Our first ever "Logical Links" come from Body in Mind on Dry Needling, Jason Silvernail on Evidence Based Practice and Deep Models, Todd Hargrove on the Importance of Squatting, and Mike Robertson on Front Squat Technique and Training.
Dry Needling for Myofascial Pain: Does the Evidence Make the Grade? from Body In Mind
Kenny:
Harvie, O’Connell and Moseley do an excellent job of critically appraising the recent systematic review and meta-analysis of dry needling for upper quarter myofascial pain by Kietrys et al. The work of Kietrys et al. and the subsequent commentary from Harvie et al. serve as an excellent example of professional dialogue and debate. These types of conversations are paramount to our growth and evolution, kudos to both groups for their work.
As dry needling continues to gain in popularity, there is no shortage of positive anecdotes on its clinical effectiveness. However, we must take care to remember that “the plural of anecdote is not data.” As Harvie et al illustrate, the positive claims might not match the data currently available:
"a far more parsimonious interpretation of the meta-analysis is that dry needling is not convincingly superior to sham/control conditions and possibly worse than comparative interventions. At best, the effectiveness of dry needling remains uncertain but, perhaps more likely, dry needling may be ineffective. To base a clinical recommendation for dry needling on such fragile evidence seems rash and risks exposing patients to an unnecessary invasive procedure."
Perhaps there is something else that is responsible for the incongruence between what clinician’s experience and what research demonstrates? New therapies should be carefully scrutinized before widespread implementation into clinical practice in order to provide satisfying proof of effectiveness. If treatments are not properly vetted prior to becoming well adopted, it becomes increasingly difficult to discard said treatments if they are later found to be ineffective. Look no further than the continued popularity of ultrasound for an example of this occurrence (http://ptjournal.apta.org/content/87/8/986.full.pdf).
What are your thoughts on dry needling, it’s popularity and current literature base? We’d love to hear from you.
Chris:
Tying in nicely to this post is a recent publication in PTJ where the authors heed the advice of the BiM team and state their conclusion much more conservatively. I’m definitely not implying a bias, but the authors did neglect to include the NNH in their abstract, which was interestingly lower than the NNT (1 in 3 had an adverse reaction vs 1 in 4 had a beneficial one). Time will tell whether this research will be construed as supportive to the TDN camp.
What caught my eye was the sham group reporting a 50% and a 25 point improvement in their VAS and FHSQ score, respectively. Perhaps it’s regression to the mean or natural course of disease, or perhaps its once again an illustration of the value that context and meaning play in patient interaction. We should consider this when deciding if we want to spend (per body region) $795-$1,300 to learn a potentially harmful intervention with unsubstantiated literature.
EBP, Deep Models, and Scientific Reasoning from Jason Silvernail
Kenny:
Jason Silvernail is consistently one of the most insightful and well spoken members of our profession and his post on “EBP, Deep Models, and Scientific Reasoning” from 2008 over at Evidence in Motion perfectly showcases this. Jason writes:
"We should focus as much on challenging our explanatory models and teaching in ways congruent with actual human physiology as we do on producing outcomes research, or the next generation of DPTs will be just one or two RCTs away from doing Reiki and Therapeutic Touch. Hey, if there’s "evidence to support it", it must be good, right? Can you see the problem with outcomes-only evidence?"
Silvernail’s message on the necessity of a deep model underpinning our reasoning and interventions is an important one. Through a deeper understanding of our treatments and paradigms we not only “open up new avenues for treatment and research” but avoid the potential pitfalls of relying solely on outcomes studies to guide our decision making. If we do not seek to answer if an intervention is effective and why, we are essentially clapping with one hand.
Chris:
Before I engage in debate, hop on my high horse, or dispute another's opinion I think to myself "WWJasonD." He continues to contribute to our profession with his perceptive understanding and well mannered speech. We should heed his advice and question the theories we have developed our practice from especially now in our evolving scientific world.
Squat Fundamentals and the Importance of Squatting from Todd Hargrove
Chris:
If we can successfully con you into regularly following our blog you will soon realize that I’m a big fan of Todd Hargrove’s thought process and writing. Movement awareness is a fundamental component to movement efficiency (it takes a lot of cues and mindfulness to learn to shoot a slap shot but once done repetitively it becomes a smooth and efficient), and Feldenkrais practitioners like Todd can offer actionable concepts for increasing our ability to move while giving us some much needed novel sensory experience and variability. In regards to squatting, he sees it as a fundamental movement that stimulates our body, and I agree with him when he says:
I think that the squat is such a huge part of our evolutionary heritage that it is hard for our bodies to function optimally without it. Squatting provides uniquely beneficial education to the brain about how to organize the foot, ankle, knee and hip, torso, etc. I would guess that a toddler who never learned to squat properly would never learn to walk. Squatting also provides a huge amount of signaling to connective tissues, bones and muscles, telling them how strong/elastic, long/short, tense/relaxed, hard/soft they need to be.
I’ll write more on the importance of movement variability in a future post, but I’d encourage you to poke around on his website and if you like what you see he just wrote a book that could be worth your time. In this post and in part 2 he introduces a unique approach for working on your squat pattern which I found to be an excellent warmup prior to loading in the gym. Prepping the nervous system and bringing our attention towards movement mechanics is a proper precursor to higher-level physical activity regardless of the event. With greater acknowledgement of the central nervous system in pain and movement we should expect to see practices such as Feldenkrais becoming more prevalent, and in my opinion more utilized in our treatments.
Front Squatting: Step by Step from Mike Robertson
Chris:
Front squats are a different animal. -Mike Roberston
It’s a logical step to follow up Todd’s blog with an epic tutorial on front squatting by Mike Robertson. Hands down the most comprehensive and educative exposé on technique and training with great videos and cues for mastering this powerful lift. Front squatting often times is a much safer way to load with less risk of putting ourselves into potentially disadvantageous and harmful biomechanical alignment. I’d recommend starting with goblet squats, either in front of a mirror or videotaped to give some real time feedback before progressing to more direct spinal loading with a barbell.