Friday, January 27, 2012

Yet another "trigger point" discussion

I've written about so-called "trigger points" before:
1.  Trigger point model deconstruction, models in general
2.  Letter to a biomechanically - minded therapist
3.  Why I don't buy the idea that "trigger points" are in muscle

Lately on Mike Reinold's blog, trigger point true believers and triggerpoint skeptics met and discussed the issue. See "Trigger Point Dry Needling for Lateral Epicondylitis" with over 100 comments, many of them quite passionate, most of the passionate ones from those defending the model of triggerpoints being somehow in muscle, or muscle generated somehow, or being source and/or cause of "pain". And that (for whatever reason) their preferred "treatment", dry needling, was the beall and endall forever amen, instead of just one "treatment", conducted as ritual, no more or less effective than a bunch of other possible choices that would be less invasive. 

Some of the comments were wonderful. One long one was from Nic Lucas, who co-authored a solid systematic review of the papers that have been done about so-called trigger points. In the comment section he said (excerpt):
"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."
(See "Reliability of physical examination for diagnosis of myofascial trigger points: a systematic review of the literature." Conclusion: "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. The reliability of trigger point diagnosis needs to be further investigated with studies of high quality that use current diagnostic criteria in clinically relevant patients.")
But back to Mike's blog.
In particular, I want to draw attention to comments made by Jason Silvernail, a fellow moderator at SomaSimple, and very cluey dude.
"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."
My bold.

A bit later, commenting on the discussion itself, how it shaped itself, Jason said (excerpt):

"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."
In a third comment, after rebuttal by a prominent triggerpointer/needler defender, Jason says (excerpt):
"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."
My bold.
Voice of reason.

Be sure to check out the blog of someone long past considering "triggerpoints" or needling or any other "meat" treatment theory, as having any validity whatsoever as they relate to the phenomenon of pain, i.e., Lorimer Mosely, at Body In Mind. As a matter of fact, Jason has been mentioned by name at that blog. See a post from about a year ago, Starting conversations: has Jason hit the Silvernail on the head? about this post in the thread, Enough is enough.
Here is a link to Lorimer's freely available articles. In particular, check out the one titled "Teaching people about pain: why do we keep beating around the bush?

1 comment:

Jason Silvernail DPT said...

Thanks for the mention Diane!