Dr Filner was one of the first to start using cold laser or LLLT (low level laser therapy). In just the last 4 years he has inactivated 150,000 trigger point in his Rockville, MD office. One of his patients was Dr Jay Shah. Shah was so impressed with the relief to his heel pain that he began to study the trigger point phenomenon in his NIH laboratory in Bethesda MD. It was Dr Shah who subsequently published his pivotal body of work on the ‘biochemical milieu’ surrounding the trigger point. Remember the hollowed out acupuncture needle?

The cold laser can switch-off trigger points up to a depth of 3 inches, but it can’t penetrate clothing or bone. Dr Filner wants it to be research-tested by Jay Shah but there are no moves afoot. The system can be bought or leased. At present there are none available in the North East to my knowledge. I will be looking into my scope of practice to see if I can legally operate one in the state of Massachusetts. I’ll keep you posted.

Funnily enough, there was another exhibitor demonstrating ‘Shockwave Therapy’. This is another European invention showing promising, but research unproven, results for trigger point deactivation. If all these gadgets prove effective we manual therapists may have to invest to avoid ending up like the dinosaurs. Of course, we will still need educated palpation skills to physically find the trigger point location first.

Dr Filner was one of many presenters who stressed the importance of checking out the feet for hyperpronation. I got into Posture Control Insoles, as marketed by Posture Dynamics, at a JBMT conference in Seattle WA. in 2002. I was convinced of their efficacy and had great results with them for the ubiquitous Morton’s foot condition. The full set of PCI testing equipment has been sitting in my garage since I arrived in MA (we just don’t have any room in our 360NMT clinic rooms). I am going to dust off the box and reacquaint myself with the procedure as soon as I can. This hyperpronation topic is worth quite a few more blog entries.

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First some of the non-painful things that trigger points can do:

• Ptosis of the eyelid
• Blurred or double vision
• Dimming of perceived light
• Reddening of the conjunctiva
• Excessive lacrimation
• Dry cough
• Sinus congestion
• ‘swollen gland’
• ipsilateral sweating of the forehead

These can all be caused by trigger points in the sternal head of the sternocleidomastoid

What about:

• postural dizziness
• hearing impairment
• stuffiness or itchiness in the ear
• dysmetria (inability to judge weight)

These can all be caused by trigger points in the clavicular head of SCM.

My question to you is, do you have the ability to distinguish the sternal from the clavicular heads of SCM with your fingers and thumbs?

If the answer is no you better stay tuned for our up-coming Myopain Seminars.

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It was an extra warm welcome when we finally arrived at the Indian Lakes Resort.

Some background on NAMTPT. This organization prides themselves on their high standards. As a double certified NMT my credentials were still considered not good enough to join as a professional member a few years back. I had to do the full Myopain Seminar certification to achieve this. Does this make the NMT certification redundant? No. But it is still a partial steppingstone. The CMTPT standard is tougher to obtain, and involves much more study and more expertise.

You don’t need to be a graduate massage therapist and you don’t use massage techniques here in NAMTPT-land. Because of this it may turn out to physically prolong our careers. Less injuries will occur when you employ techniques like Stretch and Spray as taught by Jeff Lutz from Pittsburgh, and elbow work, jackknobber and ball rolling to rid those pesky trigger points, as taught by Mary Biancalana and Sharon Sauer. These two fine ladies have recently authored a low back pain self-help book to continue the Clair Davies series of books. A free copy was in the conference pack.

The audience here at the conference all seem highly educated, skilled and seemingly all run successful businesses. The atmosphere is like one big happy family, making it easy for a new boy like me to fit in. That is until I give my presentation tomorrow.

Stew

PS Our esteemed President, Erika Bourne, also from Boston, has still not arrived after her flight got canceled.

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The day started with heavy, heavy neuroanatomy and pain physiology from the world expert and co-author of the definitive book Muscle Pain, Dr Siegfried Mense from Heidelberg.

Don’t buy this book!! It’s eight years old and a 2^nd edition is due out later this year.

People balk at the deep science of pain, but I find it fascinating. Knowledge of the anterior cingulate gyrus and the periaqueductal grey (PAG) needs to be understood. (One is the unique cortical structure that is active only with muscle pain and the other is the modulation or inhibition system needed to reduce the perception of this same muscle pain.) Dr Mense is a genius and very funny and a very approachable guy too. Can’t wait for his new edition; we’ll sample from it often in our teaching.

Next on the podium was Dr Jay Shah, the bestest trigger point researcher from the NIH, Bethesda. He was mobbed at the end of his presentation (and remember this place is full of DCs) demonstrating the power of his information. Being totally accomplished with powerpoint means he could inform, entertain and enthrall. Biased, me? Yup.

Thanks the publications by him and his colleagues there are now chemical and visual proofs of myofascial trigger points (TrPs). Vibration sonoelastography imaging (external vibrator in combo with Doppler technique) has shown areas of hypoechogenicity indicating blood vessel compression within palpable TrPs (Sikdar et al. Arch Phys Med Rehabil 90: 1829-1838, 2009). We’re on the map, but don’t expect Medical Schools to be teaching this stuff within the next decade.

The last lecture slot was filled by the organizer Michael Schneider DC, who’s borrowed some of Steve Carell’s ‘The Office’ style of presentation technique. It was hoped that David Simons would be able to attend and lecture but sadly his widow Carol McMakin told of DGS’s recent demise. I will post a memorial blog devoted to David very soon and reveal some of his deathbed confessions because each participant was given a CD of his most recent work.

Schneider’s job was to trawl and sift through the literature to help explain and distinguish Myofascial Pain from Fibromyalgia (whatever that is). He did a great job on this most important topic, recommending multidisciplinary approaches as promoted by the American Pain Society (APS). This prestigious body supports anything that minimizes pain, improves sleep quality, and enhances self-efficacy and a positive mood. Modalities singled out as beneficial by the APS included hypnosis, biofeedback, manipulation, therapeutic massage and balneotherapy (water-based therapy). This all sounds like what do and what we would love to do at 360NMT.

The afternoon was filled with more practical stuff as outlined in the previous blog and I’ll say it again ‘all presenters had a strong belief that their particular modality was the answer to myofascial pain and dysfunction.’ This despite the fact that not one of these sessions introduced or promoted any form of trigger point therapy and many had no, zero, nada to offer in the way of research backing.

Our work is still not done.

Manana,

Stew

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One of the funny things about this conference was how many Chiropractors and how few massage therapists there were in attendance. This was very different from Boston 2007 where LMTs seemingly out-numbered other therapists. Rolfing also barely got a mention, but trigger points were a constant topic and of all the presenters Jay Shah, MD, trigger point researcher extraordinaire from the NIH, Bethesda, was the man most inundated at the end of his presentation. More on this in the next blog.

As an aside, it was especially nice for me to catch up with colleagues in the myofascial trigger point therapist community. We had myself and Erika Bourne from Myopain Seminars, Bethesda, Mary Biancalana and Julie Zuleger from the Chicago Myopain group and Jeff Lutz and Richard Finn from the Pittsburg School of Pain Management.

Each day began with 3 one-hour lectures and ended with 2 two-hour practical demonstrations. This was a great balance. Well done Dr Schneider, DC, who introduced himself on-stage as ‘Doctor Michael Schneider’ and then said that he was pleased to announce that the name badges purposely didn’t have people’s qualifications. LOL.

Day one started with cuddly Leon Chaitow and his usual rambling and shambling and entertaining thoughts on soft tissue manipulations and myofascial dysfunction. Leon is a man who never lets a square inch of power point screen space go unwasted. This time the information crammed into each slide described the attributes of  HVLA (thrusting is a favourite of the DCs), trigger point stuff like ischemic compression and pressure release, positional release like strain/counterstrain, stretch techniques like MET and a personal favourite of mine Ruddy’s pulsed MET, plus the more deep and meaningful connective tissue manipulation (CTM) and fascial manipulation. All seem to work he said, although I think his main point was that he would prefer to use all of them instead of the HVLA thrusts that the DCs use.

The next delivery was from a restrained Tom Findlay, MD, a great friend of the massage profession. Tom has an encyclopaedic memory and a gift for simplification that (luckily for us) helps connect we arty LMTs to the rest of the medical professions. The way he summarized the previous two FRCs, made me think that I must have been asleep throughout much of them, both in Boston in 2007 and Amsterdam in 2009. (See my separate jottings on these.) Funny how each of us has a different memory of the same event.

Suffice to say that one of Dr Findlay’s points was that if you want to start the healing processes you’ve got to get the myofibroblasts enlisted. These connective tissue cells were only discovered in the 1970’s making them the new kids on the block. They are involved in wound healing, tissue fibrosis and pathological fascial contractures. Their differentiation (switching) from stem fibroblasts is controlled by mechanical tension, cytokines, and specific proteins from the ECM. Educated fascial manipulation and stretching gets them to front up in a positive way.

Rounding out the pre-lunchtime gigs was Terry Loghmani, a PT with a presentation on the Graston technique. This instrument assisted fascial stimulation involves abrading the skin with really expensive steel, aluminium (sic), acrylic or polymer tools, that all seem to have been made in Indiana. I kid you not. Alternatively, you could also use a 70¢ Chinese soup spoon, as found in 360NMT clinic rooms.

The afternoon practical sessions comprised four presenters, each presenting their preferred modality, all at the same time. Your choices were Aaron Mattes on Active Isolated Stretch (AIS), Leon Chaitow on Positional Release Technique (PRT) or Muscle Energy Technique (MET), Tom Hyde on Functional and Kinetic Treatment with Rehab, Provocation and Motion (FAKTR-PM) (Oh please, this acronym will never catch on) or Graston technique, and lastly Julie Ann Day giving us Fascial Manipulation^© all the way from Italy via Australia. (Funny how you can copyright the words fascial manipulation?). She was my ‘pick-of-the-day’ (get it?) and I hope to study more with her next year when Jan Dommerholt plans to bring her interpretation of the Stecco family work over to the USA. I say this while admitting to a conflict of interest, as a fellow antipodean.

Rather than describe each of these techniques above (I did them all accept Graston, mostly because I can’t afford their equipment – I’ll carry on using my soup spoon) let me tell you that most of the presenters have the utmost belief that all you’ll ever need to cure everything from pain to watery scrambled eggs is their technique. The exception to this is Mr Chaitow. He is the epitome of informed consent. He tells you that his technique is good (but not great), and that you should play around with it regardless. As editor of the wonderful JBMT of course he has to be equivocal, but that is to our advantage.

More on this in the next blog – the best is yet to be poorly described by me.

Kia ora,

Stew

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Morning session – fascia in surgery and recovery

• Dr Mick Kreulen, a plastic surgeon, showed an example of FCU reattachment to the extensor side in the case of someone with Cystic Fibrosis. There is now more emphasis on taking the fascia along with the tendon. The reattachment has to take into account the length / force curve so that the new location has an optimal range of motion. There is the need to assure that the existing FCU hypertonicity doesn’t change the previous hyperflexion to a later hyperextension.
• Willem Fourie is a South Aftrican PT who specializes in post-op rehabilitation, especially post-mastectomy. His insightful presentation showed many of the operative techniques, excavations, cannibalisms, sacrifices, amputations, collateral damage and subsequent residual damage from sewing this all back up. He showed that 67% of the post-mastectomy patients had reduced shoulder ROM, 34% developed lymphodema within three years post-op and 72% had residual pain. A cytokine, TGFb is active in the inflammatory process of scar repair but can actually go into overdrive helping exacerbate fibrosis. He quoted a study by Nicole Bouffard that showed that a single one minute gentle (20%) static stretch of the tissue could help reduce the scarring and fibrosis.
• A panel of five proponents of clinical therapies then demonstrated their techniques under the critical eyes of 3 scientists, who were to later make their comments and recommendations.
  • The five techniques included Accupuncture, TrP-Dry Needling, the Graston technique, Fulford Percussion and Functional Fascial Taping (FFT) were demonstrated by video.
  • Comments from the scientists were as follows;
    • Irnich published a study in the BMJ in 2001 showing acupuncture to be better than massage for the relief of chronic neck pain. On the other hand a large German study on acupuncture (reference needed) has shown it only to be as effective as sham-acupuncture. Placebo may be important here.
    • The Shah study confirming the ‘biochemical milieu’ surrounding the TrP is still the most compelling proof to date of noxious trigger point activity. Dry needling may destroy 800 muscle fibers per centimeter traveled to get to the trigger point. After deactivating the TrP with this violent trauma how do you then solve the problem of central sensitization?
    • Of the others; Graston techniques is also a violent abrasion of the skin and superficial fascia probably stimulating fibroblast activity; Fulford uses a device like an orbital sander to also stir up fascia and FFT may work by quickening the reaction time of low back structures.
  • All scientists were bothered by the outstanding efficacy claimed by each and attribute much of this to placebo (this not being a bad thing). The word epiphenomenon came up, which I like.

Afternoon sessions – choice of Fascia Biomechanics and Physiology, or Pathology and Treatment – I chose the latter (maybe not such a good choice).

• The seven 15-minute bites varied from the silly to the thought provoking.
  • Silly included Roptrotherapy, yet another cross fiber technique (sometimes not even knowing the right fiber direction); non-invasive surgery for ACL repair (without divulging the method of this manual surgery); a demonstration of techniques for phantom limb pain which looked suspiciously like treatment using TrP referral zones; removal of ligatures on the proximal sciatic nerve of a poor rat which still had pain afterward,
  • Middling was a so-called Fascial Distortion Model (FDM) that uses 15 minutes of excruciatingly deep and painful pressure to solve most problems in just one treatment. In this the patient was probably exposed to so much more pain than they came in with that they only needed one treatment to realize that they weren’t so bad off after all. They described ‘Body Language’ a tool for interpreting distortions and used two interesting terms; trigger band – to describe a burning or sweeping sensation; herniated point – something that is protruding thru a fascial plane
  • Contrasting to these was a gem presentation. Antonio Stecco (see an earlier review of crural fascia with Carla Stecco), are prolific researchers, authors and presenters from Italy. This time the discussion concerned a study that measured how long it took to make positive changes to fascia that will drop pain by 50%. In sub-acute pathologies (<3 months) the average time is 2.2 minutes, in chronic tissue it is 3.24 minutes. Wow – so accurate. We’ll set our stopwatches shall we? They got their results using 3 areas of the back that commonly give LBP symptoms. They found correlations with tissue condition, age and gender. They have a book ‘Fascial Manipulation – Practical Part’ to explain more of the treatment side of things. Plenty to come on this body of work.

The afternoon was rounded off with the double act of Geoffrey Bove from Portland ME and Patrick Coughlin from Philly who entertained us on peripheral nerve palpation.

• First was some basic nerve anatomy and physiology. Did you know that a nerve cell can be up to a meter in length but only 1 micron (1 millionth of a meter) wide? That’s a million times longer than it is wide! They also carry positive pressure, have an endoneurium that is filled with a CSF-like fluid, and can be fasciculated like muscle
• Peripheral nerve palpation (and mobilization) is dear to my heart. We don’t practice it enough. Coughlin gave us the chance to practice a few easy ones like the ulnar nerve and the common fibular nerve. Hoppenfeld, Petty and Moore, and Barrall have much more information on this in their texts. I will be writing more on this in due course.

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• Jaap van der Wal, a local gross anatomist, opened the day with a renegade fascial anatomy lecture that Gil Hedley would have been proud of. He maintains that connective tissue should also be thought of a disconnective tissue; it connects things and separates things. He used the word ‘dynament’ to describe how muscles attach to ligaments in a series arrangement, as opposed to independently doing their thing. Ligaments should not be thought of as passive stabilizers but actively attached to dynamic structures and continually maintaining active tension. Dissection is the only way to isolate them. He also advances the phrase ‘transmuscular units’ to describe whole functional units which combined amount to the architecture of the locomotive body.
• Various speakers talked about the crural fascia, thoracolumbar fascia and the paratendon.
  • Crural fascia is a three layer system, each layer with collagen fibers aligned at 78° to the other.
  • Thoracolumbar fascia is more a two layer system heavily innervated (? nociceptive, ? segmental), mostly in the outer dense layer, which leads me to think about skin rolling the TLF a bit more in order to lift the dense superficial CT from the loose CT layer below.
  • The paratendon is the layer between the tendon and the sheath and may be filled with areolar CT to help the tendon glide better (as opposed to the paratenon of the Achilles tendon – which I’ve been assured doesn’t even exist).
• Canadian, Peter Purslow gave a fine presentation on fascia and force transmission and showed wonderful photos of the connective tissue of muscle after the muscle protein had been digested with sodium hydroxide. His confirmation that muscle fibers only average 35 mm in length, are laid down in a staggered fashion, and have endomysium between them that stiffly transfers lateral forces explains that when only 10% of the fibers contract at one time, the other 90% also shorten. What an efficient and economic system. How the motor nerves co-ordinate all this is still a mind-blowing mystery he says. Mr Purslow’s background is with the meat industry. More on this some other time.
• The morning was beautifully rounded out by Oz-extraordinaire, Paul Hodges. His topic of fascia, motor control and the effect of pain reinforced the point that ‘core stability’ is still in. Transversus abdominis contraction should precede all movement, followed by the erectors if the movement is flexion etc. etc. Funnily enough he cautioned that over-training may create too much stability, a topic that Chaitow introduced a few years back to explain some of the common pelvic floor complaints that women have who (over) do Pilates.

The second afternoon

• I chose the parallel session covering thoracolumbar fascia (TLF) and pain. We were by now well versed in the anatomy and innervation. Langevin has found a correlation between CT layer variability, LB pain and a higher BMI. Unfortunately her subjects’ average BMIs were 25 or so in the healthy northern Vermont she lives in; I’m sure this is well below the American average. Others talked about shear forces, trigger points, myofascial release and experiments on cats???  Overall this made me think about Hilton’s Law, whereby working on the cutaneous layer will have effects on all the layers underneath.
• Wine and beer helped turn the 27 poster session presentations that followed into some very lively discussions; especially as some presenters had very personal agendas promoting novel products and novel methods.

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Introduction – a low-key start on a gray day in front of 550 delegates. Due to illness the first speaker didn’t make it. The session opened with 1 ½ hours of research which was followed by the same amount of clinical method.

Morning research session

• Paul Standley presenting on repetitive motion, strain and MFR showed a slide with four research studies in support of sports massage efficacy. These were mostly new ones and we should add to our scientific support database with these (when I can find them).
• Helene Langevin talked about the properties of loose connective tissue (areolar), whereby the fibroblasts become ‘pancake-like’ under stretch in order to help layers above and below to glide. After injury this layer shrinks and this may indeed become the actual site of ‘adhesion’.

Morning clinical session

• Chaitow, Schleip; glitterati et al
• Great presentation by Stephanie Prendergast on pelvic floor pain. She’s based in San Fran and is a PT practicing CTM (Connective Tissue Massage). Will try to connect with her myself. This method is cutaneous and sub-cutaneous only. She combines with Trigger Point, nerve entrapment release etc. and I have some good references from her as well. Our man Jan Dommerholt knows her well.
• Bove DC presented HVLA, Comeaux DO harmonic oscillations quoted the phrase ‘pain is a liar’, Chaitow demoed some olde worlde Positional Release videos, Schleip showed a video of Ida Rolf at work and talked about shear forces and adhesions forming more around neurovascular bundles.

Afternoon clinical session – the massage highlight being;

• Thomas Findlay – one of massage’s best friends. He is on a mission to help us write better (some) research studies.
  • His presentation had a classic list of things that make a therapy session work;
    • believe in it yourself;
    • make the client also believe in it;
    • make it sound technically complex;
    • get some kind of physiological change to occur;
    • include at least two different modalities;
    • don’t disregard placebo. It works. Love it.
• There were other presenters too…

Afternoon research session

• Many and various 15 minute sessions with gems like FCU the strongest forearm muscle leading to contraction, as in CP; 20% of hamstring stains show nothing on MRI – leading us believe it must be something else. Why not fascia? Most of the strain is detected down the lateral line – fascia terra firma; After repeated low load lumbar flexion/extension the ligamentous/muscular systems have a lag phase where they are inhibited. Hmmmm.

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Empirical research is laboratory controlled, reductive, statistical, exclusionary and kind of dull. In the case of hands-on bodywork it is so controlled as to be nothing like a treatment session.

Each research study always starts with a question. One then develops a hypothesis or idea, to be tested. One then devises a way to test this hypothesis. After the practical bit one analyses the outcomes, comes to a conclusion and hopes someone out there will find it interesting enough to publish.

To be top-notch research it should be randomized, double blinded and have a control group so as not to be accused of cheating. All this takes time and costs money. People get PhDs because they like to do this stuff. Most of us in the massage profession haven’t got PhDs and therefore don’t get to design a research project. Some do, however.

Let’s parallel the previous paragraphs on bench research and compare it with bedside research. This method can be called ‘evidence informed’. In healthcare evidence informed efficacy is based on  ‘the best available, current, valid and relevant evidence’. We do it each time we see a client.

Our client comes in with a problem, which raises a question; ‘how can I help them with this problem?’ We start collecting information; subjective and objective. Sounds like the beginning of SOAP charts doesn’t it? We then use some clinical reasoning to come up with a mutually agreeable treatment plan. After implementation of this plan we reassess to obtain some outcome measures; hurts less, feels better, less stiff, or maybe feeling worse. We then tinker with the plan for next time. These are the APs of SOAP.

If we develop bona fide measurement criteria like the visual analogue scale (VAS) to record the changes then this can pass for research. If more of us write up good treatment notes on lots of clients, then collate and group the results then it will become even more meaningful.

Down the line we may be able to collectively hold our heads high and say with authority that NMT is good for headaches, back pain, myofascial pain syndrome and so on. Ultimately, we may be able to prevent or at least reduce the more invasive medical procedures or drug taking.

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