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  • #91
    So let's sum things up with regards to dry needling and various defensive positions held by Dr.Dommerholt:

    1) The sum of the literature with regards to the reality or myth of trigger points is inconclusive overall. They may be a clinical entity...or they may not.

    2) Supposing they do exist, the sum of the literature highly suggest that they cannot be reliably identified.

    3) And if they are supposedly "identified" then the sum of the literature to date suggests jabbing them with needles is no more effective than other modes of care.

    I mean, rationally think about that for a moment.

    Now it seems Dr. Dommerholt holds the position that he has seen the magic of this technique with his own eyes (anecdote) so if it is effective for some...then we should be using it. Dr. Dommerholt appears to acknowledge the potential for non specific effects but effectively glosses over this rather important point of contention.

    Dr. Dommerholt then commits repeated fallacies by suggesting that most things in Physiotherapy have little evidence to support it so therefore dry needling should get a hall pass as well.

    He's wrong.

    Indeed manual therapy has some sound evidence to support it's use but for those that pay attention to the science of pain and caring for those suffering, we know the method is not the trick. It's all about context, framing and avoiding nocebo effects if at all possible. We can all get patients feeling better in various ways but it's what the patient leaves with that really tells the tale of how effective you have been.

    I can do this with good manual care and exercise.

    The problem with dry needling is that it evokes yet another culprit in the periphery responsible for all the patients problems (eh ehm...subluxation anyone). It removes locus of control. It creates worry and uncertainty within the patient ("oh dear where did these trigger points come from...why do I have them...are they just going to randomly appear again? etc etc"). And...as it stands now it's potentially mythical!

    The more invasive (dry needling) or aggressive (manipulation) the technique, the better the literature must be before a responsible professional would utilize it. Personal anecdotes while may be true in the eyes of the provider...does not make the explanatory model accurate.

    Dr. Dommerholt appears married to the trigger point concept and this is a problem. A scientist should spend equal or more time trying to disprove an hypothesis as they do trying to prove it.

    I have absolutely no vested interest in DN whatsoever. I have done due diligence with this modality by reading as much as I can and attempting to be swayed towards it's use. None of the literature cited by Dr. Dommerholt is convincing and I don't ascribe to the theory that "if it works, just do it".

    I think that's a fools errand and our profession has chased mythical creatures down far too many rabbit holes for my liking.

    Comment


    • #92
      I also find it rather hilarious that Dr. Dommerholt ends the discussion with Evan by implying he does not know the research. When in reality, perhaps the research has lead to two separate conclusions. I mean...it's not like trp's have absolutely been an established medical fact. Geesh.

      I think it's incredibly clear that Dr. Dommerholt so very much wants TrP's and DN to be true that his ability to see the underlying problems with the modality are rather massive in actuality.

      Evan did yeoman's work on that Linkedin site to attempt to lamplight the way for Dr. Dommerholt but again....it's near impossible to convince someone they should fall out of love...

      Comment


      • #93
        I've been questioning the statements that trigger points cause central sensitization. This article has been provided as 'evidence':

        http://www.jpain.org/article/S1526-5...425-6/abstract

        First off, n=12 is certainly not enough to draw any definitive conclusions. One big assumption made by the authors is that a tender bit of the extensor tendon must be a MTrP. If a MTrP has never been accurately defined, how can this conclusion be made? Then to conclude that by poking this tender region with a needle causing CS is proof that MTrP cause CS. Is this not post hoc fallacy?
        Rob Willcott Physiotherapist

        Comment


        • #94
          Sorry, but I just cannot get over this. Essentially, Dr. Dommerholt wants all to come to the conclusion that his interpretation of the entirety of the literature is the correct one...and if you do not agree...then you must not have actually read the literature?

          That's it right?

          Yet the literature on the reality of trp's as a treatable and valid clinical entity is conflicting at best and much of the available literature is of poor or questionable quality with any evidence fitting into the lower levels category.

          But if you don't agree with Dr. Dommerholt, you must be pretending to have read appropriately? Wow...just wow.

          He then proceeds to accuse Evan of arrogance?

          Listen, I've been at this long enough (near 20 years) to know that it's exciting to come accross a new treatment paradigm that will finally address many of the recalcitrant cases we come accross. But as professionals, careful scrutiny is always required but most certainly when we are going to perform an invasive treatment such as jabbing needles into people's flesh.

          When I speak of careful scrutiny, I don't mean just gathering and accepting a plethora of cited literature as justification. I mean actually reading the literature and parsing out which ones have adequate methodology to be deemed worthy. I wonder how many students of DN actually take the time to dig a little deeper into those references? Or are they just excited with the notion of the treatment and subsequently astounded by the "results" they seem to be getting with it...never once considering the potential non specific effects likely going on in the background?

          The most frequent retort I hear is "well if it works who cares...you cannot argue with results". To me, that sort of reasoning highlights a real problem in our profession and I'm near certain that lack of critical thinking skill is going to bite us in the arse one day.
          Last edited by proud; 13-12-2013, 01:50 PM.

          Comment


          • #95
            Or are they just excited with the notion of the treatment and subsequently astounded by the "results" they seem to be getting with it...never once considering the potential non specific effects likely going on in the background?
            This is exactly what is happening. For every 1 PT that figures this out and critiques the research there are 10 more that don't.
            Rob Willcott Physiotherapist

            Comment


            • #96
              Originally posted by advantage1 View Post
              This is exactly what is happening. For every 1 PT that figures this out and critiques the research there are 10 more that don't.
              And there are exactly 89 that don't read anything. So 1% actually critically appraise the literature, 10% read the literature for the sole purpose of satisfying their confirmation bias, and the remaining 90% don't give a sh**.
              John Ware, PT
              Fellow of the American Academy of Orthopedic Manual Physical Therapists
              "Nothing can bring a man peace but the triumph of principles." -R.W. Emerson
              “If names be not correct, language is not in accordance with the truth of things. If language be not in accordance with the truth of things, affairs cannot
              be carried on to success.” -The Analects of Confucius, Book 13, Verse 3

              Comment


              • #97
                This problem is insoluble.

                It's the same problem as with fascialists. They just won't admit their explanatory model might be completely wrong. They dig up all the papers with the word "fascia" in them, even though they're all like clones of each other and either they don't say anything about anyone's ability to treat it directly with any effect, or conclude the opposite, but it doesn't matter - it's about fascia, so there is the "evidence" about fascia, and they either hope you don't look close or else they don't even know what is in those papers to begin with, they're just happy to collect any paper on a big list that has the word "fascia" in it somewhere so they feel reassured it exists and that they can carry on dreaming about it and talking about it. And selling workshops about it.

                This might be about stabbing trigger points but it's in the same league, with the same lousy flimflam basis.
                Diane
                www.dermoneuromodulation.com
                SensibleSolutionsPhysiotherapy
                HumanAntiGravitySuit blog
                Neurotonics PT Teamblog
                Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
                Canadian Physiotherapy Association Pain Science Division Facebook page
                @PainPhysiosCan
                WCPT PhysiotherapyPainNetwork on Facebook
                @WCPTPTPN
                Neuroscience and Pain Science for Manual PTs Facebook page

                @dfjpt
                SomaSimple on Facebook
                @somasimple

                "Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

                “Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

                “If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

                "In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

                "Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire

                Comment


                • #98
                  And there are exactly 89 that don't read anything. So 1% actually critically appraise the literature, 10% read the literature for the sole purpose of satisfying their confirmation bias, and the remaining 90% don't give a sh**.
                  I don't like these odds.
                  Rob Willcott Physiotherapist

                  Comment


                  • #99
                    Put me down as the percentage that reads anything to refute their bias. I'm curious how many others do that. Fortunately that's why I'm dead. I have Silvernail to thank for that...
                    "The views expressed here are my own and do not reflect the views of my employer."

                    Comment


                    • are there trigger points post decapitation??
                      aren't these "brain" ???
                      KISS, keep it simple and stupid.

                      Comment


                      • Dry Needling Literature Review

                        John,

                        In your most recent post, you suggested that Dr. Dunning misrepresented the evidence in his 2013-2014 narrative Literature Review in Physical Therapy Reviews. You specifically cited issues with the knee OA section, and we would like to respond. We feel that your criticism was neither fair nor accurate. In reference to the sentence that you cited, we have summarized the supporting literature included in the attached file. We further outlined some the of the internal validity issues related to the Foster et al. (2007) for your review. We look forward to an open and transparent discussion of dry needling in the future. We feel that dry needling is an important topic to the future of the physical therapy profession.


                        Notably, Foster et al. (2007) compared a group of advice/exercise + real acupuncture, advice/exercise + non-penetrating sham acupuncture, and advice/exercise. Although the groups receiving real and non-penetrating sham acupuncture had statistically significant improvements in pain intensity and unpleasantness at short and long-term follow-up time points, there was no difference between the exercise/advice + real acupuncture and exercise/advice + non penetrating sham acupuncture on any outcomes. However, the results of this study should be carefully considered, given the following internal validity concerns:

                        • Patients had a clinical diagnosis with osteoarthritis, but the diagnosis was not confirmed with radiologic imaging.

                        • The course of treatment of real and sham non-penetrating acupuncture was only 6 treatments, which is considerably shorter than the studies outlined above. (The studies above used 10, 12, 15, and 24 sessions.) Per the authors own admission, “this may have rendered the true acupuncture intervention suboptimal…”

                        • Per the author’s own admission, the study did not control for NSAID use in any of the groups.

                        • According to Foster et al. (2010), there was no relationship in the outcome of the Foster et al. (2007) study and patient / practitioner treatment preference. There was also no difference between patient expectation and pain level at 6 or 12 months.

                        Respectfully,

                        Thomas Perreault, PT, DPT, OCS, Cert. DN, Cert. SMT
                        Attached Files

                        Comment


                        • Thomas,
                          Thank you for responding.

                          Actually, I wasn't making a suggestion; rather, I provided a critical analysis of the statement on page 6 of the Dunning et al paper stating that there is "overwhelming evidence from randomized controlled trials, systematic reviews, and metaanalyses that dry needling the knee joint without targeting specific TrPs is effective at reducing pain and disability in patients with chronic knee osteoarthritis" is not supported by the references that were cited. I was specifically referring to the studies by Foster et al in 2007 and 2010. I didn't question the results of the articles that you've provided in your attachment here. In fact, I haven't even looked at them. I was familiar with some of Dr. Foster's previous work, and suspected that her findings did not constitute "overwhelming evidence" for dry needling. After reviewing those studies, my suspicions were confirmed. Dunning et al should not have included those studies in the citation. The fact that they did is a misrepresentation. Perhaps it was an oversight or editing error. I've made no accusation of malfeasance or dishonesty. My understanding is that the Editorial Board at Physical Therapy Reviews is reviewing this issue and a response is forthcoming. They have suspended online access to the article while it is under review.

                          I don't understand your argument here describing the internal validity issues with the Foster el al studies. How does the fact that these studies were flawed as you describe refute my point that they fail to provide support for overwhelming evidence of the effectiveness of dry needling for pain and disability in this population? If anything, this adds further support to my point that these studies do NOT provide overwhelming evidence in support of dry needling in this patient population.

                          Are you arguing that they would have found significant results on pain and disability if they hadn't had internal validity flaws? If so, that would be a very convoluted argument.
                          John Ware, PT
                          Fellow of the American Academy of Orthopedic Manual Physical Therapists
                          "Nothing can bring a man peace but the triumph of principles." -R.W. Emerson
                          “If names be not correct, language is not in accordance with the truth of things. If language be not in accordance with the truth of things, affairs cannot
                          be carried on to success.” -The Analects of Confucius, Book 13, Verse 3

                          Comment


                          • Although the groups receiving real and non-penetrating sham acupuncture had statistically significant improvements in pain intensity and unpleasantness at short and long-term follow-up time points, there was no difference between the exercise/advice + real acupuncture and exercise/advice + non penetrating sham acupuncture on any outcomes.
                            If anything, this particular snippet should be given careful consideration...

                            Comment


                            • Welcome, Thomas. Thank you for your contribution/input to the discussion, which I admittedly have not the time or energy to delve into with the same fervor as others...I am simply waiting for the dust to settle and if (in the future) there is evidence to support that DN is significantly better than traditionally conservative therapy care, I will have to consider the pros/cons at that time. I am disappointed, however, with this thought (which I am NOT attributing to you directly, so please do not consider this an 'attack')...

                              • The course of treatment of real and sham non-penetrating acupuncture was only 6 treatments, which is considerably shorter than the studies outlined above. (The studies above used 10, 12, 15, and 24 sessions.) Per the authors own admission, “this may have rendered the true acupuncture intervention suboptimal…”
                              ...this seems to be the wrong direction for us to be going with PT practice if our care must necessarily be accessed 15-24 times. It would seem to me that we should be looking toward treatments that are significantly better than already available treatment options, increase locus of control and reduce the financial burdens placed upon our patients. This does not yet 'fit the bill'.

                              Again...I will patiently wait to see what happens, and keep my money in my wallet for now.

                              Respectfully,
                              Keith
                              Blog: Keith's Korner
                              Twitter: @18mmPT

                              Comment


                              • Notably, Foster et al. (2007) compared a group of advice/exercise + real acupuncture, advice/exercise + non-penetrating sham acupuncture, and advice/exercise. Although the groups receiving real and non-penetrating sham acupuncture had statistically significant improvements in pain intensity and unpleasantness at short and long-term follow-up time points, there was no difference between the exercise/advice + real acupuncture and exercise/advice + non penetrating sham acupuncture on any outcomes. However, the results of this study should be carefully considered, given the following internal validity concerns:

                                • Patients had a clinical diagnosis with osteoarthritis, but the diagnosis was not confirmed with radiologic imaging.

                                • The course of treatment of real and sham non-penetrating acupuncture was only 6 treatments, which is considerably shorter than the studies outlined above. (The studies above used 10, 12, 15, and 24 sessions.) Per the authors own admission, “this may have rendered the true acupuncture intervention suboptimal…”

                                • Per the author’s own admission, the study did not control for NSAID use in any of the groups.

                                • According to Foster et al. (2010), there was no relationship in the outcome of the Foster et al. (2007) study and patient / practitioner treatment preference. There was also no difference between patient expectation and pain level at 6 or 12 months.
                                I'm confused. If this was known then why was this study included as evidence supporting acupuncture for knee OA in the Dunning paper?
                                Rob Willcott Physiotherapist

                                Comment

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