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).
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.
Thank you for posting a rare critical perspective on ideas usually treated not just with credulity, but reverence! I look forward to more.
“I want to stand up and clap my hands off. I really do. Thank you for this, Dr. Wolfe.”
From my own blogpost about your blogpost –> http://humanantigravitysuit.blogspot.ca/2013/02/fred-wolfe-trigger-points-fibro.html
Diane
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?
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.
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
are we washer operated machine?
or has washer operated machine a central nervous system?
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
totally agree with Emanuele Careddu…
are we washer operated machine?
or has washer operated machine a central nervous system?
” EBM? We work at the acceptable level of uncertainty..” Karel Lewit
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 ….
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.
“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.”
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.
totally true….
thanks Emanuele to confirm that we do operate at a level of acceptable uncertainty….
thx to everybody have a great evening
Dear Emanuele & Giancarlo, it has yet to be shown that you do indeed operate at a level of acceptable uncertainty. However, I concede that this is an important issue that pervades the whole of current pain management.
** 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.
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.
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.
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.
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.
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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.