///What do I do with my trigger points now, Dr Quintner?

What do I do with my trigger points now, Dr Quintner?

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.

Like love…

Quite so!

Which organisation/body would you recommend for a patient in their search for current and realistic approaches to chronic pain?

My first choices would be Painaustralia and the Faculty of Pain Medicine, Australian New Zealand College of Anaesthetists.

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.

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.

By |2017-12-11T11:16:03+11:00February 1st, 2015|Learn, Professional Resources|50 Comments


  1. John Quintner March 10, 2015 at 7:36 am - Reply

    The physical therapists in Maryland are currently making representations to the Maryland Senate Committee hearing about “dry needling”. The acupuncturists are objecting to the practice, which they see as a poor imitation of traditional Chinese acupuncture. Be that as it may, it will be interesting to see whether the Senate Committee demands evidence of the efficacy of “dry needling” beyond that of placebo. Of course, there is no evidence that such is the case. It seems that this contest will soon spread to other U.S. States.

    • Soula March 10, 2015 at 9:53 am - Reply

      Excellent news John. Thanks for keeping us posted.

      • John Quintner March 10, 2015 at 8:32 pm - Reply

        In my opinion the physical therapists don’t have a leg to stand on. The American Physical Therapy Association went to great lengths to make it clear that their “dry needling” techniques and theory were completely different to those of the acupuncturists. Their case appears to rest on the safety of dry needling but the question of efficacy is not a strong point in their argument. If they are legally prevented from inserting their needles into innocent muscles, the PTs will actually have to talk to their patients. What will they say?

        • Stephen S. Rodrigues, MD March 11, 2015 at 1:55 pm - Reply

          Again your knowledge base is narrow, biased and condescending.

          Muscles are not innocent when it comes to long-term pain. Where else can pain emanate from?
          Of all the 11 organ system which is the most logical?

          These authors of the last century knew beyond doubt that long-term pain emanates from “damages” within muscles and connective tissue; Gunn, Travell & Simons’, Rachlin, Baldry, Seems, Helms, Starlanyl, Hackett, Cyriax, Craig, Gokavi, Lennard, Burke, DiFabio and Pybus, B.J./D.D. Palmer, Wyburn-Mason and Chaitow.

          All of them used needles except for a couple who used kneading, counterstrain, leverage and gravity.

          So you believe beyond doubt that all of those physicians are/were misguided, ignorance and quacks?

          Dry needling is a profound benefit to MF pain and dysfunctions. I hope that those who are suffering will get stuck with a few needles.

          • John Quintner March 12, 2015 at 10:12 am

            More rhetoric but little of substance! Appealing to past icons will not cut the mustard in this debate. In fact, the debate is all but over, bar the shouting from the wounded “dry needling” brigade. They might as well use larger needles and take up knitting.

        • Stephen S. Rodrigues, MD March 13, 2015 at 5:18 am - Reply

          HELP logic and educational review: Muscle, connective and fascia corruption.

          Why are so many people suffering in long-term pain?
          Why do some people get Migraines, Trigeminal Neuralgia, IBS, pelvic floor pain, pudendal neuralgia, regional pain syndromes, carpal tunnel syndrome or ulnar nerve syndrome?
          Why some people do not get long-term pain problems?
          Of all the 11 organ systems which system is the most logical place where pain emanates from?
          Why is taking a pill, either opiates, NSAID or anti-seizure meds so common in 2015?
          Why are these people who take all these pills still have pain?
          Why do people still suffer in pain after spinal fusion or joint replacement surgeries?
          Why are repeated surgeries for these problem so common?
          Why are these surgeries so common now without any test or evidence of the true benefits from past accomplishments?
          Why are physicians not performing through reviews and investigations into these failures?
          Why are the elderly citizens so fragile?
          Why is osteoporosis and osteopenia so common in the elderly?
          Why do some physicians today want to negate, disrespect or disavow the wisdom of prior physicians?
          Why do some physicians today want to negate, disrespect or disavow much of the history of medical accomplishments?
          Why do some physicians today want to negate, disrespect or disavow much of the history
          of prior medical therapies which were sound standard of care options?
          What do people complain about after working in the garden for hours?
          Why do people complain about sore muscles after running a marathon?
          Why do joints NOT swell up like grapefruits after running a marathon?
          What do athletes complain about when they over train?
          Why do professional athletes get regular massages and some acupuncture?
          What is wrong with a deep tissue massage for pain from muscle spasms?
          What is wrong with a deep tissue massage for muscle strain and sprains?
          What is wrong with spinal adjustments for back pain caused by muscles?
          What is wrong with traction for back pain caused by muscles?
          What is wrong with suggesting to someone who has chronic pain to do yoga, stretching, getting hands-on PT?
          What is the true cause of Migraines, degenerative joint disease, disc compression, meniscus problems, cartilage wear, bursitis, tendonitis, diabetic peripheral neuropathy, peripheral artery compression diseases, pelvic floor pain syndromes, nerve compression syndromes-Trigeminal Neuralgia, Pudendal Neuralgia, Regional Pain Syndromes, Thoracic Outlet Syndrome-TOS, carpal tunnel syndrome or ulnar nerve syndrome, chronic fatigue, postural orthostatic syndrome-POTS, Irritable Bowel Syndrome-IBS?

          There is a simple, sound, reasonable and logical answer to all of the above questions.
          Muscle, connective and fascia corruption.

          John, I can predict your response.

          Soula, you will have to reconsider who and what to believe.

          • John Quintner March 13, 2015 at 9:15 am

            Soula, how about Puff the Magic Dragon?

  2. John Quintner March 8, 2015 at 7:01 pm - Reply

    Soula, the debate has shifted to Fibromyalgia Perplex, where our additional response to the “rebuttal” article has been posted. That which we submitted to the Journal of Bodywork and Movement Therapies is now available to readers as an “article in press”.

  3. Stephen S. Rodrigues, MD February 7, 2015 at 9:41 am - Reply

    Quintner, et al.
    Do you all trust the present system we have in place with the mounting crappy outcomes?
    Are you aware that we have massive numbers of casualties from modern medicine on the frontlines?
    Do you really trust the researchers more than the physicians frontline where real life happens?
    We on the frontlines are given the privilege to use what is known grounded in reality which works in real-time real-life situations, not what you might think.
    We do not have the luxury to trust those way back behind the lines who are dealing with loose ideas, power prestige and are willing to thrown us and the wounded under the bus.
    We do not have the time or luxury to deal with the esoteric arguments, we must touch and attempt to help people.

    Oh, Quintner, I can not allow you to subvert all of those dedicated physicians some whom are deceased and can not defend their work.

    When was the last time you Quintner or anyone here actually examined, evaluated and touched a patient who was suffering with a complex pain syndrome?
    If you do in the future, PLEASE have respect, do not tell them that their pain is in their brain.

    • Soula February 7, 2015 at 9:47 am - Reply

      Hi Stephen, thank you for your comments but this is a patient site and I feel it’s getting a bit heated. I’d take this kind of debate/argument to the Body in Mind site where professionals can respond. I hope you understand. I feel it’s getting a bit personal and that’s really unnessecary.

      • Stephen S. Rodrigues, MD February 8, 2015 at 6:49 am - Reply

        Thanks for allowing me some leeway so these messages can be posted.

        The interview makes bold statements and accusations directed at a word, “Trigger Point” a debate tactic to depose the entire 300 years of the work of all the authors. Then it goes on to disparage all those who use the concepts in real time to help people in pain, and finally disrespects the deceased authors.

        If I have learned nothing else, in my 30 years in primary care, I’ve been able to discover the pieces to this complex puzzle of chronic pain. What it is, what it is not and most importantly I have collected the tools and experiences to reverse this type of pain.

        The therapy is exactly what is needed so that nature can begin to repair and restore. The force applied to the flesh by the provider’s hand and the needles does something miraculous. NOT magic. The therapy is curative!

        The human ideas and concepts can be debated but the therapy is the truth. The protocols are the only way to reverse the damage of chronic pain and the needles maybe the only way out for many who suffer in pain.

        Do you know that their is a huge number of souls who must live in chronic pain in the US, UK, Canada and Australia — WITHOUT THE PROPER THERAPY?

        Do you realized that there is a “global subculture” of people who are actively misinforming, deceiving and erecting barriers to get to those protocols?

        Apology if I step on a few toes of those who are in the way of YOUR treatment protocols.

        Social media is the only place where real people can gather the necessary data to protect themselves from profiteers, definition deceptions, agendas, free market liars and the vices of mankind.

        Peer review sites are heavily funded by those who do not have your best interest at heart. Maybe in the past but not now.

        This is exactly how science and debate is suppose to work!! But attacking or shutting down the debate is exactly what not to do. You can moderate the personal attacks but the science is the science and knowledge will empower you to be free.

        A logical solution is to invite an opposing concept for debate, Chaitow would be a wonderful choice! or Devin Starlanyl.

        People need to know ALL the facts and angles so that they can make an educated decision.
        If your agenda is just to help publicise Q and his work, that is find, just let the public know that the interview is one sided.

        • David Scott Lynn February 25, 2015 at 5:15 am - Reply


          Dr. Rodrigues, I totally agree with you. … I don’t think the Quintner paper has any relevance at all as far as whether a person should pursue trigger point therapy or not. My former partner had a documented 32,000 patient visits when I started working with her, ALL treatments using hands-on trigger point therapy, much of it derived from the Nimmo model of Receptor-Tonus Technique, and influenced by Travel & Simons. She worked in a chiropractic clinic in St. Petersburg, Florida, and they got MOST of their referrals from medical doctors in the area whom were unresponsive to other treatments. There was much interaction between the referring doctors and the DC she worked for, including full medical reports, X-rays, MRIs, etc., provided to the DCs office. (And this was still in the days when DCs were generally looked down upon by MDs.) She became known across the country for being able to successfully treat such problems when others had failed, and led several thousand students through the St. John NMT Seminars she taught for.

          Personally, if I have a choice of believing someone with 32,000 patient visits under her belt versus an analysis of literature, even literature that is quite convincing, I just don’t think the two bear comparison. Sure, if there are better scientific explanations available as to WHY it works, Great. But it will take a LOT more than that to make me doubt THAT is works.

          Anyway, the operative sentence in the Quintner paper was: “This is not to deny the existence of the clinical phenomena themselves, for which scientifically sound and logically plausible explanations based on known neurophysiological phenomena can be advanced.” … Basically, the paper turned out to be of NO use to me at all, as it said nothing that would change the way I work at all.

          So I think Soula can rest assured that, assuming she has found one of the better practitioners of myofascial therapy, the Quintner paper has NO BEARING what-so-ever on whether or not she should continue in that mode of treatment, IF it is working for her.

          But Here’s The BIG Problem: Although I sometimes find the science VERY interesting, I am sometimes dismayed by the fact that when an explanatory hypothesis for a therapy is found to be lacking, even if only partially, too many people jump to the conclusion that the therapy itself must be lacking. That is unscientific thinking in itself. As Richard Feynman the physics guy said, what happens in the Real World trumps any and all theories about it. The purpose of science is NOT to invalidate the observation, but to give better explanations as to what was observed. … Yes, sometimes the observation has some “clouds” around it, and that sometimes needs some “clearing up” as to what a therapist or physician actually observed. But too many are now saying — especially on social media forums — that trigger point therapy is illegitimate because “the science is bad,” and Dr. Quintner is their new “proof.” … I would say the “new doubters” just never received a really good treatment, or were never properly trained on how to deliver such treatments.

          I’m not a doctor, but I’ve been doing clinically successful hands-on therapy since 1981, and have worked side-by-side or in conjunction with several MDs, DO, and a few DCs, and I usually got the “tough cases” that were unresponsive to the physicians’ usual modalities. They were all very surprised (even the DCs) at how effective hands-on therapy can be to solve such complex myofascial pain problems, and how “simple” it was as soon as you figured out WHERE to work.

          (I occasionally use simple, sustained, VERY low-intensity stretching, often with an A-symmetrically designed routine. … OR far more often, long, sustained, very specific, manual pressure. … Both modes are with a No Pain means MORE Gain philosophy. The client is always in control of how deep I am working or they are stretching, and should be well within their comfort zones for maximum relaxation and minimal negative reactions. When applying pressure, I use almost NO lateral movement and NO cross fiber techniques. Just sustained pressure or stretch for, sometimes, many minutes at a time, on the targeted location. — In my model, I’m mainly [I think, anyway] going for sustained activation of, and facilitated inhibition by, Golgi tendon organs and Renshaw’s cells. … If you [or anyone] have any thoughts on that physiology, would be happy to hear them. )

          BTW, I only recently saw a video about dry-needling of trigger points. Prior to that, I had a very incorrect picture of how it works, and doubted its efficacy. But now I have a better understanding as to how and why [I think] it works and how it could in some cases be more effective than the hands-on therapies such as people like myself perform.

          And of course, not all trigger point therapy training is created equal. I once substitute taught for a trigger point course at a massage school in Sedona, Arizona. Part way through the class I got the feeling something was “weird.” I stopped and asked the students whether anyone had ever given them a definition or explanation of trigger points? NOPE! They just started “pressing on X!” … Now HOW do you teach something like that without even defining what it is?

          And BTW, as more people are realizing, no matter how well trained, certified or licensed they are, nor at what level up the chain of “higher licenses,” that is NO assurance they will be great therapists. Although some trigger point situations are as simple as “X marks the spot, PRESS HERE,” not all cases are that easy to track & treat as to the TRUE source of a trigger point (not always where it feels like it is). And sometime, they do take a much longer time to “let go” of their tension than others.

          • John Quintner February 25, 2015 at 8:44 am

            David, this debate has moved on since Soula first gave me these questions to answer. At the request of Leon Chaitow, Editor-in-Chief of the Journal of Bodywork and Movement Therapies, Jan Dommerholt and Robert Gerwin prepared a detailed article of rebuttal as a response to our paper. It has just been published. These gentlemen have been the most prominent and vocal proponents of myofascial pain theory and its treatment. We are told that our reply will appear in the July issue of that same journal. It will then be up to the discerning reader to choose between the two diametrically opposed views that have been presented to them.

          • Soula February 25, 2015 at 8:59 am

            I think we should leave it at John’s reply. Please respect that my website is for patients with chronic pain and any professional debates aren’t really that helpful for my readers and especially those who have commented and may be receiving this stream in their mailboxes.

            For a start, patients can’t understand the pro speak nor would many of them have the capacity to read to the end of them! There are professional platforms to post your extensive comments where they would be better appreciated and valued.

            Thanks everyone!

    • John Quintner February 7, 2015 at 11:37 am - Reply

      Dr Rodrigues, please don’t put your words into my mouth. And, by the way, I do not respond to ad hominem attacks, even when they come from my medical colleagues. If you wish to take part in a scientific debate, please submit your criticisms to the medical journal that published our paper. Soula made it quite clear to me that she solicited the interview with me and I responded to her questions as best I could. Social media has a role to play in disseminating information but it cannot resolve the issues that you and others have raised in response to our paper.

  4. Stephen S. Rodrigues, MD February 5, 2015 at 1:21 pm - Reply

    “The MTrP proponents believe and teach that “myofascial pain derives from myofascial trigger points” – a classical circular argument.”

    Dr. Quintner, I’ve always used the term “MFrP” to describe an “ouch-spot” within a muscle segment perceived, conveyed and subsequently confirmed by the patient at that moment during the examination.

    In the real world, I use my “TrP fudge” rule: If a patient feels something that he or she is not supposed to feel upon palpation – twitch or not = I attack that point with my needles. Why guess?? The patient need your help at this moment in time!! Why wait? The patient took off from work and is now in front of you! That is why the atraumatic needles are so perfect!

    IMO, it is inconceivable to assess a TrP without a set of benefits and tools. NO one can just read and comprehend these concepts of MFP and TrPs — no one! You need training, experiences, patient, palpation skills, time effort, needles a mentor. Most importantly the ability to fail and keep trucking.

    It is my opinion, which is as close to being complete as humanly possible, the acupuncture needle is the most profound tool in medicine! These needles are like extensions of your palpating fingers which can help to diagnose where you are in a 3 D world within a muscle. They also are the best igniter of healing and can be used as a guide wire. The guide wire concept give you the mireatuoal abilty to peek or probe into areas of the body to SEE what is there. Some area that need care are not perceived by the patients consciousness, but need attention. The perfect tool to probe, seek and destroy all in one movement.

    Pain, what is it good for? Absolutely everything!
    What many scientists failed to realize because they have no hands on, real-life, real world clinical experience with hundreds of patients is that like the word “love” it cannot be written down in a precise manner. Pain is a much more global concept designed by evolution to protect the human body from an inconvenience, injury or harm. Pain is an electrical awareness in the brain. It is unique to that individual. What one patient may perceive as painful another will perceive as soothing.

    So what is pain? “Pain” is a subconscious or conscious awareness of your body. In reality pain is not a pain until that particular person makes a statement that what they perceive is by their standard a pain. As an example if you are sitting in a chair gravity is pushing you into the chair so you perceive the sensations on your buttocks. The sensations comes and go within your consciousness-subconsciousness, back and forth. If you sit in one position for too long those sensations will become conscious and you may even shift unconsciously to soothe the sensations. If you are on a long flight and you could not get out of your seat or stand that sensation would be overwhelming and disturb your ability to concentrate, sleep, focus, problem solve and adversely affect your well-being.

    In my office, a pain based on the patient’s definition is enough to begin therapy. Be it an itch ache, numbness, imbalance, dizziness, nausea, burning etc. If it disturbs the patient’s well-being, it’s a pain.

    All types of “pains,” which disturbs a patient’s well-being must be treated to honor that patient’s request for assistance.

    • John Quintner February 5, 2015 at 2:00 pm - Reply

      With due respect, Dr Rodrigues is insulting the intelligence of the readership by expounding such nonsense. He gets full marks for his religious fervor but in my view he fails miserably when assessed on his grasp of medical science. How sad is that?

      • Stephen S. Rodrigues, MD February 6, 2015 at 6:32 am - Reply

        Respect? Your mission or concept is the epitome of disrespect all those who suffer in long-term pain.
        Do you really think that humans will find pain under a microscope?
        Do you really think that pain is all in the brain and all the same for everyone?
        When was the last time you actually touched a patient?
        Have you ever tried to palpate a TrP?
        Do you really know the ramifications of undertreated or poorly treated MFP&D?
        Do you realize that your concept is flawed and incomplete? Or as lease more incomplete than the idea of a TrP, one of which that can be written on paper.
        Are you stating that all of my (and thousands of other) clinical experiences are worth less than your circular logic and powers of persuasion?
        I’m just a practitioner who is attempting to understand pain and how best to treat those who need therapy.
        And a messenger of these wise men and women: Gunn, Travell & Simons’, Rachlin, Baldry, Seems, Helms, Starlanyl, Hackett, Craig, Gokavi, Lennard, Burke, DiFabio and Pybus, B.J./D.D. Palmer, Wyburn-Mason,and Chaitow.

        Tough questions that you will not or can not answer because you lack the expertise. Not a put down, just a fact.

        • John Quintner February 6, 2015 at 7:26 am - Reply

          Soula, this is a great example of what I will call rampant “myofascial fundamentalism”. Convert to this pseudo-religion at the point of a needle or forever be condemned to publish in peer-reviewed medical journals? My fate is sealed.

  5. Gavin Johnston February 4, 2015 at 8:54 pm - Reply

    Myofascial therapists do not believe pain arises from trigger points rather
    Restrictions and adhesions in the neuromuofascial web .

    • John Quintner February 4, 2015 at 9:37 pm - Reply

      Gavin, thanks for the information. However I think that you could be referring to an entirely different belief system to the one that we critiqued in our paper.

  6. Great thread Soula and John February 4, 2015 at 9:35 am - Reply

    As I prepare a presentation for tonight to be delivered to a group of young women living the experience of persistent pain. I declare my commercial interest in unashamedly promoting literature produced by persons who walk the talk and I could not be more delighted to see John, Milton et al paper supported by Lorimer. My own program has the backing of Steph Davies and without John’s advice delivered at Perth airport many years ago now and I would not be a Master of Public Health with an evidence based ethical program. Therefore to the persons with commercial interest declare the bias before you “challenge” the opinions of others in a public forum because that is a basic in publishing 101.

  7. Carrie Newbold February 3, 2015 at 3:54 pm - Reply

    What a great interview and wonderful discussion thread. I’m a remedial massage therapist and Pilates instructor. I took up Pilates as I felt massage can never/rarely provide a long-term change in someone’s pain/problem. My ‘other’ day job is as a medical research fellow. Which means I can’t help myself but read excessively about the validity of the treatments I provide. My two cents is we have only barely started to consider HOW things might be working, and all too often we’re caught up too long on testing and believing things we are sure SHOULD be working. So I really enjoyed Quinter et al’s article. I now have an even longer reading list, and of course, many more unanswered questions. But, as Soula has obviously noticed, I also have been unsure what to say to my clients now about their pain. More than ever my go-to answer is “We still don’t know”. Thanks again everybody.

    • John Quintner February 3, 2015 at 7:28 pm - Reply

      Carry, thanks for your feedback. Your clients must love you! I wish you every success in your studies.

    • John Quintner February 3, 2015 at 7:30 pm - Reply

      Sorry!!! I should have called you Carrie.

      • Carrie Newbold February 4, 2015 at 11:44 am - Reply

        Ha, no worries. Thank you. Happily my studies will never be completed 🙂

    • Stephen S. Rodrigues, MD February 13, 2015 at 11:01 am - Reply

      “I felt massage can never/rarely provide a long-term change in someone’s pain/problem. “
      Your clinical observation demands explanation for educational purposes. This is a factual realization of how massage has a limited therapeutic effect on long-term pain (LtP) problems.

      The Masters of MFP&D discovered this >70 yrs ago, but it gets marginalized due to poor training of physicians in the therapeutic options for LtP.

      MF disease, when left untreated or undertreated will increased in density over time in many patients. As the density increases the molecular and chromosomal cellular structures contribute to shorter, tighter having less blood flow and thus less capacity to work.

      MF release therapies come in 4 stages or levels and if you do not apply the needed therapy the desae will contract the muscles into leathery masses.
      Self Care with massage, stretching and adjustments are all effective until it reaches a plateau, then you will need the next level of intensity.
      Thin Needling Care with myofascial acupuncture, dry needling or CraigPENS or C. Chan Gunn, MD his GunnIMS until it reaches a plateau, then to next.
      Hypodermic Needling Care with hypodermic needling as wet needling, Travell/Simons injections, then to next level.
      Hypodermic Needling Care with the concepts of Edward S. Rachlin, MD protocols.

      Once you tissues devolves pass a limit level, it will take more time, effort, cost and inconveniences to restore. Most of your readers have never had this type of therapy due to concept biases and other issues. So I would summarize most will need Travell/Simons and above therapy.

      • John Quintner February 13, 2015 at 12:27 pm - Reply

        Yet another extravagant flight of fancy from the prolific pen of Dr Rodrigues! As always, take it with the proverbial pinch of salt.

  8. Mel Galbraith February 3, 2015 at 1:24 am - Reply

    I am a physiotherapist and also a chronic pain sufferer. I have been a keen follower of the dry needling/myofascial/TrPt debate from both a personal and professional perspective. I moved to a country town in WA and worked in a private practice there for a year. The principal of the practice was in her late 60’s and had quite significant OA in her hands/fingers. For this reason, she utilised a lot of dry needling in her treatments – as although she was a specialist MSK physiotherapist, she simply could not continue with manual therapy. As many patients were “used to” this treatment and expected/requested it, I had no choice but to pay $795 for a weekend course on dry needling. I am involved in workshops upskilling health professionals in Pain Management and currently completing my Masters of Science (Pain Management) where it is a requirement to read extensively a significant number of articles on the research/evidence base behind it. I have seen some ‘amazing’ results with dry needling – but on the same token, as a ‘recent grad’ I also witnessed some quite significant outcomes from manual therapy treatment that I was convinced the patients got better because I “was nice to them and chatted/took a personal interest in their lives”. My ‘age old’ argument is the old chestnut “who has done a double blinded RCT on parachutes?” – it’s a Far Side cartoon with someone in the experimental arm with a piano as his “parachute” versus a “regular” parachute………..Food for thought??

    • Stephen S. Rodrigues, MD February 8, 2015 at 7:17 am - Reply

      This is a key point to add to the discussion. Manual vs needle therapy. Gunn answered this question in his text, he may not have overtly understood it but once you add in the work of Travell/Simons you can began to establish a spectrum of muscle disease: From minor which can be restored with manual labor like hands-on options: kneading, scraping, unwinding, release.

      Then there seems to be a point of no return to wellness that get locked into the muscle design, so not matter how much effort you apply the muscles will not acquiesce and release. This barrier can only be broken with needles as per Gunn-Cannon’s Law combined concept.

      Once the needle re-boots the muscle bundles they will cooperate with therapy and all should be well.

      There is another barrier that will be erected by nature and that is when the muscle bundles become hard, stiff, “dry” and subsequently toxic masses. These patients are miserable and the cause of this illness is virtually invisible to any technology. At this level of disease, nothing is consistent and chaos is the word used in disbelief.

      Here is a short list of what patients complain about in the latter part of the disease:
      Physical symptoms include achy body, jaw clenching, hot flashes, teeth grinding, headaches, indigestion, numbness in hands/feet, rapid or irregular heartbeat, ringing in ears, sensitive muscles, sexual difficulties, shortness of breath, stiffness, sweating or clammy hands/feet and swelling in limbs. These physical limitations include decreased capacity to lift, sit, stand and walk.

      Emotional symptoms are anger, apprehension, difficulty concentrating, fatigue, fear, feelings of death or dying, forgetfulness, impatience, inability to relax, irritability, low sex drive, lack of enjoyment, nervousness, panic, insomnia, sleep that is not refreshing, restlessness, sadness, tiredness and worry.

      Metabolic and biophysical symptoms are weak immunity, temperature liability, cardiovascular erratic behavior ie POTS. Sensitivity to meds, odors, foods and the environment.

      In these case, your only clue to the what is happening is the words spoken by the patient. They are the only purveyors of this misery.

      So as the level of muscle dysfunction progresses so do the tools needed to reverse the damage:
      Self-care, Hands-on, spinal adjustments, dry/wet needling, travell Trp injections and the “the ton of bricks treatment.”

    • Stephen S. Rodrigues, MD February 8, 2015 at 7:33 am - Reply

      As a student Gunn’s text is the most concise or all things pain: See p 85, the needle will not penetrate the toxic mass next to the spine = total neuronal -metabolic dysfunction. Also note his awareness of the deficiencies in the concepts of Acupuncture = genius!

      • John Quintner February 8, 2015 at 8:28 am - Reply

        Holy war, crusade, or jihad? Take your pick. The message is always the same, ad nauseam. March to the beat of my drum and carry the banners of past icons of needling or you will be condemned to eternal damnation.

        • Soula February 8, 2015 at 9:06 am - Reply

          Stephen may I suggest you post your website details as a final comment for anyone that might want further info? And I would also suggest making the comment short if you want patients to read it. I think I can speak for most and say we just don’t have the knowledge to understand much of your comments and arguing about it doesn’t really achieve anything. Social media is a great place to gather data but I think we need to keep it simple and neat! You are welcome to direct everyone to your website.
          Regards and thanks again

  9. Geoffrey Bove February 2, 2015 at 1:13 am - Reply

    What a wonderful interview. Thank you both.

  10. John Quintner February 2, 2015 at 12:32 am - Reply

    Soula, on Leon’s Facebook page I came across a remarkably apt quote from the late Karel Lewitt, who was well known and widely respected in the world of physical therapy:
    “I am always aware of how many things which I taught in my long past have since been proved wrong. The most important attitude is therefore to be constantly aware that what you are doing and teaching now you will have to modify and correct in view of new facts. Thus you must keep an open mind for new knowledge, even if it sometimes shows that what you believed and taught before was wrong.” Karel Lewitt – 1/1/98
    Milton Cohen and I first exposed the major flaws in the MTrP construct in 1994. Our work fell on deaf ears and the fact that a response is only now being published in Leon’s journal reflects badly upon the scientific credibility of the MTrP proponents. But for our paper being published, one wonders when or even if they would have “seen the light”.

    • soula February 2, 2015 at 9:01 am - Reply

      I think I’m just used to the creative world where artist’s produce and their creativity is regurgetated. Picasso taught us: ‘Good artists copy, great artists steal’.

  11. soula February 1, 2015 at 7:08 pm - Reply

    As John mentioned there has been a great discussion on the bodyinmind.org website. Here is the link for anyone wanting to view or comment: http://www.bodyinmind.org/trigger-point-evaluation/

    • I am so amazed and in awe at your creativity, and art work. Thank you for sharing your techniques/tutorials with us. Since I stumble across your site while surfing the web I have not missed a day to see what you post next. I am so inspired to try each technique that you present, but I have to practice, practice, practice. Thank you!!!!!!Karen

  12. John Quintner February 1, 2015 at 2:37 pm - Reply

    Soula, your followers might like to know that our paper has already been the subject of extensive discussion on the weblog Body in Mind. Professor Lorimer Moseley asked me to submit an article outlining some of the views we expressed in our paper. There have also been two detailed letters submitted to the Editor of Rheumatology expressing disagreement with our conclusion. We have duly responded to each of them.

  13. Robert Echenberg February 1, 2015 at 1:00 pm - Reply

    Love, purpose and hope… what a wonderful way to perceive the true meaning of person-hood. For thousands of years that triad has withstood the test of time to counter illness, pain, suffering, and even death – which come to us all without invitation. It appears to be essential to re-integrate love, purpose and hope back into our care giving model, both for ourselves as well as for those we serve. Maybe “healing illness” instead of “treating disease”. Soula, your question session with Dr. Quintner was great and on point. Thanks for it…

  14. Rosemary McKenzie-Ferguson February 1, 2015 at 10:57 am - Reply

    I have had injured workers describe pain in ways that would not be found in medical literature everything from going 15 rounds with the Devil to God doesn’t want to dance with this to vacant
    Pain is as individual as the person who carries it, it has never been and will never be a one size fits all t-shirt.
    People look at me -even people who have known me for over the last 20+ years they could not tell you where my pain is, what level of pain I am in. I have stood and addressed a conference to speak about my injuries and the work that I do in such pain that when I left the podium I had to lay down just before I passed out, yet not one person other than the person who helped me to the sick room saw any of it.

    Pain is a part of my physical being, it is not something that can be masked by medication, it is not something that can be eased by surgery, the damage to the nerves is such that nothing can be done, I have just learned how to walk how to stand how to work with it to the point now where people see me in pain but don’t recognise what they are seeing.

    • soula February 2, 2015 at 8:57 am - Reply

      Rosemary I refuse to accept ‘pain’ is ‘my’ anything. I go through those moments but they never last. I’m grateful.. no way I’m accepting this. And especially not when new research is offered. Tomorrow may just be a different day for us both.

  15. Leon Chaitow February 1, 2015 at 9:56 am - Reply

    The Journal of Bodywork & Movement Therapies will publish a comprehensive critique of the perspective offered by Dr Quintner and his colleagues in its April 2015 issue. I advise a reading of the point-by-point counter-argument that it contains, before deciding which model you feel seems more likely to reflect your own experience, and your understanding of how the body works.

    • soula February 1, 2015 at 10:18 am - Reply

      I have a feeling a final decision will never be reached Leon. Pain is just too difficult to resolve. I will certainly read the critique. Ongoing debate and conversation is most important for all of us. Thank you.

    • Geoffrey Bove February 2, 2015 at 1:43 am - Reply

      The critique to be published in JBMT is actually “bad form.” The authors should have sent their critique to Rheumatology.

      To respond and to clarify: we were not giving a “perspective,” we were reporting facts that have been ignored. And we were not presenting a different model, just giving an example of one that makes sense based upon existing facts, which the trigger point construct does not.

      In addition, this has nothing to do with people’s experiences or understanding of how the body works, or in fact, pain. Pain is a large and broad topic. We wrote about an aspect of human physiology / pathophysiology that has been presented for decades as fact, when it is not.

      Models are only to try to help understand what we do not, and only useful until they are replaced by facts, and then new models must be designed to move forward if desired. That didn’t happen with the trigger point model, which morphed into “fact” without the benefit of favorable scientific inquiry, in fact did just the opposite.

      • Leon Chaitow February 2, 2015 at 6:19 am - Reply

        As Dr Bove is aware Rheumatology apply a word limit to letters to the editor. The JBMT critique of the article by Quintner et al has no such limit. Nor was there any limit proposed for any rebuttal that Quintner et al offered, to be published in the same issue. this offer was not accepted. “Bad form” is an interesting concept deserving of separate discussion, however my view is that the critique to be published in JBMT in April’s issue (issue 19(2)) will counter many of the assertions in the Rheumatology article, and that the resulting information, from both sides of this debate, will allow readers to make up their own minds regarding the scientific aspects of the different presentations . This should be a useful exercise in achieving clarity.

        • John Quintner February 2, 2015 at 7:23 am - Reply

          For me, it is not really a question of a journal’s word limit. I would much prefer to be published in a journal where the peer-review process is quite stringent and where the declaration of conflicts of interest is taken very seriously.

          Conflicts of interest can arise in this situation when the authors of the “critique” mentioned by Leon happen to be directors of a commercial enterprise known as Myopain Seminars. Obviously they are not going to be inclined put away their needles and recant their views.

          The MTrP proponents believe and teach that “myofascial pain derives from myofascial trigger points” – a classical circular argument. They have begged the important question as whether pain felt in muscles is “myofascial” in origin. We have argued in our paper that this may not be the case. There are other possibilities for which there is scientific evidence.

          Leon proposes that readers decide upon ” … which model you feel seems more likely to reflect your own experience, and your understanding of how the body works” Here he provides an example of what is known as The Bandwagon Fallacy, when one argues for an idea based upon an irrelevant appeal to its popularity.

          Whatever issues arise from our paper that need to be debated in a scientific forum, such a debate is best conducted on neutral ground. I agree with Geoff that the journal RHEUMATOLOGY meets this requirement.

          • Stephen S. Rodrigues, MD February 6, 2015 at 6:38 am

            How can you publish old stale data and concepts?
            Without being able to be tested in reality an idea is just and idea.
            You are totally and pathetically wrong.

            Travell et al are the most accurate which is being practiced all over the world.

          • John Quintner February 6, 2015 at 11:37 am

            It is certainly true that the “myofascial pain/trigger point”construct pioneered by Drs Travell and Simons in the 1980s drives physical therapy practice all over the world. But it was built upon speculation and flawed science that was first exposed by us in 1994 and yet again in our most recent paper. Those who disagree can freely express their views in a peer-reviewed medical journal or on the highly respected Body in Mind blog-site. Yes, we might be “totally and pathetically wrong” but the evidence we have assembled in our paper does not suggest that this is the case.

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