Dr. Moses raises three issues: the validity of the diagnostic criteria used in our research, the use NIH funds to investigate relationships that he states are self-evident, and whether our recommendations to assess fibromyalgia in myofascial face pain, or MFP, patients are trivial, because Dr. Moses believes they merely state the obvious.
We will respond to each issue in turn.
We employed the diagnostic guidelines of a major research organization, the International Association for the Study of Pain. Dr. Moses asserts that we have erred by not using Travell’s diagnostic method. While we acknowledge the historical role of Dr. Travell in focusing the medical and dental community on myofascial pain, those familiar with her work should be aware that she is primarily engaged in clinical observation rather than clinical research.
Despite the impact of her 1993 book, subsequent research did not find her "hyperirritable trigger points, usually within a taut band" concept to be a critical diagnostic factor. For example, Wolfe and colleagues1 conducted a study in which they conclude that trigger-point identification is not able to be made with sufficient reliability for differential diagnosis.
Wolfe and colleagues report that taut bands were found as often in healthy subjects as in subjects with myofascial pain syndrome or fibromyalgia. The diagnostic relevance of Travell’s trigger-point concept remains to be determined. As the NIH highlighted in the 1996 TMD Technology Assessment Conference,2 the field is far from reaching consensus about the best diagnostic systems in MFP and other TMDs.
For Dr. Moses to deify the concept of "trigger points" in MFP and to consider the diagnostic system we and others use as "misleading double-talk" is at best misguided.
Large-scale, NIH-funded research such as ours generates a rich data set from within which many issues can be explored, even those not directly related to the main aims of the funded protocol. As our article elaborates, we are the only study to date comparing MFP patients with and without fibromyalgia symptoms, in which all subjects were selected on the basis of seeking treatment for their MFP.
This is a subtle but extremely important methodological issue. In addition, it is not unusual to find that clinically "self-evident" findings do not hold up under systematic investigation. We have elaborated on the problem of the "clinician’s illusion" in an earlier issue of The Journal.3
Finally, Dr. Moses states that a comprehensive health history is part of standard clinical practice. Therefore, he suggests that our recommendation to assess for history or symptoms of fibromyalgia is stating the obvious. Does Dr. Moses comprehensively assess his MFP patients for fibromyalgia? If he does so routinely, he is to be commended. If he believes that all clinicians do so, he is also quite an optimist.
As a last comment, we would urge future letter writers in JADA to refrain from inflammatory rhetoric that is likely to obscure the letter writer’s message. Polemics serve to nurture the schism between clinician and clinical researcher, discouraging professional debate.
TOP
REFERENCES
