Pain: everything works, but nothing is effective

When treating patients, some therapists love their treatment of choice and share their testimonials of how it works. While other therapists love to bash that treatment of choice and share the research on how that treatment has not been shown to be effective. I don’t even want to begin the laundry list of “tools” in the “toolbox” that PT’s seem to pile up course after course when learning to treat their patients in pain. My hope is one day we can move past the methods (tools) of treating an individual in pain and understand the principles that can help. After attending #APTACSM 2017 in San Antonio this year, I continue to wonder if many therapists struggle with how their methods/tools fit into the principles of pain neuroscience.

I was shocked during a Thursday afternoon lecture when the speaker asked a crowd of probably 200-some PT’s about their knowledge of psychologically informed practice and only around 10 of us raised our hands. Maybe the phrase “psychologically informed practice” is new to them, even though it has been around in the literature at least since 2011. Or maybe we have a long way to go to fully understand the application of the biopsychosocial model in physical therapy. I thought Skulpan Asavasopon and Chris Powers did a great job trying to help the clinician link together biomechanical and psychosocial problems and interventions that can be occurring together in patients during their Saturday educational session: “A Cognitive-Biomechanical Approach to Common Chronic Musculoskeletal Conditions”.

Treating pain is challenging, but doing what we have always done will not move us to better care with these individuals. As Patrick Wall stated: “If we are so good, why are our patients so bad?”. The IOM report in 2011 states there are over 100 million people dealing with chronic pain conditions regularly. Why does this number grow when we hear from therapists claiming their great success with their treatment tool of choice? Why does science never seem to validate these treatment methods to work any better, if at all, than anything else? Could there be bigger underlying principles we have to understand than just learning another method when it comes to caring for those in pain?

I want to offer this thought for the readers to ponder: An apple a day keeps the doctor away. But you can keep the doctor away and never eat an apple your whole live. It is less about the apple and more about the principle the apple represents (healthy food). When we look at some of our interventions, we maybe need to see that at times it may be less about the specific intervention and more about what those interventions represent.

A specific exercise may not be improving posture or fixing a muscle imbalance. It might be improving a person’s self-efficacy because they are able to advance from one level to another in the program. Possibly also providing some gradual graded exposure in a safe environment so as to not run a pain neurosignature to reduce a learned response of pain. Or perhaps allowing the person to develop some sense of resiliency and expectancy violation with activity thus combating learned helplessness.

Manual therapy may not be putting anything back into place or releasing a restriction. It might be sharpening a patient’s homunculus of where body parts are within their sense of self. Possibly it is reducing some threat in allowing that area to be touched and developing some decreased sensitivity in the area through graded exposure. Or perhaps some non-specific effects of descending modulation are occurring with being in the presence of a health care provider.

My hope is that our profession can continue to understand the principles of what we provide through being more psychologically informed. Someday we might be less concerned about the methods of what we do and focus more on the principles behind them. A mind that can grasp principles will develop the methods needed for the person in front of them (and most likely it will not be your treatment of choice, but more of the patient’s treatment of choice). So my challenge and question to you is – do you understand ALL of the principles (biomechanically, psychologically, and sociologically) behind the methods you use, why or why not?

 

 

43 responses to “Pain: everything works, but nothing is effective

  1. GB says:

    Excellent entry Kory.

    As I understand it, John Quinter once referred to pain as an “aporia” and I think that is correct. That is, pain being exponentially multi-factorial coupled with the nervous systems capacity for rapid and unexpected adaptation render it essentially an unhittable target.

    The rabbit hole we seem to be falling into (and have been for several years) is to attempt to match this complexity with ever more complex, invasive and impressive (appearing) methods.

    I cannot be sure but I have to wonder if social media has not created an environment where the unassuming patient is coming to expect ever increasing “specialized” and “complex” treatment…and in an effort to placate this desire…things like dry needling have emerged?

    I’m of the mind that complexity often requires simplicity. In other words…back to the roots of Physical Therapy: good screening, re-assurance, education, movement and guidance. “Wowing” patients with neurophysiological party tricks seems to me to be adding yet another layer of needless complexity.

    1. Kory Zimney says:

      GB, yes John Quinter did relate pain to an aporia, Can’t agree more that pain is extremely complex, but the treatment of it does not have to be.

  2. Jessie Podolak says:

    Excellent post, Kory, and great response, GB. Maybe “wowing” our patients with the simple notion that, after hearing their story and examining them thoroughly, we are confident THEY WILL GET BETTER is a good place to start.

    Setting the expectation that tissues heal and can be influenced towards resilience and that the nervous system is plastic and can be nudged out of a pain cycle can give patients a bit of hope. We can then “open our toolbox” and decide, with the patient, which tools are likely to be a good fit. “What do you think it will take to help you get better?” The more active we can make our patients in the decision-making process, the more ownership they have over their recovery.

    I agree it’s less about the tool and more about fostering an environment (in the patient’s psyche and tissues!) in which the patient’s intrinsic healing potential can get some traction and move forward instead of spinning in place.

  3. Dan Z says:

    How about those times where a patient starts moving better or experiences less pain just because you are the first provider that has actually listened to them about THEIR concerns! Often we don’t need specialized treatment just more specialized hearing

  4. GB says:

    I would also like to hear from some of EIM’s main players in reference to how they package up dry needling in the context of TNE.

    I am certified to perform dry needling and have yet to find a defendable manner in which to bend the modality around what I am trying to convey to the patient.

    Certainly on the course I took (from kinetacore) the rationale I heard there left me feeling very…well…unimpressed.

    If someone associated with EIM has some way they explain why the use dry needling that remains consistent with TNE…I’d love to hear it.

  5. Kory Zimney says:

    I have not taken TDN course so I’m not the best to answer that. From what I understand it is novel input that the brain will do something with it, which may be pain reduction.

  6. Gb says:

    Well there are various theories out there with the two most prominent ones being Chan Gunn and Dommerholt. I’ve read both extensively and I think anyone who reads the literature would agree…wide gaps exist in both.

    The most defendable model from a science perspective is a combination of expectation (placebo) coupled with DNIC activation. If you’ve experienced TDN, you will know that it is rather uncomfortable.

    From what I gather Kinetacore does not subscribe to any specific theory but rather runs on the notion that “patienst like it so we should offer it” (my take away from the individual course I attended).

    I don’t like that…at all.

    When pressed on the topic, I received two separate responses;

    1) “Well even if it is placebo….that’s fine isn’t it?”

    2) “I tell my patients that sometimes we have to use the needle to get deep enough into the trigger point…kind of like popping a balloon…it’s just easier” (Paraphrasing).

    To me, that seems a rather scattered approach to patient care.

    What you suggest Kory is probably defendable…but I don’t see how that can be effectively conveyed to patients.

    In the end, all the patient knows is that they came in with pain and a needle got inserted and now they have less pain.

    Patients are particularly susceptible to post hoc fallacies.

    And then where does that leave the patient? That they are fragile beings wrought with dysfunctions in need of some sort of specialized intervention? Does that lend itself to self efficacy?

    I maintain the higher we up the ante towards invasiveness….the less likely it can be explained away in the context of TNE.

    That’s a conundrum is it not?

    1. Edo Zylstra says:

      GB
      Before I put myself squarely under the wheels of your bus GB, would you like to share what you do for your patients that you find effective? Or should we just throw out the rest of physical therapy as well? My very shortened view is this: Reduce pain with movement, reinforce your gains through good movement correction and exercise. Pain science is woven throughout.

    2. Mark Shepherd says:

      GB-

      I first want to say that I appreciate your thoughts on this topic. I applaud Kory for posting this as well. I think it is great to have folks really making us think about what we do and why we do it.

      Like you, I utilize dry needling (have been for about 5 years now). I can say that I have also decreased the frequency of its use, which I would argue happens with all novel treatments we learn then start to use. This is what happened with thrust manipulation for me. The main reason for this is because I feel I have become more precise with when and why to use this based on clinical experience using a test-treat-retest approach where I really try to limit my own confirmation biases.

      With this being said, I feel that these interventions are important to have in our skill set. As you alluded to, there are non-specific effects found in every interaction we have with our patients. I would argue that exercise can even be a powerful placebo. I think the essential thing for me is making sure that I provide the proper context around why I use something like manual therapy or needling. I really prep the patient with a lot of education up front regarding PNE and that we are working towards self-efficacy. I also think I really was overlooking the important role the periphery has in the pain experience. I really focused a lot of my time and reasoning that one’s pain is centrally driven. This is just not the case, even in those with central sensitization.

      One thing that I have been doing in regard to needling is working away from the idea that I am trying to eliminate a trigger point. I have gone into more of a thought process where the needle is potentially sharpening brain maps where smudging has occurred. I actively engage the patient in trying to distinguish one needle from the other where I will manipulate the needle to provide input to the nervous system. I may also give the patient a body chart with a grid and ask the patient to identify where the needle is on one’s back, neck, etc. Again the end goal is attempting to sharpen one’s brain mapping. I generally will use two point discrimination to see if there are changes.

      One may say, “well why can’t you do this with manual touch that is less invasive.” I believe the input the needle provides to the nervous system is dramatic–it is enough so that it demands the attention of the conscious and subconscious that can drive towards a learning process that is focused.

      All in all, I will see changes that usually occur within 2-3 sessions of doing this where I move towards more movement based interventions.

      I hope this helps give you some perspective on the reasoning I generally use now with needling. Thanks for bringing these points up.

      1. Kory Zimney says:

        Mark, I really like your use of TDN in regards to potentially redrawing maps. Obviously I’m a bit bias as that has been a major focus of some of our research, looking into this concept of altered body maps and interventions to assist with it. There are many interventions that can be used to assist with improving body maps, and while TDN is more invasive if the patient (and their brain) still sees it as safe it can potentially be a good teaching tool.

      2. GB says:

        I certainly appreciate it when clinicians think about what they are doing and from a defendability perspective, I’d say your premise is superior to the ones I have heard.

        Having stated that, I maintain that the needle adds yet another layer of needless complexity.

        Of course having been at this for over 20 years, I am also not a naïve dimwit either. Unfortunately, the culture we have created for ourselves (one where we compete with massage therapy, chiropractors, acupuncturists, Reikki masters, osteopaths etc etc) has backed us into a bit of a corner.

        What do I mean by that? Well, I suspect patients have come to expect a “fix” and if we don’t offer something novel with the appearance of “skill”….they will go elsewhere.

        It’s quite a mess really.

        I really feel that the Physical Therapy profession was positioned to be force multipliers a few years back but rather than forgo a piece of the pseudo-science pie…we chowed down.

        My apologies to those who take offense but I see TDN as yet another fad treatment, with little in the way of a defendable foundation. In other words…further down the pseudoscience rabbit hole. Regardless of how we try to mold the science around the modality.

        1. Kory Zimney says:

          GB, I think saying health care is a mess is the MOST defensible statement of all the ones shared. ;)
          There certainly is a tension that we must manage from what patients want to what they might need. Constantly challenging our stance and looking at this tension is what the profession and health care needs, thanks.

        2. Mark Shepherd says:

          GB- thanks for reading my reply and responding. I agree that we as PTs make things way more complex than it needs to be. I also agree that there is this perception that we need to “fix” patients who come to us. This plays on both sides of the table. The problem is when the PT assumes this and dives in with the passive treatments ’til the cows come home.

          I believe more and more that we should PTs should be investing more time and efforts towards developing interaction skills and learning how to frame their treatments (whether manual, needling or PNE).

          Thanks again for challenging me to think a little deeper about this intervention.

      3. Jim G says:

        Mark,
        I would have never thought to utilize dry needling from an input mapping stand point , thank you for sharing your insight into utilization in your clinical practice. I would agree that with any intervention I have learned I at first utilized it on more patients than not to try and identify which patients would benefit. As I have grown as a clinician I have done a better job of continually re-evaluating my individualized treatments and thought processes to get a better understanding into what treatments I utilize and why. I greatly appreciate your open and honest dialogue. Keep up the good work!

        1. John Ware, PT says:

          There’s a fairly recent study on the use of acupuncture as a sensory discrimination tool that was discussed at the BiM blog shortly after the study came out. The results of this small study suggest that acupuncture is more effective when the clinician draws awareness to the location of the needles in the back. Here’s the link to the BiM article:
          http://www.bodyinmind.org/acupuncture-sensory-discrimination-low-back-pain/

          1. Mark Shepherd says:

            Thanks for sharing, John. I had missed this blog/article when it came out.

  7. GB says:

    Jessie Podolak,

    I can certainly appreciate the viewpoint that pain modulation can provide patients with hope and perhaps provide a window for the clinician to impart TNE in an effort to grow self efficacious behaviors.

    As I stated however, I remain wary of the ever increasing level’s of invasiveness our profession seems hell bent on pursuing. I think we always have to remind ourselves that our end game is to ensure our patients leave the clinic with the full understanding that they have full agency over pain, function and coping abilities.

    Simply stated, I think TDN and overly coercive strategies such as manipulation…do not readily lend themselves to the story we want to impart.

    Edo Zylstra,

    So your take away from my entries is that I am “throwing out Physical Therapy”?

    How about:

    1) Expert NMSK evaluation and DDx with referral when indicated (well supported in the literature).

    2) Re-assurance that nothing is ripped, torn or broken or in danger of doing so.

    3) Education (TNE)

    4) Guidance (graduated return to movement and activity)

    5) Motivation (this is of course where the 5 “C”s” of good Physical Therapy come in…confidence, compassion, caring, charisma and of course…competence).

    All of the above require the skill of a Physical Therapist. Knowledgeable in neurophysiology, anatomy, differential diagnosis. The ability to speak confidently and with a caring demeanour.

    Frankly, I think things like TDN is just one way PT’s go about avoiding the requisite soft skills which I think is sorely lacking in Physical therapy. What with all the focus of the “tool box” and all…

  8. Colleen Louw says:

    GB: First – I wish G had a first name and B had a last name, but nonetheless.

    Lots of great responses here to Kory’s post. Great conversation. I found it really interesting so I guess I’ll contribute.

    As you know, dry needling is not new to physiotherapy, it’s been around for decades (in some cases, probably centuries) in other parts of the world, and actually performed much more aggressively than how it is performed here in this country in many instances. And I personally have found it to be incredibly effective for the right patient, at the right time, and under the right circumstances. But that’s like any (physical) treatment, if you think about it. And (GB) if you claim it is “more invasive” than typical PT, maybe you’ve never performed sharp debridement in wound care! TDN has come about more recently here in this country, and I think Edo and Kinetacore have done an incredible job teaching it safely and effectively (AND demystifying it) for the past 10-12 years to thousands of PT’s in the US. And they have fought hard for our profession. And I’m sure you left your course or course(s) feeling you could confidently dry needle someone safely and effectively. I know I did when I took my first course several years ago. That has always been the intent of their courses to my knowledge. If you at least felt that, then they did their job.

    That being said – Kinetacore teaches just that – dry needling. That’s what they claim to do and that is what they do. Just as McKenzie teaches extension principles. Just as EIM (and others) teach manual therapy. And on and on. I think we all understand the “jist” of Kory’s post was that we need not get hung up on WHAT we are doing (our tool boxes) as much as the how/when/where/why we do what we do and be effective when we do it. But the key here (in my opinion) is how you convey that, and subsequently perform it, on your patients. Pain science education -simplified – is meant to help people understand why they hurt, to decrease fear, to decrease anxiety, so they can move on with their life. But that alone isn’t the entire answer either. It’s part of the big picture in physical therapy, and yes, I feel a vital component at that and overall lacking in our profession (although we are getting there!).

    Louis Gifford said that before we treat ANY patient with ANYTHING, we have to get their brain shifted into a position of “readiness”. That entails many things. That’s on us, the therapist. That IS our job, if you get down to it. So to me, it doesn’t matter what you do – the patient has to be well informed, educated not only about pain but what you are physically going to do and why, and yes, you MUST seem (and be) confident in your skill sets.

    To me, the bigger question here is – when do you, the THERAPIST know when your patient has “shifted” into a position of readiness for your treatment – no matter what it is – to be effective?

    Mark Shepherd called it how you approach your patient’s treatment framing. I would also call it skilled communication. But they do expect you to do something (physical) when they come into the clinic. It’s what we do.

    Bottom line – they have to trust you.

    1. John Ware, PT says:

      I don’t think the comparison with sharp debridement is apt. We don’t use sharp debridement of wounds to treat pain per se. It’s a category error to place these interventions in the same context.

  9. MR says:

    Having attended Manipalooza and the IPSI conference in the past I’m puzzled with the dialogue here.

    How has one transitioned from light, skin deep sensory discrimination to needle insertion? How does one defend this premise? Just because we think we are sharpening smudged brain maps (quite a leap) we have yet to see consistent outcomes defending such a practice.

    Second, why do we keep coming back to safety? Safety does not justify use of an intervention. Effectively (whatever that means) inserting a needle does not justify use of needling. There are many healthcare providers inserting needles safely and effectively. I would argue their premise is justifiable to retrieve a blood sample, deliver a medication, administer a vaccine, etc. A physical therapist’s fails to have a defensible platform for inserting needles into patient’s.

    In the absence of supportive data, the only relevant defense of this practice seems to be self interest (bias, belief, financial, tribal) behind a veil of misinterpreted evidence, patient expectation, etc.

  10. Adriaan Louw says:

    GB, other contributors…

    This is a real good discussion and reminds me of manual therapy – who has (is) going through the same “revolution.” Having been around the pain sciences, manual therapy and dry needling, my two cents as to what TDN does from a pain perspective:

    • Endogenous mechanisms: We have evidence that TDN facilitates release of endogenous opioids; the periaqueductal gray area activates with dry needling, thus influencing a person’s pain experience

    • Nociception: Kory is correct – providing (healthy) nociceptive input in a safe environment help alter pain processing. Pain that is understood is not feared and the Hebbien theory – nerves that fire apart wire apart

    • Nociception: TDN does alter local tissue – acetylcholine, ATP, etc. Any (honest) pain doc will tell you that TP injections are useless when it comes to the medicine – it’s the needle that causes the local changes

    • Paul Watson’s disability model needs mention: Releasing muscle spasm and guarding, eases pain, change movement, disability, etc. Pain, disability, motor control and fear is intertwined

    • Neuroplasticticy: Mark and Kory is correct – we should consider TDN just like manual therapy from a neuroplasticity perspective – we have published some of this pertaining to manual therapy and several studies ongoing

    • Patient beliefs – placebo: I am worried about throwing in placebo – as it’s often overused. In manual therapy people come in and say “I feel like my neck just needs a crack” – and Louie Puentedura’s CPR showed patient beliefs are very important and should be considered. In TDN we are slowly seeing patients (likely who have been exposed to TDN) coming in and saying – “I feel like someone should just stick a needle in it.” So yes, for a subgroup of people their experiences and beliefs may set up TDN quite well

    o Reminds me of the quote: The more powerful the intervention, the more powerful the placebo effect. TDN is likely in the realm of manipulation…

    o Jessie’s comment about “what will it take to get you better” can be reframed and used for TDN – if they have had it, heard of it, it may be well worth exploring….

    • Nociception: Blood flow – studies are showing immediate changes locally and distally from TDN areas…

    This discussion can go on, but the question I think everyone is asking is – “How do we explain this to a patient to “enhance the treatment effect.” A lot depends on your own knowledge and bent. This exact issue is what we’re exploring in various manual therapy experiments.

    • Spasm – I think most patients understand spasm and an explanation of releasing a local spasm, which in turn eases pain, normalizes pain-free movement can easily be explained and used. The pain science part – spasm alters movement, which causes more pain and a viscous cycle….

    • Remapping – we are having a lot of success using “smudges” maps as explanations. When life is good – brain maps are sharp; when we move less, maps are altered and the more they are altered, the more pain is produced. I like the idea of TDN as a sensory discrimination technique – the brain has to be part of it. Kory has a neat fMRI paper coming out on explaining “smudging” to someone in pain and by understanding it, the brain calms down – so they can take on neuroplastic explanatory models….

    • Blood flow: When blood is removed from nerves, they “wake up” and when we flush blood around nerves they calm down. TDN releases a spasm (like clenching your fist for a long time) and when it releases, blood rushes through the area, calming nerves

    This can go on and on….I believe the basic science research supports the use of TDN and the need to further explore TDN and yes, it’s “newer” in the US, but clinically a powerful tool. There are many unknowns and this is a callout the scientists and people teaching TDN to invest into further exploration and study. The “art” is to explain it to the patient….above are some examples worth considering and we have used in the clinic. Pain science does not aim to “remap” therapy….but give it another explanation, especially non-biomedical explanation. This is true for TDN and should be true for manual therapy….Joel Bialosky and his team’s article in Manual Therapy in 2009 about the possible mechanisms behind manual therapy can easily be adapted for TDN and worth a read….

    Louis Gifford’s idea of “top down before bottom up or top down while bottom up” – is applicable here as Colleen stated. I think we should ask the TDN people how they explain TDN and then us “pain guys” will take that information and spin it in a pain language….

  11. GB says:

    Thank you for all the responses. And certainly havoing a pain science heavyweight chime in (Adriaan) helps the discussion evolve.

    Having read your response Adriaan and with all due respect…I remain unconvinced.

    Let’s see here:

    -Endogenous mechanisms: Plenty of things accomplish this. Certainly not unique to TDN. And the periaqueductal gray area activates for all sorts of reasons…including toothpicks.

    -Nociception: Boy do I ever struggle with the notion of treating pain with pain (DNIC) as implied in the above comment. Given that threat mechanisms are at play particularly in the older brain areas…I just think playing with that is a really…really bad idea.

    -Nociception (#2): Again, plenty of things result in local tissue changes.

    -Releasing muscle spasm and guarding, eases pain: Okay…except there really is very little in the way of evidence that TDN actually accomplishes this.

    -Neuroplasticticy: Once again…less coercive and less ritual laden things can have the same effect.

    -Patient beliefs – placebo: Ah….this is the sticky one for me and had I had more insight as a younger PT, I would have pursued a research career and looked at the placebo/nocebo balance. I greatly suspect that these short term party tricks are actually creating a slippery slope wherein the short term gain is substantially offset by the long term consequences of patients believing that some outside force was required. I have no evidence to support this however if we look at trends (increasing access to alternative treatments and an expanding epidemic of persistent pain), I think an argument could be made.

    -TDN is likely in the realm of manipulation: This I agree with. Both appear to be highly skilled applications…both completely unnecessary.

    -Nociception: Blood flow: Again…not unique to TDN. Even if I simply place my hands on skin this will happen.

    -This discussion can go on, but the question I think everyone is asking is “How do we explain this to a patient to “enhance the treatment effect.”:

    The above quote is something I completely DISAGREE with again with all due respect). All we have to do is look at subluxation based chiropractic care for perspective here. The subluxation explanation certainly resonates with many patients and probably serves to “enhance the treatment effect” but I think it’s a terrible idea to deceive patients in an effort to squeeze out an effect. It’s a fine line and I think TDN crosses it.

    I am not convinced at all that TDN is a “clinically powerful tool” as you suggest Adriaan. But I also think it’s safe to say that no one is going to change their mind based off a blog site discussion.

    However suffice it to say, TDN at this point has no evidence to suggest it is superior to less invasive techniques (and I doubt it ever will if we use the plethora of acupuncture literature as a lamp lighter). Also, TDN IS a passive technique with known adverse consequences already documented (And I suspect we will hear of more as this modality gains in popularity).

    I think it’s a very very bad idea.

    Time will tell.

  12. MR says:

    I attended manipalooza in 2012. I recall everyone racking and cracking, slapping high fives and patting each other on the back. Numerous spectators watching as instructors “worked” on each other. A few of us were more reserved have read the works of Bialosky, Zusman and Lederman. I even observed an instructor stick a needle into an individual with MS. The spectators were amazed by the twitch response. The instructor talked science sounding stuff and the great outcomes he observed in the clinic.

    I attended the ISPI conference in 2014 and listened to the enthusiasm of Adriaan talking about the science of pain. At that time I was hearing similar discussions from people using their hands, tools and needles. I recall stopping Adriaan briefly in passing and asking:

    “Does all this neuroscience talk simply give people justification to do whatever they want to patients so long as the talk about the nervous system?”

    I didn’t get an answer at that time. I think I know the answer.

    So, like GB suggests; are we to give people what they want or think will help? Even in the absence of efficacy and effectiveness? Do we simply perform “stuff” on people and lather it in TNE? Does that make is justifiable? Is that clinical reasoning? Will cupping soon be a course for physical therapists and show up at conferences?

  13. Josh says:

    Great discussion.

    As a young clinician, I can see both sides of the argument. Hopefully I do not offend anyone, however, utilizing TDN from a pain science perspective as explained above just does not make a whole of lot sense to me. Again, I am young, however I feel it is a bit counterintuitive. Yes, as Colleen stated nicely above, with the following:
    “And I personally have found it to be incredibly effective for the right patient, at the right time, and under the right circumstances. But that’s like any (physical) treatment”.
    I cannot argue with that statement. However, I have a hard time with the thought process that inserting a needle is more effective than light touch if the goal is sensory discrimination and “sharpening brain maps”. I have no evidence for or against this statement, however, if someone does please share.
    Thus, are some just “needling just to needle”? If that is the case, then why do it? Is that truly clinical reasoning? I think we would all agree, we should have a reason, if not multiple, for everything we do!
    One could argue the following as Adriann said previously: “The more powerful the intervention, the more powerful the placebo effect. TDM is likely in the realm of manipulation”.
    Again, I cannot argue this statement. I definitely think this way periodically throughout the work day. I personally do not see anything wrong with it either. Sometimes people simply benefit from a placebo. Some individuals, such as GB and MR, may disagree with this. However, to their points, do people really need a placebo intervention? As both, GB and MR alluded to, people need a thorough medical screen, education and to understand the power of movement/exercise.
    However, in large part due to patient expectation, it is tough to solely rely on education and exercise to ultimately transfer a patient away from an external locus of control to an internal locus of control with the overall goal of independence/self-treatment. According to Bishop, patients simply expect passive interventions to help them. Therefore, I can see the argument for using interventions such as manual therapy and TDN.
    The big question is, why expose patients, especially chronic pain, to another passive intervention such as TDN when the human hand (touch) could possibly do the same thing? I can see points for and against, however, we should ask ourselves, do the risks outweigh the benefits? As always, number one rule, DO NO HARM. Are we possibly underestimating the risks with some of our interventions?
    Again, great discussion, our profession needs more of this!

  14. Adriaan Louw says:

    GB, MR

    I am not in the habit of contributing to these blogs, but your statements are really troubling….and no, don’t worry, I won’t be back to read replies…I have too many projects we are working on to continue this dialogue…take it for what it’s worth:

    1. PAG – nobody said TDN exclusively activates it and your statement acknowledges that TDN activates the PAG…toothpicks? Really…..

    2. Nocipection – again, nobody says TDN does this exclusively….

    3. Treating pain with pain….you have never had anyone in the clinic say “it hurts so good?” Never pushed through a hard workout while enjoying it at the same time?

    4. Neuroplasticity – I should probably apologize here for having insight into unpublished research on TPD and brain mapping, TA and MF that is coming out…

    5. Placebo – party tricks? The most famous pain scientist (Patrick Wall) believed placebo to be the most powerful treatment on the planet, when carefully enhanced…obviously you need a MAJOR update on placebo and nocebo literature. BTW – why are you so defensive and adamant about this?

    6. Manipulation unnecessary? Have you read the current guidelines (from the medical world) for acute LBP?

    I realize “blogs” are designed to create discussion and even “push buttons” – hence me replying (while I could be working on research)….so let me ask some questions (since you guys are so keen on throwing darts from the sidelines – neither of you are willing to give your name and “own” what you say, and by using your initials we cannot do a search to see what research you have done as a means to further the profession….

    I two questions for both GB and MR:

    • If TDN, TNE and manipulation is NOT in your wheelhouse…can you please list (for the readers) what you do for acute and chronic LBP? Make sure, however, you ONLY list things that have unequivocal research to back it and you can provide the underlying mechanisms (all of them) why they work. We can then continue this discussion…and everyone in the “blog-sphere” can challenge you…

    • If 100 people with LBP attend PT today and all of them receive TDN, will all of them fail or will some of them leave the clinic with less pain, better movement and improved function? Surely a subgroup will get much better…the challenges (and research mandate) is now to go figure out what made this group do well with TDN..isn’t it? I’d bet many of the issues we have discussed can once again enter that reasoning process. In manual therapy (and even TNE now and likely soon TDN) the “exciting part’ of our profession right now is moving away from the biomedical explanations for treatment effects and we CAN talk about patient expectations, threat appraisal, neuroplasticity, endogenous mechanisms, therapeutic alliance, etc…..

    Do blogs change people? Probably more than you think….many people read it; some take it for gospel; others used it as a platform to spread their beliefs and…get’s Adriaan to blog…

  15. Jarrod says:

    Nice blog Kory. The challenge you put forth, of understanding the principles behind the methods we use clinically, has been met with some great commentary. I appreciate all of the thoughts and ideas expressed here.

    I regularly dry needle in the clinic having taken Level 1 and 2 KinetaCore over two years ago. Like Mark mentioned, when you first learn something new you do it often as you try learn and appreciate the subtleties and details of a new technique. However as time passes you learn how it works to best compliment the other aspects and interventions we do as therapists. It is the learning, doing, and refining of the new that deepens our ability to be better therapists.
    Some of the commentary here is quite critical of using TDN. This seems pretty common these days. The debate at CSM on “to needle or not” reflects these two sides. As many point out the debate is healthy, but should always be constructive. .

    GB, you pose some nice questions. Here are a few constructive contributions to this dialogue.

    GB states, “ I have yet to find a defendable manner in which to bend the modality around what I am trying to convey to the patient”
    This is simple. TDN should be presented as a compliment to other treatments. It is never the main course. It is a fertilizer to the main part of care. TDN can speed up the process, but it cannot do it alone. It is given as an option and is always given with the statement, “you will get better with or without the needle, but for some patients it can speed things up”. It is always the patient’s choice. Patient are paying us to help them feel better. Will it work for all, NOPE.. It is not for everyone. Will it work for some. YES. It is in the reasoning process that you arrive who it may help. There has been plenty of great feedback above as to who it might help. Marks comments about are we fixing a trigger point or doing other things like sharpening brains maps is right on!!

    GB states, “If you’ve experienced TDN, you will know that it is rather uncomfortable”. That is up for debate and a bit biased. As Adriaan already said, some patients prefer the hurts so good (John Cougar Mellencamp may have had it right) and they appreciate the feel. I of course am a bit biased the other way. If get a strained muscles I often have a colleague needle it and I usually respond well. It always comes down to patient preference. As Kory mentioned, does it feel safe. This is a big question. Both of us have a bias and this likely effects how we personally respond to the same treatment.

    GB states, “From what I gather Kinetacore does not subscribe to any specific theory but rather runs on the notion that “patienst like it so we should offer it” (my take away from the individual course I attended)”

    Always interesting how we can take different ideas away from similar material. My main take away was always be safe with it, respect it, use it as a way to treat muscles, assess and re-assess its effectiveness, discontinue it if it is not helpful.

    Thanks to everyone for taking the time to make us all better

    Jarrod

  16. Ryan Appell says:

    Great discussion.

    It will be difficult to convince anybody who is skeptical of dry needling that the above cited mechanisms are enough to justify its use – many (if not all) of them are not specific to needling and could be elicited with ANY treatment. And if it could be elicited with ANY treatment, then don’t we have to ask why we’re needling in the first place?

    The mechanisms behind needling seem to me to be the very definition of a non-specific effect – i.e. placebo. And if DN (or any passive treatment for that matter) is largely a placebo intervention, it should beg the question whether we should be searching for better “efficacy-promoting” methods and strategies for interacting with our patients. I think Cory Blickenstaff nailed it on the head with his recent blog on symptom modification – it is appropriate when “1) it serves to refute a specific and relevant expectation and 2) the patient assigns the source of the refutation to themselves.” I don’t think that many interventions we use satisfy these criteria, even if we use an explanatory model that de-emphasizes biomedical rationales.

    I struggle with conversations like these because I have two somewhat conflicting views on it – on one side we have the escalating costs for painful problems, the unnecessary surgeries (Swedish Cherry Hill anyone?? https://projects.seattletimes.com/2017/quantity-of-care/talia/ ) and abundance of inappropriate prescription medications that are literally killing people. It makes the question of whether to add DN to an otherwise well rounded multi-dimensional approach to patient care seem like a silly one. I think it was Jason Silvernail who said the question of whether to add a passive intervention to an otherwise well rounded management program just isn’t an important question.

    On the other side of that coin however, I think it is well worth considering what the long term consequences of promoting an intervention with questionable efficacy might be? It’s been said here (and many other places) that we are in the midst of a pain epidemic. I’m not sure if I agree with that. Gordon Waddell has argued (convincingly) that we are actually not in the midst of a pain epidemic, but rather a disability epidemic. This might seem a bit pedantic, but I think it is an incredibly important distinction. An emphasis on approaches that do not directly promote self-efficacy is unlikely to be helpful in counteracting the complex multitude of factors that are driving this problem. By utilizing DN or manual therapy, are we implicitly removing the patient’s source of refutation from themselves, and instead putting it in the therapists hands? And does this not decrease self-efficacy? I find it increasingly difficult (in my mind at least) for passive interventions and approaches that attempt to foster resilience, empowerment, and self-efficacy to co-exist.

    Given what we have learned (and what we are continuing to learn) about pain and disability, I’m becoming more convinced that our field is going to need to decrease our reliance on passive interventions and move towards an emphasis on the so-called “soft skills” that improve the therapeutic relationship – and are most likely the ones that enhance the context of the therapeutic encounter, self-efficacy, and the non-specific effects within.

    1. Mark Shepherd says:

      Ryan-

      Thanks for chiming in on the discussion. I am a little bummed that this seemingly started to focus on dry needling as my thought is that Kory was not specifically calling out any one intervention. I think you did a nice job pulling us back to the greater discussion about more of the interventions used by PTs.

      I completely agree with your thoughts on building therapeutic relationships with our patients. Context is a HUGE part of why folks enjoy their care and potentially why they get better. With this in mind, I want readers to view manual therapy as not being purely passive. I try to make manual interventions as active as possible–I am not talking just physically, but also “mentally.” One way folks do this is by utilizing PNF techniques, maybe combining these with physiologic mobilization. One may potentially combine hold-relax following a thrust manipulation or graded mobilization. All of these can physically get the patient involved in the session.

      I also strive to get the patient mentally involved. Much of Butler’s work on graded motor imagery has helped challenge me to utilize explicit motor imagery with manual techniques–think about doing a rotational mobilization at the cervical spine. I may ask the patient to visualize how the motion in their mind maybe with their eyes closed. From here I may have the patient guide me through the motion with my hands “following.” The point is, manual therapy should not be completely passive.

      I see manual intervention as a continuum where there is purely passive work (where the patient is not doing any physical or mental work), to physically passive but mentally engaged, physically engaged with manual assistance, to pure physical efforts and beyond. It as if we are guiding them towards self-efficacy. We need to frame the interaction as one of a guide on the side vs. a sacred “fixer.” All things that I know you would agree with!

      Thanks for adding to the discussion.

  17. GB says:

    Well, I had a rather long winded response typed out in response to Adriaan but upon reflection, I think it’s pointless given that he indicated he no longer will be participating.

    BTW…yes Toothpicks: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2832641/

    Jarrod,

    Trust me when I say I have viewed how to wrap TDN around the science from virtually every angle….including the one you suggested. I struggle with a few lines in your response:

    “you will get better with or without the needle, but for some patients it can speed things up…”

    -If you know a patient will get better without the needle…then why introduce it?

    -Does it really speed things up? That statement is way ahead of the literature. In fact….the bulk of the literature suggests it does not.

    “Patient are paying us to help them feel better.”

    This…this is a big one. Patients are paying us for our expertise and guidance. Our supposed ability to identify true structural deficiencies that would render certain movements detrimental…or alternatively identify when there are no barriers to movement (nothing ripped, torn or broken or in danger of doing so).

    I get the distinct sense that what people are advocating here is that placebo is all good. I am just not as convinced that this is necessarily the case. What about internal locus of control? What is so wrong with empowering patients to arrive at the conclusion that they have the capacity to self settle? Why are we becoming the “feel good” providers?

    I mean my goodness folks, if it was all about simply maximizing placebo then for sure we would have seen this translated into a diminishing rather than exponentially increasing pain epidemic. Are we kidding ourselves here? The subluxation chiro’s who manage to convince patients that spines just randomly become misaligned have certainly maximised the placebo effect have they not? Reikki masters who convince patients that they just had their “energy” recalibrated have maximized placebo have they not?

    And I am unconvinced that the “bait and switch” pipe dream of utilizing an invasive needle and then turning around and saying “oh the needle really was not the important thing here” is realistic. After 20 years of doing this I can almost guarantee you that the patient leaves the clinic and tells 3 other people about the “amazing needle”. That is just how the human brain works. It’s prone to post hoc fallacies.

    Is this helpful? Does this make us true forced multipliers? Or does it land us squarely in the same ball field as countless other purveyors of pseudoscience all piggy backing off the supposed “harmless” placebo effect?

    “As Adriaan already said, some patients prefer the hurts so good (John Cougar Mellencamp may have had it right) and they appreciate the feel.”

    -To that I would have you consider potentiation as a possible counter argument. Why would you take an already sensitized nervous system and introduce even more nociception into that equation?

    I really do appreciate the professional dialogue that occurs here at EIM. It seems the participants here really work towards a balanced viewpoint on a controversial topic.

    I am a bit mote of a straight shooter I guess. To me, I think we have placed the cart way before the horse with TDN.

    I think it’s a terrible idea.

    1. donna tegethoff says:

      Interesting blog. So many replies echo what I felt about TDN a yr ago. After having taken the course, and now applying it with over 200 pts, I am confident that TDN is a great tool to use. It is safe if guidelines are followed; it requires extensive knowledge of anatomy; pre and post testing are vital; it is not a comfortable intervention but patients often return and are willing to pay a premium as their pain changes in ways that haven’t with other interventions that are far more time consuming(and costly). I would highly recommend taking the Kinetacore course, if only to relearn anatomy, and reduce the bias against TDN.

      1. GB says:

        I have taken the course through Kinetacore and no….no it did nothing to convince me of efficacy. And it certainly did not convince me that this is a required tool.

        Brushing up on relevant anatomy was certainly enjoyable but then again, I could have done that for free at the library rather than the 2500$ course fee….

        I am certainly not “biased” against any intervention. Speaking of bias….I wonder…are you aware of the term “confirmation bias” by any chance?

      2. John Ware, PT says:

        Can you specify which statements show a “bias against TDN”?

        Is it possible that you have a bias for TDN?

        I see patients all the time who are willing to pay a premium for spinal surgery, i.e. max their out-of-pocket costs for the year, in order to find the fix for their chronic low back pain. Since when does the patient’s willingness to “pay a premium” reflect the true value of an intervention?

  18. GB says:

    Quickly on the topic of why patients come to see us.

    Erik Meira on his twitter page has a fun rant about that : https://twitter.com/erikMeira/status/837696384874602496?ref_src=twsrc%5Egoogle%7Ctwcamp%5Eserp%7Ctwgr%5Etweet

  19. MR says:

    As someone that doesn’t own their statements, doesn’t have peer reviewed publications, and shoots darts from the sidelines I’ll reference someone you may respect.

    Neil O’Connell discussing our effectiveness:
    https://www.youtube.com/watch?v=DY4abf1sPKg

    I think he hits it on the head starting at 2:20.

  20. Ryan Grella says:

    MR: Love the Neil O’Connell talk. There are too many key points to list.

    One comment on Adriaan’s response that I believe is worth noting (And I do not think this was his intent)

    One does not need to be conducting research to rigorously critique research. Nor does one need to be working in an outpatient musculoskeletal clinic performing intervention “x” to critique the research surrounding intervention “x”.

  21. GB says:

    Hate to harp but as I sit here this evening and reflect upon Adriaan’s question as to “why I am so defensive” I felt I simply had to add an excerpt from my un-posted response to Adiaan. Here it is:

    And you ask “why am I so defensive and adamant about this”? Well that one has a simple response: I have been doing nothing but clinical work for over 20 years now and have watched as fad after fad have come and gone…with absolutely no reaching impact on the care we provide (in fact one could argue the state of things for patients is worse than ever). But TDN is the first one where I sense an unnerving trend towards more invasive, risky and dubious efficacy interventions that are increasingly hard to re-frame in the context of TNE. I think we have placed the cart way before the horse on this one. Particularly when you acknowledge that the current state of the literature is not overly encouraging for TDN. Couple that with the larger safety issues and I think I’m justified in being “defensive”.

    I find it a fascinating study in human behavior to observe clinicians somehow defend of a modality with dubious evidence (TDN) , clear invasiveness, and documented safety issues…all under the guise of “patient expectation” and “giving patients what they want” and “helping patients “feel better” regardless of the defensible premise behind the proposed modality.

    Some may perceive this as beating a dead horse but the reality is that I am a strong advocate for my profession and an even stronger advocate for the patients we supposedly serve.

    If I come off as agitated it’s probably because I am. And I do not apologize for that…

  22. MR says:

    Why not one more…

    https://thesports.physio/2017/03/04/i-am-just-a-physio/

    I, like GB, speak on behalf of the patients I see. Maybe that’s why people don’t like our tone. I don’t stand on a stage promoting myself or a brand. I don’t act like I have something special. I don’t view myself as someone that should charge my professional colleagues to add another tool to a toolbox. I acknowledge the statement of Patrick Wall: “If we are so good, why are our patients so bad?” ” If that doesn’t make our profession stop and look in the mirror with the most critical self analysis, nothing will. Let the courses and conferences continue.

    We are anonymous because we have to be. We are surrounded by a profession made up of fixers and operators. We aren’t the tribal, high-fiving group of PT’s branding, marketing ourselves or friends. We’ve grown tired of fads and rebranding. Like it or not that’s what has happened with 3 of the most promoted and marketed “interventions” of this profession.
    Chiropractic manipulation—>joint mobilization
    Acupuncture—> TDN via trigger point or sensory discrimination
    https://www.ncbi.nlm.nih.gov/pubmed/24021562
    Gua Sha/Graston/etc—>ASTYM/IASTM

    We will continue to critique and question the practices, science and evidence for our profession. Some will consider us “trolls.” But like a very smart Ryan Appell once said:

    “Trolls, while often annoying to a passersby for demanding a toll, also serve a very important purpose: Keeping the bridge in working order. Given the current state of critical thinking infrastructure in physical therapy, I don’t think more trolls is necessarily a bad thing.”

  23. John Ware, PT says:

    Fellow troll here.

    I’m disappointed in the condescending comments made by Adriaan in his last post. I know GB and MR from years of online discussion, and I’m absolutely certain that their knowledge of the relevant science with respect to treating a primary complaint of pain is far above average, including GB’s understanding of placebo/nocebo. To suggest otherwise based on a few comments in this blog is uncharitable, at best, and arrogant at worst. We should expect more from research leaders in the profession.

    It is increasingly difficult to take a public anti-TDN/treatment du jour stance these days as more people, including employers looking to prevent any further deterioration of their profit margins due to reduced reimbursement, are watching. It didn’t take much courage, really, to defend PTs right to perform manipulation 10 or 15 years ago, and it doesn’t take that much courage now to defend TDN (on the other hand, here in Louisiana, we’ve spent $10s of thousands on doing just that). The rapidly diminishing healthcare dollar makes in increasingly precarious to publicly criticize the addition of yet another “tool for the toolbox.”

    I’m one of those trolls who doesn’t give a damn anymore.

    1. Larry Benz says:

      John, that’s a lot of issues from protecting our practice to ascribing condescending on a blog where tone and sarcasm can only be inferred. You are a skilled debater-no need for you to go there.
      As you know, I am not a overly pro TDN guy even though I have stuck thousands of patients with EMG needles over the years. I don’t think it should be a primary intervention of which in my observation for some PT’s it has become-that’s simply a shame since I have never heard even an instructor or researcher claim that it should be. I also know that if you read adverse effects on about anything in medicine it will of course lead to adverse effects. Point being that non clinical factors that impact clinical success are powerful-perhaps more powerful than ever. Fake news and fake research is also powerful. Counterfactual stories that patients tell themselves can yield both positive and negative outcomes (subject of my Manipalooza talk this year and I sure hope like hell I get a few high 5’s :) and yes plenty of research on it). I don’t get your key argument above though-do you really believe that the key reason for the exuberance and again, you know I personally believe over exuberance is to “prevent further deterioration of ..profit magins”?

      1. John Ware, PT says:

        Fair enough, Larry. Perhaps I inferred too much from Adriaan’s comments about MR and GB electing to remain anonymous. Since I have extensive experience discussing these issues with those two online, I know that their intentions are noble, knowledge of the literature well above average, and devotion to the profession unassailable. I suspect Adriaan doesn’t have this level of experience to make these judgments, and so my inference was probably rash. For that, I apologize.

        I don’t understand, however, the relevance of being able to “look up the research you’ve done to further the profession.” I think that’s inaccurate, and it struck me as haughty. Does one have to engage in research to advance the profession? Don’t clinicians who in their daily practice strive to follow the best evidence advance the profession? I think they do. I think there are far too many who aren’t even aware of the evidence, much less attempt to apply it in practice. I realize there’s a cost to credibility for choosing to remain anonymous on public blogs, but I don’t think anyone should assume that means one’s contributions to the advancement of the profession are in question, and that they’re “throwing darts from the sidelines.” Technically, Adriaan’s jab at their anonymity amounted to a form of ad hominem- an attempt to draw attention away from their arguments and towards other irrelevant aspects of their personal choices and values. I think that was unfair.

        Regarding my point relating the advancement of the “tools for the toolbox” mentality to growing financial and budgetary pressures, I’ll explain. We’re all aware of the growing concerns of reduced reimbursement and increased patient financial responsibility in the outpatient setting. We’re also increasingly aware of the precarious return on investment that new PTs are facing coming out of three year DPT programs. Those two forces, I think, combine to create an environment where gaining a “competitive edge” in the eyes of the public has become more pressing. (I think you’ll appreciate the quotation marks around that phrase better than most, since you understand how perverse the incentives are in healthcare writ large, so real competition has remain elusive.) The pressure to do what “works” in the short term in order to keep patients coming back and perhaps coughing up the extra $30 or $40 out-of-pocket for needling is seductive. Let’s face it- there’s a certain sexy allure to wielding a needle that makes the “D” in front of “PT” *seem* legitimate and justified. Despite Colleen’s argument above that needling is a natural progression for PTs since we already do sharp debridement of wounds is a category error. Make no mistake, it’s a significant leap for PTs to add invasive procedures for the expressed purpose of treating painful conditions. The question is, Is the leap justified by the science? Does it risk altering, irrevocably, the character of what we do? This is what concerns me.

        1. Larry Benz says:

          Thanks for your explanation-I get it on the “competitive edge”. I think the best example is personal trainers who seemingly stay in an endless cycle of new methods including implements, enhanced techniques, fads etc. etc. On a pendulum, we aren’t as far as they are to the right but definitely agree many providers teeter on it-all without regard to science and evidence. I don’t consider manual therapy, TDN, and pain science education along those lines but your point is well taken.

          1. GB says:

            Thanks John for the back-up there. I’ll certainly agree that remaining anonymous has, at times, not served me well when trying to engage others in professional discussion and often provides a convenient “out” for those I make uncomfortable. I continually reflect upon this but in the end, I have a family to think about and often my professional vantage point may place me at odds with my employer and colleagues which could potentially not serve me well (if you know what I mean). The points I rose with Adiaan were salient regardless.

            Larry,

            It’s interesting that you packaged manual therapy, pain science education and TDN together there. The points I made (above) were essentially about the challenges of wrapping the science AROUND dry needling…which is what I think you just did there. For one, I don’t think it’s possible (to transition from such a highly invasive procedure wrought with ritualistic tendencies—> self efficacy and internal locus of control). And for two, as things stand now the evidence is practically non-existent and the science rather dubious. Frankly, I am convinced that TDN meets the criteria perfectly for a “fad” treatment and in my mind, is far worse than a personal trainer’s flavour of the month because of the safety aspect but more-so because of the ethical boundaries we are obligated to by being licensed professionals. So ya…I disagree with you on that quite strongly.

  24. gb says:

    Old thread but to this day I am still perplexed by Adriaan’s apparent defense of TDN. Particularly when I suggested the potential downside of piggy-backing off non specific effects (nocebo if you will). I believe (without going through all the comments again, he implied that I was not well versed in the placebo-nocebo literature).

    Well I’m not the only one who thinks this embracement of placebo could be a bad thing:

    http://bjsm.bmj.com/content/early/2017/07/19/bjsports-2017-097747

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