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  • How did I miss this and how did this not create a stink on social media?

    http://www.fmperplex.com/2018/01/26/...ew-homeopathy/

    Here is a quick review of the evidence for TDN for various clinical presentations: I've left out cadaver articles, use on asymptomatic people and case level papers.

    Starting from the top:

    Premise/Origin:
    Based on Travel and Simons....enough said....read about Travel's success (cough cough failure!) with JFK...a creation of opinion, theory and beliefs. Well trained people cannot reliably identify these

    SR:
    Minimally effective for an unreliable diagnosis targeting an unreliable "lesion."

    RCT:
    No difference between needles and manual pressure for neck and shoulder pain
    Little difference between needles and waiting list for acute neck pain and range of motion at 1 hour and 1 week
    Little to no difference in pain compared to other stuff for chronic neck pain
    No better than sham for heel pain with higher NNH in needling group
    No better than cortisone injections for hip pain
    No additional benefit for shoulder pain as part of individualized PT

    Risks: increase in pain, infections, pneumothorax

    So, can anyone please justify this practice? Can anyone somehow justify spending hours and thousands learning this despite the "evidence?" Can anyone justify applying this ineffective intervention to patients who pay for this?

    To me an "evidence base clinician" would avoid using needles the same way they avoid plugging in the ultrasound....
    "The views expressed here are my own and do not reflect the views of my employer."

    Comment


    • Well it's official. I've both administered and undergone the highly discussed and debated "trigger point dry needling." Here is my review:

      I'll say this; it's not acupuncture.....if I were to choose a method of having needles inserted into my skin (I'd say no to them all)...I'd rather have acupuncture. Pushing needles to deeper levels of tissue is not pleasant. It's sometimes downright painful. The small dermatomal level injections are pretty painless. The most therapeutic part was when the needle was taken out.

      Many of those attending are going out on Monday and using this on patients. Their confidence and enthusiasm was obvious. The question of "why" need not apply to them.

      The only justification for use is pushing hard on structures. Using the pain provoked is enough to stab the area.

      It is presented the same way a manipulation or instrument assisted course is presented: Gloss over the history and creator, say its not acupuncture/chiro/massage, show research on low risk, show research on safety with PT's doing it....start stabbing.

      The evidence review shows little to no reliability, poor validity for identifying "stickable areas." The evidence shows none/little/minimal effects. This did not stop people's thirst to perform in the clinic. Evidence-be-damned....use in the clinic.

      Its uncomfortable and not very pleasant. Watching people jump, squirm and cringe....sounds therapeutic....

      Some people have read and are familiar with "pain science." This is another "tool in their toolbox" to help "maximize and play up placebo" and "meet patient expectations" to "create neurophysiological changes." These people really believe their own bull-shit. These same people think ultrasound, massage and e-stim is outdated or bad practice. News flash people: its all the same shit.

      Final thoughts:

      Trigger point dry needling is a money grabbing marketing ploy hiding behind a veil of tooth-fairy and pseudoscience. No matter how well presented, this takes the profession further away from our roots and closer to
      fringe CAM professions.
      Last edited by Johnny_Nada; 29-04-2018, 12:43 PM.
      "The views expressed here are my own and do not reflect the views of my employer."

      Comment


      • Johnny-

        I am assuming from your post that you attended a dry needling course recently. I am curious what the instructors replied if/when you asked them about the lack of reliability, poor validity, and minimal to no effects of DN in RCT's. Did they acknowledge these issues at all? Or just point to supportive articles like the Dunning et al literature review that misrepresented findings?
        Brent Cordery, PT

        Comment


        • Hi BrentC,

          Despite all of those things you listed, including questionable theories, reviews showing little to no effectiveness, the show went on.

          The instructor did his best to suggest using when you're not seeing success. He worked hard to present the evidence in an objective way. It went in one ear and out the other. I think many in the class heard "use at your leisure" or "clinical experience." Others were thinking "another tool in the toolbox that I can play up the placebo and expectation with."

          Sad really....
          "The views expressed here are my own and do not reflect the views of my employer."

          Comment


          • Originally posted by Johnny_Nada View Post
            Well it's official. I've both administered and undergone the highly discussed and debated "trigger point dry needling." Here is my review:

            I'll say this; it's not acupuncture.....if I were to choose a method of having needles inserted into my skin (I'd say no to them all)...I'd rather have acupuncture. Pushing needles to deeper levels of tissue is not pleasant. It's sometimes downright painful. The small dermatomal level injections are pretty painless. The most therapeutic part was when the needle was taken out.

            Many of those attending are going out on Monday and using this on patients. Their confidence and enthusiasm was obvious. The question of "why" need not apply to them.

            The only justification for use is pushing hard on structures. Using the pain provoked is enough to stab the area.

            It is presented the same way a manipulation or instrument assisted course is presented: Gloss over the history and creator, say its not acupuncture/chiro/massage, show research on low risk, show research on safety with PT's doing it....start stabbing.

            The evidence review shows little to no reliability, poor validity for identifying "stickable areas." The evidence shows none/little/minimal effects. This did not stop people's thirst to perform in the clinic. Evidence-be-damned....use in the clinic.

            Its uncomfortable and not very pleasant. Watching people jump, squirm and cringe....sounds therapeutic....

            Some people have read and are familiar with "pain science." This is another "tool in their toolbox" to help "maximize and play up placebo" and "meet patient expectations" to "create neurophysiological changes." These people really believe their own bull-shit. These same people think ultrasound, massage and e-stim is outdated or bad practice. News flash people: its all the same shit.

            Final thoughts:

            Trigger point dry needling is a money grabbing marketing ploy hiding behind a veil of tooth-fairy and pseudoscience. No matter how well presented, this takes the profession further away from our roots and closer to
            fringe CAM professions.
            My exact thoughts when I took the course. It's a load of horseshit peddled to the naïve, gullible or downright unethical.

            Ya I said that.


            Comment


            • I keep my eyes open for things I feel can be brought into the clinic. For anyone unfamiliar with Jocko Willink, he wrote a book about discipline, amongst a few others. He has an entertaining podcast too. In his book, Discipline Equals Freedom Field Manual, he has a chapter (more like two pages) on "Dealing with Injuries and Illness."

              The simple premise is this: "Do what you can." It doesn't matter. Do what you can. That might be a walk. Don't stay in bed all day.

              "Some injuries prevent you from doing the physical things you like to do. GOOD. Do what you can....Pick up a guitar. Write a book. Draw. Paint....Do something......get after it...."

              I wonder how people would cope with an attitude or personality like this?

              Is this not what physical rehabilitation is all about???
              "The views expressed here are my own and do not reflect the views of my employer."

              Comment


              • There's going to be a big push on this in the UK via the Chartered Society of Physiotherapy. Far too many Brits think that they have to go to the gym or engage in the latest exercise trend. For years I have been encouraging people to do house work and gardening the old fashioned way, maybe not all of it, but enough to get a work out.
                Jo Bowyer
                Chartered Physiotherapist Registered Osteopath.
                "Out beyond ideas of wrongdoing and rightdoing,there is a field. I'll meet you there." Rumi

                Comment


                • From the book: 12 rules for life: an antidote to chaos

                  These seem relevant to rehabilitation:

                  "People create their worlds with the tools they have directly at hand. Faulty tools produce faulty results. Repeated use of the same faulty tools produces the same faulty results. It is in this manner that those who fail to learn from the past doom themselves to repeat it. It's partly fate. It's partly inability. It's partly...unwillingness to learn? Refusal to learn? Motivated refusal to learn?"

                  To all of you toolbox people out there. Have you ever thought: maybe that "new tool" is a faulty one? Given this thought, have you ever thought about not picking it up and using it?

                  One more:

                  "But not everyone who is failing is a victim, and not everyone at the bottom wishes to rise, although many do, and many manage it. Nonetheless, people will often accept or even amplify their own suffering, as well as that of others, if they can brandish it as evidence of the world's injustice."

                  I think anyone seeing people with chronic pain conditions can relate to this. I can't help but think of the small sample of people I see. So many look outward for a solution, fix and cure. Any suggestion of looking inward is lost on them. This isn't "their" problem, its mine, yours and someone else to create/provide the solution.
                  "The views expressed here are my own and do not reflect the views of my employer."

                  Comment


                  • One more from the book:

                    "Rogers (Carl Rogers; humanistic psychologist) believed it was impossible to convince someone to change for the better. The desire to improve was, instead, the precondition for progress. I've had court-mandated psychotherapy clients. They did not want my help. They were forced to seek it. It did not work. It was a travesty."



                    I can't help but see parallels here in rehab. When asking patients "what brings you in today?"

                    "My doctor told me to come here." Is it fair to say we should part ways now?

                    "The views expressed here are my own and do not reflect the views of my employer."

                    Comment


                    • Start at 15:00

                      Can't help but see some parallels to pain

                      https://www.youtube.com/watch?v=RGzPeG9XIp4
                      "The views expressed here are my own and do not reflect the views of my employer."

                      Comment


                      • I've mentioned this here multiple times and elsewhere. Do we talk about pain too much? What about disability?

                        https://healthskills.wordpress.com/2...or-disability/
                        "The views expressed here are my own and do not reflect the views of my employer."

                        Comment


                        • Originally posted by gilbert View Post
                          Explaining to someone that we need to do Functional Restoration first and not "wait until you feel better" is a huge challenge. But the thing is, functional restoration will make your LIFE better and may even make your pain better in the long run.
                          This reminds me of my week. I've recently had a handful of individuals with similar presentations: over 70, no acute, insidious on-set medial joint line knee pain. Imaging with degenerative findings. Primary complaint is pain. No mechanical/structural limitations (loss of motion, instability, etc). All individuals had been self limiting their activities, hobbies and what they value. All were provided with my valiant attempt to help them understand the condition, normalcy of everything. All were able to successfully and comfortable return to their activities, hobbies, exercise without issue. Did they continue to have pain intermittently? Yes. Was that enough to keep them from seeking out injections and surgeon referrals? Nope...

                          So my question here: if pain and functional deficits exist together: does the public care about functional restoration if pain remains? Is this enough?
                          "The views expressed here are my own and do not reflect the views of my employer."

                          Comment


                          • I've called it GOWI (Get On With IT) Therapy

                            Proud has called it MERG (Motivate, encourage, re-assure, guide)

                            It sounds a lot like what Peter O'Sullivan and Jeremy Lewis are promoting.

                            https://bjsm.bmj.com/content/early/2...ts-2018-099198

                            Enough is enough...
                            "The views expressed here are my own and do not reflect the views of my employer."

                            Comment


                            • Brain circuits mediating opposing effects on emotion and pain

                              http://www.jneurosci.org/content/ear...I.2780-17.2018

                              These circuits are probably involved. The farmers I saw in the 1970s had to get on with it, being able to afford central heating in their houses made it easier for them to get going in the morning.
                              Jo Bowyer
                              Chartered Physiotherapist Registered Osteopath.
                              "Out beyond ideas of wrongdoing and rightdoing,there is a field. I'll meet you there." Rumi

                              Comment


                              • Okay,

                                This question is open to anyone that works as a clinician dealing with third party payors:

                                When and why did physical therapists EVER agree or decide to write goals?

                                Why is it "therapies" seem to be the only ones writing goals for patients?

                                Here are some of my thoughts:

                                A patient presents to a clinic. We perform objective testing. The results are put up against a set of norms justifying continued follow-up (TUG > 30 seconds, Berg Balance Test <45/56, inability to move sit to stand from 18 inch/43-45cm chair, Quad index < 50% for return to sport s/p ACL, 500 feet 6MWT). The physical therapists work to improve objective measures to reduce falls, assisted living, participation in sport and community tasks. Those are the only measures provided to the insurance company. No goals written, just the results of the measures. The unwritten goal is to improve functional measures.

                                Those measures are taken on intermittent basis to assess progress. Treatment is individualized to finding of therapist. Measurements are simply to guide the therapist, not inform the insurance companies (range of motion, simple muscle strength, self report measures.)

                                Love to hear thoughts on this topic!
                                Last edited by Johnny_Nada; 07-07-2018, 03:19 PM.
                                "The views expressed here are my own and do not reflect the views of my employer."

                                Comment

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