You earlier referred me to painscience.com which had a lot of terrific resources, so thanks a lot for that!
I even bought a couple of the e-books he had. It seemed like a good deal as he had done a lot of work with collecting research material and summing it up in a way that we can all understand.
Along with my purchase (knees and back pain) I got a free one for trigger point therapy.
Never really been into “massage”, just used a lacrosse ball sparingly for my hip.
Now I just listened to the recent Sacramento Q&A part 2, where you mentioned that the trigger point stuff should be disregarded.
Could you elaborate a bit on the issue or explain why it should be disregarded?
Thought this would be useful to more people than me, as I guess you have recommended a lot of people check out painscience.com
Is there just less/bad research that supports the claims he makes about trigger points?
Dr. Baraki, that statement seems at odds with one you made in your Aches and Pains article:
“And ‘myofascial / trigger point pain’ does seem to describe a real (and likely underdiagnosed) phenomenon, although the mechanistic science of it is still unclear.”
Am I missing the point? I’m a bit confused determining exactly where you stand on myofascial issues. I’m hoping you can provide me with some clarity.
Correct me if I’m wrong, but you seem to be of the belief that consideration of “muscle tightness” in a clinical setting is not worthwhile. Are you then taking it a step further and refusing to consider muscle tightness as a cause of pain? Or do you simply focus on the advice given in your 6 steps since it would tend to resolve issues we see as “myofascial pain.” It just doesn’t seem to follow that low correlation between a certain condition and pain means that the condition is irrelevant in diagnosis and can’t be the cause of pain. But it does make sense if it’s considered in the diagnosis, and the treatment simply covers a wide array of problems that include that particular pain.
Either way, how about cases where the cause is more tangible, such as patients with TOS? Generally, the nerve/artery compression in this case is attributed to tightness (and let’s say for the sake of this example that the patient’s is an office worker, forward head posture, rounded shoulders, etc. and the nerve bundle is being compressed by the pec minor - everything a chiro/physio would typically use to verify that tightness is the cause). Given that practitioner’s diagnosis, the proper prescription seems to be centered around resolving the tightness. Would you tend to attribute the nerve compression to a cause other than “tightness,” or would you just approach the treatment using methods other than massage/chiropractic adjustment/etc.? And would you include anything in your treatment other than advising them to sleep/exercise/etc.? If you do agree that tightness can be a valid cause of nerve compression, do you just disagree that massage/ART/etc. can do anything for it outside of placebo your client?
I don’t see it as being at odds. Focal “muscle pain” is a thing. “Trigger points”, from the available evidence to date, do not appear to be a thing. And yes, I am of the belief that “muscle tightness” in a clinical setting is not useful, for several reasons:
There is no objective definition of what constitutes a “tight” muscle (outside of clear contracture or spasticity, of course).
Given #1, there is no evidence (or plausibility, even), for inter-rater diagnostic reliability for evaluating muscle “tightness”. In other words, no one knows what the hell they’re feeling on examination.
I agree that a low correlation between a finding and pain doesn’t mean it’s irrelevant in diagnosis. However, it does mean it’s not the primary causal mechanism that needs to be directly treated. There are mountains and mountains of pain neuroscience research looking at all of this stuff, and it makes the idea of a “tight” muscle being the direct cause of pain seem rather simplistic.
Because of #4, locally-focused treatments like massage, IASTM, ART, etc. may make patients feel better, as I’ve said before, but I do not subscribe to their proposed mechanisms of action. In other words, I would not say that perceived benefits have anything to do with “lengthening tight muscles”, “releasing adhesions”, etc.
TOS is an interesting topic, and is probably a more controversial one than you think (see: Thoracic outlet syndromes. The so-called "neurogenic types" - PubMed ). The ideas around clinical diagnosis and management are not as clear cut as you suggest (“the compression is due to tightness”), there are lots of potential confounders in diagnosis, and the available evidence on the matter is not particularly compelling. The examination techniques for TOS have poor specificity and generate lots of false positives, and improvement with “typical” management (massage, adjustment, etc.) are likely – as with many orthopedic conditions, as we are starting to learn – to result from a combination of natural history/regression to the mean, centrally-acting mechanisms, and other nonspecific effects (sometimes known as “placebo”). With that said, a true compressive neuropathy is in an entirely different category than what we’re talking about above re: “myofascial pain”.