harmless) I wonder of it’s necessary.

    NO ONE has said that peripheral points (or regions, or places) of tenderness cannot be found. The literature indicates however that they are transient.

    All pain is neurogenic, and this is an unassailable fact. We have asked the question: How best to approach it?

    I don’t think a needle would be a good answer.

    • Barrett,

      If you were my patient, it is likely that dry needling would not be part of the treatment plan. I do not think that showing a needle to a patient by definition has to be a big problem. Dry needling delivered in the context of the pain sciences is usually not a problem at all.

  120. Hi Barrett,

    When I mean “sensible”, I mean in the same sense (less) as trigger points based on the bio-mechanical model.

    When I mean results, I mean the results ( anecdotal evidence) as seen with trigger point.

    I should have put those in quotes.

    What I mean they can all be lumped into one group and there is no reason to think one is superior over the others to have a discussion centered around it. So I am agreeing with you.

  121. Anoop,

    Perfectly clear now. Thanks for the clarification.

    Do “trigger points” reside in the contractile tissue as proposed and can that supposed dysfunction of the targeted tissue be altered as those who dry needle propose?

    Is the wizard actually magical? Is there such a thing as real magic?

    It seems to me that I’ve written a bit about that elsewhere.

    BTW, it has been reliably reported that Janet Travell’s father performed magic tricks. I do as well, and I know that the method is NOT the trick.

  122. Kory,

    I do agree 100% that any effort to address the left side of Melzack’s neuromatrix will only be fruitful if the total matrix is considered. Dry needling is indeed not the answer to everything. I have seen instances where dry needling clearly was not the best answer. Indeed, the needle can be a big problem, but usually it is not. Problems arise when the needle or needling is experienced as a threat at which point it is no longer therapeutic. I would not necessarily call it “detrimental” but understand what you’re saying.

    One of the main reasons we include as much pain science in our dry needling course program is to bring this body of literature to physical therapists who more often than not have never heard any of this information before. Even new grads usually have never heard even the most basic aspects of pain science. They do not know what allodynia is, never heard of the role of glia cells in pain, the role of cytokines, pain neuroscience education, etc. Dry needling in my thought process is not the treatment of some tissue. The focus of my dry needling education is not on the tissues, but on the overall pain science, of which dry needling is just a very small part.

    In one of the lectures we explore some of the other aspects of the left side of the matrix. We talk about visceral input, attention and anxiety, etc. We also emphasize the pain education aspect. Students are encouraged to explain dry needling not as a treatment of tissues, but as a way to influence the matrix by removing a persistent peripheral source of nociceptive input. I do not know how other programs are teaching dry needling. Considering that one dry needling program in the US consists of only 12 hours, I seriously doubt that any of this important information is included.

  123. Things seem to be changing rapidly – especially the emphasis.

    I have met and worked with about 100 therapists the past 4 years, ages 65 to 27. Not a single one had ever heard a thing about the neuroscience of pain and neither were any interested in it. The situation is much worse than you might imagine.

  124. Barrett, I do not have the same experience. I teach about 25-30 courses each year in many different countries. It is true that most PTs are not at all familiar with pain sciences, but once introduced to this body of work, the vast majority of students becomes very interested, starts studying the literature, and passes a very challenging theoretical examination. Based on my experience, there is hope.

  125. My experience has been entirely in the US. Disinterest, dismissa and anger are the common responses here. I would that it was not so.

    I have encountered many other therapists on other boards who have found the same, so I guess it isn’t just me, though that remains a possibility.

    Glad you’re making some headway, and, I admire your effort.

  126. Jan, thanks for the comments back. I too appreciate hearing the context of pain neuroscience is stressed in your coursework.

    Can you help make sure the other Dry Needling courses do the same ;)

  127. Jason Silvernail DPT, DSc Reply February 13, 2012 at 2:17 pm

    Dr Dommerholt-
    Welcome back.
    You mentioned that “many of you believe that a top-down approach is the only sensible pain management approach. And that is where I do not quite follow the debate.” Well, speaking only for myself, I’ll tell you that I am definitely a “bottom-up” advocate as well.  I usually treat from a bottom-up perspective attempting to address nociception peripherally while also doing the top-down approach of pain education, addressing unhelpful cognitions, and other aspects of a biopsychosocial approach. I choose an approach for localizing peripheral mechanical pain often called Orthopedic Manual Therapy or OMPT and I’m influenced by the McKenzie MDT method, neurodynamics, motor control theory from the Australian school/Feldenkrais/Hanna, and the ideomotor approach of Barrett Dorko.

    All of these methods have the advantage of being centered on the use of movement for the localization and treatment of mechanical pain problems, and this makes them defensible from a basic science perspective given what we know about mechanical origin pain as I explained above in my comment on February 1st, 2012. Several of these methods, to include OMPT and MDT, have similar kinds of problems with outdated diagnostic terminology, reliability of individual assessments, and agreement between different schools of thought. But they have three things that needling doesn’t have: widespread randomized trial support against comparable treatments, prior plausibility for mechanical origin pain, and noninvasive methodology.

    Your first question and second question about nociception and trigger points make sense at first glance but beg the questions on reliability, clinical relevance, and mechanisms we’ve spent so much time trying to work through. I think “assuming” trigger points exist in the muscle, and “assuming” they can be found reliably, and “assuming” that their constant state of contraction produces nociception through mechanical and chemical means, and “assuming” that needling reduces this nociceptive drive by reducing the chemical irritation and mechanical deformation of nociceptors, then we can make a case for needling as you have laid out.  That’s a lot of assumptions, and in my opinion posts like Dr Lucas’ make an argument that these are still assumptions. To reiterate, I’m confident that needling would compare favorably in terms of cost/benefit to an extended course of NSAIDs, and I’m quite sure therapists who graduate from your courses are using exercise and movement methods along with needling and clearly get a great curriculum in pain science and the biopsychosocial approach as well. So I’m not advocating that no physical therapist needle their patients or that dry needling is bad or wrong, just that I feel it doesn’t seem necessary to me. “Some of my best friends are dry needlers” as the saying goes.

    Relative to the costs of your courses (I won’t ask you to speak for Kinetacore of course), please understand I’m not suggesting that your courses are overpriced, underpriced, or even appropriately priced, I’m not passing judgment on your charges. I’m just providing the information in context with MDT courses for comparison and discussion purposes. Your comment on it being fair to pay instructors “a reasonable honorarium for not seeing patients on clinic days, and reimburse them for travel, lodging, and meals” is just as true of the McKenzie Institute as it is of Myopain Seminars. So the only difference appears to be “a very high instructor-student ratio” relevant to the risk involved (you  mentioned pneumothorax as one of those risks and its certainly serious). And since the treatment is more invasive than MDT, I think the higher ratio is a good idea, and I support your decision. So, it seems that essentially you are charging more than at least one other well-established education program in physical therapy because the approach is riskier; yet has less supporting evidence and less prior plausibility. This is essentially the point I was making. As a free market fellow, I’m all for what the market will bear, and it sounds like your pain science curriculum alone is excellent. But as a manager in charge of recommending approval for various CME programs, I would wonder why I was sending my staff to your particular series of courses when there are less expensive ones out there using noninvasive methods with more research support for their use.

    Thanks for your continued participation, I think this is a good example of how only on the internet can people who agree about 90% of issues have a discussion this long about the 10% of things they don’t see eye-to-eye on. This sort of dialogue is sorely needed in medicine and therapy.

  128. Jason, I agree entirely. When I accused that “only” something should be done or considered it bothers me as much as being accused of personal certainty.

    I especially liked the way you listed the “assumptions” necessary to lead one toward dry needling as an appropriate method. To me, pain science’s conclusion to date lead me further and further toward movement that isn’t coerced and handling that is increasingly gentle.

  129. Jason,

    I think we need to conclude that we disagree on the level of support that exist for the existence of trigger points and the other “assumptions” you list. I am quite comfortable with the level of evidence that currently exists, realizing that many issues have not been resolved as of yet. There are, however, many unresolved questions with some of the approaches you are incorporating into your clinical practice. I did not see a single entry in PubMed for “ideomotor approach” for example. No therapy approach has been researched to the degree that there are no more questions. I am very encouraged that trigger points are being researched by some of the word’s best known pain researchers, including Lars Arendt-Nielsen, Thomas Graven-Nielsen, David Niddam, Hong-You Ge, Siegfried Mense, and many others. We have much more to learn.

    I do appreciate that dry needling is not for everyone and respect each therapist’s decision to make informed decisions.

  130. Jan,
    Jason is perfectly capable of defending his own positions, but I think it’s important to understand that when he refers to the evidence in favor of the approaches mentioned, he’s referring to that which is gleaned from a thorough understanding of the basic sciences.

    For example, I don’t think one would find a particular study that investigated the existence of wind due to temperature gradients. Our understanding of the laws of thermodynamics and careful observations of weather patterns supports that relationship quite well.

    So it is with ideomotor or instinctual movement. It’s existence is inarguable. We move instinctually to reduce mechanical deformation. Basic neurophysiology explains why we would do this, and the mechanism has been articulated by Butler and others in the concept of neurodynamics, which has been very thoroughly studied.

    So, ideomotor movement is analogous to wind, and we have loads of basic science to explain why wind exists, but that doesn’t make it any easier to control. I think this is also true with instinctual movement. We can’t really control it in a predictable way, we can only acknowledge that it exists, appreciate that it is inherent to life, and perhaps provide a context where it can be freely expressed.

    It seems to me that inserting needles into discrete areas of human flesh is akin to trying to change wind patterns by manipulating the clouds.

    Far too much is left out of the equation.

    • John,

      you have lost me entirely. Wind and wind patterns are being studied extensively. I have no idea what an ideomotor approach would entail. I have never taken courses in this approach and do not feel I can comment on something I know nothing about other reading anecdotal stories online. I did not see any scientific literature in PubMed or ScienceDirect. Are there any studies on the ideomotor approach? If not, why not. If yes, where can I find them? Along those lines, how many interrater reliability papers exist of neurodynamic assessments? Again, I could not find too much on the subject.

      I find your description of dry needling as trying to change wind patterns by manipulating clouds rather amusing. Many PTs, massage therapists and others use manual trigger point approaches instead of needles. In fact, we offer a 6-course program in manual trigger point therapy, which is – like our dry needling program – loaded with basic pain sciences. Would it make a difference if we would stop sticking needles in human flesh, but use our hands to facilitate human movement? I agree that in a forum like this, much too much is left out. I have written close to 50 book chapters and 3 books on the subject of trigger points and there is so much more I could share……

      By the way I do appreciate how much more civilized the discussion has become.

  131. I really like the wind analogy. Beats the daylights out of my (unwritten)attempts to find one in gravity. Too much constancy there.

    Still I have always wondered why something like ideomotion needs a study to demonstrate its purpose at this point. Aren’t we supposed to be experts at motion?

  132. Dorko, Ideomotion definitely needs a study to demonstrate its purpose. Yes, absolutely. It should be held to the same scrutiny that you require of all other interventions.

    The only study in which I am aware (for ideomotor therapy) was a single system design. There may have been a conflict of interest because one of the authors was on the editorial board… there may have been a conflict of interest because the submission and acceptance dates were too close in time for what is the norm in peer-reviewed journals. AND… my interpretation of reading the article actually had me disagree with abstract. I found a TON of value in the educational process that occurred, but truly didn’t see value in the actual intervention. http://www.journalofosteopathicmedicine.com/article/S1746-0689%2807%2900068-5/abstract

    In light of what is being learned about how manual therapy actually works, in that venue of “science,” that makes sense. The placebo, expectations, perceptions & relationship aspect of what we do has a reasonable effect on outcomes. We will always have a difficult time pulling out these somewhat hidden dynamics. This also should leave us wondering how much of an impact the manual portion of our treatments truly have.

  133. I really appreciate your linking the article here.

    I especially liked the implication that the authors and editorial board colluded in some nefarious fashion to rush to publication. A nice touch. Paranoid, but nice.

    I guess you don’t think that movement has a place in care designed to reduce mechanical deformation, or that all motions are equally helpful, or, well, I’m not sure what you think. It is only obvious that you suspect some sort of foul play.

    Maybe you should tell those who are conniving. They should know.

  134. It seems to me that Barret and John are really talking about the scientific plausibility of an argument. They argue that simple contact has strong scientific plausibility and dry needling does not. If something has low scientific plausibility the consensus is that there is a higher burden of proof. The great skeptic Carl Sagan put it well, “extraordinary claims require extraordinary evidence”. However, as everything in life, different individuals have different opinions regarding the scientific plausibility of an argument.

    The disagreement here appears to be primarily about the plausibility of dry needling.

    I think a great example is the parody publication in BMJ about a systematic review of parachute use. http://www.bmj.com/content/327/7429/1459.short
    It attempts to point out that if something has strong scientific plausibility and is easily observed in real life a study is not always needed.

    With that being said, throughout medicine many scientifically plausible ideas have been shown to be inaccurate.

  135. Dr Dommerholt-
    I think you’re right, that in the end some amount of “agreeing to disagree” is probably necessary. In the end I think we are pretty much on the same page clinically, but for the needling portion. I enjoyed your list of names but the argument from authority isn’t likely to sway me, I’m afraid.

    I think your critique of some of the methods I mentioned as influencing my practice is spot on, and correct. You are right to bring up the diagnostic terminology and reliability issues inherent in approaches such as manual therapy and neurodynamic assessment, and that’s a perfectly valid criticism, one which I have to accept. I think its only fair that while we question you on the reliability of your method of TrP management, that you also question the reliability of other systems.

    While reliability is on ongoing problem in many systems of assessment, Dr Lucas pointed out upthread why that is perhaps uniquely concerning for TrP methods that need to localize a very small point while providing a very precise treatment. In systems such as manual/manipulative therapy we have determined that precision is important probably from a neurophysiologic/patient response perspective and that biomechanical precision does not seem to happen – therefore if I’m off by one segment on the spine, I am still moving nearby structures that may be more related to the patient’s complaint. Neurodynamic treatment creates movement in many different parts of the nervous system due to the nature of the anatomy we are working with. Also, as I’ve pointed out, those approaches have an advantage over needling in that they directly address the origin of the problem – which is mechanical in nature. Ideomotor movement also addresses the origin of the problem. As would, the Mulligan approach, the osteopathic approach, or any other system that uses movement to address a mechanical problem. These treatment options, as I’ve pointed out, have the advantage of prior plausibility and basic science support, before we even get to the individual RCT level of the discussion. Systematic reviews favor active over passive treatments, and all these mentioned approaches involve active movement and rehabilitation which means they all can be defended from that perspective as well. Movement treatment for mechanical pain makes scientific sense, is aimed at the origin of the problem, and is supported by systematic reviews.

    As to whether there are individual randomized trials on every single movement approach, I’ll freely admit there aren’t. Now if I have a choice between two kinds of movement treatment for mechanical pain, and one has supportive RCT evidence and one does not, I follow the evidence. If I don’t have that, and I’m faced with a situation in which I have to treat a mechanical pain problem with either a movement treatment (using neurodynamics or ideomotor approach as an example) or do a passive treatment such as laser therapy, ultrasound or needling, then my choice should be obvious. Its obvious if my understanding of evidence-based medicine includes concepts of basic science, and the “science-based medicine” conceptual model.

    The main issues here with needling aren’t that there are insufficient RCTs (though for comparison to other treatments we do need to discuss this), but that the conceptual model is problematic from a basic science perspective. No amount of published outcomes research by famous or influential people can change that.

    New methods crop up all the time in physical medicine, this is a function of the uncertainty we face in the clinic. If we understand what we should about pain and neuroscience, two things should become clear, in my opinion.

    1. Treatments for pain centered around connective tissue (fascia, joints, ligaments, muscle) as explanatory models don’t make sense since pain and function are mediated by the nervous system. The nervous tissue including the brain should be our therapeutic targets.

    2. Treatments for mechanical pain that don’t involve some kind of movement are hard to justify from the perspective of peripheral nociceptive modulation. Education and graded exposure and CBT approaches (top-down) are defensible for pain due to their central mechanisms. If we really are movement specialists and we think that peripheral treatment (bottom-up) is a large part of pain treatment (you and I agree here), then doing something that isn’t movement is hard to justify. That’s why I’m not interested in Ultrasound, Laser Therapy, Scraping The Skin with Instruments (I call this STSI, whether its plastic or metal), Needling, Electric Stimulation, or any other passive approach that doesn’t involve movement. Some of these approaches (like needling and STSI) often are packaged with movement therapy. My response to that is “ok, then just do the movement part”.

    Certainly at some point discussions like this have to come to an end. Being an active participant in social media on professional issues certainly has helped my practice and refined my thinking, but it also has provided some genuinely frustrating experiences. When Selena Horner tells Barrett Dorko he needs to hold ideomotion to the same standards of evidence he asks of other treatments, I have to just shake my head. Barrett has made no secret of the fact that the standard he’s interested in is one of plausibility and basic science and not published outcomes research, which is of course the perspective he uses to support ideomotion and other movement based treatments, as I have. That’s entirely apart from the fact you can justify an ideomotor (neurodynamic, Mulligan, Somatics, Feldenkrais) approach from systematic reviews showing superiority of active treatments. It’s from that basic science perspective that we’ve spent most of our time discussing TrPs here. I have seen her ask this question of him for about the last 10 years online, and the fact that she still does not understand the difference between a basic science plausibility case and a published evidence case is both hilarious and jaw-droppingly frustrating. She mentions that a study (I presume an RCT) needs to be done to demonstrate ideomotion’s purpose, yet you cannot demonstrate purpose with an RCT, you can only determine efficacy compared to another approach. Ten years of discussions and her criticism has not moved one inch in response to an avalanche of written words. Disheartening. I think we have a lot further to go in education to help our students and practitioners understand that there is more to science and evidence in rational therapy than doing a PubMed search for RCTs.

    It’s my hope that discussions like this, and the venue provided by people like Dr Reinold, helps move that process forward.

    • I would like to thank you for sharing your perspective. I understand and appreciate your perspective. Your thoughtfulness is miles beyond the way many PTs operate in the clinic. Again, I agree with most of your comments, but not with all, and that is OK.

  136. Thanks for that reference, Adam. And you are right when you assume that what I’m talking about is prior scientific plausibility.

    Having been a clinical PT for over 17 years now, and having tried to throw just about every imaginable intervention at patients to see what would stick, I’ve learned the hard way that the shotgun approach to treating human beings in pain is not only not working, but it’s probably making things worse, despite the fact that we have all these good intentions.

    About 6 years ago, I came kicking and screaming into a broader frame of reference where some PTs were trying to connect the dots between the human lived pain experience and what is known about human neurobiology and neurophysiology. It was quite unsettling, and I still struggle with making the connections from the extensive knowledge base and theory to clinical application.

    As frustrating- and at times isolating- as that process has been, I will not go back to a time when I chose to ignore what cannot be denied. I cannot ignore, for instance, Jason’s assertion that active movement strategies make the most sense and have the most evidence to support their application for patients with movement problems. Passive interventions applied from an operative stance by the practitioner is a very dubious approach to these problems. The basic science of human movement, pain and cognition as well as more recent studies investigating predictive factors for the persistence of pain support an active approach that empowers patients and avoids the very real risk of medicalization.

    Despite what active approaches it is combined with, needling is passive and it’s rife with biomedical explanations and contextual cues.

    As PTs, physical THERAPISTS, should we be promoting something like this?

  137. If I may speak for Selena (in a moment).

    First however, I want to say that I agree wholeheartedly with Jason that movement based therapies are defendable from a scientfic plausibilty perspective and should be the treatment of choice over passive approaches, such are those that involve needling. Although it is argued by those that utilize needling that they also incorporate active components to their programs, I would be afraid that the “contextual damage” of jabbing a needle into some mesodermal part has been done. Although the literature does support that patients are very well capable of understanding pain physiology, I just think jabbing someone needlessly undermines the “good” science we are trying to get accross. On top of that, there is no compelling evidence that suggests the use of needles does anything beyond placebo anyway. So why would I choose a passive treatment, wrought with all kinds of contextual baggage, more invasive (?dangerous), and without compelling evidence…over a science based approach that involves education and movement based therapies?

    Having supported what Jason stated about the advantages of movement based therapies, we have to recognize that we do live in a professional environment where expectations are that we will provide data for whatever particular “thing” we decide to do. There is such data for Mulligan approaches, McKenzie approaches, neurodynamic approaches, therapuetic exercise etc. As for ideomotion (and I mean this in the most respectful way), we do need more. It’s a standard that as professionals we just cannot choose to ignore because it’s a scientifically plausible approach. I think this is what Selena was suggesting here….?

  138. Glen,

    Speaking for Selena is problematic, especially when she’s asked the same question year after year. If she has an educational motive I haven’t discovered it.

    People speak of ideomotion in a fashion that reveals very little understanding of what it might be, and all the writing I and many others have done for years has failed to make a dent in that.

  139. Barrett,

    can you provide a select list of your or other publications on ideomotion from the peer-reviewed scientific literature? I did come across your article “The analgesia of movement: ideomotor activity and manual care”, Journal of Osteopathic Medicine, 2003; 6(2): 93-95, but would like to explore other articles as well. Which articles would you recommend?

  140. Are you asking whether or not I can demonstrate it exists?

    It’s as if you’re asking for proof that breathing exists and if so is it necessary to alter its expression under certain circumstances. Is that a reasonable thing to ask for?

    Google “ideomotor” today and you’ll get 559,000 hits. You might learn something about it there. After all, you’re a therapist and you’re supposed to be interested in human motion. This thing about invading the skin with needles is an invention and NOT a normal or natural part of practice. Your sale is much more difficult than mine but maybe the success you’ve had gathering students has to do with the tendency of therapists to covet “tools” and act rather than think.

    • No, I am not asking whether ideomotion exist. I asked for your recommendation which peer-reviewed articles one should read.

      Googling “ideomotion” is not what I asked for. When I Google “dry needling” I get 435,000 hits. When I enter “dry needling in PubMed, I get 89 articles; “myofascial pain” – 2103; “trigger point” – 2886.

      Googling “Barrett Dorko” is good for 331,000 hits. Googling “Jan Dommerholt” is good for only 52,800 hits.

      Googling “breathing” is good for 155,000,000 entries. When I enter “breathing” in PubMed I get 205640 entries. Apparently, others find it reasonable to have entries in PubMed about “breathing” without wondering whether “breathing” exists.

      I am done with the “discussion” It was a pleasure most of the time.

  141. I’m NOT done.

    You seem to think that I am saying that moving normally (the very definition of ideomotor) has been “proven” therapeutically superior to moving otherwise. I haven’t said that and highly doubt that it need be done.

    Does the culture commonly restrict expression? Well, I’m pretty sure it does. Is this a good idea? Certainly! Is it a bad idea? Certainly!

    Sorting that out IS OUR JOB. Examining and discussing it IS OUR JOB. Ignoring it seems to be what the beancounters would prefer. Too much work and understanding slows it up anyway.

    But I’m a therapist, and considering what I can do about the epidemic of pain at my door IS MY JOB.

    I’m going the other way and a few have joined that group. You know where we are.

  142. Dear Readers,

    I just need to address a few comments made above by SnippetPhysTher, who wrote about a single single case study on ideomotion that:

    “There may have been a conflict of interest because one of the authors was on the editorial board… there may have been a conflict of interest because the submission and acceptance dates were too close in time for what is the norm in peer-reviewed journals. AND… my interpretation of reading the article actually had me disagree with abstract.”

    First, I am the author referred to.

    Second, SnippetPhysTher knows that this issue has been responded to in detail on another forum. In particular, the ‘issue’ about the publication dates were answered. The issue about me being a co-author and editor was also answered. The disagreement SnippetPhysTher had with the Abstract was also answered. It was to do with minimal clinically important difference and there was debate about whether or not, in our single case study, we had demonstrated MCID. We provided the reference to support our conclusion in the Abstract.

    Given this, I am surprised so see, quite a few years later, that SnippetPhysTher has forgotten all this, and is instead harking back to the implication he or she made last time which is basically that there was some shenanigans going on with our journal. By sliding in the word ‘may’ in the quote above “…may have been a conflict of interest”, SnippetPhysTher is using a little bit of sophistry (a false argument made on purpose). The word ‘may’ is designed to sow the seeds of doubt in the readers mind about the integrity of that paper and also the editorial process at the journal. I, as an author and editor, must now again defend my innocence, which is why I chose to respond here.

    At the time I submitted the paper for blinded peer review, I shared a single login with the other editor to the online editorial system. Therefore, if I submitted any articles to the journal as an author, and then logged in as an editor to work on other articles, I would see who the reviewers were and therefore ruin the blinding. Since we run a blinded peer review system, any articles that I submitted as an author had to be first peer-reviewed outside of the online editorial system. Once they had gone through the peer review process and were accepted, they would then be submitted for processing in the online system – and would be accepted on or around the same day they were submitted into the system. The copy-editor for this paper, took the submission date and acceptance date from the system and this is why they are very close together.

    Also, to suggest that there ‘may’ be a conflict of interest because the an author is also on the editorial board of the journal they submit to, is to cast doubt on every single editorial board member who submits an article to the journal upon which they sit. Think about that. I wonder if anyone on the JAMA or BMJ editorial boards have published in their own journals?

    I have suggested to SnippetPhysTher in the past that there are weaknesses of our single system case study other than the unfounded suggestion of ‘may be conflict of interest’. First of all, it is a single case. We all know that doesn’t mean much – other than a justify a larger case series. The onus is on those who promote ‘ideomotor therapy’ to demonstrate it’s value beyond theory, anecdote or case studies.

    With all these things, trigger point therapy, ideomotor therapy, manipulation, whatever … we must face three simple things. If you do the treatment in one group and not in another:

    1. Is there a difference between the groups, where your therapy is better;
    2. If there is a difference, is it statistically significant; and
    3. If it is statistically significant, is it meaningful to the patient.

    I don’t care much these days about fancy neuroscience and neuromatrix theories – I was fascinated with them for over 10 years and studied that stuff in detail.

    From the consumers perspective, not the health professionals perspective, I am far more interested in:

    1. Can you reliability identify those who need your treatment, and those who dont?
    2. Is what you’re measuring accurate?
    3. Can you consistently deliver meaningful outcomes to the people you identify as indicated for your therapy?
    4. Is this outcome you deliver dependent on your diagnosis?

    Based on all the posts above, I am still left wondering what the answers are to these questions for trigger point needling and for ideomotion?

    (PS: Between you and me, I sometimes wonder if we’re too overqualified and have to engage in all this debate, minutia and intellectualising just in order to keep it interesting? LOL)

  143. Thanks for this Nic. I can’t imagine Snippet thought you would show up here. Well, maybe. Over many years I’ve gained the impression that reason doesn’t enter into the equation here.

    I’m fully in agreement with your points and questions and should make something clear here.

    What was eventually called “ideomotor therapy” (NOT my idea BTW)seems to simply be the use of naturally occuring movement in response to mechanical deformation. The “cause” of this deformation is unimportant and of that I’ve written extensively. The deformation seems MAINTAINED by a culture that prizes appearance over all else. I’ve also written of how the therapy professions have gone right along with that. Unless and until therapists stop trying to make people look the way they think is “proper” it will remain misunderstood and questioned.

  144. Hi Nic,

    Glad to see you chime in. I didn’t forget the conversation… I purposefully used the word “may,” basically because I didn’t believe your defense years ago (or even now) was credible. The journal has a defined “standard” for article submission. Apparently the journal isn’t consistent with processes. I can search you as an author and find this: http://www.journalofosteopathicmedicine.com/search/quick

    In digging through that, I can easily learn that you had 5 full-length articles published within the search results. Oddly… they all have received dates, revision dates AND accepted dates except for one lone article. That article was the one on ideomotor therapy. None of the articles had a 24 hour turn around time like the ideomotor therapy article. You have defended your position, yes, but… it doesn’t appear your explanation is consistent with processes involved in the other articles you have authored. Based on what I see and the quite different pattern, you bet I’m going to question the integrity of the published work.

    I also took strong disagreement with the abstract (and still do). The abstract conveyed an overestimation of benefit. The article itself was good… benefit of education was obvious… poor peer-review allowed for overestimation of benefit in the conclusion portion of the abstract. This is hugely problematic, in my opinion, because we have some colleagues who only read abstracts. The quick summary isn’t aligned with the provided data. Those who understand data and statistics will come up with a different conclusion than the published abstract conclusion. I still stand firm in my thoughts.

    Another study confirms the lack of substantial benefit with ideomotor therapy and specifically terms it “simple contact.” http://webcache.googleusercontent.com/search?q=cache:lh5ZA49wu-wJ:unitec.researchbank.ac.nz/bitstream/handle/10652/1342/fulltext.pdf%3Fsequence%3D1+&cd=6&hl=en&ct=clnk&gl=us&client=firefox-a

    Based on your article and the above… questions 1-3 receive “no” as the answer.

    • Snips, you’re more than welcome to submit a letter to the editor.

      As is typical of biomedical journals, you will be required to submit your letter with your real name.

      This is the professional mode of communication I am familiar with, and prefer.

      You have chosen to doubt my word, despite my repeated explanation. You have your reasons, which I believe have more to do with the way you feel about ideomotor stuff, than publication dates.

      Anyway, I have no idea who you are – you use the same pretend name as you’ve used for years. I am more accustomed to discussing things with people who are transparent and open and who are prepared to stand behind what they write and believe. Step up to that and I might start taking you more seriously.

      Hi John, I should point out that while the Australian Health Practitioner Regulation Agency prints my name on my registration certificate as Dr Nicholas Lucas, I am still to graduate from my PhD. I’m finalising the abstract for the thesis now, so I’m only a few weeks away. Personally, I am reserving the title Dr for that great day – but thanks for erring on the side of caution.

      Also, to anyone who might want to weigh in on these comments from Snips – please refrain. It will go nowhere and there are more important things to do than try to win clearly un-winnable arguments. Instead of responding to Snips, go and do something worthwhile and leave the world a better place. Snips, you should do the same.

      Cheers,

      Nic

      • Well, Nic, according to Damasio feelings serve as an integral and necessary part of our reasoning capabilities, but certainly aren’t always an accurate guide. I admit to being well-endowed- perhaps due to my Irish descent- with more than a modicum of passion when it comes to expressing my views of where I fear my profession may be heading and how some of my colleagues may be contributing to its demise.

        Anonymous assaults on a respected colleague’s professional integrity will not go unchallenged by me. I’ve been doing this long enough to know that while the perpetrator’s mind is often like concrete, there are others reading here who may become imbued with some of the same passion that drives me and then these voices may eventually drown out the petty chirping of those who hide under rocks.

      • Nic, my apologies, Selena Horner here. I made two assumptions 1) since Jason Silvernail responded with my name, you’d know who I was and 2) I figured you’d click on the Twitter account (since apparently you don’t like pretend names) and you would readily learn I am not posting anonymously.

        I haven’t been argued anything. I haven’t questioned anything. I haven’t defended anything. A particular statement motivated me to succinctly shared my thoughts with supporting links to verify the logic of my thoughts.

        • I just used 5 minutes to write a nice email to a colleague whom I haven’t seen in a while – it left me feeling warm and fuzzy :-)

  145. I’m not sure where these accusations of academic dishonesty are coming from, but personally I find them appalling.

    I recall those discussions of this study from some years ago, and I found myself satisfied with Dr. Lucas’s explanation of the proximity between the submission and publication dates. Given his reputation and extensive body of respected research, I think Dr. Lucas should be given the benefit of the doubt. Why on earth would anyone risk his career and reputation on getting a relatively small study where he served as a minor author published?

    Furthermore, I can’t fathom how an anonymous poster whose academic credentials are unknown to anyone reading here has the credibility to make such bold accusations.

    I’m trying to decide whether I’m more stunned by the arrogance or obtuseness of this charge.

  146. My presence seems to trigger something in this poster and now I see it is spreading. I will refrain from using the descriptors that come to mind in light of a strict personal policy of avoiding ad hominem.

    I will admit that this is difficult today.

  147. Yes Nic. Selena’s first post is imaginary.

  148. I have gone through both level 1,2 at kineticore and found it to be excellent. They integrate it with SFMA which to makes a lot of sense
    This is a very powerful technique. Much like mulligan techniques you expect change right away

  149. I received trigger point dry needling treatment on my shoulder after a SLAP repair and it was absolutely amazing. After 4-5 months of traditional therapy I still did not have full pain free ROM. After just one treatment of dry needling to the lateral and anterior deltoids, I acheived pain free ROM instantaneously. I am a physical therapy student at Duquesne University in Pensylvania, a state that has approved dry needling for CEU’s but still does not recognize it as within the realms for PT’s to actually administer. This works. I experienced it first hand and it saddens me that its not permitted yet in PA.

  150. As a long-term chronic pain patient, diagnosed with both fibromyalgia and myofascial pain syndrome with lots of trigger points, I have been reading through these pedantic back and forth replies and find it incredulous that common sense has not found its way into modern thinking about treating your patients. Trigger points have been well documented and known about for decades and dry needling is just another tool for therapists to use in their arsenol to help us get out of pain. Obviously, disruppting a tight band of muscle fibers will create changes, just like when your patient gets a massage. It doesn’t matter if it is the placebo effect or not, what you are looking for is a reduction in perceived pain. These arguments remind me of a crazy neuropsychologist I had the misfortune of dating years ago, even though he had some good ideas, they got lost in circular arguments and in the world of academia and never made it to the clinicians that would use them… it was too important that his ego be stroked by his peers on the internet.

  151. Lastly, good job Ann and Mike for keeping an open mind and trying new techniques such as dry needling for your pain patients – bravo!

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