Dry needling for myofascial pain. Does the evidence make the grade?

Last year, JOSPT published a systematic review and meta-analysis of dry needling for upper quarter myofascial pain. We thought it was a really well conducted systematic review, but we were somewhat surprised by the abstract, the interpretation of results and the accompanying advice to patients. So we wrote a letter to the journal. They did not publish it because they felt it was too long after publication, which is fair enough. So, we are posting it, pretty much as is, here[9].

We think that systematic review and meta-analysis is currently the best methodology available to assess the state of evidence concerning clinical interventions. This contribution[9], on the effectiveness of dry needling for upper-quarter myofascial pain, appears to be no exception. We strongly believe that the scientific method is only complete once the results have been interpreted and communicated to the end user, and done so in light of the strengths and limitations of the identified evidence and in consideration of the differences in specialised knowledge between the scientists and their audience (that is, without jargon). On that matter, we have been warned of the perils of taking abstracts on face value[2], and, in line with such warnings, we have significant concerns regarding the interpretation and subsequent recommendations that were offered by the authors, and by the accompanying advice to patients[8].

In the abstract, arguably the major determinant of clinicians’ impressions of a study[6], and in the conclusions, the authors make a clear clinical recommendation in support of dry needling based upon what they report as “grade A evidence”. In a companion article ‘JOSPT perspectives for patients’, those recommendations are repeated: “..dry needling can be effective in providing pain relief….more research needs to be done to determine whether dry needling is better for this condition than other treatment options” (p 635). When we read the full article, we found these recommendations surprising. The article itself suggests the available data are flimsy (not least because of the so-called garbage in – garbage out phenomenon – if the original articles are crap, then the best the systematic review can do is to collate crap), but if anything, the systematic review actually showed that dry needling is probably no better than sham and very possibly, it is measurably worse than comparative treatments.

We contend therefore, that the recommendations made in the abstract and in the patient-targeted advice, do not fairly represent the data provided in the article. Given the severe limitations of the evidence-base, in terms of size, quality and methodological consistency, the proposed effect is not robust. When comparing dry needling to control/sham, there appears to be a short-term effect of dry needling, which is not significant at four-week follow up. The studies with the largest samples[4,5] show no statistically significant effect of dry needling at either time-point. Moreover, the study that reported the greatest effect[3] clearly stands apart from the other included studies, possibly because it failed to apply a convincing control/sham intervention. Removing that single study from the analysis renders the result non-significant. When compared to other interventions included in the review, dry needling was less effective than comparison interventions in the immediate term and no different at four weeks. One must interpret that result with caution too, for the very same reasons pointed out by the authors, but it clearly does not point towards recommendation of dry needling, and certainly not at ‘Grade A’ level.

There is another intriguing problem here – one that is a nuisance for all of us engaged with evidence-appraisal – that of giving due consideration to the null hypothesis. In any meta-analysis of trials of mixed quality, with subjective outcomes, where blinding can be hard to ensure, the purists agree that even a completely useless treatment will probably give a picture of unreliable and marginal results, trending towards favouring the treatment. The predominance of small trials in such an analysis introduces a further bias, substantially increasing the risk of false positive results and exaggerated effect sizes[1,7]. That is, we need to see data substantially better than trending to be satisfied the treatment is better than useless (but see note below).

We contend that a far more parsimonious interpretation of the meta-analysis is that dry needling is not convincingly superior to sham/control conditions and possibly worse than comparative interventions. At best, the effectiveness of dry needling remains uncertain but, perhaps more likely, dry needling may be ineffective. To base a clinical recommendation for dry needling on such fragile evidence seems rash and risks exposing patients to an unnecessary invasive procedure.

The note below: We should always remember that ‘completely useless’ is usually relative to something, not nothing. We think that is important because a treatment that is completely useless compared to another treatment, for example a ‘sham’, may actually be useful but for reasons not related to the component that is supposedly effective. That is, let’s say, for argument’s sake, that dry needling is indeed no better than sham dry needling. It is possible that both are better than nothing, which implies something else, wrapped up in the dry needling, might be very useful indeed.

Daniel Harvie BodyInMind

Daniel S. Harvie, M Musc & Sports Physio
PhD candidate
Samson Institute for Health Research
University of South Australia

 

Neil O'Connell 2Neil O’Connell, PhD
Lecturer in physiotherapy
Brunel University
Uxbridge, UK

 

Lorimer Moseley Lorimer Moseley, PhD, FACP
Professor of clinical neuroscience
Samson Institute for Health Research,
University of South Australia and Neuroscience Research Australia

 

References

1. Dechartres A, Trinquart L, Boutron I, Ravaud P. Influence of trial sample size on treatment effect estimates: metaepidemiological study. British Medical Journal 2013;346:f2304.

2. Editorial. “Read MEDLINE abstracts with a pinch of salt.” The Lancet 2006; 368: 1394.

3. Hsieh YL, Kao MJ, Kuan TS, Chen SM, Chen JT, Hong CZ. Dry needling to a key myofas­cial trigger point may reduce the irritability of satellite MTrPs. Am J Phys Med Rehabil. 2007; 86:397-403. http://dx.doi.org/10.1097/ PHM.0b013e31804a554d

4. Ilbuldu E, Cakmak A, Disci R, Aydin R. Com­parison of laser, dry needling, and placebo laser treatments in myofascial pain syndrome. Photomed Laser Surg. 2004; 22:306-311. http:// dx.doi.org/10.1089/1549541041797878

5. Irnich D, Behrens N, Gleditsch JM, et al. Im­mediate effects of dry needling and acupuncture at distant points in chronic neck pain: results of a randomized, double-blind, sham-controlled crossover trial. Pain. 2002; 99:83-89.

6. Marcelo, A, et al. “A comparison of the accuracy of clinical decisions based on full-text articles and on journal abstracts alone: a study among residents in a tertiary care hospital.” Evidence Based Medicine. 2013; 18:48-53.

7. Moore RA, Eccleston C, Derry S, Wiffen P, Bell RF, Straube S et al. “Evidence” in chronic pain–establishing best practice in the reporting of systematic reviews. Pain 2010; 150:386-389.

8. Teyhen DS. “Painful and tender muscles: Dry needling can reduce myofascial pain related to trigger points. JOSPT 2014; 44:261-261.

9. Kietrys, D., Palombaro, K., Azzaretto, E., Hubler, R., Schaller, B., Schlussel, J., & Tucker, M. (2013). Effectiveness of Dry Needling for Upper-Quarter Myofascial Pain: A Systematic Review and Meta-analysis. JOSPT, 43 (9), 620-634 DOI: 10.2519/jospt.2013.4668

Comments

  1. John Ware, PT says:

    Stuart,
    IASP has the mostly widely accepted definition of pain at the current time: “An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” However, I must admit that I’ve taken a liking to Lorimer’s more succinct definition: “Pain is a conscious correlate of the implicit perception of threat to body tissue.”

    I’m intrigued by the notion that you’ve expressed suggesting that needling may somehow improve a patient’s motivation. Why would this be so? Could it be that the patient’s strong expectation of a result from the needling would drive this increase in motivation? I think the evidence suggest that’s the case. So, the next question is, Why would we want to motivate patients with an intervention based on their erroneous ideas of how it works? I think this sums up the tautological issues we face when we come to rely solely upon empiricism to drive our clinical reasoning.

    I think we can and must do much better.

  2. stuart miller says:

    John, thanks for the wake up call. I agree that we should not be assigning ‘grade A’ evidence for treatments that don’t have objective evidence. I also think there is a disconcerting trend in healthcare in our exchange based economy. I think Body in Mind is a gift. A forum for open discussion. Everyone has confirmation bias though. Paul ‘the walking cortex’ Hodges published a paper (with Kylie Tucker) in Pain in 2011 ‘Moving differently in pain: A new theory to explain the adaptation to pain’. I had thought of physiotherapists as movement specialists. Helping people to move better. Even the definition of pain and persistent pain is elusive. Could you provide your best definition that provides a framework to approach the patient?

    john Quintner Reply:

    Stuart, in answer to your question, may I suggest that you read (or re-read) The Structure of Scientific Revolutions (1962, 1970) by Thomas Kuhn. Of particular relevance is his Chapter VIII, The Response to Crisis.

    Leaders in Pain Medicine, such as John Loeser and Dan Carr, have told us that our pain theory and practice has not been able to cope with the tremendous advances in knowledge that have occurred over the past 25 years. We are in a state of crisis. How are we to respond?

    As Kuhn suggests: “Part of the answer, as obvious as it is important, can be discovered by noting first what scientists never do when confronted by even severe and prolonged anomalies. Though they may begin to lose faith and then to consider alternatives, they do not renounce the paradigm that has led them into crisis.”

    Our 2008 paper – Pain Medicine and its Models: helping or hindering – was written in response to what we then saw then as a looming crisis in our field of practice.

    Our subsequent work can be seen as an attempt to construct a more useful approach by the clinician to the person in pain. Of course, as this forum will testify, there are other approaches that are well worth considering.

    Kuhn goes on to suggest that “the decision to reject one paradigm is always simultaneously the decision to accept another, and the judgment leading to that decision involves the comparison of both paradigms with nature AND with each other.”

    I agree with you that Body in Mind is a gift and in my opinion an appropriate (and possibly the only) forum where these matters can be openly and freely discussed.

    Reference: Quintner JL, Buchanan D, Cohen ML. Katz J, Williamson O. Pain medicine and its models: helping or hindering? Pain Medicine 2008; 9: 824-834.

  3. John Quintner says:

    Stuart, your question is interesting but it is well outside the topic of this discussion.

  4. stuart miller says:

    Hi John and Michael; I am continuously trying to rationalize why some of my colleagues continue to do dry needling. In the stroke population that I see, there is a challenge for patients in achieving active dorsiflexion during gait (for obvious reasons and less obvious reasons). We use FES, orthoses and aerobic exercise, functional strengthening and intensity of task practice with progressive stretching to assist in the process. For some patients, stretching the gastrocnemius-soleus complex is challenging and occasionally aggravating to the ankle. One of my colleagues, with application of dry needling is able to achieve significant changes in length of muscle and load to ankle using dry needling. He finds he can better incorporate task specific practices quickly using this as a catalyst. My thoughts are this…Does it have a direct effect on pain? No – as you have so eloquently put it, John, it is a puzzle. Is it a glorified hold-relax technique with maybe longer lasting effects? Yes. Does it create co-dependency especially in a public health-care model? Yes. Does it translate into better self-management? No and sometimes yes. However, if despite best attempts on my part, patient motivation is low and progress is slow, I am tempted. I know for the patients with persistent neuropathic pain, I don’t think it is helpful and I am not tempted at all…Thoughts?

  5. john Quintner says:

    Michael, with respect, your suggestion is akin to trying to keep a sinking ship afloat. The simple answer is for the various skill accrediting bodies to cease supporting such courses (which, by the way, do not come cheaply). Continuing official support of theoretically unsound and demonstrably ineffective practice reduces the professional status of physical therapists to that of quacks. However, I do admit that quackery flourishes in our day, perhaps because of the aura you mention.

  6. Michael Ward says:

    If I could make 1 humble suggestion on the aspects of the thread re concerns of dry needling. Courses are required for accreditation of skills. This accreditation is required for professional indemnity. This drives sign up to long courses. What if it were to be suggested that as there is no convincing evidence that a specific pattern of needle insertion is required, then (for professional indemnity requirements) the safety of the patient is best served by a simple needle insertion safety course to make sure that you will not puncture a lung or other important body bit. This perhaps would serve to reduce the aura around it and it is much easier to abandon a technique if you have it than if you are trying to say it doesnt work but dont have the technique.

  7. stuart miller says:

    Hey, I really appreciate the discussion on working towards evidence based care. It starts with the patient (as stated so eloquently in a recent Body in Mind post/video) . I realize that for long-term management of persistent pain, it is imperative (I believe) that the patient has some perception of control and a strategy that helps. Usually this is the case with most things. I realize the effects of needling are transient (I have stopped needling in the last few years) and have tried my best to explain pain (as best I can). I work with colleagues who both do dry needling and injections (cortisone, botox). In the case of botox, the effects are also transient (maybe 3 – 6 months) but sometimes the patient develops a new pattern of movement and sometimes a different neurotag with significant reduction in pain. A catalyst for change is just that (neurophysiological technique or not) – input is important – there is a reason that FES for stroke has level 1A evidence. I have had many patients who have said, without the assistance of a catalyst for change (whatever that may be), they just couldn’t process any of the information I (we) were trying to provide them. I realize that reflects the strength of my education and so I am trying to listen. Please provide feedback. Thanks

  8. John Quintner says:

    Thanks John. The publicly available document calls for a reasoned response. I will now seek “neutral ground” for its publication.

    PS we have decided not to resubmit our article to the journal Rheumatology as, in our opinion, they do not want to publish it.

  9. John Ware, PT says:

    John,
    The second link in my last post has a link to a publicly available document titled “Physical Therapists & the Performance of Dry Needling Resource Paper”. On page 2, that one uses the identical language as the “Official Statement” on “Billing of Dry Needling by Physical Therapists”.

    If you can’t get it, feel free to email me at jwwarept@gmail.com and I’ll send it on.

  10. John Quintner says:

    As I do not have access to this material, would someone please send me a copy of the APTA “official statement” on the needling of trigger points? It might make interesting reading!

  11. John Ware, PT says:

    John,
    Regarding our professional association’s (in the US it’s the APTA) commitment to ethical practice: they very recently responded to the American Heart and Stroke Associations’ response to the latest bad news on cervical manipulation by vigorously defending the practice with cherry-picked research citations and a thinly-veiled tu quoque argument about the prescription of NSAIDs by our medical colleagues (http://www.apta.org/Media/Releases/Consumer/2014/8/7/). I’m not particularly encouraged by this. It’s obvious to me that the Orthopedic Section of APTA is all in on dry needling. APTA has issued an “Official Statement” on it, which includes the phrase “stimulate underlying myofascial trigger points”. I suppose that’s as opposed to the “overlying” ones (the much longer “Resource Paper” is available at the following link; the official statement on billing is only available to members: http://www.apta.org/StateIssues/DryNeedling/)

    Steve,
    Sounds like you’re in a bad mood, too. 😉

    My sense from SBM is that they have bigger fish to fry than worrying about what they may see as the inconsequential world of physical therapy- and who can blame them based on the meager effects of our treatments. I’m not as familiar with Dr. Ernst’s writing and mission as I should be, but I’ll take a look and see if sending some of this on might interest him.

  12. 1. John,
    How about dropping it in the lap of the sciencebasedmedicine folk or edzard ernst – those guys could use another example of AHPs trying to get their house in order but being stymied by biases within the publishing system.
    In general I see the doomsday situation of the paying public having it proved to them that they have been exploited in their vulnerability by quackery in professional positions that they trusted. And that we will all lose our position of trust as a result. I expect it because it is my opinion that the effects of these biases result in fraud. Fraud because of the way that wealth follows from working with the biases that allow practices like TDN or epidurals or facet joint injections or intramuscular paravertebral injections or PLIF for chronic low back pain. Because the evidence against all these treatments exist but the clinicians that profit from offering these services to the desperate are one eyed in their appraisal of the evidence. Why? They say because it works – but we know the placebo when we see it, mean regression and natural history. – Follow the money. The situation continues and the folk working within these systems get rich

    TDN is one player attempting to follow this amazingly successful model.

    Dominate (or create your own) journal board, publish supportive papers (of low quality but no-one criticizes them in the ‘open’ press) and advocate treatments, give generously to politicians, have medical boards support your treatments on the basis of the evidence in your journals, watch the income accumulate from your (mostly) safe placebo treatments, continue to pay the politicians, exclude dissent – rinse and repeat.

    Compare and contrast with interventional pain medicine, chiro etc.

    But who will be the Hercules to wash the shit out of the stables – he had to divert a river.
    Kind thoughts,
    Steve
    Edited 6th Sept 2014 with permission of the author.

  13. John Quintner says:

    John, you have good reason to be in a bad mood. In Canada, I hear that the WC authorities will reimburse PTs for up to three needle insertions (I may have the number wrong).

    I am sure that your professional associations have something to say about ethical practice. They might show a lead by refusing to approve courses in needling on the grounds that such courses only serve to perpetuate nonsensical dogma.

  14. I’m trying to think of the last time any “regulatory authority” stopped paying for an intervention because it had been scientifically discredited. I know some drugs have been bounced off the market, but that’s because they killed people or their use resulted in severe birth defects. In the area of persistent musculoskeletal pain where acts like dry needling have found a home, I can’t think of a single intervention that “regulatory authorities” have banned. Hell, they’ll still pay you to rub an ultrasound head on someone’s sore back, and, in the case of a sore neck, they’ll then reimburse you after you rip one of the patient’s vertebral arteries. I’d hate to think that some poor soul would have to perish for the needling stupidity to stop.

    The letter writing campaign is an admirable undertaking, but then we’ll have to figure out a way to get PTs to read them.

    I think something bad- probably financial- will have to happen to the profession or health care delivery in general to stop this nonsense, unless we can find a very articulate, charismatic, and effective iconoclast to wake people up. We may need several of them. I doubt we’ll see anyone emerge from academia. The general lack of engagement by academics in these pressing issues facing the profession is stunning to me, and may only be slightly exceeded by the pervasive complacency and willful ignorance of rank-and-file clinicians.

    I’m in a bad mood today.

  15. John Quintner says:

    Well, after our recent “seminal” paper was rejected by three “pain” journals (Clin J Pain, J Pain & Pain Medicine) we submitted it to Rheumatology, where it was bounced back to us, along with some excellent suggestions from one reviewer. It appears that the speciality of Rheumatology is blissfully unaware of the important issues we earnestly debate on this web-site. We will revise our paper accordingly and hope that it gets into print!

    We do have a rather pointed Letter to the Editor of Pain Medicine awaiting publication, which we hope will draw a rational and honest response from the relevant authors.

    My suggestion is that Body in Mind readers follow suit and barrage the respective Editors with similar letters. Sooner or later the “penny will drop”.

    Meanwhile, regulatory authorities will doubtless be observing the TrP controversy and hopefully will cease funding needling on the grounds that it is a scientifically discredited form of treatment.

  16. John,
    I expected to hear from you since it’s a topic so near and dear to your keen sense of rationality. But, what I’d really like to know is What should we do about it?

  17. John Quintner says:

    @ John. From personal experience I can tell you that it is harder to get a scientific article published rebutting the fantasy of the MPS/TrP construct than it is to induce a camel to pass through the eye of a dry or wet needle. The TrP aficionados are well positioned on the editorial review panels of respected journals. Need I say more?

  18. I’m still a bit steamed about this apparent dry needling advocacy by JOSPT, and I came across something that I wrote about JOSPTs “irrational exuberance” regarding dry needling earlier year when an RCT by Mejuto-Vasquez et al appeared in the April issue, which also included a “Perspective for Patients” piece that matter-of-factly extolled the potential benefits of this intervention. Here’s what I wrote, and I’d be interested to get any feedback from those who read here:

    Well, it looks like the Orthopedic Section of the APTA is all in on trigger point dry needling- not just dry needling, mind you- but the kind of dry needling that can supposedly “relax the tight muscle bands associated with trigger points.” Does it matter that the existence of trigger points remains putative, at best? That a couple of enterprising physicians decided trigger points existed based on observations going back about 30 or 40 years, which have yet to substantiated in numerous reliability studies?

    Published in the this month’s JOSPT, the official journal of the Orthopedic Section, is a full-color “Perspective for Patients” piece titled “Neck Pain-Dry Needling Can Decrease Pain and Increase Motion”. This follows the latest clinical trial by Mejuto-Vazquez et al showing that TDN had short term effects on reducing neck pain compared to a control group.

    Setting aside the short-term improvement, once again the results of this trial hinge on the dubious existence of trigger points (TrPs) in muscles. The authors spend all of a single, short paragraph on page 253 presenting their argument in support of the reliability of diagnostic criteria demonstrating that TrPs exist. They do a terrible job. Mejuto-Vazquez et al cite the Gerwin et al reliability study from 1997 and somehow come up with kappa values for the four criteria ranging from 0.84-0.88. I have no idea where they came up with these values because they are nowhere to be found in the Gerwin et al study. The kappas range from 0.36 for the local twitch response (LTR) to 0.84 for reproduction of pain (Rep P) in the upper trapezius. Furthermore, the operational definitions of the criteria don’t necessarily match between the studies. For instance, Mejuto-Vazquez et al included “the presence of a palpable taut band in the upper trapezius” but also “the presence of a hypersensitive spot in the taut band”. However, Gerwin et al include “Point tenderness on a taut muscle band”. It seems that Mejuto-Vazquez have created two criteria from one established by Gerwin et al in their study. So, it’s very misleading to suggest that the kappas from Gerwin et al were measuring the same things that Mejuto-Vazquez were measuring.

    They also fail to mention that Gerwin et al was a low quality study as determined by Lucas et al (2009) in their systematic review of TrP reliability studies, even though they reference Lucas et al in their brief defense of TrP diagnosis.

    This is how it goes in these studies where needles are inserted into something that hasn’t even been shown to exist. The authors gloss over the negative evidence and run full speed ahead with their study. Peer reviewers, in their zeal to be a part of the latest fad in clinical research, fail to perform their due diligence in critiquing the study, and then someone writes a piece essentially recommending that if you have neck pain due to a trigger point, that you might want to get a needle stuck in it.

    This is not science, folks. This is treatment advocacy by statistical manipulation and misrepresentation. It’s wrong.
    _________________________________________________

    Thus, it seems that it’s come to this: one of the most respected rehabilitation journals in the world is actively promoting a controversial and poorly supported intervention within its pages. I think this is scandalous on top of the scandal of denying publication of the editorial submitted by the BiM members. What are we to do about this?

  19. John Quintner says:

    Julia, if you think any of my input might be useful, please feel free to quote from it. But please spell my name correctly!

  20. Julia Hush says:

    Nice critique guys. Surprising that JOSPT didn’t want to publish it (publication bias?). With your permission (and due acknowledgements) i would love to use this in my EBP teaching as a great example of appraisal of a systematic review.

    Daniel Harvie Reply:

    Go for it Julia!

  21. Daniel Harvie says:

    Thanks all for reading and for your thoughtful comments. I am honoured that you took the time.

    Adam – thanks for bringing up Bayes theorem that reminds us that study findings should be interpreted in light of prior probability.

    John Ware – Thanks for your insight into dry needling and physiotherapy in the U.S. I am optimistic that physiotherapists are tiring of going from ‘fad-to-fad’ – we will soon view such ‘negative results’ as ‘good news’ that we DON’T need to do this. I for one am relieved.

    Kieran – Thanks for sharing your clinical experience – I don’t doubt your effectiveness. I will be bold however, and propose that the physiological effect of inserting needles is not the most potent part of your therapy. Perhaps the amazing thing about your effectiveness is that you get such good results not ‘with’ but ‘despite’ the use of dry needling.

    Christine – indeed we need to be careful about generalising any result to conditions that the research does not directly speak to. Of course this goes both ways though – I wonder how many clinicians would have generalised the dubious conclusions of this study to other conditions.

    ‘The Johns’ (John Barbis, John Quinter, John Ware) – adding to your discussion on ‘the existence of myofascial pain’: ‘myofascial pain’ is (I think) a bit misleading because muscles and fascia don’t ‘generate pain’ (though they can of course be a source of danger signalling/nociception). Furthermore because the name says nothing about the cause of nociception/pain (i.e. the pain mechanisms at play) it therefore offers no guide as to what to do about it.

  22. John Quintner says:

    St5e, if counter-irritation was a panacea, no doubt some physiotherapists would still be using the Kromayer lamp as their main therapeutic tool. With all honesty they could call this treatment CIA (counter-irritation analgesia). Dry needlers should take note!

    The more interesting question to consider is the anatomical source of the primary irritant (i.e. the anatomical source of nociception). Myofascial tissues are in my opinion the least likely candidates. There are other structures that are more likely to be “at fault” and the source of pain felt at a distance deep within muscles. This is not rocket science.

    I see physiotherapists as having a unique opportunity to become the pre-eminent pain theorists and educators who can fill the large knowledge gap that has been left by time-poor medical practitioners, whose armamentarium of drugs and various invasive interventions has been found severely limited in effectiveness. Those who contribute so willingly to Body in Mind are leading the way.

  23. John Barbis says:

    There was a great opinion piece in the NYT this weekend on how facts and beliefs often do not matter. In addition, knowing more facts that negate the fundamentals of ones beliefs, often make commitment to the belief even stronger. It is one of the major problems within our political, religious, and scientific worlds. It is great reading.
    http://www.nytimes.com/2014/07/06/upshot/when-beliefs-and-facts-collide.html?_r=0

  24. John Q – Hoax. Yes, but. No, but. Some folk here and around about are trying to shout this out. It only remains a hoax if our professional bodies are complicit in not policing themselves and their members. The fact that this is being discussed here has to be factored in to these organisation political stances – opinion formers in our professional world believe this treatment is a hoax and yet it remains endorsed without caveat by professional bodies – they are taking some huge risks with our reputation. And our reputation is our livelihood.
    John W. – Editor in chief – would look good on your palmares….
    Adam – Ole!

    In general the counter irritant/pain relief concept assumes a universality of CNS function which Prof Tracey’s work would indicate to be an unsafe foundation – not all PAG are equal in output/feedback/suppression. So when we come to ‘First do no harm’ then can we not do counter irritant techniques to the chronicity biased folk with their unique CNS issues.
    Kind thoughts,
    Steve
    ps please campaign to bring the TdF back to Yorkshire every year… 😉

  25. John Quintner says:

    Andrew, your question must be directed at your professional colleagues. There is no “witch hunt” being conducted by Body in Mind, which is an open forum for discussion. But we can no longer ignore the huge knowledge gap that exists between theory and practice in this area of musculoskeletal medicine, which includes a significant physiotherapy component in a number of countries. Massage therapy and chiropractic are also in the same boat, as are my medical colleagues who practice in this area. As far as I am aware, determining what is best practice continues to be an elusive undertaking.

  26. I understand where your frustrations are coming from Cameron . Exercise , manual therapy ( specifically spinal manipulation ) and now dry needling all seem to be subjected to a witch hunt of sorts on BiM where the all powerful “evidence” declares them dead and buried.
    What exactly should we be saying/doing to our patients who come in looking for pain relief ? A cup of tea and a “don’t worry you’ll be ok ” seems to be what the BiM will have us believe is best practice. Yet I also see conflicting research on explain pain, graded motor imagery etc. or am I missing something here ?

  27. John Quintner says:

    John, myofascial pain theory does make sense, but only at a folk medicine level. We know that precious little evidence is required to develop a superstitious belief, especially if it also provides a simple answer that has high face validity. In my opinion, this reasoning goes a long way to explain the evident popularity of dry needling amongst therapists and patients alike. But attempting to pass off such treatment as scientific can only bring the profession of physiotherapy into disrepute.

  28. John Ware says:

    While I’m in agreement with John Q’s criticism of myofascial theory (i.e., it doesn’t make any sense), I’m going to agree with John Barbis’s point that the main issue that we should be concerned about here is JOSPT’s failure to appreciate and publish a reasoned and well-referenced challenge to the findings from the Kietrys review. The “Grade A” evidence conclusion lacks merit, and I think a student in a freshman statistics course would be able to discern as much. As a profession, we should be embarrassed that this review passed this level of muster. Therefore, the impression given is that either the JOSPT editorial board was derelict in this particular instance or that their motives are questionable: that financial and/or political factors are unduly influencing publishing decisions.

    JOSPT has recently begun accepting applications for a new Editor-in-Chief. I hope we can find someone with both the scientific chops and political courage to stand up against the latest treatment fad and help steer the profession on a science-based course. The direction it’s headed of late is fraught with long term danger to our professional viability.

  29. John Quintner says:

    @ John Barbis. From personal experience I know that mainstream journals are reluctant to publish material that argues against the construct of “myofascial pain”. But the other, and more fundamental, question needs to be addressed – what is the evidence for the existence of a clinical entity called “myofascial pain”?

    As Christine is yet to respond to my challenge, I will happily concede that the tissues you mention are all potential sources of nociception. But it flies in the face of logic for clinicians to incriminate muscles without scientific evidence to support their hypothesis, to then insert their needles and to expect payment for so doing.

    I do hope that someone can convince me that a pseudo-scientific hoax of massive proportions is not being perpetuated upon long-suffering patients by those who espouse “myofascial pain theory”.

  30. John Barbis says:

    The question of whether we believe in myofascial pain or not is not the issue here. First of all, pain is not an input. It is an output. There is no reason to believe that fascia cannot produce sensory information that would be consistent with mechanical or chemical nociception. Clearly connective and contractile tissue possess receptors that have the capabilities to produce sensations that the brain, in the appropriate environment, could interpret as “pain”. The real importance of the message from Lorimer, et al, is the problem of editorial suppression of dissent.
    If you go to the APTA website, you can find a position paper on Dry Needling. It is a long paper. If I can take the editorial luxury of paraphrasing its essence, it would be: “Because everyone else does it, we should be able to do it too”. I have no problem with the APTA making a political decision about this or any other technique. The APTA is a professional organization that naturally has a political role as a component of its existence. It is the APTA’s right and even responsibility to produce a position on dry needling. The role of the editorial board of a professional journal is different from that of the organization itself. I would like to think that the members of an editorial board of any journal would hold themselves to a different standard and remove bias and political beliefs from their discernment processes.
    The decision of the Editorial Board to not publish or suggest potential changes in the structure of the letter to fit their publication structures, does not meet that high standard and is a stifling of dissent. I assume that we are all adults and realize that the reviewers and editors of any professional journal carry with them their own beliefs and opinions. We would all like to believe that the editors, just like our Supreme Court Justices, (Attention- this is statement of political sarcasm) make their decisions totally devoid of bias and make decisions solely on the objective evidence. We know that that cannot always be true because they are human, but we all can wish they will work hard to do so; and, where reasonable, allow thoughtful dissents to be published. The sad and, I believe, the dangerous aspect of the actions of the Editorial Board of JOSPT is that it is a disservice to the population that would most benefit from the dissent, our patients. Will practioners now make treatment decisions based on biased information?

  31. sue croft says:

    Just throwing this out there- research in psychotherapy and OT literature
    Patient Motivation: Evidence based therapy relationships
    • The therapy relationship makes substantial & consistent contributions to patient success.
    • The therapy relationship accounts for why pts improve (or fail to improve) as much as the particular Rx method.
    • Adapting or tailoring the relationship to several pt characteristics enhances the effectiveness.
    • Pts with empathetic therapists tend to progress more in Rx & experience a higher probability of eventual improvement.
    (Norcross, 2011)

  32. Thanks Cameron. Yes, that (fear reduction) might indeed be the mechanism of many treatments. though i am not convinced we fully understand the mechanisms of effectiveness of any of them, with most mediation analysis not showing any clear patterns. CBT and exercise have both previously been shown to work via reducing catastrophising (a variation of fear i guess?).
    also, thanks for those thoughts on study. definitely worth considering.
    Kieran

  33. Cameron says:

    Thanks Kieran.

    I see fear reduction as the only method we can rely on, and I appreciate you listing the different ways of going about reducing this fear.

    — ‘Explain pain’ is fear reduction through education and metaphor.
    — Exercise and graded exposure promote fear reduction by encouraging resumption of activity “it’s ok, you won’t hurt yourself”.
    — CBT is about recognizing and replacing fearful thoughts with positive or neutral ones.
    — Mindfulness is about gaining distance between ‘essential self’ and ‘thought’, so that fearful thoughts are weakened in their effect.
    — Mindfulness might also attenuate ego-consciousness, depending on how skillfully it’s applied. This would be the ultimate in fear reduction.

    About point 2) I agree, a pleasant attitude is “necessary but not sufficient”. Ego attenuation, congruence, an ability to connect would be more likely to be the ‘sufficient’ therapist qualities. I hope you can include these measures in your trial.

    Regards,

    Cameron

  34. Hi Cameron
    in response to your questions;
    1. as well as fear exposure (graded exposure), a few different approaches like “explain pain”, acceptance, mindfulness, CBT, exercise (of various kinds) and graded activity all seem to have a reasonable amount of evidence from RCTS that they offer a small-moderate positive effect on disability and small positive effect on pain. of course that is for group averages, and it is not huge, and the reviews typically show these approaches are better than doing nothing, or compared to an actively harmful treatment (bed rest), but that none of them is clearly superior to each other.
    2. as the planned RCT probably shows, i think the contextual effects are key. However there is often an assumption that seeing a therapist with a nice manner, good listening skills etc… is always good for the patient. i would say it almost always is – except (and this is just my experience, hence need for RCT) if the therapist thinks (and talks) utter crap as then their lovely demeanour can convince patients their body really is badly damaged, and they should be very careful not to “overdo” it etc… Now proving that in an RCT requires giving one group a “nice” context and then “crap” information….and that is an interesting ethical discussion!

  35. Cameron says:

    Hi Kieran,

    1) Other than fear reduction through education, are there any other techniques or approaches that have been found effective?
    2) That sounds like a useful study. Clinically, it seems important not what technique is employed, but by whom. Personality factors, vibe, etc.

    Nordberg, thanks for that. I think we’re sort of on a similar path.

    Marcel, yes I’m down with the Explain Pain themes and techniques.

    Cameron

  36. John Quintner says:

    Adam, from what I can gather from exponents of dry needling, the “treatment” can be quite painful. If this is so, counter-irritation analgesia harks back into antiquity but there are now respectable scientific explanations for this phenomenon.

    References:

    Willer JC, Bouhassira D, Le Bars D. Neurophysiological bases of the counterirritation phenomenon:diffuse control inhibitors induced by nociceptive stimulation. Neurophysiol Clin 1999; 29:379-400.

    Sprenger C, Bingel U, Buchel C. Treating pain with pain: supraspinal mechanisms of endogenous analgesia elicited by heterotopic noxious conditioning stimulation. Pain 2011; 152:428-439.

  37. Exactly right. The exotic model of symptom explanation, the more elaborate the ritual and treatment delivery, the stronger the placebo or nonspecific response. One thing I will add: there is no need for anymore RCTs to explore whether dry needling can affect human biology in such a way that it stimulates a healing response or acts to attenuate pain (objectively). There is no mechanism of action for acupuncture or dry needling. There is no plausible reason, given the laws of cellular biology, chemistry, physiology, anatomy or physics, to suggest a way in which inserting fine needles into the epidermis along ‘Meridian’ lines or ” will achieve the desired response. Like I said previous, before one conducts an RCT, ask yourself – am I working from a Bayesian perspective here, or frequentist? Bayes’ theorem would dictate it doesn’t matter how small the statistical measure or large the effect, if you’re counting how much money the tooth fairy leaves you at night, then has anyone even considered what the phenomenon is that they are *actually* exploring with their positivist frameworks and methodologies? I could throw out a null, and speculate I won’t find any fairies at the bottom of the garden. I accept my hypothesis and move on. What a total waste of time and resources. n.b. after this lengthy rabble, I am agreeing with you, preaching to the choir!

  38. John Quintner says:

    Christine, before I answer your question in the negative and risk being consigned to eternal damnation, I challenge you to address three questions:

    1. How do you define “myofascial pain”?

    2. How do you diagnose it?

    3. What is your differential diagnosis?

  39. John, I’m Not sure what point you’re making here. Do you believe MYOFASCIAL pain does not exist? Sufferers might disagree. My comment was a caution that dry needling should not be dismissed across the board based on studies of its treatment for only 1 condition.

  40. Rolf-inge Nodberg says:
  41. Very good that there is big critisism on dry needling and every other treatment in the world of health care. Although I think that good quality research on this item is very hard because of a lot of bias possibility. Thinking in cause of presented problems, not able to blind people, amount of triggerpoints and local twitch response and so on. Dry needling is very very personal therapy in which it is almost unable to do reasearch cause the much differences in ways of treatment! I can’t understand why there is so much critisism on something that actually finally does work if done properly! We have amazing results with treatments where dry needling is involved! I check my patients regularly on outcomes and long term effects and I can assure u, we have a lot of long term effects in only a couple of treatments! So keep doing reasearch and don’t believe it, I will keep on doing it and bring doen the costs of health care and help people in my best way possible!

    Sorry for my not so good english with a lot of bias but this is making me feeling very bad! Always the same story of no evidence or not better than whatever control or shit they use! Come visit me and I will show u the results!!!

  42. John Quintner says:

    Christine, in logic this type of error is called “begging the question”! Almost all of these studies start with the assumption that there is a pathophysiological entity called “myofascial pain”. The extensive literature that this basic error has generated should be taken with a pinch of salt.

  43. Andrew Claus says:

    Thanks Daniel, Neil and Lorimer,
    Bah that your letter couldn’t be published. Misleading and fraudulent publications can be rescinded or retracted if the will exists. It may be unsurprising that a particular set of authors could have experiences and interests that colour (or obscure) valid interpretation of what they read; but it is very disappointing that the editor and the reviewers failed to identify the fundamental error/distortion and reject.

  44. Toby Moen says:

    Tip of my hat to you gentlemen. Insightful and serves a very valuable balance of opinion.

    With thanks,

    Toby

  45. @Cameron
    You say nothing works in PT
    Have you looked at the outcomes of pain education?
    The sys. Reviews and other rekevant studies.

  46. John Quintner says:

    John, it is more than troubling! The word scandalous comes to mind when it becomes generally known that respected health professional organisations are teaching and accrediting a modality of treatment that appears to be devoid of therapeutic benefit.

  47. Bravo Daniel, Neil, Lorimer
    It is vital that this work is done. The biased presentation of meta-analyses results has blighted the evidence base in several other areas. Clinicians have limited time and read these pieces, frequently just the abstract and they have great power to distort the opinion base.
    The Quebec whiplash study springs to mind, one about caudal epidurals reviewing the poor research of ASIPP, the recent one about acupuncture and there must be others that purport success when describing failure.
    The bias of the group doing the study is always shown in the study findings – especially when folk have ‘skin in the game’ – profits to be made – this distortion of science to support income streams is wickedness.

  48. Yes but perhaps you should have qualified your conclusion that dry needling is no more effective than sham IN UPPER QuADRANT MYOFASCIAL PAIN as this seems to be the only type of presentation reviewed in the meta analysis.

  49. Great, and important, post.
    Much of the criticism of evidence-based practice reflects the appearance that the evidence seems to change over time. I find it VERY unlikely that a review of dry needling in 10 years time will find enhanced evidence of effectiveness, with more larger studies using better controls having been used. The clinician is then left wondering is the “evidence” will change again in another 5 years.
    I guess this post is another reminder of the fact that such apparent “changes” in the evidence are not based on outright changes/differences, but on interpretation of the available evidence, and how willing one is to really stop and think not just “let’s show how right I am” but also “could I be wrong”?. I think there are strong parallels between the evidence for many interventions we “do” to people in pain (Dry needles, “wet” needles, acupuncture, manips, other manual therapies…). In the absence of a good sham control, they appear to do something small for the patient in the short-term. But this almost always is not seen when a suitable control is used, especially over the intermediate and long-term. And they are rarely if ever seen to add anything to something like exercise, CBT or other moderately helpful treatments which the patient can actively participate in. Of course, patients seek such treatments as they “fit” their belief that pain is about “issues in the (local) tissues”. But that hardly makes it ok to proceed with such treatments as a mainstay of treatment.
    On a semi-related note, I am intrigued by the fact that the negatives linked to many of these therapies focus on the serious (but very rare!) potential downsides (e.g. artery dissection post manip). While not downplaying the very serious impact of such events for the small number of people involved, I think such discussions can miss the fact that many of these therapies (even if they do not harm the patient physically) can harm the patient cognitively as they are often linked with a catastrophic set of diagnostic terms during assessment (“oh my, look how many rigger points you have, how badly subluxed your pelvis etc, how out of balance your Qi is……”). And we wonder why patients have fear, worry and catastrophic thoughts about pain?
    Cameron: 2 coments in relation to your post. (1) I think the evidence for treatments which might be related to “physio” can be questioned, but the same applies to many healthcare groups and interventions. Instead of wondering whether “physio” or “chiro” works (these are professions, not treatments), we should be asking what treatments (if any) work. From what people on this site have shown, many of the treatments with the most consistent evidence could reasonably be used by many different healthcare groups. (2) I agree that many of the contextual/non-specific factors you mention could be key to the effectiveness of treatments with a large degree interpersonal contact. we just got funding to conduct an RCT examining whether it is indeed what you do, or the way that you do it, for CLBP. So that might answer some of your question. whether clincians or the public value such aspects of treatment (as opposed to “specific” treatments like K-tape and dry needling) is another story of course).
    Kieran
    Kieran

  50. John Ware says:

    Well, they could’ve at least asked you guys to trim it down a bit. You raise very legitimate concerns about the Keitrys et al review and the accompanying perspectives for patients piece, and I know that the editors at JOSPT have received some criticism from at least one Orthopedic Section member regarding the publication of these articles (that would be yours truly).

    I’m afraid that the therapeutic dry needling (TDN) industry has gained a foothold here in the U.S., and particularly among PTs. Advertisements by various providers of TDN continuing education are emblazoned across the top of the Orthopedic Section home page and in full page color on the inside covers of JOSPT. It’s the next “big thing” in our profession.

    I think that’s very troubling.

  51. John Quintner says:

    John, your comment reminds me of the legendary story of King Canute and the waves. There will always be a place for counter-irritation analgesia. The tragedy I see is that its implementation has become a tool to ensure the financial viability of physiotherapy practices. But medical practitioners and chiropractors are not above criticism in this regard.

  52. Loved the appraisal.

    I think Bayes’ Theorem comes to mind here.

    If a treatment has a dubious mechanism of action that questions the laws of the established empirical sciences and thus demonstrates low prior probability, then no matter now small the frequentist statistical measure or large the effect size, it should be the case that one puts the evidence in context of what is already known about the world.

    Thanks,

    Adam

  53. John Barbis says:

    This conclusion is not surprising to me given the political machinations of the APTA, Private Practice Section, and the Orthopedic Section. There is a real fiscal concern about the viability of the present financial models for private practices unless increased revenue streams (particularly high reimbursement per unit of time procedures) can be produced. Given the coding and reimbursement rates for this procedure, it makes a lot of financial sense. I do not imply that the authors have done anything overtly unprofessional nor improper. Given the expansion of CE courses on dry needling, expansion of its visibility in the US, and its sale as a financial generator, Dry needling is a tidal wave that is hard to resist.

  54. Cameron says:

    Hi Guys,

    Thanks for the article.

    The trend in physio research findings is very apparent – nothing actually works. And yet patients definitely improve under our care.

    Can I make a plea to researchers to change focus? Clinically, it seems likely that the following factors are important: touch, smiling, congruence, warmth, active listening, connection. Wouldn’t it be a huge relief to read an article which finds a strong statistical benefit for once?!!

    Sincerely,

    Cameron

  55. No big surprise that most clinical PT research (and subsequent meta analysis of) is set on confirming expectations, justifying a context of care (dry needling), and perpetuating the status quo (treatment = relief from pain.) All three need to change before we finally realize the futility of specious treatments such as dry needling (and friends: manip etc.)