Welcome back to the Healing Pain Podcast with Diarmuid Denneny, PT

We are talking about the controversial topic of whether Manual Therapy for trigger point should be used for the alleviation or the treatment of chronic pain. How is one physiotherapist doing some interesting work to help people taper off of opioid medications using psychologically-informed physical therapy principles? My guest is Diarmuid Denneny. He is a professional lead physiotherapist at the Pain Management Center at the University of College London Hospital’s NHS Foundation Trust. He has worked in a specialized pain management center for several years and is clinically advanced as a physiotherapist as well as an independent prescriber.

In addition to his clinical and managerial work, Diarmuid is the Chair of the Physiotherapy Pain Association and a member of the Guidelines Development Committee for the NICE Chronic Pain Guidelines. He was awarded an NIHR Pre-doctoral Fellowship in 2017 and 2018. He is interested in the development of clinical academic roles for physiotherapists. He also has a particular interest in the psychologically informed practice and the role of physiotherapists in supporting people who have pain and medication-related issues.

Diarmuid has published peer-reviewed articles relating to physical therapy practice in pain management, including a systematic review of trigger point Manual Therapy, which we’ll talk about on this episode, as well as the behaviors of experienced physical therapists working within a psychologically informed model. We cover a lot of ground on this episode where we discuss psychologically informed care, Manual Therapy and Trigger Point Therapy as it relates to the management of chronic pain, as well as a physiotherapist role in helping people taper off of opioids. I know you’re going to enjoy this episode. Help me welcome Diarmuid to the podcast.

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Does The Evidence Support Trigger Point Therapy For Chronic Pain And The Physiotherapists’ Role In Opioid Tapering with Diarmuid Denneny, PT

Diarmuid, welcome to the show. It’s great to have you here.

Thanks for inviting me. I’m honored. Thank you.

We had the opportunity to connect at WorldCon for the International Association for the Study of Pain in Boston. You had a great poster there, which was talking about opioids and the physical therapist’s role in prescribing. We’re going to talk about that later on this episode, but I want first to dive in because you did a great systematic review in the Archives of Physical Medicine Rehabilitation. The title of the paper is called Trigger Point Manual Therapy for the Treatment of Chronic Non-Cancer Pain in Adults: A Systematic Review and Meta-Analysis. The topic of trigger point Manual Therapy and Trigger Point Therapy is one that’s interesting and somewhat controversial in the world of pain care. I wanted to have you on to talk about your study, go through all the information on it and talk about it from the biomedical lens as well as the biopsychosocial lens. First, tell us why did you decide to study or explore this topic?

As you know, I work in chronic or persistent pain. The center I work in London is a specialized service and part of what that means is we have MDT clinics for different types of ongoing pain. One is abdominal pelvic pain. As physiotherapists in abdominal pelvic pain, we’ve been asked a lot, why don’t we do trigger point release in our service? We work with people who on average have seen five or six physiotherapists before we get to see them. Often, they’ll have tried a lot of those Manual Therapy approaches. However, the question wasn’t going away. We kept getting asked, “Why aren’t you doing this?” Some of our medical consultant colleagues were referring out of our service to services where they would do Manual Therapy.

Reflecting ourselves, we thought maybe we are biased, maybe we should be offering this. Maybe there is something and we decided to look and see what the literature suggested. We were confused, it’s fair to say. A colleague of mine, Dr. Amanda Williams, who’s a psychologist, many people will know an expert in pain. She suggested maybe we should do a systematic review. She happens to be part of the Cochrane Pain and Palliative Care, a special interest group. They started to get us to think about how to do that. We decided we would do a systematic review and that was a few years ago now. It was a long time ago that we brought this process.

I know it takes a long time to conduct research, meta-analysis, to write it up and submit. I know you’ve done some great work for a lot of time and we thank you. It’s a great paper to read. Some systematic reviews are heavy in the stat review, which has that component. There’s a lot of good information there too. You said something I want to go back to. In your service, you mentioned your work on low back and pelvic pain, the question of Manual Therapy comes. With regard to pelvic pain and Manual Therapy in your service, are you using Manual Therapy externally as well as internally? Is that where we’re thinking about?

We don’t. I’m aware this is a whole other episode or several. It’s a controversial topic. I’ve worked at our center over several years. We don’t use Manual Therapy. I’m aware that there will be some people who will find that shocking, but we don’t and haven’t done it. On average, people have seen four to five, maybe six physios before we get to see them. They will have encountered, they will have tried that approach where I’m working much more from a psychologically informed perspective. We work closely with our clinical psychology colleagues. We don’t use Manual Therapy, but we kept getting asked. That’s why we decided we need to look at this a bit more and get our heads around the evidence. We have our own biases from our approach and where we work, but we wanted to explore that as rigorously and as fairly as possible to see what to suggest.

Before we get into the nitty-gritty of this study, is the reason why you don’t use Manual Therapy in your service because patients have seen many practitioners before you that have used Manual Therapy and has “failed?”

Partly that, yeah. This is going to come across somewhat controversially, but looking at the general evidence for Manual Therapies for ongoing pain, there isn’t great evidence for it. That’s why we don’t use it. My background, my bio, I’ve come from a Manual Therapy background. I did my MACP, manipulative at the time, now Musculoskeletal Association of Chartered Physiotherapists. I’ve come from that background, but I’ve not felt like I’ve needed it in my current role.

Totally fair enough and people can take that as they like.

It’s good to know what biases I might be bringing to the table. The part of systematic reviewing is to try and be as impartial as possible as this.

It’s great information to know. What you’re saying and the story that you have is common. It echoes many physical or physiotherapists like yourself. We’ve been in the field for a couple of decades now. We’ve been through many different types of Manual Therapy approaches and sometimes you see them work and oftentimes they won’t. We can talk about this, but some of the questions that you’ll answer for us is does it alleviate pain and does it improve function? Before we dive into the nitty-gritty, talk to us about the old-world view of what a trigger point is, what it is, how it’s defined, how it’s explained and how it’s treated as a whole lot on what I asked you.

It’s a big question and an interesting question when you try to define what a trigger point is, it becomes very slippery. As part of this review, we originally applied to do it through Cochrane and we submitted our protocol, which was published through Cochrane. The editorial team there got back to us, “We need a bit more information about what do you mean by trigger points?” We had to expand on the background and to try and understand it. Honestly, I would be lying if I could say to you here is a clear definition of what a trigger point is. Even now I don’t think because there are lots of debates again on the peripheral versus the central components to that and how much weighting you can give to either.

I cause a lot of talk about pain generally read it that I suppose was almost comforting in one way to see that it mirrors our wider debate around ongoing pain generally. I’m aware I’m not giving you an answer because I’m not sure your definition of what a trigger point is. As part of this, we had to define what we would use in terms of our inclusion and exclusion criteria. When we are trying to think of it in those terms, broadly speaking, we went to this concept of a palpable lump within a muscle and within the area where the pain is experienced. To try and separate it from more of the perhaps traditional Chinese medicine approaches or more Eastern optical approaches, we wanted to think of it from a Western biomedical approach and think about they’re treating a trigger point in a muscle. That palpating that muscle, they’re feeling it there and that’s what they’re treating because it’s Manual Therapy we want to look at. There’s a lot of literature on dry needling or acupuncture. We were looking at the Manual Therapy aspects. Obviously, the sustained pressure, digital pressure or use of manual pressure. One is called the Jack Knobber and we managed to get that into our paper.

It is a tool that is used to press down a trigger point instead of using your fingers because if you’re a manual therapist and you’re doing that all day long, it’d be quite tiring and in some ways damaging to your fingers.

Many people use these devices. If they were used, we would include them.

Looking at the treatment of a trigger point with regard to Manual Therapy, did the studies you looked at or maybe the inclusion-exclusion criteria, was it provided by physical therapists or was it provided by other manual therapists?

It’s any manual therapist. In fact, that was one thing we were interested was a body of evidence from a particular professional background that we would identify. As it turns out, most of the studies were by physiotherapists and chiropractors. We didn’t limit it to the profession. We had put that we would look at subgroup analysis if there were enough papers and the possibility to do that in the end. We couldn’t do that because it wasn’t the team.

Did you distinguish between a trigger point versus myofascial pain syndrome?

Yes. We were excluding myofascial pain syndrome where it’s more widespread. We were looking at coming back to this definition and looking at pain in a particular area.

From the therapist’s point of diagnosing a trigger point, how do they “diagnose” what a trigger point is? Can a practitioner reliably diagnose what a trigger point is in practice?

Looking at the literature of this, it appears that the reliability is poor. That was a problem. I’ll have to go back and read my paper to give you the criteria we use, but it was based on one group’s recommendations for these other criteria that you should use.

In your paper, you mentioned five criteria, which are a tender spot and a tight band of skeletal muscle. The patient recognizing that there’s a pain in a certain area, referral of pain from a tender spot, a painful row spot with limited range of motion or the identification of a local twitch response to muscle palpation. It’s a lot of interesting stuff in there. When I read it myself, I’m like, “This sounds like it would be difficult for any practitioner to diagnose a trigger point in any patient reliably.” Soft tissue is different from patient to patient.

This is one of the problems with research over a real-world practice anyway. Often, the rigidity of the criteria is a reason to say that’s not applicable because in real life it doesn’t work that way often, but you have to define it somehow. That seemed to us to be the most reasonable criteria to work with, to try and decide is it a trigger point treatment that they’re offering or could it be something very different? It’s part of the process for us in doing this research. I did it with my team at the pain center was to get our heads around research and how it works. When you’ve done something like a systematic review, it changes your lens on how you read other systematic reviews for sure.

You also mentioned that trigger points could include obviously Manual Therapy, which you’re talking about dry needling, which many physical therapists use in the United States. I’m not sure about the rest of the world, but in the United States more and more local injections, laser, stretching, massage and medications. Is it almost like going through the menu of chronic pain treatments, right?

Yeah. Medication, injections and things might be things that you might consider a medic or a physician to offer. The reason we look at Manual Therapy was that that’s what we felt people would go to a physiotherapist or another manual therapist or bodyworkers. We wanted to look at that specifically. There are lots of literature on dry needling. There’s a lot but not so much high-quality literature on Manual Therapy.

As a practitioner, how do we describe a trigger point to a patient through a biopsychosocial model?

You’re probably asking the wrong person. How can I explain a trigger point?

From where you are, from your experience, what would you even explain what a trigger point is? If someone says to you in practice, “I have this muscle that’s not in my lower back.”

Half my time we’re often asked clinical, I’m managerial and research as well. I can’t recall many people coming to me saying exactly what you’ve said there. It’s not a conversation that might come up often. Occasionally people say, “I can feel a lump there. What do you think?” Using a process-centered approach and that biopsychosocial, we will go, “What do you think is going on? First of all, what have you been told? What’s your understanding?” We start to look at it more from a neurophysiological perspective. The conversation we often do have with people is treating the trigger point versus understanding a bit more about why we have these areas of tightness, the tension in the body and what might be helpful for that.

Since you’re not providing Manual Therapy, probably that topic may potentially come up less because maybe this is my bias to Manual Therapy. Oftentimes when someone is providing Manual Therapy, they may stop over a tender spot or a trigger point and press on it.

You pick it up as you’re doing an assessment or touching the person, whereas I’m not doing that. If it doesn’t come up in the conversation, then we won’t talk about it so much. I can probably count on one hand the number of times I have had discussions with people around trigger points and around what we think is going on, how it might fit in what we talked about in pain and how we work with people.

Based on your research, does treating a trigger point through the ischemic compression model, which is pressing on the trigger point, does it help alleviate pain?

Our findings were quite surprising in many ways. Our primary outcome was pain reduction along with adverse events and withdrawals. There are primary outcomes that we looked at. The short answer is it doesn’t appear too, based on our findings, particularly in the short-term. The problem is that there isn’t a lot of long-term follow-up in the literature. However, we hypothesized that if you’re going to see a difference, you would expect perhaps to see more of a difference in the short-term than in the long-term. For pain, we didn’t see a reduction. We were quite surprised by that because we thought if you’re going to stay results, there’s this type one error. All the studies we included had small sample sizes and that in itself increases the risk of type one error reporting. We didn’t say that. We were surprised by that finding.

Since it is widely used by many different types of practitioners, is it safe to be using? Are there adverse outcomes that are reported in the literature?

Adverse outcomes weren’t reported very well. This was a critique we had at the end or a recommendation. It’s a broad recommendation around following impact guidelines in reporting research in pain is that we should be reporting these. In fact, there’s only one group in ours that report on adverse events. I can’t comment on that because it wasn’t reported in the others. If it’s not reported, it doesn’t necessarily mean there weren’t adverse events as we all know.

It’s nice to know sometimes it’s not working, but at least I’m not hurting anyone.

That’s why it should be part of primary commissions that we look at. It was surprisingly under-reported. Make of that what you will. In Fitzgerald’s group who did quite high-quality research, they reported a lot of adverse events from there around after treatment, soreness and things like that. There were no depths certainly.

If people are using it internally, which some pelvic health therapists do it, I do think it’s an important topic to look at. Hopefully, someone will do that research because there are many pelvic therapists that do manual trigger points internally.

This is the other interesting thing, more generally systematic review and research are often we recommend doing more research in this area. We didn’t for lots of reasons, partly because if there was going to be an effect, we would have expected them to be over-reported in smaller studies. That was one of our main reasons. Also, there are lots of research out there. The quality is not high enough. Our understanding of the complexity of pain and that we couldn’t justify saying focusing on one specific thing like this is likely to yield many benefits. We didn’t recommend it. Coming from the side of altering something and trying to get it through journals, that’s an interesting process because it’s likely that if you make a recommendation like that, it will be bounced back until you consider from the peer-review process.

I noticed that at the end of the paper you put that stake in the ground and said, “We don’t recommend using Trigger Point Therapy for the treatment of chronic pain.” For me, it was refreshing because so often you read things as you mentioned, people say more research is needed. Part of me is like, “I’d love to read more research but do we have enough or is the researcher saying that so they can do more research and keep their jobs?” which is fine too. Obviously, people need to continue to do good, high-quality research. It is good that something like this that’s been around for probably literally centuries that we have someone like you saying, “Based on we have now, you probably shouldn’t be doing it,” or at least in isolation it is what you said in that paper.

This is the problem. There has been an interesting debate on about multimodal defining that becomes a problem in itself as well and identifying the active processes within a multimodal approach. I suppose to us, this paper speaks to even within the context of multimodal on its own, this doesn’t appear to work or it didn’t give the result of pain reduction. There was an interesting caveat around function, which we found very interesting. It wasn’t one of our primary outcomes. It’s difficult to make any broad statements about it because it was only in four very small studies with high-grade scores. They seem to be some improvement in function in the short term. Long-term follow up was very poor in all of these papers.

That’s something that is a disappointment especially with something like chronic pain or persistent pain, ongoing pain. A long-term follow-up should be what is done or undertaken in any research. To come back to your point, perhaps more research will highlight this more. I suppose maybe having Amanda Williams on our team. I’m working with Cochrane and having done many systematic reviews for self in paying more particularly in psychology, pain and group work. She said, “We want to think about what we can say here?” Rather than saying more research is needed, let’s think about what we have and think about what would be the most helpful statement to put out there.

To help practical practitioners along and apply the evidence in a way that helps them inform their practice as well as obviously help people with moving beyond that.

There are probably enough areas to look at the research. Research is expensive as well. It costs a lot of money. If you’re going to invest, it’s worth investing in things where there may be stronger signals and more likely that fits and meets our current understandings of pain.

Let’s shift gears and let’s talk about in the UK a physical therapist role in prescribing or de-prescribing opioids because when I met you at the World Conference, you and I started chatting and you mentioned to me that in the UK you have the privilege to prescribe or de-prescribe medications. Obviously in the United States, I’m not sure other countries, we don’t have that. The military is the only place where you can do it as a physio but in private practice, in hospitals and wherever in the United States of America, we have no way to do that. Tell me about this phenomenon in the UK.

What struck me in Boston was the interest in that aspect of it. Physios can do this. The UK is the only country in the world that I’m aware of that physios can train in prescribing. Over several years ago, the laws changed. In the UK, a range of allied health professions, nonmedical healthcare professionals could become at that time called supplemental prescribers. It was a little bit of a caveat that you need to have a medical mentor, someone who could prescribe to oversee what you were doing. That’s where we started. That was maybe over several years ago. In 2015, having had maybe five, six years of data to see how this was working out. That provided the argument to say we can probably legitimize independent prescribing with the right training. Since 2015, physiotherapists in the UK have been able to train to gain that qualification of independent prescribing.

How do you go about getting this privilege of qualifying for that?

It’s a university accredited training course. How do you get your qualifications through? There’s a range of higher education institutes in the UK that offer this now, maybe four or five in the London area where I am based. It differs slightly from university to university. Broadly, it’s a six-month program. It’s a long time going out for me again. I did my supplemental prescribing maybe several years ago now. In 2015, the laws changed again to allow the physiotherapist to become independent prescribers along with podiatrists and pharmacists.

That was important in terms of our autonomy and this sense of as long as it’s within your scope of practice and your competencies that you don’t require a medical mentor, you’re legally able to prescribe yourself. Before I started working in pain management, I had worked in interfaced services between primary care and secondary care. We’re looking at triaging referrals from GPs, from doctors towards orthopedics, rheumatology or pain services. At that time, I was going to do the prescribing course. I moved to pain and they initially said to me, “You’re working in pain. We’re trying to move away from a biomedical model. We don’t think you should do prescribing.” That was interesting. I didn’t drop it. After a couple of years, I saw my way of thinking that this could be a useful bridge between a more biomedical approach and biopsychosocial approach. At the moment in the UK, it’s growing that we have about between 700 and 800 physiotherapists who are qualified independent prescribers.

You can prescribe and you can also de-prescribe the right term?

Yes. That’s an interesting one. The training was on prescribing. My interest is in de-prescribing. As part of your training, you have to do so many hours. It’s like 100 hours or something like that off the top of my head. Don’t quote me on this, but I’ve mentored practice. You have to write case reports and stuff like that. A lot of my case reports were on de-prescribing. We want you to prescribe. In my practice where I work in pain management, most of our work is in de-prescribing. This is the way we work. In order to de-prescribe, you need the qualification, you need to understand the principles of prescribing. It’s still relevant.

It’s also known as tapering.

It’s weaning, there’s a range of terms that are used.

Do you receive referrals from physicians specifically for tapering off of opioids?

No. At our center, referrals come in. We will work with the patient on whether that is something that they want to do. We tried to move away from this idea of an enforced tapering or weaning. In fact, we don’t do that. We would never. We will have referrals where they might highlight that the person is on quite high levels of whatever they may be on opioids or gabapentinoids, for example. We will explore that with the person if you have the time and you explore it with someone often. You will work towards what it would be like to come off eventually.

One of the biggest problems with de-prescribing is if you take away medication and somebody doesn’t have any other strategies in place or with coping skills, they will be much more anxious. It raises anxiety and distress. They may not come back with the treatment because they can’t because they’re so worried about this. We have to look at that. I’m going to get introducing other ways to help them manage. That’s where physios and I mentioned this idea of a bridging role to bring people from that perhaps more medical way of looking at it, to think about everything else that could perhaps be helpful for them within that context.

To pick up a point on this question around, do we get referrals for de-prescribing? Sometimes. In our team, we’ve got many anesthetists who are pain specialists. We have psychologists, nurses and physiotherapists. That’s the team I work in. It may be that my medical colleague will pick up somebody who has medication-related issues. They’re struggling and they tend to ask them to be seen by our nurse specialists and our psychologists. If it’s purely to focus on tapering or weaning. I’m quite interested in this idea of why physio wouldn’t be more involved in that. That was my poster that I brought asking the patients, asking the people living with pain who are struggling with medication.

It’s an interesting thing because there’s a lot of anxiety not only from patients or people living with pain but also from clinicians on how best to support these people. With that, I was observing a bit of a fear around maybe working with this population in a group setting. I struggled to understand that. We know that in most other situations, peer support is valuable. Why would it be different with medication? I can only go on my findings from our focus group, but certainly that was the feedback. They immediately bonded as a group and already set up their own WhatsApp group and wanted to communicate more with each other. That would say something in itself that there’s potentially a role there.

It’s very supportive I think for them to do that. Obviously, it supports the literature. You do taper and de-prescribe. In my mind as I’m listening to you, this is a big topic in and of itself. Are you playing a role in let’s say addiction medicine or addiction treatment? The other thing that came up as you were talking, you mentioned you’re working in a multidisciplinary team. Are you the only member of the team that has that privilege to taper other than maybe the physician?

We have nurse specialists. A range of professionals can prescribe. Nurses can become independent prescribers. In my team, what interests me, I am a prescriber but often when we have people who are struggling, they’re not referred to me or the physio team, they would be referred to the psychologist and the nurse specialist to support them. That’s where my interest started to peak was why not surely we could have more of a role and particularly being experts in movement and helping people that function that should be where we have to support these people. It’s a nuance of how we work here, but de-prescribing is more around advising them and writing to their GPs. In reality, it’s their GP who will see that more and have to work with them more. We don’t write scripts or we don’t change prescriptions. We write to the GP and say this is how we would recommend it. We look at making sure that they have access to self-management skills development through physio psychology to support that.

The psychologist on your team does or does not, he or she has the privilege to do that?

No. A psychologist cannot.

That’s fascinating to me how things are different because in the United States, in certain states, psychologists can take a test, prescribe or de-prescribe as well but only in certain states. It’s interesting how there are so many practice acts and things from state to state as well as country to country. What would your recommendation be to a physiotherapist in another country, who was saying, “I want to try to explore this topic or talk to my supervisor or my university or maybe do a research project on this topic?”

To be clear, I don’t think you need to become an independent prescriber. There’s a lot we can do. It’s confidence in knowing what we can do. Interestingly, in the UK, The Chartered Society’s guidance on the role of physiotherapy and even without being a prescriber, which is within our practice, our constancy to advise broadly on medication. There’s a starting point there for all of us on being able to be aware of what medications people are on to notice if they’re tending to go to medication as a way of managing their flares in pain. Spotting those patterns is a great starting point to start to explore why is that? What else could be helpful rather than the medication?

I’ve been invited to do a talk here and it’s usually on the topic of de-prescribing and pain. I suppose the key message I try to raise with people is that it’s quite an anxiety-provoking thing to suggest to somebody. I’m going to take away the one thing that you’ve had for a while. We see that in the whole way things have gone in the US, the opioid crisis. We’re going to take it all away. We’ve got a blanket that doesn’t work. It’s somewhere in between these. It’s being aware of that and perhaps looking at what other strategies may help so that for the longer term they can consider at least the possibility that it might be something they could do is to wean off their medication. That’s a great starting point. If you can even help somebody to get to the place of being able to contemplate, there may be other ways I can manage this pain. This is my only option. I’m not sure if that’s answered your question, but it’s an emphasis on this. There’s a lot we can do even if we’re not prescribers. It’s flagging up if we’re noticing those unhelpful patterns of medication use. I’m thinking about the emphasis on all of the other things that might be helpful.

You articulated it in a beautiful way because what we’ve done here in the US is we pulled the carpet out from people or from right under their feet. They’re very confused as well as some people potentially may even be injured by it because when you taper or pull people off of the medication that’s been addicted for so long, there are physiologic ramifications for that. However, the important point that you’re driving home is that when you take a psychologically informed approach to physical therapy and start to increase awareness of the patient as to what pain is, what can be done to cope and manage it. Bridge the gap of, “Now that you’re starting to feel a little better, you have more education, you cope better, the function is getting better, the medication you’ve been on,” and you bridge that gap.

The opioid aware which is underneath it here have lots of guidance on opioid prescribing. It is very clear that we should be checking patient goals and patient function when we’re prescribing. When you speak to people and you ask them, “When you started that, did they talk about your goals?” More often than not, in fact 99% of the time, I have had the answer, “No, they just asked about my pain.” We want to open up the conversation and the possibilities with people. As you said, psychologically informed is all about developing that alliance, that understanding and introducing some education or shared decision making in a more healthful way for some less anxiety-inducing. I keep coming back to anxiety, fear or threat. That’s the things we need to be aware of. We’re very good at being aware of that as therapists.

We have a wonderful combination of skills to offer people who have chronic pain to help them live as best life and that they’re able to live within their ability to take our information or education, put it to play. The work you’re doing both in research as well as clinical practice is great and it’s informing all of our practice. I appreciate the work that you’re doing and being on the show. If people want to reach out to you and learn more about what you’re up to, how can they reach out to you?

They can find me on Twitter. It’s probably the easiest way. It’s @DiarmuidDenneny or if they look up, I’m the current Chair of The Physio Pain Association. They’re a professional network. It’s like a special interest group of the Chartered Society of Physio, we’re affiliated to them. For people who are interested in pain, you have to be a member of the CSP to be a full member, but we have affiliate membership and that can be from anywhere in the world. There’s some exciting stuff coming up for online training in psychologically informed approaches and perhaps mentoring and support because that’s a big gap I think for all of us. Go to the PPA. If you Google physiotherapy PPA, you will find our website or follow me on Twitter. I have a link to our webpage there as well.

Please make sure to reach out to him at his Twitter handle and make sure to share this episode with your friends and family. Share it out on Facebook, Twitter or LinkedIn or if you have a favorite Facebook group where there are practitioners interested in obviously chronic pain and want to learn about some of the things that we talked about, drop it in the Facebook group and share with your friends. I want to thank Diarmuid for being with us. We will see you all soon. Thank you.

Thank you, Joe.

Important Links:

• Diarmuid Denneny
• Physiotherapy Pain Association
• Trigger Point Manual Therapy for the Treatment of Chronic Non-Cancer Pain in Adults: A Systematic Review and Meta-Analysis
• Cochrane Pain and Palliative Care
• Musculoskeletal Association of Chartered Physiotherapists
• Chartered Society of Physio
• @DiarmuidDenneny on Twitter
• https://www.NCBI.NLM.NIH.gov/pubmed/30025997

About Diarmuid Denneny, PT

Diarmuid is a professional lead physiotherapist at the Pain Management Centre (PMC), the National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust. Clinically he is an advanced practitioner physiotherapist and independent prescriber.

He has worked in a specialized pain management center for over 12 years and prior to that, his background was in MSK (Having passed exams to become an MACP member). In addition to his clinical and managerial work, Diarmuid is the current chair of the Physiotherapy Pain Association.

He is a member of the guideline development committee for the NICE chronic pain guidelines. Diarmuid is a module lead (Strategies for the Self-Management of Pain) for the on-line UCL MSC in Pain Management. He also has interests in the non-medical management of CRPS and is a committee member of CRPS UK.

Diarmuid was awarded an NIHR pre-doctoral fellowship in 2017/18 and is interested in the development of clinical academic roles for physiotherapists. He has a particular interest in the psychologically informed practice and the role of physiotherapists in supporting people who have pain and medication-related issues.

Additionally, he is a supporter of co-production in pain management and is keen to combine these interests with further research. Diarmuid has published peer-reviewed articles relating to physiotherapy practice in pain including; a systematic review of trigger point manual therapy, a rapid review of automated outcome measures and an observational study on behaviors of experienced physiotherapists working within a psychologically informed model.