How having a treatment framework can change everything - with Jan Dommerholt - Chronic Pain Relief

How having a treatment framework can change everything – with Jan Dommerholt

Expert Interviews

jan-dommerholtJan Dommerholt PT, DPT, MPS, DAAPM is a recognized expert in the physical therapy treatment of persons with myofascial pain syndrome.

Dr. Dommerholt worked with Dr Janet Travell and David Simons for years, and now teaches courses on dry needling and trigger point therapy at MyopainSeminars.com.

In this interview, we discuss:

  • The Pain Neuromatrix Model and how this can help therapists do a better job treating chronic pain
  • Where Travell and Simons got it wrong….
  • How to learn accurate trigger point palpation
  • What happens within a trigger point at a cellular level
  • Treatment of severe trigger points in the pelvic region
  • How culture affects how we exhibit pain
  • Where to get the most up to date trigger point treatment information
  • The toughest dry needling course in the country
Find out more about Dr Dommerholt’s courses here: http://www.myopainseminars.com/

neuromatrix

Transcript:

Naomi: Welcome, everybody. Today we have on the line Dr. Jan Dommerholt, who’s a physical therapist with a doctorate in physical therapy, a diplomat of the American Academy of Pain Management, and a recognized expert in the treatment of myofacial pain syndrome and pain caused by whiplash. So welcome, Jan.

Jan: Thank you very much, and thank you for having me on the program.

Naomi: Could we start off by you telling us a little bit about where you are in the world and what kind of work you do?

Jan: Yeah, of course. I’m in Bethesda, Maryland. I’m originally from the Netherlands, but I moved to the United States back in 1986, and I’ve lived in the Washington D.C. area ever since.

Naomi: Okay. And you run a clinic?

Jan: Yes. I have a clinic, Bethesda Physio Car. It’s a small clinic that’s fairly specialized. The majority of our patients are chronic pain patients, but we also have a few specialty areas, if you want. We treat quite a few performing artists, specifically musicians, and we also have a sub-specialty in patients with *** (01:08) Syndrome or Hypermobility Syndrome.

Naomi: Okay. So reading your bio, it’s quite interesting because it sounds like you were in right near the beginning of myofascial therapy as a practice. So could you tell us a little bit about how you got started in trigger point therapy?

Jan: Yeah, it’s actually interesting because in — I’m trained as a physiotherapist in the Netherlands, and when I graduated I worked briefly in the Netherlands, then I moved to the United States, the Washington D.C. area, and at that point I really didn’t know anything about myofascial pain or about trigger points at all. I was employed at a local hospital in Washington D.C., and I tried to go to as many *** (01:54) and grand rounds and things I could go to, to learn as much as I possibly could.

One of the workshops that the hospital hosted was a workshop by Dr. Janet Travell. I had never heard of Dr. Janet Travell, to be honest, and I went to the workshop. To my surprise, I saw an 89 year old woman, physician, teach physicians and therapists about myofascial pain and trigger points. She asked ahead of time for patients with such severe pain problems that none of the doctors and therapists knew what to do anymore and kind of threw their hands up in the air, and after two, three hours of working through her stuff these patients walked out of there feeling better than they felt in years.

So that really piqued my interest, and I was like what did she do? I had never heard of her before, so I did some research and found out she lived in Washington D.C. Then I learned that she was the White House physician and doctor for President Kennedy and President Johnson, and I was like, hmm. So I contacted her. I said, okay, I attended your lecture, I’m very intrigued by what you showed and what you did, and what can I do to learn more about it. And that’s kind of my start. That was in 1989, and I could not have a better teacher than Dr. Travell, and later Dr. Robert Gerwin, who I still work with this area. Eventually I got to work with Dr. Simons, David Simons, who with Travell wrote the Trigger Point Manual. So I was very fortunate, I think, to kind of be at the right time in the right place, and I was very pleased with that. And it changed the way I worked, it changed the way I approach my patients and my whole life actually changed because of it. For patients, I think I provide a much better service than before, and I kind of feel sorry for the patients I saw before I knew this stuff about myofascial pain, because I wonder what in the world did I do with these poor folks because I probably didn’t do the best possible job I could have done.

Naomi: Trigger point therapy, as you said, has been around for several decades now. Why do you think it isn’t more popular or more widely known?

Jan: That’s a good question. First, it is usually not taught in medical schools or physical therapy schools. It’s probably more taught in massage therapy schools, but not so much in the more medically-oriented programs. The question why is that, well I think that ties into a bigger picture, that muscle skeletal pain has not really been a research object either. If you look at the pain scientists, what have people studied, people looked at neuropathic pain, people looked at the role of chemicals, of cytokines, of inflammatory diseases, et cetera, et cetera, and muscle skeletal pain, just the notion that muscles can contribute to a pain experience is relatively new concept.

Travell was a little bit ahead of the time, I think, and over the years, over the centuries, the concepts of trigger points have been brought up many, many times as far as back to the Middle Ages, the Renaissance Period. 1816 there was a publication that literally described trigger points by a British doctor, Dr. Belfort. So it’s been around a little bit, but never got anyone’s interest. When Travell came along, she really started documenting particularly referred pain. She was kind of ridiculed many times. People didn’t believe her. Her tenure even in the White House was very much questioned by Navy physicians who traditionally would get the job, and then Kennedy insisted that she became the White House doctor. They criticized every step she took, in spite of compliments of both presidents that she served as their physician.

It was many, many years later, really only the last 20 years, that gave the notion that muscles have nociceptors, the nerve structures, the sensors that connects, they lead to nociception that can lead to pain. Before 20 years ago, that was an unknown fact. People had no knowledge about this. And so I think the whole musculoskeletal research world is still fairly young. When Travell started, it got overshadowed by the focus on disc pathology. In the mid 30s the first study came out that showed that disc was the source of all back pain, and the orthopedic world certainly took their run with that. So it got overshadowed by a lot of things. Travell didn’t do an awful lot of research. It was more, hey this is what I see in my practice and she was really prolific, but the really basic sciences in muscles as a potential source of a pain experience, that’s all fairly, fairly new.

So in the context of pain sciences, muscle pain is a fairly new concept that really has developed into a big part of the research world. Having said that, that is changing very rapidly. There are researchers all over the world looking at muscles as a source of pain, trigger points as a source of pain but also other aspects of pain. The more recent time, I think it got overshadowed again by the notion that pain is produced by the brain, and especially in physical therapy there’s definitely an emphasis or a belief system that without a brain you don’t have pain, so no brain no pain. I don’t dispute that, but there’s a bit of a tendency in some circles now to mitigate anything that comes from periphery.

So people challenge me sometimes on, well are you saying that muscles can cause referred pain, and I say yes there’s lots of research on it. Why would I not say that, because that’s a fact. People say, well that can’t be because pain is produced by the brain. And so there’s a little bit of a disconnect there between what’s been found in the myofascial pain research and what other people emphasize in their discussion of what pain really entails and what pain really is all about. The chronic pain. So I think there’s a multitude of reasons why that’s kind of behind. But I’m quite optimistic that that will change fairly quickly, but change in academia is very, very slow.

Naomi: Yes, yes it’s sometimes a bit glacial.

Jan: That’s correct. It’s very, very slow. Some people told me that it takes 15 years to create any kind of major change. And when you look at that, and I do a lot of dry needling which we’re probably going to talk about later and I teach that, I have, since we’ve started teaching dry needling courses in the United States was in 1997. About 1999 I started writing a letter every year to the Physical Therapy Association, that you need to take a look at trigger points, you need to take a look at dry needling, we need to have a position statement on that, you need to look at that. Is this something you could stand behind? That was in 1999. It took until 2012 before the American Physical Therapy Association published a research manual on dry needling.

Naomi: Yeah, that’s a definite time delay.

Jan: It takes a tremendous amount of time before this goes into academia, so it’s actually taught in schools of physical therapy and taught in medical schools, I think you’re looking at another 10, 15 years perhaps, before that’s more wide spread, in my opinion.

Naomi: Wow.

Jan: There are people who would argue against that and say no, this is the worst thing that ever happened. Why are you sticking needles in people? You shouldn’t do that. There’s no reason for it. So there’s a bit of controversy still surrounding them. The research is moving so fast that I am not that concerned about it and I think it will happen eventually. About a year ago I did a workshop at one of the national conventions of the American Physical Therapy Association. There were 500 people in the audience or so, and it was sold out to the max. I asked the question, who in here’s in education. There were probably 100 people who were educated.

Naomi: Oh, okay.

Jan: So there was clearly an interest from the academic world in physical therapy, like hey what’s this all about. There are now several schools of physical therapy where trigger points are being taught fairly well. Some schools do an introductory to dry needling now, that they’ve put in their curriculum. Change in the curriculum is very, very difficult. I mean, the students are overloaded already, and to add something to it I think they could probably take some other things out of it that are probably a little outdated, but even that takes time. That’s just the way things work.

Naomi: I’ve got a question that we get asked fairly often. Just a simple thing of how to learn and feel for the trigger point. Did you learn that originally with Janet Travell?

Jan: Yeah, pretty much, and later with Bob Gerwin. People criticize me sometimes in that if it’s that hard then only experts can learn this. That’s really not true. It is not that difficult to learn, but it’s like with any other skill. If you only listen to someone’s heartbeat with a stethoscope, I think anyone can put a stethoscope in and hear a heartbeat. That’s not that hard. You can do it without a stethoscope. But then to listen carefully, like okay what do I ever hear, is there a problem with this valve or that valve, this noise or that noise, what does it mean, that takes practice. You need to sit down and listen to these things many times and repeat it and practice, practice, practice. That’s the same with any palpatory skill.

So if you want to learn how to palpate for trigger points, you need to know how to do it. So you probably need to spend some time with someone who knows how to do that. There are courses available in many different fields. In massage therapy there are many courses. In physical therapy there are several courses. Now they don’t always look at trigger points, but they do still exist. There are courses. We have a course in manual trigger point therapy.

Basically what it requires is understanding what you’re palpating for, but a lot of people don’t realize if you take a muscle and you palpate the muscle in the direction of the muscle fiber, it feels wonderful, feels great. If you palpate perpendicular to the muscle fiber, all of a sudden you can find ropy strings of tissue in the muscle. And when you do that, it’s often quite sensitive. You find that ropy string that’s usually in a bed of contracted muscle fibers, it’s called a contracture rather than a contraction, you palpate along that fiber and very commonly you find an area that’s exquisitely sensitive. And many times people say that really is painful. Well, that’s when you have a trigger point.

So to find a trigger point you first need to find the torn band or the band of contracted muscle fibers, contracture muscle fibers. Once you have that you palpate along that torn band until you find an area that’s exquisitely sensitive. It could be a nodule, that’s possible. Not always the case, sometimes it’s just an area that feels a little bit harder. So again, just like with the stethoscope and listen to the heart noises, to appreciate that you just have to do it an awful lot of times, until it becomes so natural that you’re like, hey that is not normal. And once you get it in your fingers, it’s actually like, how did I do without it. It’s really not that difficult. But it is a learned skill. I don’t think that you can just say, okay I know how to do that, or trigger points don’t exist because I can’t palpate them.

Naomi: When you’re doing a physical treatment, how do you usually go about releasing the trigger point?

Jan: In my office we use a technique called dry needling, a fair amount, because that, in my opinion, is the fastest way to do that. But if you don’t have access to it or if you’re in a discipline, say massage therapist, where you can’t use needles, or a physical therapist in some states can’t use needles either, that’s not approved in every state in the U.S., or in every country for that matter, you can release it manually. There are different techniques for it. They don’t really differ that much. The manual techniques, whether you put your finger this way or that way really doesn’t matter that much.

There have been comparative studies on looking at different hand positions and this kind of pressure, that kind of pressure, it really doesn’t matter that much. So really what you need to do, once you’ve identified the trigger points, you apply pressure on that trigger point. Not what people used to call ischemic pressure, that’s really not necessary. So in Travell and Simons’ first book, they talked about ischemic pressure. That’s basically so much pressure that you cause ischemia or lack of blood flow. That would be counterproductive, because a trigger point, in our current understanding of it, so Travell and Simons were wrong in their initial assumptions, but now there’s been enough research in looking at trigger points and the National Institute of Health has contributed tremendously. If you now look at trigger points, the trigger points are already ischemic. They have a lack of oxygen. So the last thing you want to do with your pressure is apply so much pressure that you even cause more of a lack of oxygen, because you’re going to make the problem worse.

So light pressure over a trigger point, you don’t have to press very hard, you can just do pressure itself, that will help release it. It’s a little bit more effective if you ask the patient to gently contract the muscle that you’re compressing. That works a little bit better, I think. The first time you create kind of a fixed point on a trigger point, the patient gently pulls these muscle fibers back and forth in relation to that fixed point, and that’s a little bit easier of a release. And it’s also a bit of a distraction for the patient, because the pressure can be quite sensitive. You can ask the patient, “Hey, contract your muscle 14 times.” I often say 13 ½ times or some other strange number that people get a little confused and focus more on the counting than on the sensitivity, and that is a very easy way to release trigger points.

The dry needling is my preference. People say why would you put needles in, that hurts and people are fearful of needles. That usually really is not that big a problem once you explain, okay this is the quicker way to do that because it’s much greater specificity. If you take a ping pong ball and you take a big pillow and you want to squish that ping pong ball with a pillow, you’re not going to be very specific. If you take a hammer, you hit the ping pong ball flat, it’s done. So if you use the thumb in relation to a trigger point, it’s probably about the same ratio as a ping pong ball and a pillow. You can use your thumb and you can change things. Some of it’s probably nerve, physiological rather than pure mechanical, but if you can put a needle directly in it and get what is called a twitch response, it is so much faster.

It’s a little uncomfortable for most people, and some people it’s the worst thing they’ve ever felt, they tell me, but that’s usually not the case. The vast majority of people, once you say let’s work together, let’s figure it out, you put it in the right context, nothing really severe happened. People are perfectly content with it and do fine. People see the changes so fast, that it doesn’t really – the discomfort from it, for most people, really doesn’t matter. Most people say it’s well worth it. It is perfectly fine.

Naomi: That is very interesting. I had a question pop up while you were talking about dry needling. Now I’m trying to remember what it was. Ah yes, that’s right. A complaint that we’ve had in the past from manual therapists is that – well there’s two things. The first is that sometimes patients say I had trigger point therapy and two days later I was covered in bruises. And the other one is from manual therapists saying that my hands get really tired from doing massage, so I can see why your point is to do a really gentle pressure and then using dry needling would be very helpful in those two cases.

Jan: Yeah. So the first comment about the bruising, there are currently, to my best count, 17 different education programs in the United States alone that teach courses in dry needling. Now we started in 1997. We were the only ones for many, many years, there was no competition, we were the only program that did dry needling. We very much follow the trigger point model, and we still do that to a great extent. Now there are 16 other programs that teach some form of dry needling. Inevitably, there’s a lot of variations now in how people do dry needling. People now do more peri-neural dry needling. Needling close to nerves or actually needling directly into nerves. Other people use dry needling for fascial restrictions and scar tissue and use acupuncture points along with that.

So there are lots of ways you can use a needle. And I believe that it depends a little bit on how you are taught and how you implement this technique, whether you get bruising or not. The vast majority, 95-plus, 99-plus do not get bruising in our clinic. It just does not happen. Having said that, in one of my courses I show a slide of a patient whose entire inner thigh is one big bruise. Now that was not after dry needling, but it was after a trigger point injection by a physician. The physician probably hit an artery deep down in the leg and didn’t know it, and it kept bleeding. The patient probably had poor coagulation. It was very impressive. I was like, oh my that is really not good.

Every now and then you may hit a deeper vessel that you don’t know about. But if you really, really, and I’m kind of passionate about it and people who have taken our courses they’ll support that, if you focus more on actually palpating the trigger point accurately, by the time you put that needle on the skin and you tap the needle in, then there’s no question that the first time you bring a needle towards the trigger point you should be very, very accurate. Get a local twitch response and you treated the trigger point, you go back and forth several times in that same tiny, little region where the trigger point is palpated, you get a twitch response after twitch response, that may be 2 to 3, that may be 5, 6, that may be 10, 15, depending on how sensitized the person is.

There’s usually no bleeding whatsoever. You take the needle out, we immediately apply pressure on the puncture site. And so if there is any bleeding, if you hit any deeper vessels, it will stop right away. And if you do that, there really is not much bleeding. I’ve seen demonstrations of other people who do dry needling, where the palpation is done fairly shortly and kind of like rough and not very precise. Okay this is where it hurts and they kind of put a little tension on the skin. There’s no finger anywhere near the trigger point, the needle is inserted. Now with the needle, people are trying to find that trigger point again. That leads to a lot of what I would consider unnecessary pathways of needle sticks throughout the tissue, and yes you’re going to hit many, many more blood vessels and you’re probably going to get much more hematomas and bleeding. It really does not need to happen.

We did a study on dry needling on the adverse events of dry needling in Ireland, and it’s been published. It’s online now. It’s not yet in the print version of the journal. But the Journal of Manual Manipulative Therapy has accepted the paper, and it’s on the website already. We looked at adverse events. So an adverse event by definition is anything that may occur that’s not the intended therapeutic outcome for anything. so if you stick a needle in a trigger point and the patient says, oh that hurts, that would be a adverse event. So it’s fairly common, and one of the reviews of the paper, he said why did you include that because isn’t that true for everyone. That’s not an adverse event, that’s something you would anticipate. But if you look at the strict definition of adverse events, we don’t needle people to hurt them. We needle to get rid of pain, to get rid of trigger points and improve mobility, so technically that’s an adverse event. The most common adverse events were pain during and after needling, bleeding and hematomas. Those are the most common.

But the ratio was still very low. If you look at anything beyond that, there really were no adverse events to speak of. I mean, one person stated that they’re claustrophobic. Well, when we looked into it we found that it had nothing to do with the needling. When the patient’s head was placed in a roll on the table and needling or not, the patient never liked that and was always claustrophobic. It was reported in our study that it was a side effect of dry needling, an adverse event of dry needling.

As far as serious side effects, like significant adverse events, yeah with the needle you can cause a pneumothorax and a collapsed lung, and that certainly has happened in the country. Not a lot, but we don’t really know how often it happens because no one reports these things. So we don’t really know how often it happens. In our study, which was a prospective study of almost 8,000 treatments by physiotherapists in Ireland, there was not a single significant adverse event, and then we calculated the risk. We found it was less than 0.04 percent. So that is four-hundredths of a percentile, and less than that was the risk of a significant adverse event, by people who are trained properly.

So it’s very, very safe. Yeah, bleeding does happen, bruises do happen, and they’re not the end of the world, but yes you do cause a puncture wound whether you like it or not. It goes through tissue, so if you hit a major vessel and you do not apply homeostasis right after that, then yeah you could cause bleeding. It is possible. Again, in our clinic it really doesn’t happen a lot. Occasionally we have some patients that come back with a bruise on the area treated, and usually it’s several days later, which means that the puncture of a vessel, a blood vessel, was fairly deep inside the tissue, and four or five days later it finally comes to the skin. Yeah, even if you applied pressure then, you may not always be able to stop the bleeding. But it’s pretty rare. Now when these Harry Potter movies were so popular, one of my patients had a bruise and she called it the Mark of Yom from the Harry Potter movies, which is kind of funny, I thought. It really is not that big of a deal.

As far as your other comment that it saves hands, because trigger point therapy, manual trigger point therapy, yeah it can cause a fair amount of discomfort, and the number one problem with physical therapists who do a lot of manual therapy is thumbing. It’s your strongest digit and we use a lot of pressure. And trigger point therapy, I would state that most people probably use way too much pressure. That used to be the thinking, and you put a lot of pressure, and I really don’t think that’s necessary. The current research does not support that. There are probably 10, 15 outcome studies of manual trigger point therapy, and some of them are comparative studies. They really do not show one method being superior over another. So I would explicate the least amount of pressure. If you’re going to treat it manually, the least amount of pressure, let the patient actively contract the muscle. That will save your thumbs a lot.

For big muscles, the linear muscles for example, you have a muscular partition of a slightly overweight or obese person, I recommend you use a tool. Take a tool, take a trigger point pressure tool, there’s lots of them on the market. Some of them are great, some of them are not so great. Many of them have really large surfaces. I would say the smaller the better, but not so small you’re going to pierce the skin, of course. They can’t be that small. The thumb is usually too thick for that. Trigger points are one to two millimeters in size. I mean, they have been measured now. We have measurements of active trigger points and latent trigger points, with ultrasound at The National Institute of Health. They’re very really tiny little structures, so the smaller tool you can use without being too pointy to where it’s uncomfortable, that would be the best way to go, I think.

Naomi: Okay. We get asked quite a bit about the use of laser and TENS machines. What’s your opinion on those?

Jan: Yeah, for the TENS units there really is no good research that supports electrotherapy with a TENS unit. There are some papers that suggest it helps. If you look at the *** (27:30) osteopath in Australia, they did a comparison several years ago. The research was not very good. There was not much evidence that TENS units really work. We do use it sometimes with needles, especially on deeper structures like lumbar multifidus muscles, we sometimes put two needles in and put a current on the needle. I think that may work a little bit better, but again, the research did not really that supportive, from an empirical clinical perspective. I do think that it has a place doing this, but there’s not a lot of good research on it.

The advantage of using a needle with electricity is that you don’t have to worry about skin resistance. So the biggest *** (28:15) electrodes is that the skin stops much of the current, and it kind of goes from electrode to the skin. It doesn’t really reach deeper tissues. When you put a stainless steel needle through the skin, directly into the multifidus, the current will go through the needle and actually reach the target region. And after 10, 15 minutes of using electrotherapy through needles, people are very, very numb. *** (28:42) block the nociceptive input from the muscle or other structures conveyed with the electricity, and that’s really what happens. As far as application of electrotherapy, I think there’s not much evidence that’s very useful.

Now if you look at laser, that’s the other thing you asked, I think. If you look at laser, the research is very mixed. It’s probably 50/50. I never really did a true analysis of studies. There are studies that say it works and others say it does not work. And we have multiple laser units in our clinic, very expensive ones and very inexpensive ones, and for superficial muscles we find it to be very, very helpful. And again, there is research that supports that, but there’s also some studies that don’t support it. You kind of have to see the power of these studies, how good they are. It’s kind of a 50/50.

For superficial muscles, I think laser can be very, very useful. For deeper muscles I don’t think that laser beam penetrates deep enough to come anywhere close to changing anything. To look at how laser would work, I have never seen a good study that explains why laser would be effective in pain management. I have looked for it, I can’t find it and I don’t believe it exists, but it may be. I don’t claim to know all of the literature that’s out there. There’s one notion that in trigger points it may work because it’s a source of energy, that the mitochondria in the muscle cell may respond to it. That’s an interesting hypothesis. As far as I know, it has never been proven.

So the idea behind it is that, again, if we expanded that a little bit, that in a trigger point the fibers are so contracted *** (30:41) band in the most contracted areas, that’s why we call them trigger points, that actually the local blood flow is diminished. So these contracted fibers actually may compress the little capillaries in the muscle and cause a limitation of blood flow. And back in 1990, back in Germany the study by a researcher called *** (31:04), they measured the oxygen saturation within a trigger point and right outside it. What they found is that if it’s normal muscle tissue they get a baseline, they got close to a trigger point, all of a sudden the oxygen saturation went up. It was much higher than they expected. When they went into the trigger point it drops to practically zero, maybe 15 percent of normal.

Many years later, here at the National Institute of Health, right in my town in Bethesda, Maryland, they did it a little different. They used Doppler ultrasounds and looked at trigger points and looked outside of trigger points, and what they found, that in a trigger point indeed there was practically no blood flow, presumably because the fibers are so contracted that they block these little blood vessels. Then they looked right outside the trigger point, there was a huge vascular volume of blood. Again, that’s kind of like you put a damn in the river you get a lake. So it complements, in a way, the old study from 1990, that in a trigger point there’s not enough oxygen, but right outside it there’s a lot of blood, so therefore there’s a lot of oxygen. So these two studies actually complement each other very nicely.

If there’s no oxygen in a trigger point and there’s a contracture, well to release a contraction or a contracture you need oxygen. But there is no oxygen. We just stated that. So mitochondria need oxygen to produce ATB and adenosine triphosphate. So you need ATB, because ATB is the only way *** (32:43) and filaments in the *** of the muscle, can release the contracture. So without ATB it will stay contracted, and I think that’s one of the reasons trigger points don’t always go away. The system came to a standstill. There’s no oxygen, mitochondria can’t make ATB, the muscle can’t let go. It will stay contracted.

So the thought behind laser, or one of the thoughts behind laser, that laser beam may provide enough energy for the mitochondria to get to work, start producing ATB and the muscle relaxes. That’s certainly what we see. Clinically in superficial muscles were you use laser, patients can experience palpable changes in muscle tension, and usually that leads immediately to a reduction in pain, because now oxygen can flow again, the muscle will restore itself, these nociceptive chemicals that have been built up in the trigger point can be moved out of the region and patients are much happier. That’s one of the results of lack of oxygen. When there’s no oxygen in the system or so little, as several studies now have shown as I mentioned, anywhere in the body, whether you talk about trigger points or anything else, if there’s not enough oxygen, immediately the PH of the tissue will drop.

Back at the National Institute of Health, they measured the PH of trigger points, of active trigger points, pain-producing trigger points and latent trigger points that only hurt when you press on them, and of normal muscle tissue. Normal muscle tissue has a PH between 6 ½ and 7, somewhere around there, and active trigger points the PH drops as far as 4.5, so extremely acidic. As soon as the patient becomes more and more acidic, we actually have sensors in our body, we have several different ones, we have acid sensing ion channels, so like ASIC receptors. When the PH goes down to 6 ½, 6, 5, those receptors get activated, they stimulate the nervous system, the nervous system actually releases lots of chemicals, serotonin, *** (34:52), calcitonin gene-related peptide, live currents like *** factor, cytokines, et cetera, et cetera, that normally you do not find in muscle. These chemicals don’t belong there.

They start activating nociceptors, nociceptors in the muscle. Again, 20 years ago people didn’t even know we had them ,but now we do know that. And they feed into the nervous system and cause local pain, what’s referred to as peripheral sensitization, that ongoing barrage of these nociceptive inputs into the nervous system fairly quickly can lead to *** (35:29). Now you have a chronic pain patient. So once you break that cycle, whether it’s with laser or with manual techniques or with dry needling, dry needling has shown if you get a twitch response, you get the muscle to contract even more before it releases, these chemical concentrations decrease. It has been showed in humans, that has been shown in rabbits, it’s a well-described phenomena. These chemical concentrations drop within minutes.

So if you can release, if you can remove that ongoing peripheral nociceptive input, you can start referred pain, you can stop local pain and people do much, much better. What Travell did in that workshop we see almost every day in our clinic. I thought it was magic when she did it. It was like, how in the world could she do that? Once you understand it, you look at the research and you’re like, okay well how can we deal with this, it makes so much sense. I know that not everyone agrees with me, but I always question did people really read that research. And I’m not saying all the research is perfect, it is not. There are no perfect studies. But there is plenty of stuff that really supports this whole hypothesis that we’re on the right track with explaining what Travell found, what Belfort found in 1816, what tons of physiotherapist and massage therapy – tens of thousands of therapists, massage therapists, physical therapists, all over the world find every single day.

So when people criticize this field, and there’s a fair amount of criticism, just look online you’ll see plenty of it, I participate every now and then in these debates or exchanges as I like to call them, and we don’t know all the facts. We don’t know all the facts of anything we do in clinical practice. That is the reality of the art and science of clinical work. We don’t know everything that happens. But every scientific experiment starts with observations. I saw a patient yesterday, I’ll just give you a clinical example. He was referred to me by another physical therapist, a local physical therapist. This gentleman three years ago was weight lifting, he did a dead man’s pull and felt something rupture in his groin. Immediately he had severe pain. He’d been all over the place, he’s now in the hands of a good physical therapist in the region, and this therapist said you know, I think you may have pelvic floor muscle problems, you may have trigger points there. I’m not trained to do that, so he referred this fellow to me.

So when I palpated in that region, I palpated the pelvic floor muscles, just like any other muscle they have contractures, too, and they have trigger points as well. I did an internal exam, I looked at his *** (38:21) muscle, *** rectal palpation. He was very, very sensitive in one muscle in particular, and that was the bulbospongiosus muscle. Right in the groin, very important muscle for sexual function which was terribly being impaired in this particular case, a young man who really *** (38:43), has the erectile dysfunction, et cetera, et cetera.

He had already had some dry needling with the other therapist, so I said you know, we can certainly treat this muscle as well. I said it’s a bit of an odd place to put a needle in, I understand it, because it’s literally right between the scrotum and the rectum. He said do whatever you can. I can’t live like this. I treated the bulbospongiosus muscle with dry needling. Assuming, again, that there’s a chemical release of all these chemicals I just mentioned, it’s contracted, the system came to a standstill, it’s a source of ongoing *** (39:21) that leads to pain, that leads to referred pain, that leads to motor dysfunction, et cetera, et cetera, in this case erectile dysfunction on top of it.

I treated the muscle. It twitched unbelievably, for a tiny little muscle it twitched a lot, and when we were done the patient said, oh my gosh I do not have my pain anymore. He actually got up from the table, he put his clothes back on when we were done, he could lift his leg, he could walk around. He said that pain is totally gone for the first time in three years. That doesn’t happen with every single patient, but you can say, well pain is in the brain, which I don’t argue, the brain is a very essential organ to produce the pain experience, but when you can change something that fast, and I don’t know how he is today, I haven’t talked to him today. I’ll plan to call him tonight to see how he’s doing. I haven’t heard from him since yesterday afternoon, but this man was in shock. He was like, I can’t believe this. He has been seen by urologists who all told him it’s anxiety, there’s nothing wrong with you. Every test is fine.

These things don’t show up on MRIs and CT scans. You can do whatever scan you want. It requires good palpation, it requires good treatment. Now I wish all my patients would respond like that. That’s not what necessarily happens. But if you look at that model again, okay people criticize it and I understand that, it is still a hypothetical model. It’s called the integrative trigger point hypothesis. It has been expanded several times, actually *** (40:54) one article called Expansion of the Trigger Point Hypothesis based on their research, but it’s still a hypothesis.

Any scientific process, as I stated earlier, starts with observations. Yesterday I had an observation that treating this bulbospongiosus muscle caused a dramatic change in pain experience, dramatic. The man was shocked. I was too, quite honestly, but he definitely was shocked. Now we can say, hey okay what happened? Pain is in the brain. Well, he didn’t have his brain in his scrotum I assume, so that can’t be quite exactly right. What really happens? Well, now we need to take a look at what is going on with that. What happened to these chemicals? Again, studies have done that. What happened with the referred pain that he may have experienced? What is the mechanism? A lot of research all over the world are looking at these questions. We don’t have all the answers. That’s why it’s called a hypothesis.

So I believe that in the trigger point land, if I may call it that, there’s much greater emphasis on getting these answers and looking at the research, in many other fields of physical therapy and massage therapy, for that matter. So I think people should take the time to look at that literature. There’s a lot of literature. I write a quarterly review column for the Journal of Musculoskeletal Pain, and I can barely keep up with the number of studies that are produced every quarter. There’s a tremendous amount of papers that come out, and often I have to make choices. Like well, this is probably not that great a paper, and sometimes I still review them. But at least every quarter I include 20, 25, 30 papers.

Naomi: Oh wow, that’s really encouraging, yeah.

Jan: Yeah, so it is changing. When I see changes like that in patients, it’s like well, we’re doing something right here because this man has been walking around for three years in pretty severe misery. He couldn’t sit because it hurt. He couldn’t ride his bike because it hurt. He couldn’t exercise. He hasn’t been in the gym since this happened, because he can’t do anything. He took off from school. This is a student. It’s a young man in his early 20s. He took off from his college degree, education, because he had so much pain.

Naomi: So it was a life-changing treatment really, for him.

Jan: Well, we don’t know if it lasts. We have to see. As I said, I have to follow up with him and he may go back for a few more visits, that’s possible, but if this continues like that it truly is a life-changing treatment. Again, as a disclosure not every patient responds like that. I have patients who need many more treatments than that, but trigger points are still, like you go back to the question why is it not taught, trigger points are still overlooked. People don’t pay enough attention to it, people think it’s voodoo, people say there are no good integrated liability studies, which is not really true.

There was one paper in 2009 by Nick Lucas from Australia. They looked at several integrated liability papers, they devised a system to evaluate those. At the time the paper was published, that system had not been validated. Later they did validate the system. That is one way to look at it. But every system to create to evaluate things, any review you do you can’t escape that you set up certain parameters, they will or not meet that parameter, you will draw a conclusion to whether it’s valid or not. And some of the critics, they say some of the integrated liability papers were done experts, and that’s not reproducible in the field for normal clinicians. Well, there may be some truth in that, but if experts don’t do these studies who in the world is going to do it?

So I don’t really know how to overcome that dilemma. Some of the older integrative liability studies were very poor. They were very poor. One was done by physical therapy students. They had no clue how to palpate them. That’s like saying okay let’s take a group of random massage therapists, to go back to the stethoscope, give you a stethoscope and find this particular valve problem with a stethoscope, in the heart. Well, if you don’t know how to do that you have either 100 percent agreement because no one can find anything, or you’re all over the board because no one knows what they’re looking for. Well, if you ask untrained individuals to find trigger points and agree on what you find, you’re doomed to fail.

More recent studies *** (45:40) did a paper, and he looked at experienced physical therapists. Can they agree on trigger point locations in three shoulder muscles and arm muscles? And the integrative liability was extremely high. There are *** (45:57) liability papers. Can the same therapist find the same trigger point a day later? Very good results.

Naomi: That’s a difficult one though, because don’t you in examining for the trigger point, wouldn’t you change the state of the muscle, possibly by doing the palpation?

Jan: Well you can, but if you just palpate the trigger point it’s not going to go away just because you palpate it briefly. I don’t think that’s very common.

Naomi: Okay.

Jan: I hear there’s arguments of that, people going, well it already changed because I palpated it. Well, in most clinical patients that wouldn’t go that fast. That’s highly unlikely, and I don’t really believe that.

Naomi: Can you tell me your view on chronic pain and myofascial pain syndrome, how that differs from somebody who has a lot of trigger points? Exactly what that term means, to have myofascial pain syndrome.

Jan: Well, that’s an interesting question. I actually raised that question with Dr. David Simons when he was still alive. It’s like are we really correct to call it myofascial pain syndrome? I still question that, to be honest. I’m not 100 percent sure that that is the right term. If you look at studies of pretty much any pain region you could think of, whether it’s low back pain, neck pain, migraine, headache, tension type headaches, tennis elbow, these are some of the studied ones, every single paper that looked at the role of trigger points in these conditions like migraine headaches, they always find trigger points that are relevant for the migraine.

So I argued with David Simons. He didn’t buy my argument, but I’m not quite letting go of that yet because I wonder sometimes whether trigger points are just not an epiphenomenon of pain in general. So when people have a pain state, whether you call it the migraine, a tension type headache or a tennis elbow, doesn’t really matter, it hurts at the elbow, I have pain in my elbow. You almost always, if you look for it and many studies have done it, you almost always find trigger points, and when you press on these trigger points they produce the pain associated with the migraine headache. They produce the pain associated with the tennis elbow.

So is that then called myofascial pain syndrome, or should that be called, okay trigger points are part of pain and dysfunction of muscles. I’m not too sure that myofascial pain syndrome really is the best way to look at that. Because what does it mean? What do you have at that point? If you have trigger points in the muscles and you have migraine headaches, which diagnosis would be the most important one? Is it do you have a migraine headache or do you have myofascial pain syndrome with headaches? I mean it’s kind of a tossup. Maybe it’s semantics, I’m not sure.

I’m more inclined to say okay let’s look at, okay you have migraine headaches. Could there be a potential role of myofascial trigger points in initiating, perpetuating, maintaining, aggravating that migraine headache? To me that makes a little bit more sense than what is myofascial pain syndrome. I’m not really convinced that that’s the smartest way to talk about it. My review articles call it that, myofascial pain syndrome, because the journal insists on that, but I am not 100 percent convinced that that’s really the best way to talk about it.

Trigger points have been found in correlation with any pain problem you can think of, whether it’s phantom pain in amputees, and again I’ll just mention migraine headaches, tension type headaches, rotator cuff pain, thumb pain that people think is De Quervain tendonitis. I’ve had several cases in my clinic when people have been diagnosed with De Quervain tendonitis, one I actually published, an organ player who couldn’t play anymore because she had pain in her thumb. She went to see three orthopedic surgeons, they all told her you have De Quervain tendonitis, you’ve got to get surgery right away, and the third one said, well you probably need surgery but let’s try some physical therapy. It probably won’t work, so we can still do the surgery later.

When I saw this young lady she was 25, 26 at the time. When I did the test for De Quervain tendonitis, called Finkelstein’s Test where you put your thumb inside the hand and do all the deviation, it hurts with the elbow flexed. It did not hurt at all with her elbow extended. None of the doctors had done that. I have never seen it in the literature, and I don’t recall why I actually did that, but once I saw the difference I said okay, that’s interesting. You do not have De Quervain tendonitis, because that muscle does not cross the elbow. That should have no impact. I suspect you have referred pain into your thumb. Let’s figure out, from my perspective, which muscles can cause referred pain in the thumb. I had to look it up, I didn’t know off the top of my head. I went by all these muscles, I treated them and low and behold her pain went totally away. She never had surgery.

So is that myofascial pain syndrome? I don’t know. Is it some pain where trigger points are correlated with the pain? That’s probably more likely. I prefer to think about trigger points in that sense. I rarely think of trigger points as the cause of anything. Cause and correlation is often a confusing concept. Trigger points may be related to it. If you don’t treat trigger points, you could probably still treat this individual. Trigger points are just one way of thinking about it. There are multiple ways to think of it. If your patient has migraine headaches, you can do thoracic mobilization and thoracic manipulations and have an impact on the headache.

What’s important is that you change the peripheral nociceptive input, one way or another. If you do that through education, that may help. There’s lots of ways to skin a cat, so to speak. If you never want to treat trigger point in your life, well that’s perfectly fine, as long as you still get the task done of decreasing the peripheral nociceptor input.

Naomi: It’s the result that matters, really.

Jan: Yeah, I think if you look at pain, pain is indeed an experience that we have after the brain processes it and maybe does an assessment. I don’t really like that terminology that much, but I understand the thinking behind it. You need a pain to have pain. There’s no question. So if there’s peripheral nociceptive input that can contribute to that pain experience of the migraine headache, as long as you get rid of that input, and it doesn’t really matter how you do that, I think you can complete the task, because now that patient is happy because they don’t have migraine headaches anymore.

Naomi: Right.

Jan: I often do that through muscles because it’s, in my opinion, by far the easiest and has very high specificity. So why would you not do that? But some people say, oh you treat the skin, other people say you need to treat the joints, other people say you need to do talk therapy. Why not do whatever you have available to you and see what works best? We don’t know what works best, and that may be different from one person to the next.

So to me, the results against a framework of a scientific evidence-based kind of thing, that’s what determines whether you’re going to get good results or not. Whether you do trigger point, dry needling or massage therapy or manual trigger point therapy, that really doesn’t matter that much. I mean, that’s just – it’s one framework, it’s one model that you can treat it with. In my opinion, a very effective model, so I do this a lot and we have great results with our patients. And so I kind of dismiss – I really don’t dismiss it, but I kind of dismiss all the criticism. People put it in very black and white terms, certainly in online forums.

I got requested the other day to explain in four sentences or less why dry needling would work, on an online forum. I politely declined that, but to me that’s just setting up a trap because no one can – how long have we been talking now? Almost an hour. Who can explain these complex, multiple facetted research studies in four sentences or less? So I declined it. All that will do is that people will ridicule it again, and that really is not what it’s all about. Whether people use trigger points or not, I don’t really care. Some people came against trigger points.

Ronald Malzack, who came up with the Gate Control Theory back in ’65, who later developed a neuromatrix, phenomenal model, really excellent model to think about pain. And where you have input systems, you have a processing and you have an output system. And some of the people, even just a few weeks ago, I posted that online and said even Ron Malzack put that into his model. And when he first published the neuromatrix, in his illustration he clearly stated trigger points are a source of peripheral nociceptive input. No question about it. On the *** (55:29) he had three different categories, he listed a whole lot of different things in there. He listed cytokines, he listed ***, the immune system, trigger points, visceral inputs, et cetera, et cetera. So he clearly looked at that.

Well, in the next publication he did not mention trigger points in the illustration. Not at all. He didn’t mention it at all. He just said musculoskeletal – I’m actually looking it up as I speak to make sure I say it correctly. He said cutaneous visceral musculoskeletal inputs. Did not mention trigger points. I have seen reviews online where people say see, now Malzack got smart, he no longer believes in trigger points.

Naomi: Interesting.

Jan: That’s what’s being said. You can look it up. Two weeks ago it was published on the website that I participated in very briefly. When I looked at that, I said well that’s interesting. I’m surprised at this response, that you actually think that Malzack took it out and no longer believes that trigger points are relevant. Because does that also mean that you believe now that Malzack does not believe that cytokines are relevant? The next publication he did mention cytokines, he just said limbic system and associated homeostatic stress mechanisms. So do you think that he no longer believes that cytokines are important, that the immune system is no longer important, that the *** (56:52) are not important, that attention, expectation, anxiety, depression are no longer important? Because he didn’t include them in the picture.

Well if you read the text of the articles and *** (57:04) last year, 2013, Melzack and Katz published a paper. They have a very simplistic picture again. They took it out, and if you read the text trigger points are still in the text. He still says trigger point injections are relevant. So when I posted that I said the fact that it’s not in the picture but it’s in the text, doesn’t that support that Malzack still believes that trigger points are relevant? The comment was, well I guess we need to ask Malzack.

So I did that. I emailed Ron Melzack. I have his email. He’s spoken at our conference several years ago, so I have his email address and it’s not that hard to find. So I emailed him. I said Merry Christmas, happy 2014. I referred to we had actually met each other and et cetera, and in your first illustration you did this, the second illustration you made it simpler. What do you think? What’s your opinion about trigger points? I would greatly appreciate you replying. The day I got an email back from Dr. Melzack, it said thank you for your email, happy new year to you, too. Trigger points are a fact. I decided to turn the *** (58:14), because the first version was too wordy, end of story.

So people who say Melzack, oh the neuromatrix, Melzack does not believe in that, there is no question that trigger points are one of the many sources of input in that neuromatrix, but it’s relevant enough that depends on all the other inputs. Whether you need to give it any weight depends on all the other inputs. If someone is morbidly depressed, dry needling is probably not going to work. You need to deal with your depression first. You need to deal with, okay why are you so unhappy? What’s going on in your life? If someone just got fired from their job and the husband abuses them beats them every day, we hear these stories of course in our patients. We don’t like to hear these stories, but we do see horrendous stories of patients. Don’t believe for a second that we say okay, now you need to stop whining about that, I need to put a needle in your trigger point. That would be the dumbest thing in the world.

So looking back at the neuromatrix, all these input systems in a job as a clinician, and I don’t care if you’re a massage therapist, a physician, a physiotherapist, it doesn’t matter. Whatever level you are trained to and educated to get some kind of sense which inputs are relevant for this person. What is that pain position? What’s their cognitive function? What’s their sensory? How do they walk? How do they move? How are they dealing with stress? You need to look at all these things combined, then make some kind of judgment call, because that’s what we always do. That’s not always 100 percent scientific. We do the best we can. The more experience you have, the more patterns you recognize, hopefully you get a little better at it over time, but that’s what you do.

Then you make a decision, okay for this individual and with these circumstances, what would be a reasonable approach to see if we can generate some change so that this person can actually make sense of their life? Now I saw another new patient yesterday. He’s a veteran, he could barely walk because she has terrible, terrible dysautonomia and all kinds of other problems. A neurosurgeon referred her to me to get my input, because he’s considering should I do surgery, should I not do surgery. This is a very complex case.

Dry needling was not on the agenda for her whatsoever. She was debating does she need surgery, does she not need surgery, and then is it going to make a difference. Is there anything that we can see clinically? So again, her input systems were so far removed from trigger points. I’m sure she had them. I didn’t even look for them, because that’s not what was at stake today.

So back to the neuromatrix, I was so pleased to see that email from Dr. Melzack, trigger points are a fact, end of story. We can argue until the cows come home. It doesn’t really matter. Do the very best you can. Get educated in as many things you can. Whenever you’re in the healthcare world, again, that’s any professional background, if you’re a body worker, massage therapist, physical therapist, physician, it doesn’t matter, the neuromatrix of Melzack is a phenomenal model to look at chronic pain. And every person, individually evaluated, individually looked upon, say okay what combination of factors determines where you are right now. What can we do to help you? Whether you have fibromyalgia, myofascial pain, it doesn’t really matter what you call it. That’s just a label.

What in that neuromatrix produced this kind of outcome and how can we possibly intervene and make a difference? I think that is the key to the clinician. And whether you look at trigger points or not, that’s kind of irrelevant. But Melzack said, trigger points are a fact, they are here to stay and I think it would be foolish not to consider anything, if *** (01:02:10), by all means. If you look at the cytokines release or at the ***, what can I do as a physical therapist with that? Well, dry needling has been shown to reduce the number of cytokines in the immediate environment of a trigger point, so maybe I can do something with it. If I look at depression, I’m a physical therapist, I’m not a psychotherapist, but I can still be supportive. I can make recommendations. Like look, this is one of the potential input systems. You need to address your depression or anxiety.

I have a young man now, he’s in his 40s. He is so angry, because he feels his life fell apart. He’s so angry at everything under the sun. He’s angry at anything. He’s not angry at me, I just laugh at him. It’s like okay, as long as you stay this angry I really can’t help you. I insisted that he gets help from a psychiatrist and a psychologist. I’m happy to help you, to work with you, but you need to commit to seeing a good psychiatrist or psychologist, and/or psychologist, who can deal with your anger. As long as you’re this angry, you will not go anywhere. I thought in the neuromatrix, that his anger and depression were much bigger input systems than the input systems from trigger points. It needs to be addressed. Whether you can do it yourself that’s another story, but it needs to be addressed. If you look at the pain matrix, and I like the original one because it lists all the other things, if you look at the more recent paper, the 2013 paper, you would actually have to read the article and you’ll see the exact same thing. You come up with the exact same conclusion.

Naomi: Would you recommend that people have used this neuromatrix as a framework, to make sure to look at the whole problem and all the possible things that are affecting the pain, so that you don’t miss something?

Jan: Absolutely. I think the neuromatrix is the best model that we currently have, particularly for a chronic pain patient. What happened to you? Get input. Why are you so angry? But also you need to learn what is your culture. How does your culture deal with pain? And I’ll never forget a phenomenal booklet that came out, I think it was by – I forget the author now. It was a book about a medical anthropologist who compared the pain experienced and the attitude of physicians in Puerto Rico and in Boston, I believe it was. And she looked at how did people in Puerto Rico present their pain. Let’s say they have back pain. How do they go about it? What do they say? What’s their behavior? And it was very much, oh my gosh I have a lot of pain, doctor, you need to help me. It was very much a reliance on activating the village, make a lot of noise, but in that culture it was totally acceptable, totally normal.

The exact same behavior in Boston was frowned upon, and people said oh they’re magnifying. Their symptom magnifies. And the reports in Boston would say these subjective complaints could not be objectified. In Puerto Rico, not a single doctor would write that, because they understood that in that culture, in the Hispanic culture in Puerto Rico, making a lot of fuss about your pain is part of the culture. Every culture has its own things. Well Melzack has recognized that. Chronic input from the brain, cultural learning, past experience, personality variables, these are all things you need to pay some attention to. I’m not the expert in culture. I’m not an expert in depression, either. I know a little bit about it, but that’s not what I do for a living. But if you recognize that, work with it.

Now I teach courses all over the world. I teach courses in Dubai, we teach courses in South America, in Europe, in the United States, all over the world. One of the most fascinating things to me is to see what are the cultural differences, and believe it or not, physiotherapists in Ireland behave different when they have to take their shirt off than physiotherapists in the Netherlands or United States. There’s a difference between Canada and the United States. How do we deal with that? How do we deal with taking our clothes off in front of colleagues? In the United States everyone wears a gown when you come to physical therapy. In the Netherlands, these gowns don’t exist. People come to visit me from the Netherlands, we just had two therapists from the Netherlands spend a week with us here in our clinic. They were like, why do people wear these silly gowns? You can’t see anything. In the United States they’re pretty much the standard of care. In the Netherlands, they don’t exist. If you want to have one you couldn’t get one. They don’t exist.

Well for patients, it’s just another variable. I just taught a workshop and a course in Dubai in November. Well, there are women in the courses who were *** (01:07:21). Well we picked one muscle in the lower back to kind of practice a little dry needling. We all dealt with it, there were 25 people in the workshop with 15 different nationalities. If you understand cultural input and how we deal with exposure of skin, how we deal with palpation, what we’re going to do about this in this group, it was one of the most fascinating learning experiences I’ve ever had, as a teacher. It was really interesting to see how people go about it.

I left it totally open to the participants. I said, you do whatever you’re comfortable with, from your background, your religion, whatever, culture, whatever it is.

Naomi: And what did they do?

Jan: Everyone participated. Even the women, they worked with each other, but they did not shy away from asking me as a male instructor, like hey I don’t get it, can you show me this. Of course. I respectfully said, is it okay if I palpate here, and you respect what other people need to do. It was no problem whatsoever.

Naomi: Interesting.

Jan: Everyone participated, 15 different nationalities. It was like the United Nations of dry needling, I called it in the course. It was really kind of interesting. The patients with chronic pain, as a clinician, again, doesn’t matter what your discipline is, you need to consider all these things. I think that the neuromatrix is the most comprehensive model that we have, but it is a model. And again, you need a model to work with. I think it’s the way to go.

Naomi: Great.

Jan: I hope that makes sense.

Naomi: It’s fantastic. Now we’re already slightly past the hour, and you’ve been very generous with your time and thank you very much. I’ve got one last question for you. What would you recommend for people, therapists or body workers, who want to learn more about trigger points? What do you think are the resources that you would direct them towards?

Jan: Well that’s a tricky question, for someone who offers courses on it.

Naomi: No, definitely. Yes, please tell us about your courses.

Jan: I have a course institute called Myopain Seminars. I’m going to promote my own courses very briefly. This is a shameful advertisement.

Naomi: Oh, I think you should.

Jan: We have courses for manual trigger point therapy, and on our website MyopainSeminars.com these are listed. We have several course programs coming up in the Boston area, in Bethesda, Maryland, in New Jersey. But we’re working on bringing these courses to Dubai as well. So those are courses for physiotherapists, for physicians, for physical therapy assistants, for body workers, massage therapists.

These courses are a little bit different from others, because they do the same thing we do for our dry needling courses. They do include a lot of scientific review. So we really look at, okay what do the studies say. Does it make a difference how you place your hand? What does the research say? So they’re very much up to date resources. Many courses for body workers are more hands-on courses. These courses are hands on, too. In the first course we cover 40 different muscles. So that’s a lot of muscles, and that course is taught by Stewart Wild and Katie Adams, in the Boston region. Phenomenal instructors, they have the best hands.

And part of that course, it’s interesting, they have a body work, massage therapy, neuromuscular clinic in the Boston region. All their clients are referred by other healthcare providers. By doctors, by physical therapists, et cetera. Pretty unique that they also teach body workers. How did we do this? How did we get to a position that we are part of mainstream medical practice, that physicians refer to us. Katie Adams speaks every year at a medical conference in her region. She’s invited every year again because of the quality of the coursework that they present. So I’m very, very happy that they’re part of our team.

That’s if you don’t want to do any kind of invasive procedures. For dry needling courses, we have two different programs. We have an *** (01:11:32) program, mostly for dentists and people who work with head/neck/facial patients. Knee pain, we have a separate course for that. Those therapists came to me and said, you know what, we never treat someone’s knee. We just see patients at the dentist. We don’t know how to needle muscles around the knee. Can’t you do a course that’s more tailored to us? So we have that program, we do it every year a few times.

Our largest number of courses is in dry needling. We have 60, 70 courses a year now in the U.S. alone, in dry needling. So it’s a very busy program. We have a lot of instructors, and we also teach this course, as I mentioned earlier, really all over the world. There are other programs. There are a lot of very good programs done by body workers. I would really look at what’s the background of the individual. How long have they been doing this? There’s a phenomenal program in New Mexico, there are several programs in Chicago. In the United States, there’s a great organization, The National Association of –

Naomi: Yeah, Myofascial Pain Therapists or something.

Jan: Yeah, that’s exactly right. You interviewed Erika Borne recently. She was the former president of that organization. I think that’s a phenomenal resource to look at. Where should I be going for good education? They list a lot of things on their website. I think it’s a really good resource for body workers, massage therapists. So there are lots of options. And the people who are part of that, they all have sat for an exam. These are the people who take life a little more serious and want to do the best possible job they can. So there are a lot of options.

In March, I’ll actually be speaking at the conference in Vancouver for the Massage Therapy Association there. We do a workshop with that as well. So there really are quite a few options that people can learn this, but I would like to see a little more evidence-based and not just look at Travell and Simons books as the bible of everything. The last book was published in 1999. That’s a really long time ago. That’s 15 years ago. Frankly, the research part of these books is very outdated. So you can’t keep going back to those books and say oh this is what I need to do. Yeah, there’s a lot of wonderful information. Again, I learned from Travell and from Simons. I worked very closely, especially with Simons, for many, many years, spent hours and did research together, we did all kinds of stuff but the book is outdated. It’s 15 years old. But it was three years before when it went to the publisher, so it’s probably 18 years old, and there’s a lot more current research available.

In our courses we incorporate all the research. Our dry needling program is by far the toughest dry needling program in the country. I have no doubt about it. Our exam is very extensive. There’s a long theoretical exam, 80 multiple choice questions, two practical exams. People are a little overwhelmed when they start. The manual trigger point program, we do a little bit less rigorous, it’s a little easier, not quite as much reading. The dry needling people read over 400 pages of articles. They actually have to know these articles. The nice thing about it is by the time people go through the process, we have a pass rate of 95% in the first time, and in the end usually everyone passes. Some people may have to repeat one or two parts of it, but in the end pretty much everyone gets through the process.

If you ask people, and I get lots of emails that support that, was it worth your while. I recently got an email from a therapist in Wisconsin, and another one in Virginia, this is in the last few weeks. They say I was in another panel, I did a presentation, I was asked about trigger points, thank goodness for your certification program. I had no stress, I felt so comfortable, I could answer every question and cite the appropriate research. That’s what I like to look for in courses. It doesn’t have to be our course, but lots of other courses, the National Association does a very good job in categorizing it and adding lots of resources all over the country. That’s what I would look for.

Naomi: Fantastic. Great, well again, thank you so much and I will put a link to Myopain Seminars underneath the interview and really encourage people to go and have a look at those courses.

Jan: Very good.

Naomi: And thank you so much for sharing your knowledge on trigger points. This has been a fascinating interview. I’ve learned a lot, and I’d be very interested to find out more about your work and research going forward.

Jan: Very good.

Naomi: Okay.

Jan: Take care.

Naomi: Thanks, Jan.

Jan: Bye.

Naomi: Bye.

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