John Quintner, Professor Milton Cohen and Dr Geoffrey Bove recently published a very controversial review – A critical evaluation of the trigger point phenomenon. Their article aims to show the hypothesis – “Myofascial Pain arising from Trigger Points” – formulated in the 1980s by Travell and Simons, is ‘flawed both in reasoning and in science’.
Being closely aquainted to John (albeit via cyberspace), I sought a patient’s explanation. What does this mean for me and others with chronic pain erroneously attributed to myofascial trigger points?
How many years have you been practising and researching chronic pain?
I commenced my career in rheumatology in 1975. My interest in chronic pain dates from 1985, when I admitted to myself that I had no idea about what was then being called “RSI”. Without a research background I was left with no other option but to learn “on the job”. I remember that some of my rheumatology colleagues would laugh at those of us who were making a serious effort to understand these conditions. But these were extraordinary times when a fierce debate over the validity of “RSI” as a compensable condition was raging across Australia.
Do you believe pain will be explained one day?
The short answer is NO. Attempting to explain the experience of pain is inextricably linked to our inability to explain consciousness. You could ask if we will ever explain LOVE and I would give you the same answer.
What might your research mean for someone with chronic pain?
Along with those with whom I have collaborated, and the list includes Professor Milton Cohen, Mr Robert Elvey and Dr Geoffrey Bove, my research has been aimed at shining the torch of critical scientific inquiry upon a number of complex and poorly understood conditions. From our attempts to do so, I hope that in some small way we have helped people in chronic pain to avoid the stigma that is so often conferred upon them by members of our society, including their well-meaning medical and other health professionals.
Stigma can obviously be damaging for patients. Often we are left to doubt what we’re feeling and the ideas we believe might help us if it’s not in line with recommended treatments/approaches. Would you say patients should feel a confidence with this latest research by yourself and your colleagues and perhaps listen to themselves a bit more? Could the patient be doing most of the work during these treatments without knowing it?
Those patients (from the Latin patiens – to suffer) who cannot produce a “cause” for their pain or a source of ongoing tissue damage are still at risk of being stigmatised. They can be placed on the back foot and blamed for their pain and disability, and particularly so when they happen to be caught up in our systems of personal injury compensation. In my view, the systems themselves are potentially damaging to them. You would be well aware of this scenario.
Can you explain your research in simple terms?
Most of it has been theoretical research and has involved deconstructing existing theories, critically examining them and, should they be found to be wanting in terms of their logic and/or science, to then offer more credible explanations for the symptoms and signs of the patients who present to us. This approach has served us well when we applied it to “RSI,” “Whiplash Associated Disorders,” “Fibromyalgia,” and ‘Myofascial Pain Syndrome.” Of course as the knowledge base in neurobiology broadens, this type of research will need to continue. Sad to say, there is no source of funding for such research.
It would only make sense that we reevaluate our opinions as we learn more about the experience of pain. Do we need to listen to the patient more?
Of course the answer is a big YES. But it takes more than just listening, otherwise the friendly neighbour chatting to you over the back fence would be your preferred “go to” person. We all tend to hear what we want to hear and health professionals are no exception. Sometimes in our role as clinicians we have to keep reminding ourselves that our patient happens to be the expert in his or her own pain. Helping that person to make sense of their pain in the context of their life can be a powerful act of healing.
What might your research mean for someone who is having dry needling or trigger point therapy?
The evidence we have recently presented suggests to me that they may well be wasting their time and money. Trigger point therapists (with their techniques of “dry needling” and “myofascial release”) will of course disagree with me, but they are standing on rather loose ground (or perhaps are even standing on quick-sand). But the new view of “trigger points” that we have just published is well supported and more likely to be correct than that advanced some 50 years ago by the late Drs Janet Travell and David Simons. In my opinion, the question that needs to be answered by “trigger point” therapists becomes “how on Earth could we ever have been so stupid as to hold our former beliefs in the first place.”
What might your research mean for someone who is having remedial massage and acupuncture treatment? I personally have felt relief from my practitioners.
The relief you have experienced is largely attributable to the context in which your treatment has been carried out.
Is this what you might mean? Could I have known my massage was coming up and been more active in the lead up? is the massage treating the ‘wind up’ and layers that build above an initial injury? Am I thinking I’m actively taking some part in treatment and feeling better?
In part this is likely to be true. Perhaps the ancient art of massage (from the Arabic Mass’h – to press softly) can temporarily calm a sensitised nervous system. However, the personality of your therapist and the environment in which he or she administered your treatment were more likely to have been important factors contributing to your favourable response. In current Pain Medicine practice, there is much less emphasis being place on passive treatment than it was some years ago. Tailored exercise programmes are now being recommended. Dr Stephanie Davies and I formulated what we called the wHOPE (whole person engagement) Model of Care. We encouraged our patients to take up creative activities such as music, dance, mindfulness meditation, art, photography etc. They can all be therapeutic when pursued with passion.
I can certainly vouch for creativity being a form of catharsis and expression. It’s a huge release and it may well be possible this is my key treatment along with my peripheral stimulation device.
Does your experience suggest that the effects are either placebo or possibly coincidence?
Yes, both are possible explanations. Placebo (from the Latin: “I will please”) is sometimes used as a derogatory term and in view of this, perhaps it should be replaced by “contextual effects”. These effects are important factors to consider when evaluating all forms of treatment, including medical treatment.
So is it time for a new pain dictionary?
The pain dictionary is not all that helpful when people present with pain that is not due to obvious tissue damage (= nociceptive pain) or due to detectable damage to the nervous system (= neuropathic pain). People with diagnoses of fibromyalgia or myofascial pain find themselves in this position. A third term is urgently needed to ensure that these people are not being excluded from the ranks of legitimate pain sufferers. The Taxonomy Committee of the International Association for the Study of Pain (IASP) is well aware of this gap, but as yet there is no agreement on a new term.
Does your reading indicate that pain is indeed in the brain? Or is it in my nervous system?
Pain is always located in the body. The idea of there being a “pain centre” in the brain is no longer scientifically credible. It so happens that the powerful tools of neuroscience are being applied to the brain. But this does not necessarily mean that the neuroscientists will find a “thing” called pain residing within it.
Which organisation/body would you recommend for a patient in their search for current and realistic approaches to chronic pain?
This is difficult to imagine but what do you think you would do if you were living with debilitating chronic pain?
I would reach a stage where I ask myself whether my life was still a meaningful one. On a good day, I think I would be able to answer YES. I once heard an eminent psychiatrist propose that for a life to be meaningful, three elements are required – LOVE, SOMETHING USEFUL TO DO, and HOPE. On a bad day, I would probably be thinking about entering the next life. But the Biblical injunction to “CHOOSE LIFE” would be a powerful motivator for me to remain in this one.
March 19, 2015 update
Futher to this research the authors John Quintner, Geoffrey Bove, and Milton Cohen have posted their response to the ‘rebuttal’ by Dommerholt and Gerwin.
‘Did we miss the point?’ now appears on the website of the Journal of Bodywork etc.
Six months free access has been granted.
- The question of bias
- With what do Dommerholt and Gerwin in fact disagree?
- How scientific inquiry works
- Uncited references
March 28, 2015 update
The authors have responded with e-letters concerning their paper: A critical evaluation of the trigger point phenomenon.
The letters and our responses can be freely accessed from this link on the website of RHEUMATOLOGY.