Myofascial Trigger Points.

To the Editor:

I am a practicing physical therapist in a private orthopedic and sports medicine practice in downtown Manhattan. In my practice, a vast majority of my patients have cervical, scapular, and thoracic pain as well as headaches with related trigger points throughout the scapular musculature. In reviewing the literature and attempting to expand my expertise in this area, I have found a disappointingly sparse amount of research focusing on the treatment of myofascial trigger points. Because of this, I was excited to find "Effectiveness of a Home Program of Ischemic Pressure Followed by Sustained Stretch for Treatment of Myofascial Trigger Points" by Hanten et al in the October 2000 issue of Physical Therapy.

As a physical therapist, I am fully aware of the pressure that third-party payers place on our practice patterns and patient care, many times forcing us to treat patients for a shorter period of time than our better judgment would otherwise dictate. In keeping with Hanten and colleagues' statements, I am also in favor of involving my patients in their treatment as much as possible through home exercise programs and patient education. I feel that doing so is as important as any other element of the care we provide for all diagnoses, especially in orthopedics.

I believe that Dr Hanten and his colleagues used sound research and data analysis. Their results are important to our profession and should lead to further study in this area. I find a problem, however, with the statements in the conclusion of the article. 'The authors stated, "Our results indicate that clinicians can manage neck and upper back pain associated with trigger points through a home program of ischemic pressure and sustained stretching with periodic monitoring by a physical therapist." I believe that home stretching and trigger point release along with thermal modalities are crucial aspects in the treatment of trigger points associated with pain, but I contend that we must not underestimate the importance of what physical therapists do in placing our hands on the patient.

Patients, in my opinion, expect their physical therapists to treat them with the many varieties of manual therapy (ie, soft tissue mobilization, massage, ischemic trigger point release, myofascial release, and joint mobilization) that we are licensed and qualified to perform. On a nearly daily basis, I encounter clients who report to me that they have previously received physical therapy for the same diagnosis for which I am currently treating them. In an overwhelming number of cases, these patients report that they were dissatisfied with their previous therapist and the care they received. Why? Based on the patients' reports and my experience as a therapist in several clinics where patients received treatment in the manner I describe, I contend that their therapist did not spend enough individual (ie, one-to-one) time utilizing manual therapy. These patients were given home programs of excessive and difficult strengthening and stretching exercises; they received ultrasound, heat therapy and electrical stimulation; and they exercised with a physical therapy aide. Is this how we want the public and other health care providers to envision our profession?

In my practice, I believe that manual therapy is paramount. I spend 30 minutes with each patient exclusively, primarily using manual therapy, and, in my opinion, my patients both improve and are pleased with the care they receive. I believe that we must attempt to maintain this type of practice in order to appropriately position our profession as the most qualified to treat myofascial pain syndromes, which (as Baldry[1] defines in the non-peer-reviewed literature) result from trigger point activity. Doing otherwise, I argue, would be yielding to the expectations and demands of insurance companies. But most importantly, in my view, it would deprive our patients of the high-quality care that they deserve and expect and may lead to the overall decline of the physical therapy profession in the eyes of patients, insurers, and other health care professionals.

In reading Hanten and colleagues' article, I am aware of the statements on limitations of the study and where further research must focus. Again, I believe that the research was sound, but third-party payers read with a different focus than clinicians do. While we are looking with an astute eye for knowledge and new skills in order to provide the highest quality of care for the patients that we manage, insurance companies are critiquing our literature with an eye focused on further limiting our ability to treat as we see fit.

With the current environment in health care, and the emphasis that insurers place on research for validation of our interventions, Hanten and colleagues' quote in the conclusion of their article may prove to be dangerous. I believe that such statements can significantly affect the reimbursement and fee schedules that physical therapists receive for the treatment of all myofascial pain disorders, especially those involving trigger points. As a profession, we must remain aware of the fact that we are constantly under the microscope of insurance companies, doctors, chiropractors, athletic trainers, and especially the general public. We must not add fuel to the fire of those who wish to deprive us of autonomy in our clinical decisions. We also must instill confidence in those who have limited respect or understanding of the physical therapy profession that we are the most qualified to provide treatment for myofascial pain and dysfunction.

I again would like to state that I feel research in this area is crucial to the future of our field, and I thank Dr Hanten and his colleagues for their contribution. I ask only that we place the statements that we make under the same microscope that third-party payers and other health care professionals do, and in turn allow important data, such as the data presented in this case, to be utilized appropriately in the continued advancement of the physical therapy profession.

Jeremy VanDevender, PT Physio Sports Center 45 Broadway, 14th Floor New York, NY 10006

References

[1] Baldry P. Cited by: Chaitow L. Muscle Energy Techniques. New York, NY: Churchill Livingstone Inc; 1997.

Editor's Response:

Mr VanDevender expressed concern about the harm that may be done due to the discussion of limitations in the article by Hanten et al. While I do not share this view, my greater concern is the belief that this should be an issue in discussing any published research. The role of research is to provide information and not necessarily to promote a profession or "validate" treatments. Too often we hear people speak about the need to "validate" our treatments. I believe that this suggests an unacceptable bias and implies that research is needed to prove what we already know (ie, that our interventions work).

We should be examining our interventions so that we can eliminate those that do not work, modify those that can work better, and develop new interventions that will best serve our patients and society. Properly conducted research should provide us with new knowledge. If this knowledge justifies what we do, that is great, and we hope that services based on that knowledge will be respected by payers and others. If the new knowledge indicates we have done things poorly in the past, then that is a reason to change, and I believe it is also a justification for payers and patients to object to those treatments. Validation is not the issue. The issue is inquiry and evidence gathering.

All research has limitations, and part of our role in a peer-reviewed journal is to make sure that those limitations are noted and discussed. In the research process, scientific credibility is most important. Neither the Journal nor authors can avoid discussion of limitations, even if they fear information may be misused. If the information is used inappropriately, there are ways to seek redress. We all might wish for more generalizable results, and results that are limitation free, particularly when we like those results. The best way, however, of making research useless is to engage in bias and selective discussions. In the Journal, we pride ourselves on the credibility of the papers we publish and will continue to make every effort to see that limitations; as well as strengths, are recognized, regardless of whether the study indicates that physical therapy interventions have any value.

Jules M Rothstein, PT, PhD, FAPTA Editor