Travell, Simons and Cargo Cult Science

In an important article, Wally Smith writes about ‘Pseudoevidence-based medicine.’1 He defines it ‘as the practice of medicine based on falsehoods that are disseminated as truth. Falsehoods may result from corrupted evidence – evidence that has been suppressed, contrived from purposely biased science, or that has been manipulated and/or falsified, then published. Or falsehoods may result from corrupted dissemination of otherwise valid evidence. These falsehoods, when consumed as truth by unwitting and well-intentioned practitioners of evidence-based medicine, then disseminated and adopted as routine practice, may well result not only in inappropriate quality standards and processes of care, but also in harms to patients.’

But I would suggest a second concept— ‘pseudo-pseudo evidence-based medicine (PP-EBM): disseminated ‘evidence’ that never reaches the level of evidence. It represents assertions, ‘facts,’ definitions and beliefs that are derived without testing or without adequate scientific basis. Like Smith’s P-EBM, PP-EBM finds its home in journals, where citations transform it from opinion to fact. It thrives in lectures, advertising, and in some guidelines from professional organizations. It transforms hypotheses into facts.

There is a lot of PP-EBM in fibromyalgia. Pharmacologic treatments are effective. Central sensitization explains or is the primary mechanism for fibromyalgia. Fibromyalgia is a disease. Fibromyalgia ‘causes’ symptoms. And so on. Feynman’s idea that ‘science is the belief in the ignorance of experts’ and Joseph Conrad ‘s that ‘Skepticism is the tonic of minds, the tonic of life, the agent of truth – the way of art and salvation’ ought to find a place with us whenever we think of fibromyalgia.

David Simons, who with Janet Travell were the authors of Myofascial Pain and Dysfunction: The Trigger Point Manual (TPM),2 was a remarkable physician. At his death in 2010, he was memorialized in a long New York Times obituary that included this: ` David G. Simons, whose ascent more than 19 miles above the Earth in an aluminum capsule suspended from a helium balloon set an altitude record in 1957 and helped put the United States on the road to manned space flight died April 5 at his home in Covington, GA’ [a record that still stands (FW)]. Janet Travell was equally famous. President Kennedy’s physician, the first woman physician at the New York Hospital, she was also the author of an illuminating autobiography. If trigger points needed a mother, she was it. In fact, the Travell and Simons drawing of trigger points and their radiations began as a poster presentation at an American Medical Association meeting that was later published as an ‘exhibit.’3

But if there ever was need for examples of PP-EBM, these authors provided it. In a book that was filled with extraordinary anatomic drawings, Travell and Simons provided figures of locations of trigger points, radiation of pain, injection and `spray and stretch’ techniques.  In one 61-page chapter, the authors provided detailed information about perpetuating factors for myofascial pain (MFP) and trigger points, including 317 references. The book was an enormous success—a bible of trigger points. It found it way into academic libraries and practitioner’s offices through several editions. In a perfect example of science by citation and PP-EBM, it was repeatedly cited as an authoritative reference. Many, like me, trying to understand trigger points, read deeply in the book. But the more I read the more I doubted. The book represented opinion, not science. None of the trigger points or their treatments were validated; none were tested for reliability. There were almost no studies in the Travell-Simons book, just testaments. Most of the perpetuating factors were plain wrong, and represented outdated, overthrown junk science.

For Travel and Simons trigger points and myofascial pain could be perpetuated by nutritional inadequacies (`crucial perpetuating factors’), ‘low ‘normal’ levels of vitamins B1, B6, B1, and folic acid. Then there were vitamin C deficiencies, problems with calcium, potassium, iron, trace minerals, borderline anemias, sub-optimal thyroid function, hyperuricemia, hypoglycemia, allergies, and many other factors. If they were so wrong about simple, well-established science, how could we believe what they wrote about myofascial pain and trigger points? Funny, hard as I tried, I could never find many of the trigger points and ‘taut bands’ they wrote about. In the hands of this apostate at least, stretch and spray and injections were of dubious benefit.

In 1992, we performed a study of trigger points. A group of four myofascial pain experts, selected by Simons and including Simons, blindly examined four patients with MFP. The examiners were allowed to take as much time as they needed; they could examine but not interview the patients. As we had mixed MFP patients with those who had fibromyalgia, it was a blinded experiment. These MFP experts were no ordinary examiners. They were the best. They wrote the book, they did the lectures. But, in the end, they could not find or agree on the trigger points. It was a disaster. The examiners were distraught. After the results were in, they protested and wanted to change the protocol and purposes of the study (post hoc). It wasn’t fair, they said. Glenn McCain, one of the rheumatologists, exploded in outrage. It was intolerable, he said, to alter study results. He was so angry that the opposition stopped. Subsequent delays and disagreements over the methods, results and discussion continued and almost prevented publication. But time took over; people forgot, and the study—a little toned down—came out in the Journal of Rheumatology.4 If we believed in trigger points and The Trigger Point Manual before, we were a lot less secure in our beliefs now.

Janet Travell came to Wichita, Kansas in the 1980s, by which time she was in her 80s. She had been invited by the Wichita dental community, and a patient demonstration was scheduled. I was in full-time practice of rheumatology, and I attended together with medical people from my clinic. Dr. Travell was perched on a high seat, and patients were brought to her. I remember it this way. ‘What is your trouble, my dear?’ The patient explained that she had thoracic and low back pain. ‘And what did you do.’ She went to see many doctors, but the pain persisted. ‘Then they sent me to Dr. Wolfe.’ Now I recognized her. This was going to be bad. ‘And what did he say, my dear?’ ‘He said there was nothing he could do for me.’ That was something I never said to patients, but she had read me right. The patient had terribly severe S-curve scoliosis and there wasn’t much I really could do. ‘We’ll see, my dear,’ Dr. Travell said. She took out her bottle of ‘Flouri-methane’. The patient’s blouse was removed. Dr. Travel stretched her out in front of the audience and sprayed. I knew I was lost. Dr. Travel would cure her. ‘Did that help?’ ‘No.’ Three more positions and stretches and sprays followed. Still, ‘no.’ The skirt was removed. The audience of male dentists drew closer. Travell sprayed and stretched again and again. But it didn’t work. It didn’t work. ‘Do you have any allergies, my dear?’ ‘Yes, I do.’ ‘Dr. Travell spoke almost sadly, ‘Oh, then we won’t be able to help you until your allergies are cured.’ So there it was all the time, perpetuating factors. There are always perpetuating factors—ready when you need them.

I was reminded of Peter Medawar’s Advice to a Young Scientist,5 quoted in James Wilson’s Conduct, Misconduct, and Cargo Cult Science,6 ‘I cannot give any scientist of any age better advice than this: the intensity of the conviction that a hypothesis is true has no bearing on whether it is true or not.’ PP-EBM is a reversal of that advice. It pervades our specialty.

1. Smith, W.R. Pseudoevidence-based medicine: what it is, and what to do about it. Clinical Governance: An International Journal 12, 42-52 (2007).

2. Travell, J.G. & Simons, D.G. Myofascial pain and dysfunction: The trigger point manual (Williams & Willkins, Baltimore, 1983).

3. Travell, J.G. & Rinzler, S.H. The myofascial genesis of pain. Postgrad.Med. 11, 425-434 (1952).

4. Wolfe, F. et al. The fibromyalgia and myofascial pain syndromes: a preliminary study of tender points and trigger points in persons with fibromyalgia, myofascial pain syndrome and no disease. J Rheumatol 19, 944-51 (1992).

5. Medawar, P.B. Advice to a young scientist (Basic Books, 1981).

6. Wilson, J.R. in Proceedings of the 29th conference on Winter simulation 1405-1413 (IEEE Computer Society, 1997).

 

 

97 Comments

  1. The mathematician and philosopher, Alfred North Whitehead, pointed out the “Fallacy of Misplaced Concreteness”. This occurs when one mistakes an abstract concept about the way things are for a physical or “concrete” reality. In my opinion, the whole “trigger point” belief system launched by Travell, Simons, and perpetuated by their enthusiastic followers falls into this category. Milton Cohen and I carefully deconstructed Myofascial Pain/Trigger point theory in 1994. We found it then to be scientifically insupportable. Why is it still pervading our specialty in 2013?

    References:
    Whitehead AN. Science and the Modern World. New York: The Macmillan Company, 1925: 55-79.
    Quintner JL, Cohen ML. Referred pain of peripheral nerve origin: an alternative to the “Myofascial Pain” construct. Clin J Pain 1994; 10: 243-251.

    • “Why is it still pervading our specialty in 2013?”

      Because myofascial pain does exist and non-pharmacological, manual therapy protocols do remove pain/joint restrictions. You do offer good rationale for an alternatives to ‘trigger points’ in the above paper but do not disprove them. I don’t believe for one moment they resolve every musculoskeletal disorder but there is a place for the protocols advocated by Travell & Simons.

      In practice, using ‘trigger point’ techniques alongside other soft tissue manipulation techniques can have a profound effect on tissue tension, pain and dysfunction. More and more research is being published about the role of the myofascial system, in conjunction with the nervous system, to physically adapt to peripheral pain (or in the management of). I’m sure this is done at an individual level and responds in a variety of different ways that we yet have a the capability to scientifically measure.

      • Mark, belief is no substitute for scientific inquiry. Did you know that some of the MPS research is based upon the belief that “latent” trigger points can be identified in the skeletal muscles of rabbits? How stupid is that?

        If you read our 1994 paper carefully you will find that the Travell and Simons construct does not stand up to critical examination. Whitehead’s Fallacy of Misplaced Concreteness applies in this context.

        As for the claimed efficacy of treatment based upon the construct, the literature does not support you. Poor science can only generate poor outcomes.

  2. Paul, those who have long worshipped at the shrine of the “myofascial trigger point (MTrP)” are not going to be swayed by either logic or science. “Dry” or “wet” needling carried out between consenting adults is not a problem unless the practice is consuming valuable health dollars that would be better spent elsewhere.

    Of concern to me are those authorities in rheumatological circles who believe that peripheral nociceptive input from MTrPs initiates and maintains “central sensitization” that appears to one of the characteristics of the syndrome of Chronic Widespread Pain (aka Fibromyalgia). They have seized upon the MTrP as being a credible source of such input! Where is the evidence?

  3. http://journals.lww.com/clinicalpain/Abstract/2009/07000/Multiple_Active_Myofascial_Trigger_Points_and.9.aspx

    http://www.sciencedirect.com/science/article/pii/S1526590010003937

    http://onlinelibrary.wiley.com/doi/10.1016/j.ejpain.2007.12.005/abstract;jsessionid=496F3AF32BF042FC4453E77029153AB8.d02t02?deniedAccessCustomisedMessage=&userIsAuthenticated=false

    http://www.sciencedirect.com/science/article/pii/S0022534709020552
    http://www.biomedcentral.com/content/pdf/ar3289.pdf

    http://journals.lww.com/clinicalpain/Abstract/2010/02000/Increased_Spontaneous_Electrical_Activity_at_a.10.aspx

    http://online.liebertpub.com/doi/abs/10.1089/acm.2007.0810

    http://journals.lww.com/clinicalpain/Abstract/2012/07000/Referred_Pain_From_Myofascial_Trigger_Points_in.8.aspx

    Should I carry on? Referring to Myofascial trigger point as pseudo pseudo science is a tiny bit too much, and why should we substitute that with drugs (again! As though people are not already stuffed up with chemicals!)? What about the side effects of drugs? Are we forgetting about celecoxib and its side effects just to name one? Why would we want to dismiss something that is so effective and risk free for patients?

    It’s full of research and scientific evidence about TrP, about their existance and about their referred patterns…

    • Emanuele, for my sins I have recently taken the trouble to trawl through most of the MPS/TrP literature.

      Raising the issue of drugs does not obscure the fact that there is no evidence that physical treatment methods relieve the pain attributed to TrPs.

      In their systematic review of treatment of “trigger point pain”, Cummings & White [2001] were unable to find rigorous evidence that needling therapies have any specific efficacy beyond that expected from placebo treatment.

      Tough et al. [2009] reviewed 1517 studies but could find only 7 that were of high enough quality for meaningful analysis. They found limited evidence that dry needling of TrPs was associated with a treatment effect compared with standardized care. They commented on limited sample sizes, uncertainty as to whether TrPs were the sole cause of pain, as well as technical issues such as the variability in the location of TrPs as well as in the depth of needle insertion. The studies also varied in the intervals between treatment and the overall number of sessions of treatment. Finally, measurement of outcomes were applied at different times in different studies.

      Rickards [2006] reached a similar conclusion and commented that the strength of evidence for any treatment should be considered as limited. He surmised that a few of the treatments studied may be effective, however whether or not they actually address the proposed pathological entity or some other processes is impossible to determine.

      Ho & Tan [2007] reported that the current evidence does not support the use of botulinum toxin A injections in the region of trigger points. They located 21 RCTs, with 12 eligible for consideration and only 5 of these suitable for inclusion in systematic review. However, they found the data to be limited and clinically the patient populations to be heterogeneous.

      Annaswamy et al. [2011] performed an evidence-based review and commented on the heterogeneity of study populations in terms of aetiology, mechanism and duration of pain. They found that there were no single, widely accepted, standard diagnostic criteria for MPS. Not surprisingly, they concluded that there is insufficient evidence to support the use of most interventions studied.

      As I have said before, Alfred North Whitehead [1925] coined the term “Fallacy of misplaced concreteness” for the process of regarding something abstract as a material or “concrete” entity. In the case of the TrP, the fact that it was always a theoretical construct, and therefore abstract, was quickly forgotten by those who formulated treatment regimes on the basis that it existed as a concrete reality. It therefore comes as no surprise that treatment predicated on the basis of “eradicating” the Myofascial TrP has been an outstanding failure.

      References can be supplied on request.

  4. Emanuele Careddu has, I believe, misread what I said. I did not say that myofascial trigger points represented ‘pseudo pseudo science.’ I said that aspects of the Travell-Simons book represented pseudo-pseudo evidence based medicine (PP-EBM): ‘But if there ever was need for examples of PP-EBM, these authors [Travell and Simons] provided it.’

    The issue of myofascial trigger points includes the extent to which they are reliable and valid—properties that can be measured and described statistically, something that has yet to be done adequately. There are important questions about trigger points and trigger point therapy that go beyond my post, including effectiveness. Studies need to be blinded, with appropriately and unbiasedly selected subjects. Treatment studies must include placebos. Evaluators cannot be the persons who supported the underlying hypotheses—they must be neutral. The questions about myofascial pain and trigger points is not whether they are true, valid, reliable and helpful, but the extent to which they have these characteristics.

    For now, a 2004 paper by Huguenin can be helpful in identifying some of the issues (Huguenin, L.K. Myofascial trigger points: the current evidence. Physical therapy in sport 5, 2-12 (2004)). The following are excerpts from that paper:

    “There are, however, several caveats to bear in mind when establishing examination findings, not the least of which is the lack of a gold standard for assessment of trigger points. This lack of standardised assessment makes validity studies near impossible, although reliability trials have been performed. Wolfe et al. (1992) examined patients with chronic myofascial pain or fibromyalgia, and the most common finding in their subjects was local tenderness and taut muscle bands. Reliability of examination for taut bands, muscle twitch, and active trigger points, however, was problematic.

    In a blinded trial of physiotherapists experienced in treating lower back pain (Nice et al., 1992), the reliability of assessment for the presence of three trigger points described by Travell and Simons was poor and it was noted that issues as simple as patient positioning, palpation technique, and the amount of force applied significantly influenced results. Of interest, reliability was not improved when the sample was reanalysed for only those therapists reporting the use of trigger point examination in their routine practice.

    In a more recent study, Lew et al. (1997) found that both inter and intra-rater reliability, using two highly trained examiners for assessment of the presence and number of trigger points in asymptomatic patients, was poor. In a study by Gerwin et al. (1997), it was found that extensive training of four clinicians together resulted in improved reliability of identification of trigger points [Note from Fred Wolfe: Gerwin was a participant in the Wolfe study and the Gerwin study was designed with the purpose of showing improved reliability]. In a study by Hsieh et al. (2000), it was reported that localisation of trigger points was unreliable in untrained examiners, and only marginally more reliable in trained examiners. Further, Hsieh et al. (2000) found that taut band and local twitch responses could not be reliably assessed, and examination for referred pain had low reliability when extensive training had been undertaken, but was not at all reliable without this. Another study has shown moderate reliability for the presence of local tenderness and production of recognised pain, but poor reliability for twitch responses and the production of referred pain (Njoo and Van der Does, 1994).”

    Imagine what it would be like if auto mechanics, computer servicemen and the people who fix my washer operated with the same level of reliability found in the studies above. But patients, unlike mechanical and electrical devices, often get better on their own.

    Fred Wolfe

  5. If the aim of research is to confine the complexity of the human neuro-psyco-endocrine system in boxes (or let’s call it reliability, sensitivity or specificity or whatever we want to call it), with the presumption to apply a “x” modality in order to always switch on or off a behaviour or a phenomenon exactly as we can do with machines in general then that this is pseudo-pseudo science too.

    We cannot consider ourself as simple washing machine with a simple network, the human system is way more complex than this as I am sure you would agree with me on that point.

    The referred pain areas are commonly seen but not everyone of course will refer pain exactly in that specific pattern… Travel and Simons books should be seen as a reference guide, a basic platform from where to start assessing and studying certain phenomena, the fact that they are regarded as a bible for TrP can or cannot find my approval, what matters more I think, is that patients and practitioners in the field of Manual Therapy everyday deal with these issues and patients get very satisfactory results without gulp doen pills over pills… if patient often get better on their own then why should we give medications? And why lots of the patient we see everyday in practice have been taking drugs for weeks and weeks, medications which just marginally help them to cope out with their problems, but then they can find often (not always of course) enormous relief from manual approach, dropping completely any medication?

    • Emanuele and Giancarlo,
      With respect to drug treatment, I would agree with you. With respect to whether trigger point therapy is effective, I refer you to John Quintner’s post about therapy. With respect to washing machine servicemen, if they diagnosed problems as poorly as trigger point therapists diagnose trigger points, they would be out of the washing machine service business pretty quickly. Giancarlo, what is the acceptable level of uncertainty? In the study I referred to the greatest of trigger point authors and experts could only rarely agree with each other on what was a trigger point. I would call that an unacceptable level of uncertainty. What this means practically is that if a patient went to Dr. B rather than to Dr. A, he might receive a different diagnosis and treatment for the same problem.

      Fred Wolfe

    • Dear Giancarlo, the same Karel Lewit [1] observed that therapies such as manipulation, spinal traction, remedial exercise and pharmacotherapy were commonly employed in the management of conditions presenting with localized deep somatic pain.

      In cases where these measures were unsuccessful, Lewit was able to obtain immediate pain relief (the “needle effect”) when the inserted needle was used to locate and stimulate the point of maximum tenderness within scars, ligaments, tendon insertions, muscles, and over bony prominences. He referred to these regions as “pain spots” and commented: “Intensity of the painful stimulus seems indeed to be crucial for producing the needle effect.”
      This sounds mighty like counter-irritation analgesia [2].

      1. Lewit K. The needle effect in the relief of myofascial pain. Pain 1979: 6: 83-90.
      2. Piche M, Arsenault M, Rainville P. Cerebral and cerebrospinal processes underlying counterirritation analgesia. Journal of Neuroscience 2009; 29: 14236-14246.

      • yes,,and so?
        I think this is a confirmation that goes against what you are saying or not?
        but that’s okay, not bad …
        not that you have to convince anyone here do not sell carpets ….

  6. I bet we’ll see the same debate rage on about “fascial therapy” soon, once more research is published.

    For those of you who seem to be out of sorts about Wolfe and Quinter and their careful interpretation of the research, please, help yourself to this video before making any more comments that borderline a discussion of the philosophy of science.

  7. “The first principle is that you must not fool yourself, and you are the easiest person to fool.” ~ Richard Feynman

    What about simple plausibility? There is a lot of tissue in the way: cutis/subcutis (hypodermis), smooth muscle, cutaneous nerve, vessels, dense fascia— l-o-n-g before one’s hands ever even arrive at muscle, assuming they actually could.. which they can’t, but indirectly, like feeling through a thick diving suit full of warm pulses.. Physiologically important tissue between hands and muscle easily gives rise to palpatory illusion based on conceptual hallucination. I used to think I could palpate anything.. but then, I had an opportunity to dissect the superficial layers to expose cutaneous neural rami, and became a muscle trigger point skeptic.

    A short paper on operator versus interactor models of manual therapy: https://docs.google.com/document/d/1ruRBlTM-7eJq2EbJCsdfrRf3Pgg0SsShvKIkEoyKP-c/edit
    A series of three blogposts on how I consider explanatory models and treatment models along a continuum:
    http://humanantigravitysuit.blogspot.ca/2012/04/treatment-continuum-i.html

    In manual therapy we will never be “right” about anything we do. Given all the human foibles and cognitive biases there are, we can only aspire and strive to be “less wrong.”

  8. In licterature we can find everything that states the contrary of everything and most of the time they alway state standard final sentences such as “further research should be carried out” “at the present we cannot be sure whether…” (as also the reviews quoted by John Quintner states) , and that shows once more how we cannot be definitive on what we know and apply, and here I agree with the last sentence of Diane Jacobs’s comment, “In manual therapy we will never be “right” about anything we do. Given all the human foibles and cognitive biases there are, we can only aspire and strive to be “less wrong.” “.

    We may not agree whether a TrP is present or not in someone or indeed if they exist or not, (then I wouldn’t mind to have an alternative explanation about a phenomenon that is commonly observed in patient in our practices i.e. pressing over an “hot spot” within a particularly “tight” or relatively hypertonic muscle, often refers pain somewhere else…)

    what I think it matters more than this, it’s then the ability to recognise muscoloskeletal dysfunctions which manifest themself anyway with myalgia, and try to identify a plausible reason why these locomotor dysfunctions start to manifest themselves through pain… and sometime the best evidence it is indeed clinical… you do you anamnesis, your clinical thinking, your tests and a treatments and see what happens, you see which kind of results you get out of your reasoning/hypothesis.

    And funnily enough Fred, that happens also with machines, I bet that if you would take your car to several garages because it has an x problem, I am not so sure that every mechanic would point out the same issue for your car, (maybe the exhauste pipe? maybe the spark plug? maybe the oil pan? Maybe all of them?) and this is particularly true if the car is old (chronic issue or maybe an insidious problem raising from several maintaing/predisposing factors) and cars and machine are way way way less complex then we are as I think you would agree with me…

    What you have described Fred, is what happens everyday in the real world for everything, someone will come to you and complaining of something and you will diagnose that with x, someone else may agree with you, some won’t, however maybe all of you will achieve an acceptable result at the end of the treatment/sessions or maybe we fail…

    To me and lots of other practitioners worldwide, TrP therapy is a valid approach to address muscoloskeletal condition, and I don’t think that patients who are relieved from their pain from myofascial pain through certain approaches are all suffering of hallucination or it is just placebo.

    That said, I believe it is vital to stress out that the aim of treatment shouldn’t be just “seeking for TrP” as Tom Thumb would seek for bread crumbs, but the whole process should be focused to understand why TrP or relative muscle hypertonicity or anyway myalgia may develop, and therefore hit the “primary lesion” which is the “saint graal” of all manual therapies… not easy to prove and I have the gut feeling that no systematic review or experiment or clinical trial will be ever able to 100% demonstrate an x modality is always better than something else just because we are too complex… we do operate at a level of acceptable uncertainty.

  9. ** To me and lots of other practitioners worldwide, TrP therapy is a valid approach to address muscoloskeletal condition, and I don’t think that patients who are relieved from their myofascial pain, through certain approaches that may also imply TrP de-activation (with PIR, ischaemic compression, soft tissue massage or whatever) are all suffering of hallucination or it is just placebo.

    P.S.
    sorry for the re post

    • Emanuele, it is possible for treatment to be “accidentally” effective, despite it being based on false theoretical foundations. The fallacy known as “post hoc ergo propter hoc” deserves mention in this context. The treatment administered may well have had causal effects for reasons outside the purview of the practitioner.

      However, more common explanations for improvement following treatment include the placebo effect, the natural history of the particular problem being treated, and regression to the mean. These factors can all be relevant to the self-reported experience of pain.

      There are also occasions where a lack of real improvement can be obscured by an observer’s “confirmation bias,” here defined as the natural human inclination to interpret information that supports pre-existing expectations. In this case, irrespective of its truth value, a hypothesis is more likely to be confirmed than being found wrong. The propensity to confirmation bias can be explained by the natural inclination to avoid an unpleasant psychological state (known as cognitive dissonance) and reject research findings that contradict one’s hypothesis.

      A similar bias that can be found in the MPS/TrP literature is that known as “expectation bias”. Here, the researcher’s expectations of a study’s outcomes leads to the publication of data that is in agreement and the playing down or worse of data which appears to conflict with them.

      In my opinion, based upon cold hard evidence, TrP therapy does not pass muster as a valid approach to musculoskeletal pain.

  10. Emanuele wrote:
    >>> “We may not agree whether a TrP is present or not in someone or indeed if they exist or not, (then I wouldn’t mind to have an alternative explanation about a phenomenon that is commonly observed in patient in our practices i.e. pressing over an “hot spot” within a particularly “tight” or relatively hypertonic muscle, often refers pain somewhere else…)”

    I have yet to find any better proposal for what “they” are, than Quintner and Cohen’s paper suggesting peripheral nerve pain, plain and simple. WAY higher plausibility.
    REFERRED PAIN OF PERIPHERAL NERVE ORIGIN: AN ALTERNATIVE TO THE “MYOFASCIAL PAIN” CONSTRUCT http://www.pain-education.com/referred-pain.html
    Lundborg’s work on peripheral nerve entrapments provides plenty of detail on what constitutes a nerve trunk, their care and feeding, what happens if they are entrapped or irritated. Peripheral nerves branch extensively, make their way all the way out to supply skin. Cutaneous branches and rami of these are much more superficial (therefore probably more easily palpable) than anything supposedly inside muscle.

  11. uhm… let me cast some doubts about what you have just stated… 1st nerves pass throughout what? Myofascial structures, so I do agree that nerve can be pinched and irritated but still the main cause would be always within the muscle (TrP? Relative muscle hypertonicity? doesn’t matter same soup) or potentially para-articular (a facet joint for example) so always on these structures one should work on… 2nd cutaneous branches have well defined areas of distribution, and irritation of just a cutaneous branch is not so common is it? I can think to chieralgia parestetica, I can think to meralgia parestetica, maybe the entrapment for the superficial branch of median nerve around the 2 head of pronator teres or between the flexor digitorum sublimis and profondus… I am not aware of other possible pure cutaneous branch nerve entrapments… not a lot of possible cases are they? What about all the rest? What about a patient of mine reporting funny referred pain along the right arm when pressin an area over the serratus posterior inferior? Not so sure that can be considered nerve entrapment can it?

    At the end one thing matters more than others, patient’s wellbeing.

    Ad maiora.

  12. Dear Emanuele, you will remember that Travell and Simons claimed “taut bands” containing TrPs could entrap peripheral nerves. This mechanism has never been confirmed in the extensive literature dealing with nerve entrapment but lives on as yet another example of their epistemological errors.

  13. The bad science isn’t going to go away until good science replaces it. By that I mean a better understanding of the aetiology.

    The problem is that Fibromyalgia is still stuck in a catch-22 of low funding and prestige.

  14. Pingback: How does foam rolling work? | Gotcher Back - Massage Therapy

  15. Suzanne, I found your discussion interesting and in fact did read through all of it. Nice story but it appears to me to reinforce Cartesian dualistic thinking. Substitute the homunculus (the “little man” in the brain who adjudicates the matters you raise) for the pineal gland (see the original diagram of Descartes) and you will see what I mean. I sincerely hope that Lorimer Moseley is aware of this philosophical problem.

  16. Emanuele/Giancarlo,

    Can anyone who conflates triggerpoint with allodynia/hyperalgesia and ‘increased’ tone explain the areas of allodynia/hyperalgesia and ‘decreased’ tone or allodynia/hyperalgesia and ‘normal’ tone without invoking the anatomical structures and physiological characteristics of the spinal cord/central nervous system?

    Can anyone who reports being able to determine the ‘correct’ tonic responses of an individual to a particular environmental situation do so without invoking the anatomical structures and physiological characteristics of the spinal cord/central nervous system?

    Can anyone who conflates nociception with pain explain the causal mechanism so without invoking the anatomical structures and physiological characteristics of the spinal cord/central nervous system?

  17. @ Mark. I suspect that those who espouse the teachings of Travell and Simons will not be able to respond to your questions. They remain firm in their belief that Myofascial Trigger Points are primary causative entities, despite every study that has been reported since the early 1980s refuting their hypothesis. Dry and wet needling of such points continues to be popular with those who cling to the scientifically untenable theory that has generated these treatment modalities. In the immortal words of Marcus Tullius Cicero, cui bono?

  18. Hello all, hello John … I’ve been using myofascial release techniques with and without needles for 15 yrs in my office to treat hundreds of patients with chronic pain syndromes of various types. I have developed my own “view” of the therapy. There are some key scientific and clinical issues missing. These issues have been discovered or uncovered because of a few reasons; The definitions used to describe pain, diagnostic consideration and pain therapy all have to be viewed differently. The analytical and testing models can not be used in a reliable basis and must be redefined.

    The one key issues was uncovered by C. Chan Gunn, MD in a paper called; Cannon WB, Rosenblueth A. The Supersensitivity of Denervated Structures: A Law of Denervation.New York: MacMillan; 1949.

    The beauty of the stainless steel needles used by Gunn and The Travellians accomplishes 2 powerful events simultaneously. 1. Triggering the healing cascade and 2. Reboot or reset tight muscle fiber thus igniting the all necessary components to set complete healing in motion. Take away either of the two and ignition will be incomplete.

  19. @ Stephen. The absence of the key ingredient called scientific credibility positions your idea alongside that of the homeopathic principle – “like cures like”. Create a lesion in order to heal a mythical lesion. How stupid is that?

    I am puzzled as to why inserting stainless steel needles into innocent muscles continues to be so popular amongst medical and non-medical practitioners. My sole consolation is in the knowledge that it took many centuries for “front-line” approaches such as bleeding and purging to be expunged from the armamentarium of Medicine.

  20. I was in a pretty bad position 15 yrs ago attempting to help patients who had FM, odd aches, pains, stiffness and nerve issues, imbalance, digestive, urinary, respiratory, fatigue issues … etc.

    Over the years I began to use the only tools that the patient noticed helped them the most. The tools are simple myofasical release techniques hands-on and with needles.
    Humans have used these tools for millennia in various forms from simple stretching, yoga, heating, kneading, hands-on manipulations, acupuncture, dry needling to finally Travell trigger point injections.

    So, John why would I exclude these simple and effective therapies from a logical treatment plan knowing good and well they could help a miserable suffering patient?

    John, how many patients would it take for you to believe this surgery works and IMO, the most cost effective procedures in medicine?

    To the group, How can I help in this daunting task to put these therapies on the table?
    I know of other naysayers who block such efforts plus the RUC committee of the AMA is another entity in the way.

    AMA/RUC panels; http://www.marketplace.org/topics/life/health-care/secret-world-health-care-pricing
    and
    http://studentdoctor.net/2010/10/little-known-ama-group-has-outsized-influence-on-medicare-payments/

    • @ Stephen. The argument that the venerability of the tools you mention makes independent evaluation of their efficacy unnecessary is based upon a confusion between millennia of use and millennia of accumulated evidence of usefulness. What confronts you is the inescapable fact that the weight of scientific evidence (derived from formal clinical trials) happens to be against your particular belief system. Your task is indeed a daunting one.

  21. Fred,

    I have been practicing PT for 20 years and have used spray and stretch in my clinical rotations but never as a practicing clinician. My question for you is not regarding diagnosis or treatment but with respect the the referral patterns Simons and Travell mapped. The heart and pec minor, gall bladder, RTC to name a few. Are you disputing those as well?

    • @ David. May I respond to your question? The patterns mapped by Travell & Rinzler [1] were based upon their allegedly meticulous records from about 1,000 patients and depicted the usual locations of trigger points in 37 muscles, and the characteristic pattern of referred pain in response to pressure on each. By a process of circular logic, Travell and her colleagues argued that because each muscle had a characteristic pattern of pain referral, the clinician could locate and eliminate the offending trigger point in the respective muscles simply by consulting the maps that they had produced. Not only had they fooled themselves but also succeeding generations of their followers.

      1. Travell J, Rinzler SH. The myofascial genesis of pain. Postgrad Med 1952; 11: 425-434.

  22. In his Caltech Graduation Address (1974) Richard Feynman suggested that the first principle of scientific integrity is “you must not fool yourself.” He added a rider, “and you are the easiest person to fool.”

    Despite the concept of “myofascial trigger points” being thoroughly discredited (see above), Marcus et al. (2013) have fallen into the trap of fooling themselves when arguing without any evidence: “It is reasonable to assume that if acute episodes (of low back pain) are related to soft tissue dysfunction, ongoing residual dysfunction may also be.” Many researchers would strongly argue that such an assumption is quite unreasonable!

    Nevertheless, in the study, their conjecture enabled Marcus et al. to launch into their protocol of performing multiple “muscle tendon injections” purported to destroy those tissues said to contain sensitized nociceptors. The precise targets for treatment (muscles and entheses) were allegedly determined by the responses elicited using an electrical muscle stimulation instrument invented by one of the authors.

    The fact that this article has been published in a main-stream pain medicine journal is sufficient evidence that Richard Feynman’s first principle is still being ignored, both by the authors of this article and those who reviewed it.

    Reference: Marcus NJ, Shrikhande AA, McCarbeg B, Gracely E. A preliminary study to determine if a muscle pain protocol can produce long-term relief in chronic back pain patients. Pain Medicine 2013; 14: 1212-1221.

  23. You are absolutely right about the book of Travell and Simons. It is not evidence based and many things are not referenced to high quality studies. Often there is a statement without any reference. But taut bands I believe most therapists and health care practitioners within the field manual therapy have felt in palpation of patients muscles. Referred pain from tensed muscles (trigger points) have been found in manual examination. Different treatment modalities have reduced tension headache among other things where the symptoms could have come from trigger points. There is one study showing the possibility to even find taut bands with MR [1].

    1. Chen Q, Basford J, An KN. Ability of magnetic resonance elastography to assess taut bands. Clin Biomech (Bristol, Avon). 2008 Jun;23(5):623-9

  24. >>>> “But taut bands I believe most therapists and health care practitioners within the field manual therapy have felt in palpation of patients muscles.”

    I’d change that to, “But I believe, and most therapists and health care practitioners within the field of manual therapy believe, that the taut bands (they palpate) …. are in muscle.”

    The paper you cited says, in its intro, “Taut bands are currently thought to represent is a discrete group of muscle fibers that have contracted for unknown reasons. ”
    (That is a direct quote, strange sentence structure left as I found it.)
    (So incurious about these “unknown reasons.”)
    Further in, they say: “In summery, myofascial taut band is considered a contracted or shortened muscle fiber band with increased muscle tone.”
    More replication of the standard blame-the-muscle meme. Plus, no one checked their spelling.

    In other words, it’s merely belief that taut bands are located in, and/or are comprised of, or are confined to, misbehaving striate muscle.

    I’m a manual therapist who used to believe I could palpate taut bands in muscle, until I dissected hypodermis and was surprised by a) how thick it is and b) how full of “taut bands” it could potentially be.

    The “taut bands” we think we can palpate so accurately through a thick layer of physiologically active thermoregulatory organ, as being in “muscle,” may well be, in most areas of the trunk and limbs, the much more superficial cutaneous nerves/neural tunnels/vascular structure lying above the dense fascia (which encloses muscle completely, and poses a daunting obstacle to palpating fingers!), and within (much more easily accessed by palpation) hypodermis.

    Neural and vascular structure has plenty of smooth muscle cells within its walls: if subjected to localized autonomic (afferent and efferent) dysregulation, due to mechanical deformation of some kind, possibly due to lack of movement/not changing posture often enough, a situation could arise which could ostensibly be sufficient to create in these structures, grounds for nociceptive input with consequent tenderness, referral, reflexive twitch, and palpable tautness – nothing to do with striate muscle itself, whatsoever. Don’t you think?

    The paper’s authors examined trapezius muscle, and supported the notion that taut bands are found inside muscle itself. (I would love to see a paper some day that examined all tissue, not just muscle tissue. But I digress..)
    In many parts of the body where muscle is too deep to be directly palpated, something much more superficial, something autonomically misbehaving perhaps, is more likely to be felt by the practitioner in hypodermis, long before their fingers could ever penetrate dense fascia into actual muscle.
    Furthermore, If muscle is involved, logically I would expect areas of tautness are a result, not a cause, of the phenomenon. In other words, taut bands that DO exist in muscle would be the result of the same disturbance that likely affects other structure in the neighbourhood, and should not be implied to be the cause of.. themselves (!), or of pain.

    • I agree that palpation is not as accurate as one could wish for. I also remember a researcher in biomechanics who is doing EMG-studies questioned muscle tension itself and that it is uncertain what we therapists really feel.

      Moore research is needed before convincing evidence can confirm or refute taut bands and referred pain mechanism from trigger point.

    • You state:
      The “taut bands” we think we can palpate so accurately through a thick layer of physiologically active thermoregulatory organ, as being in “muscle,” may well be, in most areas of the trunk and limbs, the much more superficial cutaneous nerves/neural tunnels/vascular structure lying above the dense fascia (which encloses muscle completely, and poses a daunting obstacle to palpating fingers!), and within (much more easily accessed by palpation) hypodermis.

      In my 20 years I would have to disagree. Could there have been few instances I was wrong. Absolutely. With the biceps – never to name 1 muscle. Nerves and VAN’s – if you palpate it, you know and the patient for sure knows so I am not sure why you cite these.
      In my experience, PT’s are far more accurate in palpating muscle than is your experience.
      Cadaver work is awesome and I feel is wasted on students early in their education. I think cadaver lab should be after clinicals. I had 1 full year my first year of school. Participating in cadaver labs after school has been so much more enlightening. But my experience with muscles and overlaying structures has been very different than yours

  25. @ Wolfe you expected a practitioner to perform magic … there is no magic in medicine.
    The demonstration was of an unfortunate case the was beyond manual therapy and thus would have require more intensive therapy which included needles and addressing all the perpetuating factors like sleep, mineral deficiency, medication adverse reaction. I see these cases daily and they do respond miraculously. No magic needed.

    @Wolfe you discount all the wealth of data Travell and Simons compiled which is an insult to the authors. Most text are compiled and written based on well vetted studies to make it easier to understand and teach.

    @Quintin, how many cases would it take for you to believe the word of a patient. 20? 200? or 2000? Well I have a few thousand cases in my files, most I have helped with these techniques. I just hope you are not in a position to impose what you believe on others. That would be immoral and a disgrace to the oath you took to do no harm.

    Taut bands in muscles and the all diagnostic criteria are for a “classic unit.” In clinical practice, all the academics, have to be put on the back burner as per Edward Rachlin, MD. A muscle full of trigger points will act very erratically so trying to elicit a twitch maybe a futile task. And the muscle could be 2-6 inches into the flesh. These infected muscle still requires therapy. Delay or neglect will subject the patient to more pain and suffering. Clues that a muscle is affected area density changes, tightness, loss of range of motion and surface sensitivity changes.

    The best diagnostic and therapeutic tool to determine if a muscle is infected is a stainless steel needle wire. The thin filament type wire needle once it touches the erratic muscles will elicit a response in the patient. The only person who can tell you that information. The patient is the soul detector of this therapy and has to be a part of the diagnostic team. You have to trust their words! The other detector of MF diseased flesh is the practitioner. What the provider feels in their fingers are vital to a good outcome. Finally the post treatment exam cannot be neglected or discounted. The patient and the examiner has to note a better range of motion and less pain.

    I know what you are thinking … I can’t use sophisticated equipment! I have to believe what the patient is saying! I can’t figure out a way to double blind this technique! The simple puny needle is the best diagnostic tool and best therapeutic tool all in one!

    In a discussion of open minded scholars the goal should be on how to help the masses not disparaging the clinicians and practitioners. We and the suffering patients need your help not your skepticism.

    To gain more insight into these procedure, read these text books … especially Gunn. He linked the myofascial therapy extremes from simple stretching, yoga, spray and stretch, hands-on manipulations, acupuncture, Gunn-IMS, dry needling to finally Travell trigger point injections.

    >Intramuscular Stimulation using the techniques of C. Chan Gunn, MD.
    >Trigger Point Injections using the techniques of Janet G, Travell, MD, David Simmons, MD and Edward Rachlin, MD.
    >Ligament and tendon relaxation techniques of George Stuart Hackett, MD.
    >CraigPENS as per William F Craig, M.D.
    >Myofascial Release by Gokavi, Cynthia N. Gokavi, MBBS.
    >The Trigger Point Therapy Workbook: Your Self-Treatment Guide for Pain Relief, Second Edition by Clair Davies, Amber Davies and David G. Simons (Aug 1, 2004)
    >Fibromyalgia and Chronic Myofascial Pain: A Survival Manual (2nd Edition) by Devin J. Starlanyl and Mary Ellen Copeland (Jun 30, 2001)
    >Advanced Soft Tissue Techniques as per Leon Chaitow, ND, DO
    >Medical Acupuncture as per French Energetic protocols of Joseph Helms, MD.

  26. @ Stephen and David. I commend to you this excerpt taken from the book “Hippocratic Oaths: Medicine and its Discontents” by Raymond Tallis (2004). “The greatest of all the obstacles that medicine has had to face in its journey towards a full developed clinical science has been the overthrowing of its own authority. In an act of collective humility, it has cultivated a routine distrust of its own practices. This humility has been almost as important in the development of effective therapies as biomedical science.”

    I hope this will make you understand why I am so skeptical and critical of “trigger point” therapy, also known as “myofascial release therapy”.

  27. @ Stephen. I am not in a position to impose my beliefs upon others. If by some chance I happened to be in such a position, I would insist that those who choose to insert stainless steel needles into the muscles (diseased flesh!) of people in pain provide a modicum of scientific evidence to justify their practice. On this score, they would be in deep trouble. There are better explanations of the observed phenomena, none of which justify launching an all out assault upon innocent muscles. I see no justification for clinicians in the 21st century to wilfully perpetuate the logical errors of past icons of the Myofascial Pain/Trigger Point construct. I see no immorality or disgrace in holding to my viewpoint.

  28. Here are a few anecdotal testimonials of patients with various complex pain problems who were never really told that Myofascial Release Therapy with needles even existed and suffered with pain for many months, years and decades. Some wanted to sue but were so thankful to be in less pain, that they were persuaded against such a venture. (delete if inappropriate for study or evidence).

    http://www.youtube.com/playlist?list=PLi9Pftf1qzEjZ8qdvLT0lQJ3nknhcerwD

    The next question should be, “What did you do doctor?” The Answer would be … “read the text books and apply what you’ve have learned.”

  29. @ Stephen. You are quite correct. Your case studies published on YouTube do not constitute scientific evidence. The authors of the various text books that you have listed continue to reinforce the fallacious reasoning of past “trigger point” icons.

  30. @ John … whatever malady is embedded within the muscles that causes the pain and dysfunction, I will leave up to the future studies. All my patients know and can testify that the therapy works!!! (in the majority of cases) It is not as simple as popping a pill, it requires 1 on 1 care, a lot of time, effort, hands-on care and lots of jabs with various solid and hollow needles. NO harm will result from this therapy in the hands of a well trained nurse, physician assistant, family member or doctor!! Actually more harm will result if the therapy is delayed. That would be inhuman.

  31. @ Stephen. You seem to be saying that anyone who delays inflicting “lots of jabs” upon people in pain causes more harm to that person and on this ground is not a human being. You are using a form of philosophical argument known as “reductio ad absurdum”. I must therefore reject your premise.

    The argument pursued by Marcus et al. (2013)* also falls into this category.

    *Marcus NJ, Shrikhande AA, McCarbeg B, Gracely E. A preliminary study to determine if a muscle pain protocol can produce long-term relief in chronic back pain patients. Pain Medicine 2013; 14: 1212-1221.

  32. To clarify my points;
    >”when you have eliminated the impossible, whatever remains, however improbable, must be the truth?”
    >Myofascial release therapy is a valid therapy in many aspects of physical therapy. Gunn linked the hands-on and needle therapy with the Cannon’s Law.
    >Doing harm to a patient is malpractice ie delay in diagnosis, misdiagnosis and delay in treatment. I would consider this inhumane or inhuman for any physician who wishes to believe that myofascial therapy is invalid because it is not scientifically substantiated.
    >Lots of jabs as in Acupuncture, TP injections, Gunn-IMS is included in a comprehensive chronic pain treatment protocol is safe and effective therapy.

    We need to listen to patients and not to MDs who have a
    [Conflicts of Interest and Disclosure: Norman Marcus, MD, is an inventor of an electric muscle stimulation instrument. ... For the remaining authors none were declared.]

    Devin is stating that; [Both the muscles and their tendon attachments were critical pain generators. ] http://homepages.sover.net/~devstar/new_ref5.htm

    Please John … we can not really have a dialogue that would truly help patients and our lopsided healthcare systems if we keep debating about your study which may be important in some aspects, but to my patients who are suffering who come to my office for pain care … I’m gonna pull out my best set of tools that have a known track record of success. Oh … this is my last response to any of your jabs … ouch.

  33. @ Stephen. The conclusion is inescapable – “myofascial release therapy” lacks scientific credibility and on this score does not qualify for recognition as being a valid form of treatment. It may have a place alongside reflexology, homeopathy, and colonic irrigation etc. but it needs to be said that none of these latter treatment modalities purports to work by inflicting more pain upon the patient.

  34. John,

    You never answered my original question regarding referral patterns mapped by Travell and Simons
    You simply restated your opinion regarding treatment of TP’s

    Again, referral pattern of RTC, pec minor and heart, gall bladder – are you disputing this and stating they do not exist

    I have treated somewhere between 6-8,000 patients. pec minor referral pattern is always the same. RTC, mild variance but overwhelming majority of RTC patho, gallbladder, etc..
    Are you disagreeing with this?

  35. @ David G. Sorry, but I thought I had answered your question. As far as I can ascertain, Travell and Rinzler never provided any clinical or experimental data to substantiate the accuracy of their diagrams. They took a leap of faith when they placed an X on each muscle at the site where an examiner might expect to find a “trigger point”. Sadly, their many followers believed and perpetuated this non-science.

  36. John,
    I have not commented on Travell and Simons position and research and books on trigger point identification and treatment

    I was specifically addressing their mapping of referral patterns specifically mentioned before
    pec minor, heart, RTC, gall bladder.

    Are you here and now disputing referral patterns of RTC, pec minor and heart?

  37. RTC = rotator cuff

    Simons and TRavell were the first to map referral patterns. You have disputed their work. I was simply wondering if you refuted the referral patterns such as the ones I referred to. It sounds like you are stating now that you do not dispute that part of their research

  38. As far as we (John Q, Milton C. and I) can tell from exhaustive searches, Travell and Simons took most their diagrams from Kellgren, and made up the rest. They never did any research as I define it (coming up with a hypothesis, designing an experiment to test that hypothesis, doing the experiment, and reporting the results). It is irrelevant really where the pain referral is; it can almost always be understood and explained by spinal anatomical convergence. The issue is the root etiology. We dispute the concept that there is something wrong in the muscle. There is no evidence, and not for lack of trying, that there is anything wrong in there! That does not mean that nothing is wrong. It does not mean that your treatments don’t “work,” either. Just beware of making the most common clinical error, post hoc ergo propter hoc, on a daily basis. Be open to other possibilities than what you believe, when what you believe in regards to “trigger points” may have essentially been programmed into you.
    (Kellgren JH: On the distribution of pain arising from deep somatic structures with charts of segmental pain areas. Clinical Science. 4:35-46, 1938.)

    • @ David G. Please let me know what you find.

      My opinion of Kellgren? I hold him and his research in the highest regard.

      You might also like to look at these papers:

      Feinstein B, Langton JNK, Jameson RM, Schiller F. Experiments on pain referred from deep tissues. J Bone Joint Surg 1954; 36:981–97.

      Hockaday JM, Whitty CWM. Patterns of referred pain in the normal subject. Brain 1967; 90: 481-496.

  39. I haven’t commented for a number of reasons. But I do agree with Drs. Bove and Quintner. Some years ago when I was researching all of this I attempted to find out where Travell’s research was published. But there was no research publication. I did find, and one time owned, a copy of her 1944 poster abstract. It had her Ipse Dixit for sure, but no data and no research. I wouldn’t have blamed her much because these were the dark days of the 1940s (Travell, J., Berry, C., and Bigelow, N. Effects of Referred Somatic Pain on Structures in the Reference Zone. Federation Proceedings, 1944, 3:49 (Abstract)). But by the 1980s, when she and David Simons came together, proper research methods were known. In addition many of the really wrong ideas about about hormones, vitamins, minerals, and the like, were widely understood in the Internal Medicine community. One might not have expected them to know knowledge in other fields so well, but one did expect them to look up references and try to understand current knowledge because they wrote about it. They never did that much. Some of what they wrote was correct, much was incorrect, but the totality of it was non-science. It might have been non-science in the 40s, but by the 80s it was junk science.

    • @ Fred. Although Janet Travell had passed on when Milton Cohen and I published our 1994 paper, David Simons was still actively promoting the MPS/trigger point stuff. He studiously ignored the fact that we had effectively demolished this construct, as did the many others who continued to promote “junk science”. As a result, many therapists who believed the gospel of Travell and Simons might have enriched themselves financially but have not succeeded in reducing the burden of chronic musculo-skeletal pain in the communities in which they practice. That they continue to defend the indefensible is beyond my ken.

  40. Bove:As far as we (John Q, Milton C. and I) can tell from exhaustive searches, Travell and Simons took most their diagrams from Kellgren, and made up the rest. They never did any research as I define it (coming up with a hypothesis, designing an experiment to test that hypothesis, doing the experiment, and reporting the results).

    D:So you are going on record that they were frauds and stole Kellgren’s data.
    Because you are the authority? Pretty outrageous position to take just because you don’t agree with their data. Many arguements to make, that seems a bit extreme. Do you have any published case studies or actual research in a peer reviewed journal – books?? Just wondering where you are coming from. Not that anyone needs those to read books and articles from a research perspective. But research only has one result and conclusion and when 2 people take away different conclusions and extrapolations, the process is contaminated and loses purity.

    Bove:It is irrelevant really where the pain referral is; it can almost always be understood and explained by spinal anatomical convergence. The issue is the root etiology. We dispute the concept that there is something wrong in the muscle.

    D: OK then. SO you are neuroscience / neuromatrix explanaotry model / spine person . Everything top down . I feel that any school of extremes is wrong and our profession(PT) or yours (chiro) is full of those. If I felt everything is bottom up I would be equally wrong.
    But to use your logic, overuse, tendonitis, bursitis are all rooted and must be treated by directing your focus at the brain. Everything is defense. No defect. If that is your position, there is no point in discussion as their is no middle ground and our profession is not better for this. Then again, was soft tissue ever your focus. Or was it always spine – if so, this is just another approach to justify and rationalize your bias. Did you ever give your patients exercises to maintain proper alignment?

    The root etiology of pain from stepping on a splinter is the splinter. Treat the brain all you want but until you remove the splinter, the defect and source of the pain exists. Splinter is the source – sends input to brain – brain interprets response and sends output of pain yet you argue brain is source of pain and the root is neuro.

    Bove:There is no evidence, and not for lack of trying, that there is anything wrong in there! That does not mean that nothing is wrong. It does not mean that your treatments don’t “work,” either. Just beware of making the most common clinical error, post hoc ergo propter hoc, on a daily basis. Be open to other possibilities than what you believe, when what you believe in regards to “trigger points” may have essentially been programmed into you.

    D: LOL Back at you. we all must be aware of our bias. Agreed – no arguement. Statistics is very simple. Go to vegas – house wins majority of times. If I find defect – you say I am wrong – stats say if you are right, I can’t get accidental success more than 50% of the time. Most skilled and experienced ortho PT’s with shoulders and knees will average high 80-s to high 90 percentile success. You say by accident? Do they have excellent communication skills, eval skills, account for psychosocial and unknown variables – the good ones do.

    Do you perform techniques on infants? Curious as your profession does promote this and is common in my city and past 2 cities I have lived in. Curious from an evidence based position if you do or if you support?

  41. Hi David G.
    Well you are a sensitive zealot! BTW, it is fallacious to insult to try to get your way. I’ll have none of that. You have sorely misinterpreted what I wrote, more than likely (sorry) out of ignorance. And you obviously also sorely misunderstand chiropractic (*sigh*). Your comments are consistent with racism. No matter. Where did you get the idea that Travel and Simons produced any data? They didn’t. All opinion.

    Where am I coming from. I am a career neuroscientist, focusing on deep nociceptor physiology. I have designed, performed, and published a ton of data, indeed, data you more than likely informs your practice (and supporting concepts of peripheral generator, RE: your splinter comment). You should read more! Most of my papers are available on my website. They are REAL research, not opinion masquerading as research. You need to learn the difference.

  42. @David G: ‘The root etiology of pain from stepping on a splinter is the splinter. Treat the brain all you want but until you remove the splinter, the defect and source of the pain exists. ‘
    I am running towards the road where my daughter is on the other side and I step on a splinter and I feel pain. So the splinter must have caused my pain.
    I am running towards the road where my daughter is laying on the road and I step on a splinter and I feel no pain. So the splinter must have … caused my analgesia or my daughter caused my analgesia or …?
    Your analogy doesn’t work. In the above I could equally and fallaciously argue that the context of the situation was the ‘cause’ of the pain. My daughter standing on the other side of the road caused my pain. Then I am back to ‘point the finger, point the bone’ superstitious thinking. There are a lot of real world examples where it appears that one thing causes another but upon research it does not appear so, even though it may be perceived as so. I am not against splinters or structures or ways of scanning tissue or how tissue looks however determining where they are in the story of pain and what role they have is important.
    I perceive that I am looking out of my eyes but science and research indicates that light is travelling in. And I have had 10′s of thousands of hours of this experience to back myself up with, I perceive I am looking out, it must be true. No matter how much cognitive restructuring I do I cannot stop that perception but I can cognitively rationalise that it is not so (I am not looking out) and in doing so I can then realise I choose on where I want to actively look. Much like for my clients, they may perceive that a needle or my hand makes the pain go away however, if the mechanism behind that pain and it’s resolution is more complexly and more simply understood, then I can also choose on how I may (as a therapist) want to act and also the story I may want to tell them. Personally I like a story that gives my clients the power to help themselves instead of one that long term makes them dependent upon my needles or hands.

  43. Fred,
    Great article! Its neat to hear this arguement from someone who interacted directly with T and S! Obviously a sensitive subject for many…

    David,
    You state, “LOL Back at you. we all must be aware of our bias. Agreed – no arguement. Statistics is very simple. Go to vegas – house wins majority of times. If I find defect – you say I am wrong – stats say if you are right, I can’t get accidental success more than 50% of the time. Most skilled and experienced ortho PT’s with shoulders and knees will average high 80-s to high 90 percentile success. You say by accident? Do they have excellent communication skills, eval skills, account for psychosocial and unknown variables – the good ones do.”

    What is accidental success? Do you mean success elicited through non-specific effects from your therapeutic encounter? I think it is great if your success rate is 80-90% but what is your measurement of “success”? A reduction in symptoms? An improved outlook of ones disability? When so many variables can influence a therapeutic interaction, how can we attribute more weight to one vs. another? With the amount of research that is being conducted on this currently, we must be cognizant to avoid confirmation bias….

    And again (I have interacted w/ David in the past), nociception is not necessory, nor sufficient, for an output of pain.

  44. (As a side comment, the concept of pain as an “output of the brain” was stated as “pain is not an input to the brain, it is an output of the brain.” While the first part of that is true, the second part, though very catchy I guess, is just plain silly, and I hope it disappears. All we pain scientists understand pain as an integrated sensation, plain and simple.)

  45. Joe B.:What is accidental success? Do you mean success elicited through non-specific effects from your therapeutic encounter? I think it is great if your success rate is 80-90% but what is your measurement of “success”? A reduction in symptoms? An improved outlook of ones disability? When so many variables can influence a therapeutic interaction, how can we attribute more weight to one vs. another? With the amount of research that is being conducted on this currently, we must be cognizant to avoid confirmation bias….

    D: Your statement infers randomness – thereis zero randomness in the evaluation process, on the manual techniques chosen, the specific exercises/exercises chosen and the progression of exercises. Might these effects unknown variables – yes. Are they responsible for the “success” primarily – no.

    How do I measure success with a shoulder or knee: If SAJI or menisectomy or ACL – Full resolution. OA is different. If there is an exacerbation – resolution
    We just had a bilateral bone on bone sent to us for prehab before Bi TKA. came with 7/10 hip pain, 6/10 knee pain, and instability in shifting of knee on every step on a stair. After 1 month, hip pain resolved, knee pain 1/10 and 100 resolution of instability/rachetting. Pool environment was chosen for this patient to conduct rehab – This is how I define success.

  46. Hmmmm … I think I understand a few issues in this discussion.
    1. We are trying to explain how the human body and thus God works. That would be a futile task. Besides I have patients to see who have been neglected by naysayers of myofascial pain and dysfunction and the therapy needed to treat pain and restore their quality of life.

    2. The X’s in the referral pattern is just a starting point. It is up to the therapist to find the x and treat it with the tools available. Heat, stretching, massage, spray and stretch, leverage and needles.
    Some muscle will have dozen of X’s and they all need to be treated. You have to use your hands, finger or needles, have a 1 on 1 dialogue with the patient and determine after therapy if the pain has decreased and the range of motion is better. Simplistic, but time consuming and labor intense. NOTE. No study in the past decade have included this essential clinical detail and thus are incomplete studies as per my authors.

    3. Every patient is in essence is it’s own study and you must believe and be guided by the patient and the clinician has to treat the patient in a dynamic setting. So how would you randomized and double blind this situation???

    Who in this discussion actually is involved with hands on patient care? If you researchers and bean counters please allow us on the front lines a little respect, empathy, sympathy and support. We have a tough job so allow us to treat patients with the tools we have available.

    Again I have hundreds of one on one patient encounters that will prove this therapy is valid.
    Besides the therapy works, I have treated hundreds of failed backs, carpal tunnels, shoulder, cervical, jaw, hips, knees etc with this simple effective therapy.

  47. Bove:
    Hi David G.
    Well you are a sensitive zealot! BTW, it is fallacious to insult to try to get your way. I’ll have none of that. You have sorely misinterpreted what I wrote, more than likely (sorry) out of ignorance.

    Firstly, if I did come accross too srtong it was because your statements were identical to what a neuromatrix explanatory model PT would say and after 1 solid year of trying to cimmunicate, may patience is short. Regardless, it is our first time communicating so if I came across too strong, my apologies.
    Secondly, I do find it ironic that after accusing me of insulting you, you insult me in the same sentence by accusing me of ignorance –

    Bove: And you obviously also sorely misunderstand chiropractic (*sigh*). Your comments are consistent with racism. No matter.

    D: First you accuse me of ignorance and now racism. My first degree was Poli Sci and I have been a student of history for over 30 years. Racism – completely inappropriate and inaccurate and insulting. The word you were looking for is stereotype. But I am not guilty of that. I grew up with Chiro’s as family friends, After graduating PT school, 2 X a month I would meet with a chiro to exchange ideas and techniques for 2 years straight, took a KT course with 90% chiropractors with significant and professional discourse, and know quite a few chiros where I live now. Their words – 2 schools, old school and new school. Old school saw patient 10-15 years for same diagnosis and would never give exercises to maintain alignment. New school does. Whether a PT or a chiro – to see a patient repeatedly for the same diagnosis and complaints, not addressing cause but symptom without any long term success is…. (use your own words) I asked about infants to see if you did so I could ask you to defend from research perpective. You did not answer. Instead accuse me of racism. Nothing I stated even comes close to stereotyping let alone the base of racism – look up the definition as this is a heinous accusation and blatantly false.

    Bove:Where did you get the idea that Travel and Simons produced any data? They didn’t. All opinion.
    Where am I coming from. I am a career neuroscientist, focusing on deep nociceptor physiology. I have designed, performed, and published a ton of data, indeed, data you more than likely informs your practice (and supporting concepts of peripheral generator, RE: your splinter comment). You should read more! Most of my papers are available on my website. They are REAL research, not opinion masquerading as research. You need to learn the difference.

    D: I know the difference. Where did I defend them. Someone here said when they published their work, “dark days” and proper research methods not implimented”. That is why their work was accepted and not torn apart as you suggest it should have. My only comment was regarding referral patterns – I did not defend their work on TP’s. ARe you saying they stole Kellgrens referral diagrams and did not give credit as that would be wrong. Others speak highly of Kellgren. We don’t have referral patterns from healthy muscles – how did he reproduce these referral patterns? What research method did he use?
    Please provide web site so I can read your papers – thank you. But did that give you the right to have an opinion and find them guilty of your hypothesis. If they didn’t use acceptable research methods that did not exist at the time, did they have a good hypothesis that had never been put forward before? Were they ahead of their time of just greedy people out to make a buck as some here have inferred. Or did they actually believe it? I belive your insulting commennt was innapropriate, my opinion.

    Bove It is irrelevant really where the pain referral is; it can almost always be understood and explained by spinal anatomical convergence. The issue is the root etiology. We dispute the concept that there is something wrong in the muscle. There is no evidence, and not for lack of trying, that there is anything wrong in there! Be open to other possibilities than what you believe, when what you believe in regards to “trigger points” may have essentially been programmed into you.

    D: Again, I disagree with your hypothesis that everything is top down as you are arguing here that it isn’t bottom up. And you close that if anyone disagrees with you it is based on their bias and you site research is on your side – I disagree. Cherry picking some articles that represent a fraction of the body of literature to back your bias appears to give you authority to accuse evryone else of being wrong and you are right. Is the nervous system involved – yes. Is defense involved – yes. Are some conditions partially or even fully top down, yes.

  48. J:As a result, many therapists who believed the gospel of Travell and Simons might have enriched themselves financially but have not succeeded in reducing the burden of chronic musculo-skeletal pain in the communities in which they practice.

    D: I don’t follow them although 20 years ago, there work was taught in my PT school. The referral patterns in their books that originally came from Kellgren were my take away point that help in diagnosing. Regarding TP’s. whther you want to call the knots or taut bands do exist and any DC or PT who can’t palpate them may want to spend more time treating than in acedemia.

    Yesterday I had 11 cervical patients all requiring manual. So I devised a little study. Without asking the patient, could I find the spot that would duplicate their pain. Simply with touch – I would find an area that I describe as having increased turgor versus the sorrounding tissue. I did this with levator scap and upper trap and nuchal line. My palpation was gentle so as not to have them move or tighen or make a sound. Afyter palpating the muscle globally, I would locate the area of “maximal turgor (if numerous), and then I would then increase my pressure and ask if that was the spot. 11 out of 11 times it was “That’s it” That’s the spot”. Levator pain was local to the spot 11 out of 11; 6 upper traps referred back into the head, either occipyt or temple, and nuchal line 7 had referred symptoms that began to reproduce their HA sumptoms, some referred soley to occiput while 5 referred to occiput and then to eyes (ramshorn).
    So for those who don’t believe in Trigger points – why is this.
    Do I feel a map of TP’s is the way to go. I think there is so much variance, unlikely but in 20 years I have found areas where I will usually always find the TP’s. My general rule is mid muscle belly and I did not come up with that but it is usually dead on for a primary spot, especially upper trap. But then the nuchal line as well. And levator is usually at insertion and secondary at origin or just before.
    But your positions are that they don’t exist
    My tension HA/migraine patients have exceptionally high resolution rates.( I can’t do anything for chemical migraines). Manual is not the only thing I do as I do address poor posture, tight ant and weak post, weak core to support posture, endurance of lumbar, increase joint motion in C-spine, address soft tissues which becomes less symptomatic with each visit and don’t forget about bifocal/progressive lenses which for many is the cause. For those who manifest stress in their neck – they will always have exacerbations but they will be few and less intense and resolve very quickly per patient education

    Have at it. For those who do attack this large statement, I gave you plenty of ammo – please let me know if you are currently treating 30 hours or more per week –

    Thank you
    SO how is this possible, unless I am simplying lying and making this up

  49. David: but you ARE ignorant, as evidenced by your writings. And I DID mean to insult you back. That is not necessarily a negative thing, though I understand it carries negative connotations. RE: racism. PERFECT word, stereotyping is accurate as well, but the anti-chiropractic crap is racist, by definition. RE: cherry picking, that’s just silly. http://www.doctorbove.com.
    I have stayed away from this site because I do not think that it is particularly functional, it just gives us a good venue for tossing bad blood about. The only value I see is that the discussion is consistent with the global lack of knowledge of sensory physiology. It is a sad state of affairs. I urge you all to take some postgraduate education related to the topic, though these are hard to find. Self study is far too hard and can lead down the wrong paths. A comprehensive review of the fallacies and junk science of “trigger point” ideas, with a testable hypothesis will appear soon we hope (if we get it finished!).

    I commented because two friends asked. And now I shall leave again.

  50. Mark:@David G: ‘The root etiology of pain from stepping on a splinter is the splinter. Treat the brain all you want but until you remove the splinter, the defect and source of the pain exists. ‘
    I am running towards the road where my daughter is on the other side and I step on a splinter and I feel pain. So the splinter must have caused my pain.
    I am running towards the road where my daughter is laying on the road and I step on a splinter and I feel no pain. So the splinter must have … caused my analgesia or my daughter caused my analgesia or …?

    D: Really – you are speaking to medical professional here
    I am sitting down, my dog jumps on me and scratches me – it hurts – you are arguing I am wrong
    No emergency as you included to blur the discussion – I step on a nail (splinter analogy) – I feel instantaneus pain, I ispect and see I have stepped on a nail. Using your logic, how do we know this is the cause – no other variables! Intensity of pain is a brain issue – is it appropriate or ver magnified but I am not discussing appropriateness of the out determined by the brain. Nail – pain – you argue to leave it there. I argue it is the source – remove it, tend to the wound. But you are extreme and can’t even allow for the simplist example because everything is top down for you. So Bove, this is why I get frustrated. after 1 year of this logic. Pain only comes from the brain? Sometimes. Brain interprets input and determines output (simple english) But some will only recognize defense and disgard defect, like the nail.

    M:Your analogy doesn’t work.

    D: It wasn’t an analogy Mark – not even close – it was an example

    M:In the above I could equally and fallaciously argue that the context of the situation was the ‘cause’ of the pain. My daughter standing on the other side of the road caused my pain. Then I am back to ‘point the finger, point the bone’ superstitious thinking. There are a lot of real world examples where it appears that one thing causes another but upon research it does not appear so, even though it may be perceived as so.

    D: You added a situation that could have a fight or flight reaction. I did not. Pure defect in my example. Zero logic or NMEModel logic/neuroscience extreme logic – You argue against a splinter being the source of pain by using an example of fight or flight. Another neuroscience person used a similar example of a friend who was shot in the femur and not in pain at the time of injury. What about 12-24 hours later? Please finish the story. Fight or flight is a survival mechanism and is very short term. Adrenaline is a wonderful thing – Unfortunately I have experience it many times. I never felt nothing (double negative – sorry), I felt something and was able to go on without any trouble until task was completed only to find out later that I had broken a bone or did some other damage. And 100% of the time, for me, 1-3 hours later flood gates opened and MR. pain walked in. You are stating here that does not happen? Are their exceptions. Yes. Are they rare. Yes. Is there asymptomatic patho – yes. Does it negate symptomatic patho – no. Some bone on bone OA are functional with minimal pain for varying periods of time. Other with moderate OA or disabled by pain with severely compromised function. TKA is only indicated when pain is disabling and function compromised beyond tolerance of patient. X-rays and bone on bone don’t determine TKA so let’s not re-use that argument Mark

    M: I am not against splinters or structures or ways of scanning tissue or how tissue looks however determining where they are in the story of pain and what role they have is important.

    D: You are not against splinters – read this sentence several times and not following you. All I will say is the history of the patient, mechanism of injury , the story is very important because it provides context. Is it pure defense, pure defect, Defect with some defense overlay. That is where our history taking in the evaluation occurs. Often the histroy alone can explain the majority of the condition, sometimes not. From there, the rest of the evaluation is to confirm our hypothesis which may take us in another direction which we must be prepared to follow. But for experienced and skilled clinicians, the history tells us a lot, especially with ACL and meniscal injuries to name 2.

    M:I perceive that I am looking out of my eyes but science and research indicates that light is travelling in. And I have had 10′s of thousands of hours of this experience to back myself up with, I perceive I am looking out, it must be true. No matter how much cognitive restructuring I do I cannot stop that perception but I can cognitively rationalise that it is not so (I am not looking out) and in doing so I can then realise I choose on where I want to actively look.

    D: ??? You are speaking to medical professionals. Who here disagrees on how our eyes work?
    Not following this analogy at all as it does not apply to any of us.

    M: Much like for my clients, they may perceive that a needle or my hand makes the pain go away however, if the mechanism behind that pain and it’s resolution is more complexly and more simply understood, then I can also choose on how I may (as a therapist) want to act and also the story I may want to tell them.

    D: In english, you are saying that 100% of dry needling is accounted for in placebo effects. Please provide body of research to substantiate that claim. I am not here to defend or promote TPDN.
    I am not discounting role of placebo and unkown variables – I hope to maximize placebo any way I can. But placebo is not my goal – addressing defect and defense is to resolve. Trust and communication can enhance placebo effect that can expedite recovery/resolution.

    M:Personally I like a story that gives my clients the power to help themselves instead of one that long term makes them dependent upon my needles or hands.

    D: Now you are assuming that all PT’s and chiros are charlitans providing treatments they can charge more for that will make the patient depending on them.
    I can only speak for PT’s – good PT’s are bad business people – the goal is to identify the root/source as best we can and treat it – enable the patient as a partner in the process. If succesful, they never come back for the same thing unless it is incurable like OA. But even then, we prepare them for exacerbations. And I feel I don’t only speak for PT’s but for any skilled and experience and ethical clinician versus your assumptions that they are unethical. The goal is to maximize function and outcomes and educate the patient to maintain gains and handle exacerbations if and when they occur – this is 100% contrary to your last sentence

  51. David: “I am sitting down, my dog jumps on me and scratches me – it hurts – you are arguing I am wrong”

    Yes. Pain is a consequence of the brains response to that event. Your brain may very well interpret the information as threatening and respond. Your brain may not.

    If you experience pain, it may be related to the tissue deformation and elicited nociception, or it may be contextually related to the “dog”. How can we seperate the two? What happens if the scratch comes from your dog vs. a stranger dog? What happens if its a small vs. large dog? What if you were petting the dog when this happened vs. the dog approaching unnoticed? What if the dog “growled” while they scratched you vs. “wagged” their tail?

    This is off-beat from the original article, but to attempt to discuss the concept of tps, we must have some understanding and agreement of basic “sensory physiology” (as Dr. Bove puts it).

  52. Bove: David: but you ARE ignorant, as evidenced by your writings. And I DID mean to insult you back. That is not necessarily a negative thing, though I understand it carries negative connotations.

    D: Really – very professional – and it is not a negative thing – just trying to enlighten me as to your opinion and superior intellect that I am ignorant – no examples – just your opinion.

    B: RE: racism. PERFECT word, stereotyping is accurate as well, but the anti-chiropractic crap is racist, by definition.

    D: There is a Chasm between the definitions of racism and stereotyping – none of which I presented here. You are dead wrong. What anti-chiro crap did I state??? My response was clear. I have no patience for any clinician, PT or chiro, who provide short term fixes for 10-15 years. I don’t recall accusing you of that. My statements came from chiro’s, not an opinion based on ignorance or a stereotype – from your own profession and you chose not to address any questions or statements I made – I addressed the comment – you gave no answers and just make a gross statement without contextual quotes – You are wrong and being beyond inappropriate. And you are a scientist?

    B:I have stayed away from this site because I do not think that it is particularly functional, it just gives us a good venue for tossing bad blood about.

    D: In 99% of my life’s experience in professional discourse with people of the same or different opinions – always constructive and productive. 2 exceptions – here and Evidence page on Linked IN.
    After I responded to you, and even apologized, you had an opportunity to have a constructive dialogue and your first response was to insult – you are not a victim here but part of the problem. You initiate insults even when offered an olive branch. I don’t have to agree with you to have a professional and productive conversation

    B: The only value I see is that the discussion is consistent with the global lack of knowledge of sensory physiology. It is a sad state of affairs. I urge you all to take some postgraduate education related to the topic, though these are hard to find. Self study is far too hard and can lead down the wrong paths. A comprehensive review of the fallacies and junk science of “trigger point” ideas, with a testable hypothesis will appear soon we hope (if we get it finished!).

    D: Intellectual elitism – insults – no context to your insults – you chose not to address any of my comments, rather – you toss out insults and words like racism and ignorance. You made no attempt to have a constructive dialogue and complain that it is not constructive. AT least I made the attempt.

  53. David: “I am sitting down, my dog jumps on me and scratches me – it hurts – you are arguing I am wrong”

    J:Yes. Pain is a consequence of the brains response to that event. Your brain may very well interpret the information as threatening and respond. Your brain may not.

    I gave a specific scenario and you argue it is wrong when it is not. My daughter head buts me in the nose by accident, I put my hand on the stove by accideent, my dog/your dog scratches me, I step on a nail – input goes to brain, brain interprets as pain and send out painful output. If fear was involved, could it change the degree of pain – sure.

    J:If you experience pain, it may be related to the tissue deformation and elicited nociception, or it may be contextually related to the “dog”.

    MY example was pure nociception – no fear – context was clear. Yes, if a strange dog attacked me and scratched me I may not notice at the time as fear is primary. But later, I will feel the pain from the scratch or bite. It is the source of pain. Yet here we are, 1 year later, arguing the scratch is not the source of pain in the simple example I gave where no fear was involved?

    J: How can we seperate the two?

    D:Easily – with context – are their some exceptions, sure. If I am a hand model and my hand gets scratched by the dog – immense fear response. But alas, I am not a hand model so if the dog scratches my hand, no fear, just pure nociception – pain and based on my psycho-social – if not pathological – appropriate pain response in 99% . You want to list other variables that may overrode the noxious stimulus to complicate – go for it

    J:What happens if the scratch comes from your dog vs. a stranger dog?
    D: As long as no fear – the scratch hurts the same – Actaully I have experienced both of these in past 2 weeks!

    J:What happens if its a small vs. large dog?

    D: No difference if no fear

    J:What if you were petting the dog when this happened vs. the dog approaching unnoticed? What if the dog “growled” while they scratched you vs. “wagged” their tail?

    D: Now you directly change the context and enter fear to assist your bias.

    My example was pure and simple nociception. If context changes and fear added – the brain may chose a different output or modified or delayed. No arguement – never have. Yet you argue against nociception?

  54. Travell/Simons-Gunn-Rachlin-Hackett-Acupuncture protocols + hands-on, Chiro and leverage therapy would release all “joints” from aches pains and stiffness. TKA would NOT even be on the table or a legitimate choice to a patient. Travell knew this a half century ago. JOint manufacturers and surgeon want you to believe otherwise.

    Chronic pain + fear (no resolution, help or assistance) will evolve into a Post-Traumatic Stress Syndrome type illness that require therapy in addition to the above protocols.

    Acupuncture: What is it?? It is not what y’all think it is. I been using Acupuncture for 15yrs and it is not what I was taught! So it’s not what YOU think. How can you design a study around something that does not exist in the context of your thoughts. No one can correctly define this Acupuncture in modern terms.
    1. There are many types which will affect the outcomes.
    2. Effort is involved. Less effort will alter the outcomes.
    3. Needle manipulation or resting will alter the outcomes.
    4. Number of needles, location of needles, length of the needles all affect outcomes.
    5. Number of local and Ah-shi points affect the outcomes.
    6. Health and wellness of the patient.
    7. Medications will stall or stop the effects.

    So you can NOT sham acupuncture, like you give a sugar pill … it’s impossible. Acupuncture and Travell needle therapy is about what and how a patient feel. Why sham that interaction. To prove that a natural and effective therapy is invalid. Why, it makes no logical sense??? Besides patient know the difference and doctor know the different too.

    Actually that would be a good study to see if you can actually sham acupuncture. On second thought it is not necessary…it would be futile.

    Anyone who doubts this therapy is on the wrong side of history, have a financial interest, have legitimize their life or is working as a puppet.

  55. @Wolfe … I found a few of your articles on FM … comprehensive but only a smidgen on therapy. Feel free to use that proactive list as a guide. all are safe, nontoxic and effective. Each patient will have to use the modality that they find most rewarding. You should also read Gunn, Rachlin and Hackett to be more informed as to how to manually and safely reverse the negative tissue transformations that we can now see under the microscope.

    • @ Stephen. Please reveal to any of us who have patiently waded through your “smoke and mirrors” nonsensical approach to gullible and desperate patients if there is any scientific evidence whatsoever to support your core belief – that of “negative tissue transformations” which not only are demonstrable microscopically but also are reversible through the application of manual methods of treatment (presumably including the insertion of steel needles).

      • @John … Since I am in a solo clinician practice my primary goal is to help patients and cover my overhead, prepare for the ACA and ICD-10. I invite anyone to come in and see the practice and witness the simple techniques. You know good and well no entity will finance a study that will upset the natural order of the chaotic healthcare system based on pills and complex replace and dismantling surgery. “All hell would break loose” with the law suits. The entire medical paradigm would have to be changed.

        • This is who you would ask to finance your research: http://nccam.nih.gov/

          I am curious what drove you, an individual who was medically trained in the United States, to develop a practice based upon acupuncture and myofascial release, both concepts outside of a modern understanding of standard human physiology (as taught within US medical institutions)?

          I think everyone here can agree that the treatment of pain and central sensitized disorders could be better (to say the least). In 2010, we spent between $500-650 billion dollars treating pain (1). This is 4x the amount we spent on the treatment of pain in 1996 (1). We spend more treating pain, then we do treating cardiovascular disease, cancer and diabetes combined. Do you suspect, the utilization of acupuncture and myofascial release would have an effect on this number (having an economic impact)?

          Gaskin DJ, Richard P. The Economic Costs of Pain in the United States. The Journal of Pain, 2012; 13 (8).

        • @ Stephen. You have deliberately avoided my request to supply the vital information central to your argument and upon which you apparently base your clinical practice. You leave us a subspecies of reductio called “proof by contradiction” (or reductio ad impossible). You do indeed have a case to answer but I will not hold my breath waiting for you to provide an answer.

  56. What a great article!! After reading several comments, I can see that many continue to believe that knowledge from their clinical experiences triumphs over our current scientific understanding of neuro-biology.

  57. I don’t think we speak the same language. Over the last 50 years, the randomized control trial has become the standard method for evaluation of therapies; and offshoots of the RCT methodology are systematically applied to observational studies. Data from clinical trials are available for most treatments that are regularly used for fibromyalgia. On the whole, such treatments show little, if any, sustained benefit. Meta analyses are available for many therapies. Recent well-documented guidelines for FM treatment have been published by German and Canadian groups.

    The treatments in your list appear to be for local or regional disorders, not fibromyalgia. I can’t find clinical trial data for any of your suggested treatments in fibromyalgia. It appears to me that the evidence for efficacy of your treatments is based on testimonial and your personal experiences and beliefs. Science gave up that approach years ago. Peter Medawar pointed out that “the intensity of the conviction that a hypothesis is true has no bearing on whether it is true or not. The importance of the strength of our conviction is only to provide a proportionately strong incentive to find out if the hypothesis will stand up to critical evaluation.” Many of the treatments you suggest do not meet the standard of the Daubert Rule evinced by the US Supreme Court for acceptable evidence.

    Every time I come up to non-scientifically documented treatments I ask why the practitioners don’t undertake a randomized trial. The usual answer is not enough money or time; or I’m just a practitioner. So it goes.

    On a slightly different note, I don’t see what local and regional pain problems have to do with fibromyalgia, except in rare instances.

    • @Wolfe, we are not (unfortunately) speaking the same languages and what is even more unfortunate is our intent to share wisdom to help patients is NOT our main the issue.

      Confirmation bias is rampant in medicine and I can not trust but one person to direct me on which course of action they need to free themselves from pain … the patient. and I find that the folks on the back lines are trying to dictate what works on the front line. Nothing that I have read in any article will prepare me to treat FM or any other complex pain issues … except with pills. That is mis-management in my opinion today.

      Academics want to be able to instruct the courts, the AMA and insurance co on what is best medicine. Well this construct has cause mass misery. Academics don’t have to see the urgency and desperation in patient’s eyes who look to you for help. Academics all seem to have an agenda beholding to controlling profit margins, unrelated to the well-being of patients to promote mass misery.

      What is FM?
      An academic would use the check boxes in the diagnostic criteria and them make a determination. For an exam or for court or legal testimony that is standard and needed.

      A clinician views disease with different eyes; FM is a chameleon or a masquerader with different presentations different times of the year, under different stressors, altered my different medications and therapies. It is not a static entity. As clinicians we treat all aspect of the different presentations … ALL. Because we know that things will change and we have to help patients weather each and every storm.

      An academic can NOT see the clinician’s view, so if a patient comes in with aches, pains and stiffness in the upper and lower back, headaches, jaw tightness, fatigue, insomnia … in my office that patient has FM. Plain and simple. It would be malpractice, in my mind, if I did not focus on the patient’s top pain locations which could be consider “regional” in locations. The beauty of this therapy is that it is effective for FM, a bum knee, hip or shoulder or “Lowerbackus-SI-hippus-Jointus Out-of-whackus.” It is safe and effective without drug complications.

      Gee if all of our agendas can’t be merged into one … we are doomed.

  58. Author: Evan Burke, PT
    Comment:
    What a great article!! After reading several comments, I can see that many continue to believe that knowledge from their clinical experiences triumphs over our current scientific understanding of neuro-biology.

    D: This is an extreme statement and in this form is wrong.
    Clinical experience is wraught with error and misperceptions, and other times is spot on – you forgot about that. But how do we know it is wrong, partially right or dead on. Clinical experience is the basis for most of the research we do. So to throw it out without looking at it is against the scientific method! When compared against evidence – no contest unless there is no evidence or poor evidence. Then experience is all we have.
    WHere do you come off comparing clinical experience to neuro-biology – it should be compared to evidence – thanks for sharing your bias but didn’t help this conversation

  59. David G: You added a situation that could have a fight or flight reaction. I did not. Pure defect in my example. Zero logic or NMEModel logic/neuroscience extreme logic – You argue against a splinter being the source of pain by using an example of fight or flight. Another neuroscience person used a similar example of a friend who was shot in the femur and not in pain at the time of injury. What about 12-24 hours later? Please finish the story. Fight or flight is a survival mechanism and is very short term. Adrenaline is a wonderful thing – Unfortunately I have experience it many times. I never felt nothing (double negative – sorry), I felt something and was able to go on without any trouble until task was completed only to find out later that I had broken a bone or did some other damage. And 100% of the time, for me, 1-3 hours later flood gates opened and MR. pain walked in. You are stating here that does not happen? Are their exceptions. Yes. Are they rare. Yes. Is there asymptomatic patho – yes. Does it negate symptomatic patho – no. Some bone on bone OA are functional with minimal pain for varying periods of time. Other with moderate OA or disabled by pain with severely compromised function. TKA is only indicated when pain is disabling and function compromised beyond tolerance of patient. X-rays and bone on bone don’t determine TKA so let’s not re-use that argument Mark

    M: David, your example didn’t explicitly state a fight or flight reaction or contextual scenario, i agree. However in the real world the parasympathetic and sympathetic or fight or flight systems are always working, just because you don’texplicitly state a context in your example doesn’t mean that your example if applied to the real world wouldn’t implicitly have context.. Sometimes they’re more facilitated, sometimes they’re more inhibited, however they’re always there and functioning. The adrenaline based theory of pain relief is also simplistic, how does the body decide to regulate those neurohormones? the adrenaline isn’t floating in the bloodstream looking for some pain to dampen, some part of the human body has to determine the appropriateness of releasing it or not. The fact that a visual, audial, or somatosensory stimuli can evoke this really only leaves few possible explanations.

    M: Yes, I am talking to professionals and, from reading the above, it is obvious that there are facts and different interpretations and part of the discourse is determining what is fact and what is interpretation. No one so far has disagreed with the fact that some professionals use needles or their hands on others in a manner that the patient reports less pain afterwards, that is what the article is discussing. No one so far has disagreed with the fact that there can be patholgy (as observed on scans or by an external observer) correlated with pain (a subjective personal experience), the article is teasing apart which is which. The sight example was pointing out that thousands of hours of personal experience doesn’t guarantee an understanding of the process by which the experience is created. People for millenia have been poking and needling (and seeing) and ascribing it to various reasons, over time the reasoning has changed even if the methods may not have. The procedure is the same, the methods maybe modified a little, the process by which the result is achieved is being questioned.

    D: Now you are assuming that all PT’s and chiros are charlitans providing treatments they can charge more for that will make the patient depending on them.
    I can only speak for PT’s – good PT’s are bad business people – the goal is to identify the root/source as best we can and treat it – enable the patient as a partner in the process. If succesful, they never come back for the same thing unless it is incurable like OA. But even then, we prepare them for exacerbations. And I feel I don’t only speak for PT’s but for any skilled and experience and ethical clinician versus your assumptions that they are unethical. The goal is to maximize function and outcomes and educate the patient to maintain gains and handle exacerbations if and when they occur – this is 100% contrary to your last sentence

    M: Um, really don’t know how to respond to this except to say I’m a physio, like you I respect my profession. I’m not an academic, I deal with people. I haven’t said anything about physio’s or chiro’s. I’ve stated clearly what I like to do and why. I’m not claiming anyone is being unethical. With a plethora of information available i expect everyone to have differences of opinion, no one can read all the research and even if they could there’d still be disagreeance with others. I like my clients to know that the process of pain relief and pain managment is at their fingertips and not mine. I’m all for them using professionals to elicit that relief and learn that management and get educated about them selves. I like my clients to have a context for the situation they’re in that helps them to make sense of it. I’d pull the splinter and explain why the pain still persists even when the splinter has gone. I’m glad that there are professionals, like yourself, who are willing to debate and discuss, it’s what helps drive learning. I do however find your interpretation of my statements signficantly off the mark.

    Fred – apologies for moving off the topic.

  60. M: David, your example didn’t explicitly state a fight or flight reaction or contextual scenario, i agree. However in the real world the parasympathetic and sympathetic or fight or flight systems are always working, just because you don’texplicitly state a context in your example doesn’t mean that your example if applied to the real world wouldn’t implicitly have context.. Sometimes they’re more facilitated, sometimes they’re more inhibited, however they’re always there and functioning. The adrenaline based theory of pain relief is also simplistic, how does the body decide to regulate those neurohormones? the adrenaline isn’t floating in the bloodstream looking for some pain to dampen, some part of the human body has to determine the appropriateness of releasing it or not. The fact that a visual, audial, or somatosensory stimuli can evoke this really only leaves few possible explanations.

    D: Thank you for your prefessional response. Regarding your above statement, I am not disagreeing for the mos part. But for the overwheming % of people and instances, the effect of adrenaline or other neurohormones is minimal. My original splinter example still stands. Even moderate injuries don’t illicit fight or flight for majority and if so, mild and very temporary. It is the amount of fear. Being shot or sudden car impact can be a massive release. But for the overwheming majority of people and instances, pain is usuallyt ordered by brain with little impact from neurohormones. Even very painful shoulder dislocations. So i am not sure the purpose of this disagreement.

  61. D: But for the overwheming % of people and instances, the effect of adrenaline or other neurohormones is minimal. … It is the amount of fear.
    M: For me I think our disagreeance would be around that statement and whether a verbalised statement of how a client feels (a cognitive representation of their psychological/emotional state) can be accurately correlated with the amount of neurohormones in their bloodstream or with their relative level of parasympathetic/sympathetic activity. I believe that my clients believe their belief but I am also aware that a belief (even my own as i have found out with experience) may not accurately represent a state of affairs. Heck i’ve cursed a table for causing my toe pain when i’ve stubbed it but (once the hopping and cursing has subsided) realised that it was my inaccurate relationship between my internalised model of the world, my subsequent movement patterns (e.g. i was clumsy), and a sensory deviation (to my internalised/expected response) provided by the external world is really part of the pain prosess. The table didn’t jump onto my toe, I kicked it when aiming to do something else. Anyhow glad to read other health professionals are agreeing and disagreeing. I’ll believe my beliefs and you yours and somewhere in the interaction we’ll work out our comparisons and contrasts. Thank you for calling out where you think I am wrong, i’ll pause to think it over.

    Fred – ‘I cannot give any scientist of any age better advice than this: the intensity of the conviction that a hypothesis is true has no bearing on whether it is true or not.’ PP-EBM is a reversal of that advice. It pervades our specialty.

    Not just your speciality as the comments will attest to. Having reread the article and especially the line ‘we were a lot less secure in our beliefs now’ i’d like to say thanks for some food for thought. For me the start of further progress in understanding is that curious feeling of uncertainty that leads to a better question rather than a more boundaried answer. I’ll admit that Diane Jacobs pointing out the ‘Quintner JL, Cohen ML. Referred pain of peripheral nerve origin: an alternative to the “Myofascial Pain” construct. Clin J Pain 1994; 10: 243-251.’ article as well as your one have helped my questioning a lot and also changed my practice, many thanks.

  62. M: For me I think our disagreeance would be around that statement and whether a verbalised statement of how a client feels (a cognitive representation of their psychological/emotional state) can be accurately correlated with the amount of neurohormones in their bloodstream or with their relative level of parasympathetic/sympathetic activity.

    D: I would agree that we can’t make an accurate correlation. That was never my intent. I was only stating that in the majority of cases, we can guestimate pretty accurately. I have treated 6-7000 patients and unfortunatley have lead far to active a lifestyle suffering hundreds of minor injuries and several score moderate to severe injuries. My experience with burns are predictable – bone bruises – predictable, scratches and cuts and bruises of unknown origin, predictable. By the same token, I have experience pain when their was no nociception at all. 25 years ago if I had to make a public presentation: 10 seconds on TV or 30 minutes in front of hospital staff – my nerves/anxiety would lead to physical pain – felt sick and nauseaus – felt horrible – and then elated afterwards to the point where I wanted to do it again – high from adrenaline makes one stupid – Being kicked in the sternum during a regional Karate tournament -blinding pain for 2 seconds – resolved until 5 hours later then moderate to severe pain for 6 straight weeks. Etc.. So I understand you point – and I can’t give you correlations. But your response to stubbing your toe was predictable based on your description and probable past experience. Now if you did that while running to aid one of your children – it would have been different – you may have skipped the entire pain process which would normally only lasted 20-90 seconds.
    Every human being is different. And based on our psychosocial well being, our pain responses are pretty predictable and consistent, on an individual basis unless their is a major change in our psychosocial well being or when we will definitely have a surge in our parasympathetic/sympathetic activity.

    M: I believe that my clients believe their belief but I am also aware that a belief (even my own as i have found out with experience) may not accurately represent a state of affairs. Heck i’ve cursed a table for causing my toe pain when i’ve stubbed it but (once the hopping and cursing has subsided) realised that it was my inaccurate relationship between my internalised model of the world, my subsequent movement patterns (e.g. i was clumsy), and a sensory deviation (to my internalised/expected response) provided by the external world is really part of the pain prosess.

    D: I am a little confused – whether you blame yourself or the table – the quality of the pain you felt will be the same and predicatble based on similar and previous injuries. I find that craddling the injurred part soothes me mentally or maybe the increased pressure applies to Moseley’s orginal Pain model. But the qulaity of the pain is usually poredictable in hindsight per each unique individual. Unless you hurt your hand – then we have a huge psychological fear based input as you will have fear of having your livelihood affected. But I have been focussingnit on these examples but on the vast majority where there is minimal parasympathetic/sympathetic activity.

    M:The table didn’t jump onto my toe, I kicked it when aiming to do something else. Anyhow glad to read other health professionals are agreeing and disagreeing. I’ll believe my beliefs and you yours and somewhere in the interaction we’ll work out our comparisons and contrasts. Thank you for calling out where you think I am wrong, i’ll pause to think it over.

    D: I am hopeful that the majority of our discussion is based on semantics and we have more to agree on then disagreement. I think when we have areas we feel strongly about, exact wordage is precious and protected. Again, as clinicians, I hope we can find more common ground to agree upon than the converse

  63. Has anyone defined FM here. I just got on regarding the Travell and Simons beating.
    No one went out on a limb here, maybe on a previous discussion.

    From my reading, participation in FM groups and lectures, experience:
    Briefly:
    Usually sleep deprivation for extended period of time – internal causes
    Often a psychosocial component
    muscle inefficiency leading to muscle cramps, spasms or yes TP’s
    increased activity usually leads to exacerbations
    Decreased activity secondary to pain
    Fear avoidance of activity as it will lead to pain
    Poor endurance
    Poor postural endurance resulting in back pain and HA’s

    Please comment on above

    Treatment: Many different approaches. I love heated H2O2 pool and so do they
    slowly increase cardio/conditioning – this will slowly increase muscle efficiency thus decreasing toxins
    Slowly increase strength through resistance – gentle eccentrics – low resistance slowly building reps
    Avoid fatigue
    Address manually but here is where I am very cautious. I have found it is very easy for this patient population to become dependent on us to feel better rather than perform the above. By the same token, I don’t believe in letting someone suffer so I will do manual but keep it to a set time with the focus being on proper exercises and stretches and progression
    Oops, forgot meds to assist in sleep in indeed their is a sleep disorder
    Rule out Lymes and other conditions that can have similar presentations – thorough eval and with this diagnosis, be familiar with other disease process that have similar presentations.

    That’s enough – she piss some group off here. There are many theories as to causation, most of which have been disproven – too much potasium was a big school and still is despite research in Washington state that disproved this. I just find it interesting that we have drugs to treat a disease or process that is still has no official cause.

    S.R.:An academic can NOT see the clinician’s view, so if a patient comes in with aches, pains and stiffness in the upper and lower back, headaches, jaw tightness, fatigue, insomnia … in my office that patient has FM. Plain and simple. It would be malpractice, in my mind, if I did not focus on the patient’s top pain locations which could be consider “regional” in locations. The beauty of this therapy is that it is effective for FM, a bum knee, hip or shoulder or “Lowerbackus-SI-hippus-Jointus Out-of-whackus.” It is safe and effective without drug complications.

    D: I do agree regarding pure academics. Academics and researchers who still maintain a practice is different. We have same attitude towards bean counters running a PT clinic – they are clueless on how to schedule and what is involved. Theory land is safe and predictable. Nothing like a real patients where clinical problem solving, evaluations, history, interpersonal communications, life, etc..occur. I love your second to last sentence. a good laugh to end my day
    In closing this is a very difficult diagnosis to treat so making sure the diagnosis is accurate is important and effective and empathetic communication. But as stated before, focusing on just making them feel better can be counterproductive – making them dependent on you. Enabling them while helping them feel better is best approach, in my opinion, experience, reading. literature

  64. Evidence based ‘pain’ specialties are *impossible* under current ‘so called evidence based medicine’. There’s no *evidence of pain or it’s abatement in medicine* other then trust and verify (non-evidence based) there is NO WAY to help a person in pain.
    “No reliable evidence is the oldest scam in to book.”

    *It’s illegal to test people in a way that would harm them so there will never be an evidence based treatment of pain in North America period!*
    Oxymoron comes to mind.

Leave a Reply

Your email address will not be published. Required fields are marked *

You may use these HTML tags and attributes: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <strike> <strong>