iSAW 03.02 That Myth Really Hurts!

Rheumatology – A Critical Evaluation of the Trigger Point Phenomenon

Back in 1994, the West Australian John Quintner et al, mounted a peremptory attack on trigger points. It went nowhere. Two decades later, Quintner, Bove and Cohen revived their trigger point stance with a paper published in the journal Rheumatology (December 2014) entitled ‘A Critical Evaluation of the Trigger Point Phenomenon’. The paper had been rejected by many other journals, and had undergone many revisions before publication in Rheumatology. The conclusion starts off, “The construct of MPS (which, to explain is Myofascial Pain Syndrome) caused by trigger points remains conjecture. All working hypotheses derived from this conjecture have been refuted and therefore the theory can be discarded.” (The authors have mixed up conjecture, hypothesis, and theory. Three entirely different things! Losing me.)

“The trigger point strikes ….out”

A month later, Quintner found another outlet for his viewpoint in fellow Aussie, Lorimer Moseley’s Bodyinmind.org website. The blog post was titled “The trigger point strikes ….out“. In this post he mentions taut bands: “The existence of such bands had never been demonstrated.” He also maintains “no one has ever succeeded in demonstrating nociceptive input from putative myofascial trigger points.” Wrong on both counts, but only if you have read recent research papers. See, it’s dead easy to criticize the Travell and Simons Trigger Point Manuals because the most recent of their texts is now 16 years old. So much has happened since then. Quintner’s post generated hundreds of comments, which also made for great reading, until like many other online discussions it went a bit ‘ad hominen’ and personal.

The Trigger Point Strikes Back in the Outback

Curiously enough, Quintner’s host, Moseley, himself wrote the excellent chapter on pain in the equally excellent 4th edition of the text Clinical Sport Medicine(2012). Here are some Moseley excerpts: “Trigger points are present in all patients with chronic pain and are thought to reflect sensitization of nociceptive processing in the central nervous system… Patients with active trigger points present with persistent regional pain… These patterns clearly reflect central convergence of peripheral inputs, which further implicates the central nervous system in their generation and contribution to a pain state.”

A Critical Evaluation of Quintner et al: Missing the Point

Leon Chaitow. the editor of the Journal of Bodywork and Movement Therapies, invited Drs. Jan Dommerholt and Robert Gerwin to write a rebuttal to the original Quintner article. Quintner et al were also invited to participate but turned down the offer over some perceived slight. The Facebook reason for this can be found here, somewhere. Without summarizing the Quintner article or Dommerholt rebuttal, I recommend you read them both and decide for yourselves. I know what camp I’m in, because it’s the one supported by the best currently available science.

The myth that really hurts

It would be good to have this ‘against and for’ discussion continued in bodyinmind.org, allowing someone like Jan Dommerholt to be able to post his rebuttal. Not likely to happen, mate. I’ll quote from a man who is admired in both camps, Neuroscientist Patrick Wall; “If pain is a puzzle, we should not throw away pieces of the jigsaw just because we are obsessed with a preconceived single solution.” I was telling one of my patients, herself a psychologist, about the people who don’t believe in the trigger point. As I worked my way through her various scapulohumeral muscles at one point she said ‘That myth is really painful.” That’s the point.

Stew

6 thoughts on “iSAW 03.02 That Myth Really Hurts!

  1. Lorimer Mosely freely admits that he is not an expert on trigger points. We agree with him.

    By the way, our response to Dommerholt and Gerwin’s rebuttal is in the process of being written. It will be submitted in due course to JBMT.

    Our paper was rejected in record time by each of the three North American pain journals to which It was submitted. On each occasion the respective reviewer(s) did not provide us with their detailed report, if one was ever prepared. I wonder why?

    Our decision not to respond to Dommerholt and Gerwin’s rebuttal in the same issue of JBMT was made on the basis of our perceived bias of the Editor-in-Chief.

  2. Thank you for your comments, confirmations and clarifications.
    What changed your mind on JBMT? Has Mr. Chaitow’s bias improved?
    I look forward to reading your response.

  3. We changed our minds after reading the “rebuttal” paper prepared by Jan Dommerholt and Robert Gerwin. This paper was far too lengthy for it to be accepted for publication in RHEUMATOLOGY. They have seen fit to criticise us, mainly on the grounds of our errors of omission in relation to more recent publications that they feel will support the “Integrated Hypothesis”. We will be happy to deal with this matter in our detailed response.

    The crux of our argument is that many physical therapists around the world have reified (“to make into a thing”) pain that is felt in voluntary muscles and called it a “trigger point”. They have then set about attempting to destroy (desensitise) the very “thing” they have created.

    We well understand that our paper is a major challenge to the core tenet of their belief, and see them as “bending over backwards” to prove us wrong. For them to be wrong would negate their very existence as credible health care professionals.

    In our 2014 paper, which was severely shortened to meet the requirements of the journal, we point a way forward to those who wish to pursue this scientific endeavour.

    We hope that our reply to Dommerholt and Gerwin will be found acceptable by the editors of JBMT. But with journals, one never knows!

  4. Stew, our response is in the form of a Letter to the Editor of JBMT. We have been notified that it will be published in the July issue of that journal.

    For your information, the comments on my article in Body in Mind were closed off at my request because the principal proponents of the “integrated hypothesis” had not responded. It can be reopened.

  5. Stew, if you visit the blog Fibromyalgia Perplex, you can read our more detailed response to the “rebuttal” paper by Jan Dommerholt and Robert Gerwin. As far as we are concerned, the scientific debate is now well and truly over. Those who continue to advocate and teach the practice of “dry needling” can no longer hide behind the pseudoscience that originated with the work of Drs Janet Travell and David Simons.

  6. Stew, you will no doubt be interested to know that our abstract – Debunking the trigger point myth – will be presented next week to Annual Scientific Meeting of the Australian Pain Society in Brisbane, Queensland. This presentation will leave no doubt that the MPS/TrP theory has been well and truly refuted. We will argue that when conjecture was taken as fact, a pseudo-scientific hypothesis was constructed. This then generated a spurious belief system that spawned therapeutic approaches (e.g. “dry needling”), which have not been shown to produce positive outcomes beyond placebo. If we are correct, this fundamental error of reasoning has important implications for our health care system.

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