Decoding the Brain: Will Future Physical Therapists Manipulate Hippocampi Instead of Spines?

Interneurons
Image courtesy NIHCD via Flickr

National Geographic Channel is featuring a slick new program:

Breakthrough: Decoding the Brain” on Sunday, November 15, at 9 pm ET on National Geographic Channel. 

As part of this show’s launch, they’re posing the following question for commentary:

“What if scientists were able to implant or erase memories? For some, like those suffering from PTSD this could be life-changing, or do you think this is scientific innovation gone too far?”

This question is right up our alley!

The Brain and Chronic Pain

The recent meeting of the American Academy of Orthopaedic Manual Physical Therapists (AAOMPT) in Louisville, KY was a bit unique. Unique, because in contrast to years and years of this conference unsurprisingly featuring scientists purporting the evidence for using manual therapy techniques like spinal manipulation for patients with musculoskeletal pain, this year the conference featured speakers who didn’t use their hands. The conference keynote was delivered by Dr. Peter O’Sullivan, (his cool blog is here) who spoke about his work related to Congnitive Functional Therapy for patients with chronic pain. Other talks revolved around pain science, big data, and a general change in the tenor was noticeable.

Manual therapists have long struggled with patients who have chronic symptoms, as short term gains are quickly realized, but long terms gains are extremely difficult to achieve. So, what prompted the AAOMPT, a scientific academy founded around manual therapy techniques, education, and science, to feature a pallet of speakers speaking about techniques that didn’t involve hands or cavitating  joints? Well, friends, science is always a moving target, and it’s broad, and sometimes you need to look outside your cerebral solar system to learn new things. This is one of those times for physical therapists!

But, perhaps we don’t need to travel too far! This new traditional neuroscience science is now showing up in manual therapy journals like…well, Manual Therapy! In a recent article, entitled, “Exercise therapy for chronic musculoskeletal pain: Innovation by altering pain memories,” Nijs et al address the concept of movement-related pain memories and exercise for patients with chronic pain. They suggest that clinicians should preempt exercise therapy by first priming the brain via neuroscience education, and then utilizing movements to help the body ‘forget’ those memories associated with those movements and pain. Sounds just like Peter O’Sullivan’s CFT doesn’t it? This work builds on work by neuroscientists who are exploring the role of the hippocampus in generating pain-related memories. This is a wide open field, and the potential of learning how to impact pain related memories is truly astonishing!

Manipulating Hippocampi?

While the concept of having memories erased seems on the surface frightening… (I wouldn’t want to forget that cool downhill bike ride down Mount Snow even though it hurt!)… it does seem that breaking links between pain experiences and memories is one of the keys to managing chronic musculoskeletal pain conditions. Just how we do that best remains to be seen! Will future physical therapists have a cadre of tools that not only allows for mechanical inputs to alter central nervous system activity (spinal manipulation), but also precise strategies to target pain memories and more directly impact cognitive reasoning about pain? I sure hope so!

I’m excited for the new Breakthrough series on NatGeo. It just seems like one of those times when all sorts of science is converging on something…on the true potential of that “3lb mass in our heads!”

 

 

What are the Issues with Therapeutic or Trigger Point Dry Needling? 9 Considerations to Ponder

Dry needling continues to garner increasing popularity within physical therapy. And, the focus is not just clinical, a pubmed search for “physical therapy” and “dry needling” illustrates an 8 fold increase of manuscripts from 2010 to 2015 (66) compared to 2000 to 2005 (8).1,2

The number of continuing education courses, certifications, and companies offering dry needling continues to rapidly expand. Further, there appears to be no shortage of anecdotal reports of the remarkable “power” of this intervention and clinical experiences suggesting it’s “the next big thing.” But, I have some questions, and justified concerns regarding the outpatient orthopaedic physical therapist’s most invasive intervention. Larry Benz has commented “trigger point dry needling is not #physicaltherapy.”3

Yes, while there is a paucity of evidence, TDN probably works in some instances-likely more to “meaning effect” and placebo than anything else (which of course is fine but in states with informed consent forms it probably works as a  nocebo).  My concern is the nocebo effect of TDN on our profession.

The irrational exuberance around TDN within the #physicaltherapy profession is ironic if not downright damaging.  We fight and defend for direct access, expanded scopes of practice, evidence as the core basis of our interventions, and being recognized in the healthcare chain as force multipliers within the musculoskeletal world yet state legislators in many states are hearing PT’s fight for the right to stick needles into patients. TDN is hardly a transformative intervention and regardless it does not define #physicaltherapy.

Like Larry, I am concerned and request that we as a profession take a moment to appraise this intervention, in terms of applicable clinical evidence and appropriate critical reasoning, before enthusiastically implementing dry needling, let alone recommending it to patients in professional publications.4 Further, the issues and assessments are not limited to dry needling specifically, as the approach can be applied to other interventions and concepts such as cupping.

Clinicians utilizing dry needling will exclaim “dry needling is not acupuncture!”, but the paradox is proponents continue to use acupuncture“evidence” (of both traditional Chinese medicine and biomedical flavors) to supposedly support their practice. Obviously, dry needling is not actually acupuncture. I’m not sure it even bears repeating that rarely is dry needling the sole intervention provided by a physical therapist. But, given the invasive nature and significant learning cost, in terms of both time and money, the addition of dry needling to a treatment plan as either an additive intervention or in replacement of other interventions, seems suspect without research supporting significant improvement in outcomes.5 And, this improvement should be specific to needling itself, not the byproduct of other non-specific mechanisms. Or, alternatively, needling must illustrate some measurable, or even highly plausible, physiologic effect known to improve a patient’s condition, main complaint, or medical diagnosis.

What issues with dry needling should be considered?

1) Acupuncture Literature Applies
2) Dry Needling Research is Underwhelming and Misrepresented
3) Poor Terminology Surrounding Needling, Trigger Points, and Myofascial Pain
4) Lessons from the Evolution of Manual Therapy: Manipulation
5) Treatment Targets and Proposed Mechanisms
6) Insights from the Study of Pain
7) Risk vs. Benefit and Invasiveness
8) Cost and Time
9) Bias in Research Interpretation and Conflicts of Interest

The Acupuncture Literature Applies

I contend that the acupuncture literature can provide us with some insights on the specific effects of inserting a needle into human flesh, be they physiologic, psychologic, perceptual, or otherwise.6 Of course, this is dependent on the assumption that any specific meaningful effects exist beyond transient, clinically irrelevant short term improvements in symptoms and subjective reports likely mediated by meaning response, expectation, context, non-specific effects, and placebo.7

In short, it is unambiguously clear from high quality investigations, systematic reviews, and meta analyses that acupuncture is nothing more than a “theatrical placebo.8 The research illustrates:

  • Poorly designed smaller studies with high risk for bias showing promising results
  • Larger, well controlled studies show no meaningful clinical benefit
  • Needling location doesn’t matter
  • Needle depth doesn’t matter
  • Skin penetration doesn’t matter18
  • The needle doesn’t even matter, toothpicks work just as well

Interestingly, similar to potential mechanisms in manual therapy what does appear to modulate, or predict, small observed outcomes in select patients is expectation, patient beliefs, and individual practitioner factors among others.7,9-14 Specifically,

The individual practitioner and the patient’s belief had a significant effect on outcome. The 2 placebos were equally as effective and credible as acupuncture. Needle and non-needle placebos are equivalent. An unknown characteristic of the treating practitioner predicts outcome, as does the patient’s belief (independently). Beliefs about treatment veracity shape how patients self-report outcome, complicating and confounding study interpretation.

Whether studied as a means to move qi along meridians or under a more western and biomedical informed lens, acupuncture has consistently failed to show that is an effective treatment.15 Such results should not only give us pause regarding the recommendation of acupuncture to patients for the treatment of various painful problems, but should also raise serious questions regarding the enthusiastic implementation of dry needling into physical therapist practice, clinical research agendas, and post professional education.

If needle insertion, needle location, needle depth, or even using a toothpick do not seem to affect outcomes in acupuncture, I’m perplexed by those who propose dry needling is somehow, in some way profoundly physiologically different.16-18 And furthermore, how anyone can subsequently claim dry needling location, depth of penetration, and other specific factors relating to application technique can robustly impart some important physiologic effect or meaningfully impact on clinical outcomes. Physical therapists should likely temper claims of mechanistic specificity, or effect, and be cautious in citing acupuncture literature to support the practice of dry needling.

Dry Needling Research is Underwhelming and Misrepresented

Many will claim the research around dry needling is growing, and promising results suggest broad applicability. Oddly, some will state that dry needling is not acupuncture and in the next breath cite flawed, or misinterpreted, acupuncture literature as a seemingly evidence base plea for the usefulness of dry needling. While the volume of manuscripts relating to dry needling continues to rise, the actual trial data is underwhelming at best, if not outright negative. Yet, articles in professional magazines, clinical perspectives, and (flawed) systematic reviews positively frame the intervention as effective.19-21 These assertions may mislead casual readers to conclude the data supporting dry needling is quite strong. This is not the case. Harvie, O’Connell, and Moseley at Body in Mind conclude:22

We contend that a far more parsimonious interpretation…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.

A more recent systematic review effectiveness of trigger point dry needling for multiple body regions concluded “The majority of high-quality studies included in this review show measured benefit from trigger point dry needling for MTrPs in multiple body areas, suggesting broad applicability of trigger point dry needling treatment for multiple muscle groups.”23 Unfortunately, that is not what the trials included indicated as only:

  • 47% showed a statistically significant decrease in pain when compared to sham or alternative treatments
  • 26% displayed a statistically significant decrease in disability
  • 42% did not include a sham or control intervention group
  • 32% investigated only the immediate effects (ranging from immediately post-intervention to 72 hours) of TDN which is a research design with remarkable limitations24
  • 3 assessed the quality of the blinding in the sham group
  • 1 was retracted at request of the journal editor

Specifically, one randomized trial effectiveness of trigger point dry needling for plantar heel pain found a number needed to harm (NNH) of 3 and a number needed to treat (NNT) of 4. So, for every 3 patients treated with needling 1 is likely to develop an adverse event while for every 4 patients treated only 1 is likely achieve a beneficial outcome. Or, in other words, patients in the treatment arm were more likely to experience an adverse event than a beneficial outcome. One of the most commonly reported adverse events, in addition to bruising, was an exacerbation of symptoms, which I will argue is only acceptable if intermediate and long term outcomes of dry needling are somehow superior. An invasive intervention that results in more adverse events, lacks long term benefit, or fails to measurably change an underlying physiologic derangement should likely not be employed. Subsequently, available interventions that are effective, less invasive, and less likely to result in symptom exacerbation such as graded exercise/activity/exposure, cardiopulmonary exercise, pain education/therapeutic neuroscience education, and non-invasive manual therapy should be preferentially implemented.

These are significant and specific concerns that require careful consideration.

Poor Terminology: Trigger Points, Myofascial Pain, and Needles

Unfortunately, dry needling is riddled with poor terminology and vague language. Admittedly, such an issue is not unique to dry needling, and thus this entire post is applicable to many interventions and trends within physical therapy: cupping, scraping the skin with instruments (instrumented assisted soft tissue mobilization), and trendy tools in the proverbial tool box.25,26 But, never the less language is a significant issue as researchers attempt to investigate and understand the intervention in greater depth and clinicians continue to broadly implement it into practice. It’s not just semantics, precision in language is an absolute necessity.28

What are the actual differences between trigger point dry needling, dry needling, therapeutic dry needling, intramuscular manual therapy, functional dry needling, systemic dry needling, integrative dry needling, or any other form of physical therapists poking patients with needles?

Regardless of the clinical trial data (which is actually weak), those utilizing a myofascial trigger point approach to dry needling need to acknowledge the current issues with regards to a lack of consistent criteria defining a trigger point, the questionable clinical importance (if any) of the proposed trigger point construct, and the poor reliability in trigger point identification. There are many foundational issues at the core of the trigger point theory including an absolute lack of established validity. John Quintner upon evaluating trigger points:29,30

The existence of such bands had never been demonstrated and it was therefore highly speculative and erroneous to attribute nerve entrapment to such a mechanism. Other weaknesses in their theory included the somewhat metaphysical concepts of “latent trigger points,” “secondary trigger points,” “satellite trigger points” and even “metastasising trigger points”. To further confuse matters, it was later shown that “experts” in MPS diagnosis could not agree as to the location of or even the presence of individual MTrPs in a given patient. The mind-boggling list of possible causative and perpetuating factors for MTrPs was completely devoid of scientific evidence and therefore lacked credibility…Finally, those who became “dry needlers” appeared to be unaware that when justifying their assault on MTrPs they were following the “like cures like” tenet of homeopathy. In their parlance, physical therapists (including physicians) were obliged to create a lesion in muscle tissue in order to cure (“desensitise”) a lesion (for which there was no pathological evidence)…

…subsequent literature was also notable for its failure to acknowledge that the underlying hypothesis was flawed – no one has ever succeeded in demonstrating nociceptive input from putative myofascial trigger points. All subsequent “research” simply assumed the truth of what started out – and remains – as conjecture.

Also, worth mentioning are the significant issues such as tautological reasoning inherent in not just trigger point theories and hypotheses, but also myofascial pain syndromes and fibromyalgia.30-33 I do agree with the term “Therapeutic Dry Needling.” I contend this language and nomenclature separates the technique from theoretical and mechanistic principles, thereby allowing continued growth and open discussion as the science evolves. In addition, the current terms, and many of the accompanying theories, are not fully encompassing of the state of the literature in regards to trigger points, myofascial pain, pain treatment, and possible treatment mechanisms. Lastly, some further perpetuate specific targets and theories of intervention that are quite frankly unreliable, and worse, invalid. Not to mention, understanding will inevitably change over time. Specifically, precise operational definitions are required for scientific inquiry. Vague language leads to vague reasoning and muddies research results. Geoffrey Maitland is credited with the insight “to speak or write in wrong terms means to think in wrong terms.”

In aggregate there is sufficient reason to not only doubt, but discard, the foundational premises  of trigger points, myofasical pain, and potential “needleable lesions” as clinically meaningful entities and necessary treatment targets.34-35

The Evolution of Manual Therapy: Manipulation

History, some may say, is our greatest teacher. A rearward glance into the evolution of manual therapy practice and mechanisms, specifically manipulation, appears eerily applicable to the current discussion. Specific derangements such as sacral nutations, ESRL, FSRL, sacral flares, leg length discrepancies, static posture position, and subtle biomechanical “faults” supposedly necessitated specifically matched techniques for proper symptom resolution. The minute differences between techniques such as angle, spinal level, specific joint mechanics, and other application factors such as speed were presented as highly important to garnering the proper effect. The tissues were hypothesized to be the primary dysfunction and treatment target. Concepts such as the “manipulatable lesion” were developed.

The paradigm of assessment and treatment attempted to mirror diagnostics in other segments of medicine, a laudable effort to be sure. Clusters of information, in the case of manual therapy the patient’s symptoms, palpable dysfunctions, and malalignments, were supposed to be aggregated into a specific diagnosis. Specific diagnoses warranted specific treatment at a specific dosage or speed or spinal level. Unfortunately, the fatal flaw with this diagnostic approach in manual and physical therapy is the overall lack of essential diagnoses, commonplace in medicine, and the high prevalence of nominal diagnoses.36 Outpatient orthopaedics is primarily characterized by pain complaints, often times absent of significant trauma, tissue injury, or diagnosable physiologic derangements. In a failed attempt to solve such a conundrum, nominal diagnosis or clinical syndromes such as patellafemoral pain syndrome or “pain on the front of the knee mostly when squatting or bending the knee with the foot on the ground” and shoulder impingement syndrome or “pain on the front of the shoulder mostly when raising the arm overhead that sometimes feels like a pinch” were created with the goal of improving the specificity of treatment and our ability to match interventions to patient presentation.

Proposed mechanisms included changing tissue length, loosening joint capsule, breaking adhesions, unsticking stuck joints, and improving tissue related joint mobility. Minute, subtle, questionably detectable, but in actuality irrelevant, biomechanical faults were pitched as the cause of patient symptoms. But, years of research now state otherwise.37

Matching a specific manual therapy technique to a specific, theoretical, but quite frankly imaginary, fault proved not only to be futile, but unnecessary.38 The amount of force provided through the hands lacks the speed, acceleration, and load to meaningful change tissue length and other material properties. Manual therapy techniques were shown to result in movement at many levels of the spine. And, the specific technique utilized didn’t seem to matter much. Overall, technique type, long lever vs. short lever, speed, and exact level of the spine didn’t seem to matter much either. Predictors of response to treatment did not include classical palpation and hands on motion testing. Fear avoidance beliefs and length of symptoms did however. The neurophysiologic mechanisms of manual therapy appeared similar to placebo mechanisms.9 Patient expectation of success was important as was therapeutic alliance.11,39,40 Clinician expectation was correlated with outcome. Framing of the intervention’s potential effects seemed to affect degree of analgesia.41

Manual therapy can now be conceptualized as a neurological input and patient interaction whose overall effect, in both direction and magnitude, appear to be related to host of a complicated interacting factors, most of which have little to do with the specific technique.10

Yet, those teaching and researching dry needling appear to be clearing an old trail. Peripheral derangements, specific techniques, and minute, likely minimally important dysfunctions as a root cause of a patient’s symptoms. Assumptions, in my opinion incorrect ones, are leading us down a long road, which if manual therapy and manipulation research is any indication, will require an even longer journey to reverse.

Treatment Targets & Proposed Mechanisms

In addition to vague language, the currently proposed treatment targets and purported mechanisms of dry needling fail to integrate understanding from the acupuncture literature and compose an incomplete consideration of potential mechanistic factors.

Trigger points, latent trigger points, twitch response, trigger point referral patterns, facilitated segments, neuro-trigger points, micro-tissue trauma, chronic local inflammation healed by needle induced inflammation, and the list goes on. The fact that a dense array of sensory receptors of various types, including nociceptors, exist in nearly every layer of tissue including the cutis and subcutis, suggests it is not only possible, but quite likely that stimulation of these receptors is sufficient to produce the proposed therapeutic benefits. This is anatomically and neurologically true regardless of needle depth. The clinical studies of acupuncture support such a claim as neither needle location nor depth nor skin penetration nor the needle itself appear to specifically contribute to outcomes. The skin contains dense array of free nerve endings, and other receptors. Those who present possible dry needling constructs should acknowledge the current, multi-factorial mechanisms of manual therapy and the various factors contributing to overall treatment responses.

  • Can we ascertain specifically which structures are needled?
  • Is it not likely we are needling a host of structures?
  • Can we ascertain the receptors that are stimulated during needling?
  • Is it not likely we are needling various receptors?
  • Can we actually target specific tissues or receptors?
  • Is targeting specific tissue necessary, or even sufficient, for symptom resolution or a positive clinical outcome?
  • Does specificity in anyway affect outcome?

There are many inherent issues with assuming, let alone presenting, specificity of a treatment target and subsequently proposed mechanism based on test/re-test assessments and clinical observations of benefit. Such an explanatory model assumes the underlying theoretical construct is accurate but also that:

1) The test is specific to that tissue, structure, or defined dysfunction (validity)
2) A positive, or negative, test (or test cluster) is accurately identifying the tissue, structure, or defined dysfunction (reliability, sensitivity and specificity)
3) The subsequent treatment intervention is specific to the identified dysfunctional structure and thus
4) The mechanism of effect specifically relies on treatment target, application, and location
5) Resolution of the symptom and clinical outcome is dependent on the preceding

A test/re-test approach, while clinically appropriate for assessing response to treatment, is inappropriate reasoning as a mechanistic explanatory model. So, we must further explore:

  • What is the premise of this intervention?
  • Is it more efficacious, effective, or efficient than other interventions?
  • Are the models of assessment and treatment plausible? Valid? Reliable?
  • Are there other explanations that may explain the observed effects, and thereby question the necessity of needling?
  • Is this intervention as specific to certain tissues or explanatory models as it is presented?
  • Is needling necessary, or even sufficient, for symptom resolution? Or, a positive outcome?

All approaches to and explanations of dry needling need to incorporate current, multi-factorial mechanisms of manual therapy and various factors contributing to overall treatment responses in pain. Such research would suggest that targets and mechanisms of many of our interventions for pain are not nearly as specific as previously assumed and currently presented. With this this in mind, one should be cautious in making claims of specificity. How can all the other potentially stimulated neuro-vascular structures, contextual factors, patient-practitioner interactions, and various other treatment effects be ruled out, or at least addressed as not only potential contributors to outcomes, but confounders to study results?

Pain Science and Complexity

Pain is now understood as a multifactorial, individualized, lived sensory and emotional experience much more profound than mere peripheral nociceptive signaling. The neurophysiologic, psychologic, environmental, contextual, as well as social factors present in the concept of pain are exceedingly complex. And, that is not inclusive of the profound philosophical and linguistic challenges of defining, studying, understanding, educating, and ultimately interacting with someone in pain. Attempting to accurately reconceptualize pain illustrates:42

 …the biology of pain is never really straightforward, even when it appears to be. It is proposed that understanding what is currently known about the biology of pain requires a reconceptualisation of what pain actually is, and how it serves our livelihood. There are four key points:

(i) that pain does not provide a measure of the state of the tissues;
(ii) that pain is modulated by many factors from across somatic, psychological and social domains;
(iii) that the relationship between pain and the state of the tissues becomes less predictable as pain persists; and
(iv) that pain can be conceptualised as a conscious correlate of the implicit perception that tissue is in danger.

These issues raise conceptual and clinical implications

And thus, it is worth mentioning not only a few of the myriad of factors that contribute to symptom severity, symptom report, and seeking medical treatment, but also the the swarm of interacting constructs that contribute to effect.43

Treatment Mechanisms in Pain
>Non-specific effects
>Placebo
>Nocebo
>Patient Expectation
>Provider Expectation
>Context
>Previous Experience
>Believability of the Intervention
>Psychologic State
>Framing and Language Surrounding the Intervention
>Regression to the Mean
>Naturally History
>and others

Obviously, such factors are not unique to dry needling. They are present in all treatments, especially those for pain. But, given the current understanding of pain stemming from a multitude of varied scientific disciplines, how can we assume, let alone propose, that sticking a human in pain with a fine needle contains sufficient and significant effect to be a primary contributor to relief and positive outcomes in both the short and long term? And, more importantly, why should we? It appears we’ve learned little from decades of research into the nature of pain, the mechanisms of treatment, passive vs. active approaches to care, acupuncture, “wet needling,” and manual therapy. Physical therapists, will rightly so I might add, critique the overuse of “wet needling” (and other interventions) by physicians, yet barely raise but a whimper of protest at the proliferation of dry needling. It may be time to refine our internal, smaller picture to facilitate crossing the chasm.44,45

Risk vs. Benefit and Invasiveness

The invasiveness of dry needling within the scope of physical therapist practice presents a unique and complicated challenge when attempting to assess risk vs. benefit in isolation, risk vs. benefit in comparison to other medical procedures, as well as risk vs. benefit in comparison to other physical therapist delivered interventions. It seems we over simplify, and potentially misunderstand risk versus benefit analysis as it applies specifically to physical therapy interventions. Sure, comparing dry needling adverse event types and rates to other medical interventions is tempting. It is an interesting health services inquiry. And, such an approach does hold some value for comparing intervention risks, benefits, and efficacy within the spectrum of the many possible health care interventions. Arguably, and quite plausibly, dry needling within the confines of a physical therapy treatment plan is safer than early imaging, prolonged NSAID use, delayed physical therapy referral, opiates, and of course spinal surgery. But, it seems to me this particular argument, even if compelling, even if true, is a weak and incomplete justification for needling. Although, please note even acupuncture may not be as safe as assumed.46-48

Comparisons regarding the risk, invasiveness, efficacy, and effectiveness of specific physical therapist delivered interventions are necessary.49 These comparisons are required in general, but also specifically within various conditions, complaints, diagnoses, and patient populations. Given the invasiveness, regardless of risk profile, to justify widespread utilization dry needling must illustrate robust effectiveness (or even significantly more efficacy) in relation to other physical therapist delivered interventions. And, any potential effectiveness must be assessed in the context of possible negative effects such as an exacerbation of symptoms and other more significant adverse events.

On the grounds of efficacy, effectiveness, risk, invasiveness, and potential benefit when compared to our other interventions for pain, I can’t understand an argument that currently justifies dry needling. Physical therapists must not merely claim superiority, or justify interventions, on the tenuous foundation that we are less invasive and less risky than other medical interventions. It’s not quite that simple. Physical therapists must provide the same internal scrutiny to comparing our own interventions in addition to comparing physical therapy interventions to physician practice patterns.44 Further, when taking into account the training cost and time it does not make sense to advocate for this intervention.

Training Cost & Time

An often undiscussed problem with dry needling is both the cost and time required to learn the technique. Currently, all states that allow physical therapists to practice dry needling require further training or even certification. So now, unfortunately, physical therapists are burdened not only with assessing the potential applicability, safety, risk and benefit of the intervention, but also the cost (time and money) required to even be granted permission to practice dry needling. Such a situation is quite acceptable for an intervention with robust effectiveness and broad applicability. But, for a single, questionably effective, invasive intervention this seems unnecessary if not wrong. For clinicians, what knowledge could be gained or other skills developed? For professional organizations, what other legislative challenges could be addressed? Who stands to benefit from such a scenario? Well, most obviously those who sell dry needling courses.

Bias in Research Interpretation and Conflicts of Interest

Similar to manual therapy, an alarming number of studies investigate immediate effects only which regardless of results is likely “much ado about nothing.”24 Many of the manuscripts pertaining to dry needling also contain overstated conclusions or even a misrepresentation of results.

In this regard, it is worth noting that many of those publishing positive systematic reviews, providing anecdotes and patient stories of success, and presenting on the potential favorable impact of dry needling teach or directly financially benefit from the teaching of dry needling.19, 20 For example, Kenny Venere and I observed that the authors of a highly positive viewpoint on acupuncture for knee osteoarthritis that was published in PT in Motion not only teach dry needling continuing education courses, but also offer a certification in dry needling.15,50 Oddly, this section and the subsequent statements were edited out of the final printed version of our letter. In any case, one of the authors is the “President of the Spinal Manipulation Institute and Dry Needling Institute of the American Academy of Manipulative Therapy” which offers a postgraduate diploma (which I’ve been openly critical regarding the name).51 The diploma is described as such:

an evidence-based post-graduate training program in the use of high-velocity low-amplitude thrust manipulation and dry needling for the diagnosis and treatment of neuromusculoskeletal conditions of the spine and extremities.

Now, other individuals and companies in the dry needling post-professional education business are all also at risk of being significantly influenced by financial incentives. For example, a program director for another dry needling continuing education company, continues to publish manuscripts defending the construct of myofascial trigger points which are, unsurprisingly, the foundation of their approach to dry needling.51 I’m sure many will contend I’ve unfairly singled out these individuals. But, I am by no means insinuating those financially vested in the dry needling continuing education business are insincere or intentionally misrepresenting trial data.

I do however wish to highlight the potential for interpretation bias of research evidence when significant (or even potential) conflicts of interest and financial incentives are present. Chad Cook, PT, PhD referring to manual therapy research poignantly states don’t always believe what you read:53

…there have been a number of manual therapy studies that were designed by clinicians who have a personal interest in the success of one intervention over another. These clinicians have either a vested interest in the applications that are part of the interventional model because they provide instruction of these techniques in continuing education courses in which they profit from (although it may seem minimal, it is not); or because the tools are part of a philosophical approach or a decision tool that was designed from their efforts or efforts from those they were affiliated with. In nearly all cases, the bias is not intentional and certainly not malicious…

I am concerned that new clinicians, passionate followers of selected manual therapy approaches, and in some occasions, seasoned clinicians, will be mislead because they lack expansive/formal research training with respect to study methodology. Certainly, once information is advocated within the clinical population, it takes years to diffuse its use, even after acknowledgement of its erroneous findings.

Dr. Cook’s concerns, which I urge you to consider, relate intimately to the surge in dry needling literature and clinical application. In physical therapy research the impact of potential conflict of interest and resulting bias of researchers also highly involved in continuing education companies is in a word: unknown. But, it is quite obvious that there is a potential conflict of interest and subconscious bias present for individuals who directly financially benefit from teaching a specific technique, or approach. And, this issue transcends dry needling. Regardless of intent, there is an incentive for positive conclusions surrounding that particular technique or school of thought. What and where are the incentives? I understand, and openly support, those who identify and ask difficult questions surrounding the possible unidentified conflicts of interest which have historically been neither discussed nor disclosed. It absolutely requires consideration. More disclosure within academia and the research literature regarding business relationships and continuing education ties is warranted.

In designing, or interpreting research conscientious checks and balances, for example blinding and proper study methods, must be executed. My sense is that it would be profoundly difficult to conclude an intervention is minimally effective, or even unnecessary, after designing, teaching, and selling courses founded upon the apparent diagnostic power and treatment effectiveness of a single intervention or specific treatment paradigm.

Summary & Conclusion

Unfortunately, I sense that dry needling is the new manipulation, which to be clear is not a compliment nor an endorsement. The intervention is not going away, and precious research dollars, cognitive space, and professional resources will undoubtedly be devoted in attempts to “prove it works” (or even “how does it work?”) which is in direct contrast to the true scientific method which is founded upon falsifiability, or “prove yourself wrong” (or even “does it even work?).

But, in getting to the point, the terminology is poor, the constructs questionable, and the current research underwhelming. Acupuncture literature suggests effects are small and non-specific to needling, and the current dry needling data demonstrates the same pitfalls in both design and interpretation. Note this is our most invasive intervention for pain, and it is technically quite passive. Additionally, many of the theoretical constructs and clinical explanations are myopic, vague, and appear invalid. Assessing risk vs. benefit of the intervention in isolation, and in comparison to other physical therapist delivered interventions, is an important, under discussed complexity of implementing needling into practice. Significant potential conflicts of interest and bias are present in the literature. As if that wasn’t enough, the time and cost to learn this intervention are astounding.

Yet, positive clinician experiences, professional publications, and overly optimistic reviews continue to escalate. Jason Silvernail, DPT, DSc, FAAOMPT asserts:

We should all – every one of us – be nothing but disturbed by our colleagues’ use of emotional anecdotes. I look forward to the day when mentioning an anecdote automatically makes our students shake their heads and turn away…Highly recommend people look into MJ Simmonds’ work on intolerance of uncertainty in our profession and how that anchors practitioners beliefs into concrete and wrong explanatory models loaded with nocebo and external loci of control.

Given the discussed issues, and likely others, the current unbridled enthusiasm and growing popularity of dry needling seems unwarranted, if not a mistake. I urge physical therapists, educators, clinicians, researchers, students, and professional leaders to re-consider.

History, it appears, has taught us little in this regard.

References & Resources

1. Pub Med Search. "Physical Therapy AND "Dry Needling" 2010-2015. Performed August 3, 2015

2. Pub Med Search. "Physical Therapy" AND "Dry Needling" 2000-2005. Performed August 3, 2015

3. Benz L. Trigger Point Dry Needling is Not #PhysicalTherapy. Evidence in Motion Blog. March 2014

 4. JOSPT perspectives for patients. Painful and Tender Muscles: Dry Needling Can Reduce Myofascial Pain Related to Trigger Points. J Orthop Sports Phys Ther. 2013;43(9):635

 5. Ridgeway K. Measuring Outcomes, Outcome Measures, and Treatment Effects. Physical Therapy Think Tank. December 13, 2014

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 11. Bialosky JE, Bishop MD, Cleland JA. Individual expectation: an overlooked, but pertinent, factor in the treatment of individuals experiencing musculoskeletal painPhys Ther. 2010 Sep;90(9):1345-55

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 19. Ries E. Dry Needling: Getting to the Point. PT in Motion. 2015;5

 20. Dunning J, Butts R, Mourad F et al. Dry needling: a literature review with implications for clinical practice guidelinesPhys Ther Rev. 2014 Aug; 19(4): 252–265

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 24. Cook C. Immediate effects from manual therapy: much ado about nothing? J Man Manip Ther. 2011 Feb; 19(1): 3–4

 25. Cotchett MP, Munteanu SE, Landorf KB. Effectiveness of trigger point dry needling for plantar heel pain: a randomized controlled trialPhys Ther. 2014 Aug;94(8):1083-94

 26. Brence J. The Tools We Use. Forward Thinking PT. July 29, 2013
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 28. Ridgeway KJ. Precision in Language. Physical Therapy Think Tank. May 7, 2014

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 32. Cohen M, Quintner J. The horse is dead: let myofascial pain syndrome rest in peace. Pain Med. 2008 May-Jun;9(4):464-5

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 34. Quintner JL, Bove GM, Cohen ML. Response to Dommerholt and Gerwin: Did we miss the point? J Bodywork & Move Ther. July 2015;19(3):394–95

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 39. Ferreira PH, Ferreira ML, Maher CG et al. The therapeutic alliance between clinicians and patients predicts outcome in chronic low back painPhys Ther. 2013 Apr;93(4):470-8

 40. Fuentes J, Armijo-Olivo S, Funabashi M et al. Enhanced therapeutic alliance modulates pain intensity and muscle pain sensitivity in patients with chronic low back pain: an experimental controlled studyPhys Ther. 2014 Apr;94(4):477-89

 41. Bialosky JE, Bishop MD, Robinson ME, Barabas JA, George SZ. The influence of expectation on spinal manipulation induced hypoalgesia: an experimental study in normal subjectsBMC Musculoskelet Disord. 2008 Feb 11;9-19

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If You’re Going, You Might As Well Get There

[list][/list]Sometimes, it’s pure and simple logic that prevails as the best solution to something. This was the case in an important new study published ahead of print in Spine. You may have seen the presser released by APTA, AAOMPT on the matter. They’re exuberant, and they should be. Well, mostly.

The study, published by Drs. Julie Fritz, John Childs, Rob Wainner, and Tim Flynn, examined a payor database and looked at over 32,000 data sets of patients with low back pain with the purpose of describing physical therapy utilization in primary care settings. Further, they looked at both associated healthcare costs and the question of whether the physical therapy care being provided was either adherent with practice guidelines for an active treatment or non-adherent. Treatments were classified as non-adherent when they included things like ultrasound that are not proven interventions for patients with low back pain. While not a perfect practice, the researchers used billing codes as their determination factor for treatment adherence.

The findings of this study are fascinating to me. Albeit, many public health studies that look at low back pain and care patterns and/or costs are fascinating to me, so I’ll let you be the judge.

The key findings of the study were:

[list style=”circle”]

    • For patients receiving physical therapy, early referral (within 14 days) was associated with less overall healthcare utilization, which included lower use of surgery, fewer doctor visits, less injections, and less advanced imaging that those with delayed referral (14-90 days).
    • For patients receiving adherent care, overall health utilization was also lower, but to a lesser degree that that seen with the early referral group.

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Graph demonstrating health utilization costs related to low back pain. Series 1 is costs for patients in early referral (gray) vs. delayed (orange). Series 2 shows costs for adherent care (gray) vs. non-adherent care (orange).

 

As you can see by the graph above, significant savings were realized by early referral to physical therapy and by adherent physical therapy care. Logic sure does shine forth here. If you’re going to go somewhere, well you might as well just get there. Significantly, the finding in this study is important because it runs counter to the suggestions by many LBP practice guidelines that suggest primary care physicians delay referral to other services as many patients are likely to improve anyway. Overall trends to reduce the medicalization of LBP are important, but this study reflects a trend whereby physicians are referring about half of patients to physical therapy within 14 days anyway. It turns out, this may end up being an evidence-supported practice.

Not all was rosy, however. Here are some other findings that were important:

Overall patient data sets and 7% utilization for patients with low back pain.

 

[list style=”circle”]

    • Overall utilization for physical therapy for patients with low back pain in this data set was only 7%.
    • Overall healthcare costs were higher for patients receiving physical therapy. This might reflect increased severity, co-morbidities, etc, we just don’t know.
    • Only 21% of the physical therapy care provided was able to be classified as adherent. This could reflect an imperfect measuring tool, but I suspect there’s a problem here.
    • Wide geographic variability persists in the management of LBP, including physical therapy utilization and adherence to guidelines.

[/list]

This study is full of many other gems. It’s gated at Spine, so apologies for not including a full text link. The good new: Spine is a huge journal and this will be seen. As with many studies, this leaves more questions to ask. Such as, what factors make the patients who are referred early have lower subsequent utilization. The authors hypothesize it may have to do with the concept of self-efficacy. I like it.

I like it so much, in fact, that I’m involed in a related study with some of the authors to examine a similar question in a Department of Defense database. I’m eager to see what we find.

This study was jointly funded by grants from the Orthopaedic and Private Practice sections of the APTA, AAOMPT, and a faculty research grant from Texas State University.

SI Joint Mechanics in Manual Therapy: Relevance, Please?

In a separate post Publishing in Science: Are Industry Standards Serving Researchers, Clinicians and Science? Jason Silvernail and I outline some of the perceived cons of the current publishing paradigm. We describe our experience writing a letter to the editor of Manual Therapy. In the end, our goal was, and is, to express our interpretation of the study Inter-tester Reliability of Non-invasive Technique for Innominate Motion by Adhia et al, including it’s relevance to the context of the current scientific research on the sacroilliac/pelvic region, pain, manual therapy, and modern clinical practice. We hoped, and continue to hope, to facilitate scientific discussion and discourse surrounding the topic.

Recently, others in the blogsphere have written about the assessment and treatment of the SI joint including Mike Reinold Assessing the SI Joint: The Best Tests. John Childs from Evidence in Motion, in the piece A blast from the past highlights how some continue to cling to old views of pain and “SI dysfunction.”

We feel our original, longer piece (which was denied prior to review) summarizes the issues of assessment and treatment of the SI/pelvis region quite well, while connecting various scientific and clinical issues. We cannot share the piece that is currently in press for Manual Therapy [Ridgeway K, Silvernail J. Innominate 3D motion modeling: Biomechanically interesting, but clinically irrelevant. Manual Therapy (2012). doi: 10.1016/j.math.2012.02.017] as they own the copyright. Although, we will provide the link when it is electronically published. Yet, we can share a completely different version of our letter that we were working on before we modified it for length. To be clear the version below is not the letter that is currently in press.

Here is our best reply, in full, to Adhia et al:

We would like to thank Adhia and colleagues for their contribution to the literature regarding the non-invasive modeling of Sacro-Iliac joint (SIJ) motion. This study is interesting from a biomechanical perspective of the inter- and intra-rater reliability of measuring innominate motion via non-invasive palpation based measurements. However, in our opinion, this study has limited relevance to practicing clinicians and to the overall science and practice of manual therapy. The authors conclude “The results support clinical and research utility of this technique for non-invasive kinematic evaluation of SIJ motion for this population. Further research on the use of this palpation digitization technique in symptomatic population is warranted.” This seems to be a rather large logical leap given the results of their investigation and other data in the literature on the manual therapy assessment and treatment of the SIJ and pelvis region. We feel the clinical utility of SIJ palpatory movement testing has not been demonstrated by other research and we struggle to understand how such an assessment tool assists in evaluation, clinical assessment, or treatment with manual or physical therapy.

Movement of the SIJ appears to be very small, highly variable, and difficult to measure. Although undoubtedly complex, movement and translation of the SIJ is estimated to be small and variable between individuals (Harrison 1997, Goode 2008) while variation in anatomy exists even within individuals (Cohen 2005). Historically, SIJ dysfunction and pain has been “diagnosed” clinically via palpation-based tests aimed to identify hypo/hypermobility as well as asymmetry in anatomical landmarks. (Arab 2009)  From a basic anatomical and biomechanical plausibility perspective, measuring this motion and connecting it to a diagnostic process may be futile given the small amount of motion that occurs at the SIJ relative to other joints and the anatomical variation between and within individuals.

The evidence from diagnostic and therapeutic studies of the SIJ and pelvis area doesn’t suggest a clinically useful role for SIJ diagnosis via palpatory movement. A growing body of research indicates that positional palpation based testing in the spine and pelvis region, including the sacroiliac joints, is unreliable within and between examiners (Goode 2008, Laslett 2008). Investigations that do find some measure of reliability for testing have wide confidence intervals for their measurements, calling into question their applicability (Robinson 2007, Arab 2009). Such testing may not assist clinicians with the clinical reasoning process. Symptom provocation testing, rather than positional palpation, appears to have greater literature support, and in fact is the criteria used in guidelines produced by the International Association for the Study of Pain (IASP) (Szadek 2009). After investigating the reliability of individual provocation testing maneuvers (Laslett 1994), Laslett et al. went on to perform a high-quality double injection study (Laslett 2003) for diagnosis of SIJ related pain. This study examined the validity of provocation and movement testing in the diagnosis of a painful SIJ. In 2 separate investigations, they found that physical testing, specifically a composite of tests, aimed at provocation of symptoms was more useful in identifying individuals likely to respond to diagnostic injection, currently the most commonly-accepted “gold standard” (Laslett 2003, Laslett 2005, Laslett 2008). However, even the use of provocation testing and double injection validation according to criteria used by the International Association for the Study of Pain (IASP) does not conclusively diagnose SIJ related pain. The review by Szadek et al. illustrates some remaining issues and concerns when discussing the complexity inherent in making the diagnosis of SIJ related pain (Szadek 2009).

On the subject of clinical utility, in a developed (Flynn 2002) and subsequently validated (Childs 2004) clinical prediction rule aimed to identify a sub-group of patients who responded to an “SIJ region” thrust manipulation, no palpation based testing of the SIJ were included in the final rule. This rule was constructed via regression analysis and many palpation and movement based tests of the pelvis, lumbar spine, and SIJ region were examined, including techniques and landmarks similar to those used by Adhia et al. The final predictors of response to treatment did not include any SIJ palpatory assessments.  Certainly the failure of these investigations (both double injection diagnosis studies and manipulative treatment studies) to find positional or movement assessment of the SIJ of any clinical value raises serious issues about the validity of such assessments. Yet, it is palpatory assessment which Adhia et al investigate in their paper. Despite rigorous testing in different clinical environments, palpatory movement tests have failed to demonstrate their usefulness in helping clinicians diagnose SIJ related pain or treat pain in the SIJ and lumbo-pelvic area. We stress that overall manual palpatory examination seems to have a valid role in manual therapy in this region, but the current evidence seems to indicate that this validity is related to symptom provocation and mechanical testing (Laslett 2005, Laslett 2008) and/or an impairment-based clinical reasoning approach (Whitman 2006). Such a patient-response, impairment-based approach is quite different from the positional and movement diagnostic process advocated by Adhia et al.

Lastly, this paper seems to further perpetuate an overly biomechanical focus in the assessment, treatment, management, and understanding of pain. Moseley stated “equating pain to activity in nociceptors is seductive” (Moseley 2012), and so too is a strict biomechanically focused clinical frame of reference. This biomechanical model of pain, dysfunction, manual therapy application “target,” and treatment effect appears to have little empirical support in the current literature (including clinical trials) investigating mechanisms of action of and predictors of success with manual therapy treatment (Bialosky 2009). In light of our improved understanding of the multifactorial neurophysiology of the pain experience (Bialosky 2009, Moseley 2012 and Melzack 2001), 3D modeling of small and variable joint motion via classically unreliable, and likely invalid constructs lacks meaningful clinical utility. When taken into account with clinical trial evidence and pain neurophysiology, we do not advocate its use clinically regardless of the precision of any associated biomechanical measurements.

We are not stating that this research is flawed, or even that it is unimportant. Indeed, Adhia and colleagues should be commended on the rigor of their methods. The investigation holds immediate relevance to the non-invasive modeling and measurement of the SIJ, and there may be biomechanical studies of some value that could take advantage of this process.  However, we disagree with author’s conclusion that the investigation results are clinically applicable and we urge the readership to consider the study results in context of the current evidence – which calls into question the reliability, validity, and clinical relevance of palpatory SIJ testing and diagnosis. We are confused as to how we as clinicians could utilize the author’s technique effectively in day to clinical practice, and why, given the current state of the literature, the authors propose we should.

Kyle J. Ridgeway, DPT

  • Physical Therapist, University of Colorado Hospital, Aurora, CO
  • Physical Therapist, Panther Physical Therapy, Littleton, CO
  • Consultant, University of Colorado Anschutz Medical Campus: Physical Therapy Program, Aurora, CO

 

Jason Silvernail, DPT, DSc, FAAOMPT

  • Physical Therapist, US Army, El Paso TX
  • Adjunct Faculty, Army-Baylor Doctoral Fellowship in Orthopedic Manual Therapy, San Antonio TX

The authors of this letter have no financial interest to disclose. The views expressed are those of the authors alone and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.

References

Adhia DB, Bussey MD, Mani R, Jayakaran P, Aldabe D, Milosavljevic S. Inter-tester reliability of non-invasive technique for measurement of innomiate motion. Man Ther 2012;(17):71-76

Arab HM, Abdollahi I, Joghataei MT, Golafshani Z, Kazemnejad A. Inter- and intra-examiner reliability of single and composites of selected motion palpation and pain provocation tests for the sacroiliac joint. Man Ther 2009;14(2): 213-21

Childs JD, Fritz JM, Flyn TW, Irrgang JJ, Johnson KK, Majkowski GR, Delitto A. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: a validation study. Ann Intern Med 2004;141(12):920-8

Cohen SP. Sacroilliac Joint Pain: A Comprehensive Review of Anatomy, Diagnosis, and Treatment. Anesthesia & Analgesia 2005;101(5):1440-53

Flynn T, Fritz J, Witman J, Wainner R, Magel J, Rendeiro D, Butler B, Garber M, Allison S. A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine 2002;27(24):2835-43

Goode A, Hegedus E, Sizer P, Brismee J, Linberg A, Cook C. Three-dimensional movements of the sacroiliac joint: A systematic review of the literature and assessment of clinical utility. J Man Manip Ther 2008;16:25–38

Harrison DE, Harrison DD, Troyanovich SJ. The sacroiliac joint: a review of anatomy and biomechanics with clinical implications. J Manipulative Physiol Ther 1997;20:607–17

Huijbregts PA. Evidence-Based Diagnosis and Treatment of the Painful Sacroilliac Joint. J Man Manip Ther 2008;16(3):153-154

Laslett. M, Williams, M. The Reliability of Selected Pain Provocation Tests for Sacoiliac Joint Pathology. Spine 1994;19(11):1243-1249

Laslett M. Aprill CN, McDonald B, Young SB. Sacroilliac Joint Pain: Validity of individual provocation tests and composites of tests. Man Ther 2005;10:207-218

Laslett M, Young SB, Aprill CN, McDonald B. Diagnosing painful sacroiliac joints: A validity study of a McKenzie evaluation and sacroiliac provocation tests. Australian Journal of Physiotherapy 2003;49:89-97

Laslett M. Evidence-based Diagnosis and Treatment of the Painful Sacroiliac Joint. J Man Manip Ther 2008;16:142-152

Melzack R. Pain and the Neuromatrix in the Brain. Journal of Dental Education 2001;65(12):1378-82

Moseley LG. Teaching people about pain: why do we keep beating around the bush? Pain Management 2012;2(1):1-3

Robinson HS, Brox JI, Robinson R, Bjelland E, Solem,S.,Telje, T. The reliability of selected motion- and pain provocation tests for the sacroiliac joint. Man Ther 2007;12(1):72-79

Szadek KM, van der Wuff P, van Tulder MW, Zuurmond WW, Perez RSGM. Diagnostic validity of criteria for sacroiliac joint pain: a systematic review. The Journal of Pain 2009; 10(4): 354-68

Whitman JM, Flynn TW, Childs JD, Wainner RS, Gill HE, Ryder MG, Garber MB, Bennet AC, Fritz JM. A Comparison Between Two Physical Therapy Treatment Programs for Patients With Lumbar Spinal Stenosis. Spine 2006;31(22):2541-2549

And, in the end “Enough is Enough”

State-of-the-Art in Postural Control: Pelvic Floor

Dr. Paul Hodges undertook the difficult task of explaining the intricate connection between the respiratory / pelvic floor / and abdominal muscles. I have the difficult task of summarizing what he presented! Dr. Hodges has a presentation style I really enjoyed – pose a question first and then proceed to address that question.

Question 1 – Do the muscles of respiration and continence contribute to postural control of the trunk?

Yes. Many of the muscles of the trunk (diaphragm, scalenes, erector spinae, intercostals, pelvic floor muscles) and pelvic floor (anal, periurethral, vaginal) are active during breathing and they are modulated in concert with breathing. Dr. Hodges provided evidence of this by presenting recordings from many systematic studies which measured the all of the above muscles in tasks such as respiration, modifying posture, and when a mass was unexpectedly dropped into a box held by the participate.

Question 2 – Can postural control, respiration, and continence be coordinated?

It seems that concurrent modulation of all these muscles is normal and that tonic and phasic activity can be modulated concurrently by the nervous system. In chronic respiratory disease, posture is compromised with greater disturbances in the ability to balance in the medial/lateral direction (trunk and hip stability). One obvious example of coordination is when someone is sprinting or lifting something heavy –  you don’t breath for a short time (Dr. Hodges had us stand on our toes, reach up as high as we could, and notice how we held our breath).

In low back pain, postural function is disturbed for sure. But why? It seems that there is reduced activity of the transversus abdominis muscles, which leads to delayed activation, less tonic activity, muscle atrophy, and cortical reorganization.

Question 3. What are the conseqeunces of poor coordination of postural muscles?

The immediate implication is that breathing disorders, back pain, incontinence are linked together. Sure enough, Dr. Hodges presented results from an epidemiological study showing that those who had a breathing disorders were more likely to develop low back pain!

Question 4. What are the implications for rehabilitation?

For low back pain:

  • Considerations from continence – activation of pelvic floor muscle to facililatet abdominal mucsle activity
  • Considerations from breathing – ppl with back pain with breath in a more vertical manner (upper chest shallow breathing)
  • access breathing patterns thru palpation, observation, US imaging – train breathing patterns
  • goals – reduce activity, changin breathing apptern, train TVA, bretah mmore efficiently

For pelvic floor disorders:

  • Consideration from lumbopelvic control – tva activiaiton may assist with PFM – supericial muscles maybe over active, change posture
  • Considerations from breathing – overactive supericial abs incre IAP and can strain PFMs

For breathing disorders:

  • Consideration from lumbopelvic – breathing pattern may be affected by lbp
  • Consideration from incontinence – pelvic floor muscle function may be changed, consider PFM training

Although Dr. Hodges used the specific example of low back pain rehabilitation, the principles apply to other areas

  • Training the transversus abdomonis successfully changed its recruitment by as evidenced by a shift in the timing of activation closer to normal controls with specific training
  • Can these changes in timing be maintained? – yes
  • What do you do? -Situps without conscience attention to TVA activation
  • The brain of someone with LBP is different than normal control – brain mapping with TMS shows a shift in the locus of TVA cortical region – reorganization
  • Specific training can make the brain look like a control
  • Does motor training make a difference? – yes but the treatment needs to be targeted and indiviualized – the more severe the impairments in TVA activation the better the change with training
Conclusions

Patients will present with a range of issues, but it is impossible to separate the systems. You must look at your patients as a whole and develop a strategy that addresses all of their problems.

Bottom line – YOU MUST BE A MULTISYSTEM THERAPIST

Sickening Report from WSJ

Spine Surgery Greed

Already controversial, yet continually growing more common, instrumented spinal fusion surgery took a public relations hit in an article in today’s Wall Street Journal. “Top Spine Surgeons Reap Royalites, Medicare Bounty” is an excellent, if not disheartening piece of investigative health journalism.

This piece is a must read for anyone involved in the care of patients with back pain, anyone with back pain, and hopefully, anyone involved in health policy that can help. Senator Grassley, You read this, right?

“One surgeon at a hospital in the Midwest disclosed receiving between $400,000 and $1.3 million in royalty, consulting and other payments from three spine-device makers. Using the Medicare-claims database, the Journal found this surgeon performed 276 spinal fusions on Medicare patients in 2008, by far the most of any surgeon in the country.”

“At least my spine is aligned now…”

Comfortably Bad Medical Beliefs

http://www.flickr.com/photos/evilerin/3353917569/These were the words of a friend who had just been to see a chiropractor for her sore back. I had treated her back the day before and had asked how it felt. The response was, “Well, I went to see a chiropractor today and it’s still really sore, but at least my spine is aligned now.”

While experiencing the obvious professional snub, the part of the statement I took exception to was the “aligned” part. I could tell she had taken comfort in the fact that no matter how her back felt, the chiropractor had “fixed” the alignment and she was on her way to better health. The only problem is, the explanation she was given as justification for the treatment doesn’t make any sense.

The theory of vertebral subluxation, first introduced as a medical theory in the 1800’s, has never been shown to be a valid theory. In fact, chiropractors themselves have issued loud warnings about threats to public health that come from relying on the concept that the spine can be misaligned and needs to be “adjusted” via spinal manipulation. Here’s a research article published by chiropractors which concludes:

“No supportive evidence is found for the chiropractic subluxation being associated with any disease process or of creating suboptimal health conditions requiring intervention. Regardless of popular appeal, this leaves the subluxation construct in the realm of unsupported speculation. This lack of supportive evidence suggests the subluxation construct has no valid clinical applicability.”

But still, people take comfort when they hear a theory that makes sense to them. In these instances, the comfort of the explanation can be so powerful that it causes the person to disregard facts to the contrary. There is also a public education problem here in the case of back pain and spinal alignment. It’s a particularly interesting dilemma, in that spinal manipulation is very effective for low back pain, just not for the reasons most chiropractors purport. This perpetuation of back medical theory is a real problem as we work to help patients make smart, cost-effective choice in the face of limited resources.

The Irrational Mind of Public Health

In an excellent piece of science writing by Christie Aschwandan, entitled, “Convincing the Public to Accept New Medical Guidelines,” this interplay between strongly held beliefs and public health data is explored. Runners who take ibuprofen, the controversial new mammography guidelines, and invasive and expensive imaging for low back pain are all discussed as examples of where beliefs and data are in conflict.

“But when facts contradict a strongly held belief, they’re unlikely to be accepted without a fight. “If a researcher produces a finding that confirms what I already believe, then of course it’s correct,” MacCoun says. “Conversely, when we encounter a finding we don’t like, we have a need to explain it away.””

Such is the case with many things in life. It is easier for us to believe something that makes sense. It’s more comforting to take action. Thus, when the best course of action for back pain is to wait it out, stay active, and not to get an MRI, it feels like the wrong decision. This has as much to do with the way our minds process information as anything.

“There’s this common assumption that we’re just going to educate people about the facts, and then they’re going to make use of them,” says Brendan Nyhan, a health policy researcher and political scientist at the University of Michigan. “But that’s not how people process information — they process it through their existing beliefs, and it’s hard to override those beliefs.”

What this all translates to is the need for researchers, public health officials, and health providers to improve the way new information is communicated to the public. I guess we should include the media in that as well! As Aschwandan concludes, “Explanations that offer hope and empowerment will always hold more appeal than those that offer uncertainty or bad news, and when new evidence offers messy truths, they must be framed in a positive light if they’re to gain traction. You can ask doctors to give up ineffective interventions, but you must never ask them or their patients to abandon hope.”

How true. Except often, it’s hard to know where to start.